Case Study: Management of Patellar Tendon Rupture

in a 70-year-old Male

A 70-year-old male reportedly had a fall stumbling down the stairs followed by pain and swelling in the left knee and left foot. The patient was taken to the ER where a left cuboid fracture was diagnosed on X-ray. He had a below-knee walking splint applied in the ER but was unable to walk. Subsequent examination suggested a rupture of the extensor mechanism of the left knee.

A sulcus was palpable in front of the left knee and the patient was unable to perform a straight leg raise test. The examination of the bilateral hips and spine was normal. There was ecchymosis in front of the left knee. X-ray of the left knee revealed a patella Alta and the presence of soft tissue swelling.

MRI of the knee in the sagittal section showing a complete tear of the patellar tendon.

MRI of the knee in the sagittal section showing a complete tear of the patellar tendon.

MRI of the left knee suggested a full-thickness midsubstance tear of the patellar tendon with approximately 1.7 cm fluid gap and associated patella Alta. There was diffuse infiltration/edema within the infrapatellar and prepatellar fat. The patient is a retired banker and had an active lifestyle before the injury.

The patient’s past medical history was significant for chronic kidney disease, chronic bronchitis, hypertension, and hyperlipidemia. The patient’s current medications include enalapril, hydrochlorothiazide, atorvastatin, and albuterol inhaler.

Various treatment options were discussed at length with the patient. The patient agreed to surgical management. The risks and benefits including failure, infection, bleeding, nonhealing, need for repeat surgery and reconstruction, knee stiffness, rehabilitation, systemic complications like blood clots, cardiac, pulmonary, neurological complications, and even death were discussed at length with the patient. The patient understood and signed the informed consent.

X-ray of the right knee showing patella Alta secondary to the rupture of the patellar tendon.

X-ray of the right knee showing patella Alta secondary to the rupture of the patellar tendon.

PREOPERATIVE DIAGNOSES:

  1. Left mid substance patellar tendon rupture.
  2. Fracture cuboid, left foot.

POSTOPERATIVE DIAGNOSIS:

  1. Left mid substance patellar tendon rupture.
  2. Fracture cuboid, left foot.

OPERATION: Patellar tendon repair primary with augmentation using dermal allograft and sutures using SwiveLock and anchors.

PROCEDURE: The patient was taken to the operating room. The anesthesiologist did an adductor block. General anesthesia was induced. The left short-leg splint was removed before the procedure.

The left lower extremity was prepped and draped aseptically in a usual fashion. A high thigh tourniquet was applied. The Time out was called. Preoperative antibiotics are given. A thigh tourniquet was inflated to 325 mmHg.

The incision was planned from the anterior part of the patellar to the tibial tuberosity. A midline incision was given. With sharp and blunt dissection, a patellar tendon was reached, which was found to be ruptured with ragged margins.

The tear was extending into the lateral and medial patellar tendon. The knee was opened and washed thoroughly with irrigation. The ragged margins of the patellar tendon were removed. The primary repair of the patellar tendon was planned.

Intraoperative image showing the torn patellar tendon.

Intraoperative image showing the torn patellar tendon.

A 2 mm fiber tape x4 was used to put Krackow suture, one on either side on the proximal and distal end of the patellar. The tails of the sutures were in the midline. Now, the lower wall of the patellar was exposed, posterior to the patellar side. It was cleaned with the use of curette and Bovie. The bone was decorticated and two drill holes were done and planning for suture anchors.

Four drill suture anchors were brought on either side of the patellar, posterior to the patellar tendon. The sutures were brought to the front through the patellar tendon and reticulum using a suture passer.

Once they were brought up, the tails of the suture in the midsubstance of the patella were tied to each other using four knots separately. The knots were buried and cut. An Arthroflex was opened. It was put on the patellar tendon and sealed proximally.

The distal one-third of the graft was removed and little of access. The allograft was found to cover the patellar tendon and is to eternity. Now the two sutures from each side of the suture anchors proximal were crossed, one set was crossed and one set was taken straightening, put in the tibia lateral to the tibial tuberosity using SwiveLock on either side. Excellent configuration was achieved.

Intraoperative image showing the repaired patellar tendon with overlying allograft.

Intraoperative image showing the repaired patellar tendon with overlying allograft.

The knee was flexed in 30 degrees at that time. Then the patellar tendon repair was stopped. The allograft was posterior to the sutures opposing to the patellar tendon repair in the patellar tendon. The wound was again washed.

The patellar retinaculum was repaired on either side using #2 FiberWire. The sutures and towards the center of the patellar retinaculum were incorporated into the Arthroflex graft.

The wound was again washed and closure was done using Vicryl #2-0 for subcutaneous and Monocryl #3-0 for the skin. The dressing was done using Prineo. The further dressing was done using Webril and Ace wrap. A posterior short-leg splint was re-applied. A long knee brace was applied.

Postoperative images at 2 months follow up.

Postoperative images at 2 months follow up.

 

Postoperative images at 2 months follow up.

Postoperative images at 2 months follow up.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
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00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
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00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
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19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
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20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
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15:02 02 Mar 23
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21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
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20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
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16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
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21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
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19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
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21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
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23:31 19 May 22
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The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
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19:54 16 May 22
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19:37 09 May 22
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19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
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00:46 03 May 22
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20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
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19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
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03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
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22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
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16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
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02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
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14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
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01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
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The staff here are great, I was seen at the time of my appointment and was well taken care of!
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18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
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19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
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18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
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17:26 17 Nov 20
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I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.