Introduction
Tibial tubercle avulsion fractures are rare, accounting for less than 1% of physeal injuries. Similarly, patellar tendon ruptures are uncommon, and their precise incidence is not clearly reported. Both conditions typically require careful diagnosis and appropriate management. Patellar tendon rupture with tibial tuberosity avulsion is a very rare injury that are seen in young adolescents/adult typically involved in sports activities.1, 2, 3, 4 It has not been reported much in road-traffic accident in adult. In this article, we present an extremely rare case where tibial tuberosity avulsion with patellar tendon rupture with anterolateral rim of tibial plateau fracture occurred in a middle-aged male patient in a road-traffic accident due to direct impact on the knee. It can present challenges in both diagnosis and management. A variety of surgical techniques to address the tibial tubercle fracture include open reduction and internal fixation with Kirschner wires, Sherman or cancellous screws and cerclage wires,5 while techniques to repair the patellar tendon rupture use suture repair of tendon to periosteum or transosseous sutures through the tibia.1, 5 In this kind of rare injury, the absence of a clearly favored operative fixation approach highlights the challenge in establishing standardized protocols. This case report aims to detail the diagnosis, operative management, and post-operative rehabilitation of a middle-aged individual having a combined patellar tendon rupture with tibial tuberosity avulsion, coupled with an anterolateral rim injury to the tibial plateau. This comprehensive documentation provides valuable insights into the treatment and recovery process for this specific injury pattern. We have obtained the patient’s informed written consent for publication of the case report.
Case Presentation
A 42-years old male working as labourer who had fall on knee presented to the hospital with chief complaints of right knee pain with swelling and inability to walk after fall down from bike. On physical examination of the right knee, the skin was intact with no abrasions or open wounds. There was diffuse soft tissue swelling around the knee as well as a moderate knee joint effusion. He had severe tenderness on palpation directly over the tibial tuberosity and patellar tendon, with an asymmetrically high-riding patella on palpation compared to the contralateral extremity. A defect at the inferior insertion of patellar tendon palpated. There was no neurovascular compromise. The extensor mechanism was compromised. Distally, he demonstrated full motor strength with ankle and great toe dorsi-and plantar flexion. Radiographs demonstrated tibial tuberosity avulsion with anterolateral rim of tibial plateau fracture extending upto proximal tibial physis with concomitant patella alta. MRI was advised but due to economical constraints, it was omitted and CT scan was done instead.
Figure 3
a): The computed tomography scan (b): Coronal section and c): Sagittal section) study demonstrates the tibial tubercle fracture
Patient was taken for surgery after 24 hours of presentation. An anterolateral approach to the knee was used. First overlying traumatic haematoma was evacuated and fracture site exposed. The radiographic findings of tibial tuberosity avulsion and patellar tendon rupture were confirmed intraoperatively. We started with open reduction and fixation which was achieved with tension band wiring with the help of kirschner wire. Transosseous suture with two continuous locking suture with ethibond 5 were taken. Tibial tubercle piece fixed with tension band wiring and cannulated cancellous screw. Patellar tendon sutured through krackow technique.
Result
Our report suggests that cancellous screws, along with tension band wiring and K-wire is effective in fixing patellar tendon rupture with tibial tubercle avulsion. The positive outcome, allowing patient to return to routine activities without any complications, emphasizes the importance of preserving the bony avulsion of the tibial tubercle to enhance the overall holding strength of the construction.
Discussion
Tibial tuberosity avulsion is more common in adolescent population than any other because of an open physis. Systemic illness like diabetes, chronic steroid use, quinolone treatment, chronic renal failure1, 6 may increase risk of patellar tendon rupture because of tendon degeneration.7 This article describes the case of a simultaneous patellar tendon rupture with tibial tuberosity avulsion fracture in a middle-aged person in a road-traffic accident. We believe the mode of injury in our patient was direct impact on the knee due to accident causing tibial tubercle fracture with anterolateral rim of tibial plateau fracture with patellar tendon rupture. This has been reported seldomly. Zernicke et al. reported that a load of 17.5 times the body weight is required to rupture the human patellar tendon.7 In tibial tuberosity avulsion fractures, the initial avulsion may be followed by rotation, causing tension in the surrounding soft tissues. The presence of rotation is often evident on radiographs. This mechanism is plausible in our case. Desai and parikh reported that a high-riding patella, palpable gap at the site of patellar tendon and an inability to perform active extension are important findings suggestive of patellar tendon injuries.1 Though physical examination is important, it is difficult to perform because of pain and swelling. In our case, fractured fragment was large enough for screw fixation and tension band wiring was required in our patient. Tension band wiring has been done to provide additional stability to the tibial tubercle fracture and institute early mobilization of the knee joint. In patients with radiographic evidence of tibial tubercle fracture, lateral flexion extension radiographs, ultrasonography, computed tomography and/or magnetic resonance imaging are important to rule out concomitant patellar tendon avulsion.8, 9 Previously, isolated distal patellar tendon avulsions have been treated with transosseous sutures or suture anchors.1, 10, 11 In adolescents, combined lesions have been treated using a variety of methods, including staples, wires or suture tape, tension banding, lag screws, suture anchors, and/or transosseous sutures.12, 1 The preferred suture technique for patellar tendon repair is the krackow technique for most of cases and bunell technique is also used in some cases. While there may not be specific clinical studies comparing treatment methods for this particular scenario, achieving stable fixation of the bone fragment and ensuring proper repair and reinsertion of the patellar tendon are generally considered crucial for satisfactory clinical outcomes.
Conclusion
Patellar tendon rupture with tibial tuberosity avulsion with anterolateral rim of tibial plateau fracture is very rare and challenging condition and its incidence is very less. The combination of open reduction with insertion of cancellous screw and tension band wiring with K-wire and patellar tendon suturing via krackow technique gives excellent and satisfactory clinical outcome.