case_images: PMC7210899_01
case_images: Pre-operative posteroanterior (a) and lateral (b) radiographs showing patella alta before repair of a proximal medial, distal-lateral Z-type patellar tendon rupture after bonepatellar tendon-bone autograft harvest for anterior cruciate ligament reconstruction.
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case_images: F1
case_images: PT rupture 2 years after a BPTB ACL reconstruction due to a fall from her bicycle. Physical exam showed a large effusion, palpable defect inferior to the patella, patella Alta on clinical exam and lateral X-ray, and no active extension of the leg (Fig. 1).
case_images: (a and b) Pre-operative magnetic resonance imaging showing significant patellar tendon remnant on the tibia medially and
  a larger remnant on the patella laterally.
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case_images: F2
case_images: Magnetic resonance imaging was obtained and revealed disruption of the PT (Fig. 2).
case_images: Intraoperative view: (a) Proximal medial remnant of the patellar tendon attached to the tibia (b) distal-lateral remnant of the patellar tendon attached to the patella.
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case_images: F3
case_images: On examination, the PT was found to have ruptured medially off of the patella and laterally off of the tibial tubercle in an angulated fashion, as previously described (Fig. 3).
case_images: a) The proximal-medial and distal-lateral patellar tendon remnants prepared with Krackow stitch using Suture Tape, with the proximal medial remnant accommodating two Krackow flat braided sutures, and the distal-lateral remnant accommodating one Krackow flat braided suture. (b) The four suture limbs on the medial aspect of the tibialbased patellar tendon remnant were passed through a knotless suture anchor that was preloaded with Fiber Tape.
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case_images: F4
case_images: Of note, the angulated nature of the rupture presented with a larger medial segment as compared to the lateral-patella based segment and was able to accommodate two SutureTape limbs along its width while laterally only one Krackow suture was possible (Fig. 4).
case_images: Intraoperative view: In preparation for repair, the proximal medial patellar tendon remnant was retracted, and the inferior pole of the patella was prepared with a bleeding bone bed for healing.
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case_images: F5
case_images: A bleeding bone bed was then created on the medial aspect of the patella to improve healing and reattachment of the tendon to the patella (Fig. 5).
case_images: Intraoperative view: (a) Showing two anchors in the patella proximally, two anchors in the tibia distally, and Fiber Tape limbs from the proximal medial and lateral aspects of the patella to the distal suture anchors laterally and medially on the tibia, respectively. (b) Care was taken not to over constrain the tendon after repair, with preservation of some laxity through the final Internal Brace construct.
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case_images: F6
case_images: Tape and Tiger Tape and both limbs of the Suture Tape from the lateral patella-based tendon were then passed through the third anchor and secured at the lateral insertion of the tendon on the tibial tubercle. The remaining limbs of the Fiber Tape and Tiger Tape from the medial patella were passed through the final anchor and secured at the medial aspect of the tibial tubercle (Fig. 6).
case_images: Intraoperative view showing repair of the paratenon, juxtaposed to the bursal tissue on its anterior and posterior surfaces over the patellar tendon reconstruction to potentiate regeneration of the tendon tissue within the defect.
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case_images: F7
case_images: The paratenon was then repaired in a running fashion with absorbable suture (Fig. 7).