Post-traumatic patellar tendon ossification in children: a case series

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Abstract

Background. Fractures of the bones that form the knee joint in children are quite rare, accounting for up to 6% of all bone fractures. These include avulsion fractures of the patellar apex as well as tibial tuberosity avulsion fractures, which may result in patellar tendon ossification. Based on literature, the ossification may also occur in cases of primary or chronic (complete or partial) patellar tendon tears. Such a complication is quite rare in pediatric traumatology; it requires differential diagnosis and various surgical tactics.

The aim of the study is to present a clinical and radiological picture of post-traumatic patellar tendon ossification in children and its surgical treatment outcomes using a case series as an example.

Methods. We present a monocenter retrospective series of 4 male patients. Anamnestic, clinical, radiological and histological data were analyzed.

Results. The patients’ mean age was 14 (range, 11-16) years. In all cases, there was a history of trauma. Initially, after getting injured, the patients were treated for a knee injury. In one patient, as a result of his falling on 2 limbs, a bilateral pathology was observed; in other three cases, the pathology was unilateral. Flexion contracture and pain syndrome prevailed in the clinical picture. All patients underwent surgery ranging from excision of ossifications to excision of ossifications with reconstruction of tendon defects and refixation of the tibial tuberosity with osteosynthesis. In all cases, knee joint contracture was eliminated and the volume of movement was fully restored. Histology showed fragments of mature bone tissue represented by thinned bone beams with focal osteoclastic reaction and areas of endochondral ossification.

Conclusions. The clinical picture of pediatric patients with patellar tendon ossification manifests in the form of a chronic cascade of symptoms and functional and topographic disorders: patellar tendon ossification, patella alta, anterior knee pain, flexion contracture and rectus femoris muscle hypotrophy. X-ray and MRI data determine a formation of bone density with uneven clear contours in the projection of the patellar tendon, along with patella alta and the Caton-Deschamps index increasing more than 1.3. The primary treatment method of the developed complication is the surgical one, which leads to the restoration of the full amplitude of movements in the knee joint.

About the authors

Kirill A. Kartavenko

H. Turner National Medical Research Center for Сhildren’s Orthopedics and Trauma Surgery

Author for correspondence.
Email: med-kart@yandex.ru
ORCID iD: 0000-0002-6112-3309
SPIN-code: 5341-4492

Cand. Sci. (Med.)

Russian Federation, St. Petersburg

Vyacheslav I. Zorin

H. Turner National Medical Research Center for Сhildren’s Orthopedics and Trauma Surgery; Mechnikov North-Western State Medical University

Email: zoringlu@yandex.ru
ORCID iD: 0000-0002-9712-5509

Cand. Sci. (Med.)

Russian Federation, St. Petersburg; St. Petersburg

Sergey A. Lukyanov

H. Turner National Medical Research Center for Сhildren’s Orthopedics and Trauma Surgery

Email: Sergey.lukyanov95@yandex.ru
ORCID iD: 0000-0002-8278-7032

Cand. Sci. (Med.)

Russian Federation, St. Petersburg

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Supplementary files

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2. Figure 1. X-rays of the knee joints with unilateral patellar tendon ossification: a — AP view, patella alta, ossifications in the projection of the patellar tendon; b — lateral view, an injured limb, patella alta (Caton-Deschamps index — 1.8), ossification in the projection of the patellar tendon thickness; c — lateral view, a healthy limb

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3. Figure 2. MRI of the knee joint in children with patellar tendon ossification (sagittal, frontal and axial views): a — T2-weighted imaging (patient 1), ossification in the projection of the patellar tendon (indicated by an arrow); b — T2WI (patient 4), multifragmental patellar tendon ossification (indicated by an arrow); c — T2WI (patient 2), the cut at the level of the widest part of the ossification (indicated by an arrow), extending over the entire patellar tendon width

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4. Figure 3. CT of the knee joints of patient 3 with 3D reconstruction: a — bilateral pathology; b — an ossification fragment with an intraarticular location is visualized in the right joint

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5. Figure 4. CT of the knee joints of patient 4 with 3D reconstruction: right-sided fragmentary patellar tendon ossification

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6. Figure 5. Surgery for single-sided patellar tendon ossification (patient 4): a — appearance of the patellar tendon ossification (indicated by an arrow), patella alta; b — wound appearance after removal of the ossification; c — condition after bringing down the patella and its tendon defect reconstruction

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7. Figure 6. Surgery for patient 3 with bilateral patellar tendon ossification (right knee joint): a — extraarticular part of the ossification (indicated by an arrow) after patellar tendon mobilization by osteotomy of the ossification at its base in the projection of the tibial tuberosity; b — intraarticular part of the ossification (indicated by an arrow), serous effusion from the joint cavity; c — right knee arthrotomy with excision of the capsule fibrotic areas with ossification fragments, joint cavity appearance with signs of chronic inflammation; d — the patella reduction, fixation of the base of intraligamentous ossification part in the bed of the tibial tuberosity after processing the bone-contacting surfaces with chisels, two-screw osteosynthesis

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8. Figure 7. Lateral X-rays of the knee joint before and after surgical treatment: a — before surgery (Caton-Deschamps index — 1.8); b — after surgery (Caton-Deschamps index — 1.1)

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9. Figure 8. Caton-Deschamps index numbers before and after surgery in the case series

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10. Figure 9. Patellar tendon ossification with inclusion of connective tissue and bone tissue at varying levels of morphological maturity: a — photomicrography at a magnification of ×10, ЗСТ — connective tissue zone, ЗФГХ — forming hyaline cartilage zone, ЗЗКТ — mature bone tissue zone, ЗЖСТ — adipose and connective tissue zone; b — photomicrography at a magnification of ×20, КБ — bone beams of mature bone tissue, ООР — focal osteoclastic reaction, ЭО — enchondral ossification, АД — adipocytes, КВСТ — cellular fibrous connective tissue, ФГХ — forming hyaline cartilage. Hematoxylin-eosin staining

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