SBRATE

Quero me associar
Esqueci minha senha

Casos Clínicos

11.Rotura do ligamento patelar

Clique para ampliar

MM, 25 anos, fem, negra, nat e proc de São Paulo, atleta profissional de atletismo


Autor: Dr. Cristiano Frota de Souza Laurino

Diagnóstico: Ruptura total do ligamento patelar do joelho

ID: MM, 25 anos, fem, negra, nat e proc de São Paulo, atleta profissional de atletismo

QD: Dor súbita no joelho durante um salto há 1 hora

HPMA:
Atleta relata que durante o treinamento de barreiras sentiu dor súbita no joelho esquerdo com sensação de luxação da patela, levando à queda e limitação funcional para estender ativamente o joelho, associado à dor.
Foi auxiliada a posicionar o joelho em extensão, sentindo um ressalto com retorno da patela à posição original.
Nega antecedentes de dor sobre o ligamento patelar antes do acidente ou instabilidade patelo-femoral.

IC:NDN

ex fisico:

• Inspeção: edema ++++/4 difuso

• Palpação: “gap” palpável sobre o ligamento patelar, rechaço patelar ++++





• equimose +

• extensão ativa do joelho ausente

• Provas meniscais e ligamentares restantes inalteradas.

HD: Ruptura total do ligamento patelar

Conduta:

• Cirurgia de reconstrução do ligamento patelar no mesmo dia da lesão.



• Reparo do retináculo medial

• Tecnica de Haas e Calloway + Tecnica de Kessler- modificada Confecção de 3 túneis ósseos longitudinais com passagem de fios de ethibond 5, com reinserção do tecido remanescente no polo inferior da patela. Flexão do joelho a 30 graus e amarração dos fios na extremidade superior da patela.





• Tecnica de Krackow-Bunnell + 2 âncoras metálicas no polo inferior da patela (figura)



Gaines R, Grabill S, DeMaio M,: Patellar Tendon Repair with Suture Anchors Using a Combined Suture Technique of a Krackow-Bunnell Weave. Journal of Orthopaedic Trauma 2009; 23(1): 68-71.

• enxerto de tendões flexores passados proximalmente à patela no interior da porção distal do tendão quadricipital e distalmente atraves de perfuração óssea na inserção tibial na TAT .



Matava M: Patellar Tendon Ruptures. J Am Acad Orthop Surg 1996;4:287-296



• Retirada do garrote e movimentos de flexo-extensão joelho.



  Pós-operatório:

• 0-2 sem:

o Imobilizador do joelho em extensão com carga parcial e muletas
o Movimentação passiva ate 60 graus

• 2-6 sem:

o Imobilizador articulado e ganho de arco de movimento progressivo

• Retorno aos treinamentos leves em 4 meses

Referências Bibliográficas

1. Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981; 63:932-937.

2. Haas SB, Callaway H. Disruptions of the extensor mechanism.Orthop Clin North Am. 1992; 23:687-695.

3. Pritchard CH, Berney S. Patellar tendon rupture in systemic lupus erythematosus. J Rheumatol. 1989; 16:786-788.

4. Chiou HM, Chang MC, Lo WH. One-stage reconstruction of skin defect and patellar tendon rupture after total knee arthroplasty. A new technique.J Arthroplasty. 1997; 12:575-579.

5. Lynch AF, Rorabeck CH, Bourne RB. extensor mechanism complications following total knee arthroplasty. J Arthroplasty. 1987; 2:135-140.

6. Rand JA, Morrey BF, Bryan RS. Patellar tendon rupture after total knee arthroplasty. Clin Orthop. 1989; 244:233-238.

7. Zanotti RM, Freiberg AA, Matthews LS. Use of patellar allograft to reconstruct a patella tendon-deficient knee after total joint arthroplasty. J Arthroplasty. 1995; 10:271-274.

8. Cadambi A, engh GA. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. A report of seven cases. J Bone Joint Surg Am. 1992; 74:974-979.

9. emerson RH Jr, Head WC, Malinin TI. Reconstruction of patellar tendon rupture after total knee arthroplasty with an extensor mechanism allograft. Clin Orthop. 1990; 260:154-161.

10. Kretzler Je, Curtin SL, Wegner DA, Baumgaertner MR, Galloway MT. Patella tendon rupture: a late complication of a tibial nail. Orthopedics. 1995; 18:1109-1111.

11. Scuderi GR, Scott WN, Insall JN. Injuries of the knee. In: Rockwood CA Jr, Green DP, eds. Fractures in Adults. Philadelphia, Pa: JB Lippincott; 1996:2023-2028.

