In acute tears of the substance of the tendon, direct repair should be reinforced with a cerclage wire passing through a patellar osseous tunnel, the distal part of the quadriceps tendon and an osseous tunnel at the level of the tibial tuberosity. When the rupture is located in the osteotendineous junction, the tendon must be re-attached to the bone by means of sutures going from the tendon to the bone via transosseous tunnels. An alternative to the aforementioned bone tunnels is the use of anchors. They provide a solid re-attachment and allow an earlier and more aggressive rehabilitation programme (similar to that employed for treatment of ruptures of the quadriceps tendon) [16]. In acute ruptures, El-Desouky et al. described a technique of primary repair of the patella tendon augmented by a semitendinosus autograft, which was strong enough to permit early motion and weight-bearing with achievement of good and excellent results [17].

After a primary suture the knee must be initially immobilised in extension. In our practice, the sutures are removed at 2 weeks and at that point an orthosis is provided allowing isometric exercises. Active flexion exercises are prohibited for 4 weeks after surgery. Until the sixth postoperative week, active flexion of the knee must be maintained in a range of 0°–90°. Then, a greater range of knee flexion will be allowed. The aim will be getting a full range of knee motion at 8–10 weeks after the procedure. Finally, the patient will perform isokinetic closed-chain exercises to strengthen the quadriceps muscle and then exercises of eccentric contraction to recover the preinjury level.

In chronic ruptures, a direct repair is usually insufficient [18]. A number of reconstructive procedures have been described using autograft, allograft or synthetic grafts for reinforcement of the primary repair. The Kelikian procedure uses semitendinous tendon, which is sectioned proximally to preserve its distal attachment. Two tunnels are made, one proximally at the level of the lower pole of the patella, and the other one distally at the level of the anterior tibial tuberosity. This way, a square can be formed with the semitendinous tendon that will finally be attached on its own in its distal attachment [15]. Jain et al. modified this procedure by performing a percutaneous reconstruction of the patellar tendon using semitendinosus tendon, reporting excellent results. Picrusting of quadriceps along with lateral release may be required to pull the patella down [19]. Maffulli et al. report results of an open hamstring reconstruction technique at over 5 years’ mean follow-up [20]. They found that hamstring tendon reconstruction of chronic patellar tendon rupture provided good functional recovery and return to preinjury daily activities. Sundararajan et al. modified this technique by using both gracillis and semitendonosus tendons, detached from their tibial insertions and threaded through bone tunnels in a figure of eight, reporting excellent results [21].

Alternatives to hamstrings reconstruction include other autografts such as vastus lateralis, allograft, xenograft or artificial grafts. However, the evidence base for each are limited. A recent systematic review of the literature suggested that for chronic ruptures, autograft-augmented repair was the treatment of choice [18].

In contrast to acute ruptures, rehabilitation programme must be more conservative, maintaining the knee immobilised until 6 weeks, going then to the protocol previously outlined for acute ruptures.