Patellar tendon ossification after anterior cruciate ligament reconstruction using bone – patellar tendon – bone autograft
© Camillieri et al.; licensee BioMed Central Ltd. 2013
Received: 28 October 2012
Accepted: 18 April 2013
Published: 10 May 2013
Among the various complications described in literature, the patellar tendon ossification is an uncommon occurrence in anterior cruciate ligament (ACL) reconstruction using bone – patellar tendon – bone graft (BPTB). The heterotopic ossification is linked to knee traumatism, intramedullary nailing of the tibia and after partial patellectomy, but only two cases of this event linked to ACL surgery have been reported in literature.
We present a case of a 42-year-old Caucasian man affected by symptomatic extended heterotopic ossification of patellar tendon after 20 months from ACL reconstruction using BPTB. The clinical diagnosis was confirmed by Ultrasound, X-Ray and Computed Tomography studies, blood tests were performed to exclude metabolic diseases then the surgical removal of the lesion was performed. After three years from surgery, the patient did not report femoro-patellar pain, there was not range of motion limitation and the clinical-radiological examinations resulted negative.
The surgical removal of the ossifications followed by anti-inflammatory therapy, seems to be useful in order to relieve pain and to prevent relapses. Moreover, a thorough cleaning of the patellar tendon may reveal useful, in order to prevent bone fragments remain inside it and to reduce patellar tendon heterotopic ossification risk.
KeywordsPatellar tendon Ossification Anterior cruciate ligament reconstruction Bone-patellar tendon-bone graft
Reconstruction of the anterior cruciate ligament (ACL) using bone – patellar tendon – bone graft (BPTB) is a common procedure in orthopaedic surgery but the patellar tendon ossification is an uncommon occurrence. In fact only two cases have been reported in literature [1, 2]. We report a case of patellar tendon ossification at 20 months after ACL reconstruction using BPTB.
There is no unanimous opinion in literature on the causes and the treatment of the patellar tendon ossification but a traumatic etiology seems to be the most affordable hypothesis. In literature the ossification of the patellar tendon has been reported mainly related to knee injuries [3, 4] or as a consequence of total/partial patellectomy [5, 6] and intramedullary nailing of the tibia [7–9]. A rare and interesting report was described by Chen et al., an extensive heterotopic ossification after patellar tendon repair in a 32-year-old African-American man with a rare trisomy 8 mosaicism. These authors suggested an association between trisomy 8 mosaicism and increased risk of heterotopic ossification .
As our case, two authors previously reported symptomatic patellar tendon ossification following the reconstruction of the ACL using BPTB [1, 2]. Valencia and Gavìn first reported a case of ossification of the proximal 2 cm of the patellar tendon after ACL reconstruction with BPTB. The patient was asymptomatic until the eighth postoperative month, when he started complaining of pain in the proximal insertion area of the patellar tendon. The clinical and radiological examinations showed ossification of the proximal third of the patellar tendon that was removed by surgery. A postoperative rehabilitation based on early mobilization and a 6 week anti-inflammatory therapy with indomethacin were done . Six months later the patient was free of pain without range of motion limitation.
Recently, Erdil et al. described another case of symptomatic ossification of the patellar tendon after ACL surgery with BPTB in a 36-year-old man. The patient had range of motion limitation and pain occurred six weeks after the ACL reconstruction. The clinical and radiological examinations showed the ossification of the proximal half of the patellar tendon. The first strategy was based on a conservative treatment using physical therapy and a rehabilitation program consisting of mobilization and achievement of normal range of motion. One year later, as the persistence of the ossification and the pain, the lesion was surgical removed. Surgery was followed by indomethacin therapy for 6 weeks and rehabilitation to recover active/passive range of motion (0°-135°) and muscle strength. The examination at 36 month follow-up revealed the achievement of full range of motion without recurrences .
A similar case was described by Erdogan et al. who reported a case of patellar tendon calcification (not ossification) after ACL reconstruction with BPTB . According to Erdogan, the calcification was due to the retention of bone debris within the patellar tendon during the graft harvest and tunnel reaming. Moreover these authors believed that an aggressive rehabilitation program in the immediate postoperative period may subject the tendon to excessive loads resulting in microtrauma with focal degeneration followed by calcification .
In our opinion to reduce patellar tendon heterotopic ossification risk in ACL surgery with BPTB, a thorough cleaning of the patellar tendon may reveal useful in order to prevent bone fragments persistence inside it. Moreover, we suggest that, at the patellar and tibial bone defect sites, the soft tissues and the periostium should be used to prepare a containment floor to avoid dispersion of bone fragments.
According to the literature, the surgical removal of ossifications followed by anti-inflammatory therapy and an immediate rehabilitation protocol for range of motion recovery, seems to be useful in order to relieve pain and to prevent relapses of ossification.
“Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.”
Anterior cruciate ligament
- CPM device:
Continuous passive motion
International knee documentation committee.
We would like to thank Dr. Sara Verrilli for her important contribution in drafting the manuscript and revision of the language without sources of financial support.
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/164/prepub
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