12. Marumoto JM, Mitsunaga MM, Richardson AB, Medoff RJ, Mayfield GW. Late patellar tendon ruptures after removal of the central third for anterior cruciate ligament reconstruction. A report of two cases. Am J Sports Med. 1996; 24:698-701.

13. Bonamo JJ, Krinick RM, Sporn AA. Rupture of the patellar ligament after use of its central third for anterior cruciate reconstruction. A report of two cases. J Bone Joint Surg Am. 1984; 66:1294-1297.

14. Podesta L, Sherman MF, Bonamo JR. Bilateral simultaneous rupture of the infrapatellar tendon in a recreational athlete. A care report. Am J Sports Med. 1991; 19:325-327.

15. Rosenberg JM, Whitaker JH. Bilateral infrapatellar tendon rupture in a patient with jumper’s knee. Am J Sports Med. 1991; 19:94-95.

16. Sherlock DA, Hughes A. Bilateral spontaneous concurrent rupture of the patellar tendon in the absence of associated local or systemic disease. Clin Orthop. 1988: 237:179-183.

17. Webb LX, Toby eB. Bilateral rupture of the patella tendon in an otherwise healthy male patient following minor trauma. J Trauma. 1986; 26:1045-1048.

18. Larsen e, Lund PM. Ruptures of the extensor mechanism of the knee joint. Clinical results and patellofemoral articulation. Clin Orthop. 1986; 213:150-153.

19. McMaster PR. Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. J Bone Joint Surg. 1933; 15:705.

20. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991; 73:1507-1525.

21. Kelly DW, Carter VS, Jobe FW, Kerlan RK. Patellar and quadriceps tendon ruptures - jumper’s knee. Am J Sports Med. 1984; 12:375-380.

22. enad JG. Patellar tendon ruptures. South Med J. 1999; 92:563-566.

23. Yamaguchi GT, Zajac Fe. A planar model of the knee joint to characterize the knee extensor mechanism. J Biomech. 1989; 22:1-10.

24. Zernicke RF, Garhammer J, Jobe F. Human patellar tendon rupture. J Bone Joint Surg Am. 1977; 59:177-183.

25. Berg ee. Bipolar infrapatellar tendon rupture. J Pediatr Orthop. 1995; 15:302-303.

26. McLaughlin HL. Repair of major tendon rupture by buried removable suture. Am J Surg. 1947; 74:758-764.

27. Miskew DB, Pearson RL, Pankovich AM. Mersilene strip suture in repair of disruptions of the quadriceps and patellar tendons. J Trauma. 1980; 20:867-872.

28. Azar FM, Pickering RM. Sports medicine: Traumatic disorders. In: Canale ST, ed. Campbell’s Operative Orthopedics. St Louis, Mo: CV Mosby; 1998:1423-1428.

29. Fujikawa K, Ohtani T, Matsumoto H, Seedhom BB. Reconstruction of the extensor apparatus of the knee with the Leeds-Keio ligament. J Bone Joint Surg Br. 1994; 76:200-203.

30. Levin PD. Reconstruction of the patellar tendon using a dacron graft: a case report. Clin Orthop. 1976; 118:70-72.

31. Frazier CH, Clark eM. Major tendon repairs with Dacron vascular graft suture. Orthopedics. 1980; 3:323-325.

32. Levy M, Goldstein J, Rosner M. A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report. Clin Orthop. 1987; 218:297-301.

33. Kelikian H, Riashi e, Gleason J. Restoration of quadriceps function in neglected tear of the patellar tendon. Surg Gynecol Obstet. 1957; 104:200-204.

34. Larson RV, Simonian PT. Semitendinosus augmentation of acute patellar tendon repair with immediate mobilization. Am J Sports Med. 1995; 23:82-86.

35. Lindy PB, Boynton MD, Fadale PD. Repair of patellar tendon disruptions without hardware. J Orthop Trauma. 1995; 9:238-243. 36. Mandelbaum BR, Bartolozzi A, Carney B. A systematic approach to reconstruction of neglected tears of the patella tendon. A case report. Clin Orthop. 1988; 235:268-271.

37. Marder RA, Timmerman LA. Primary repair of patellar tendon rupture without augmentation. Am J Sports Med. 1999; 27:304-307.

38. Hsu KY, Wang KC, Ho WP, Hsu RW. Traumatic patellar tendon ruptures: a follow-up study of primary repair and a neutralization wire. J Trauma. 1994; 36:658-660.



Comentários

13/04/2012 - A atleta permanece em atividade, mantendo alta performance esportiva 5 anos e 4 meses após a cirurgia. - Cristiano Frota de Souza Laurino