Rupture of the quadriceps tendon isa relatively infrequent but serious injury requiring prompt diagnosis and treatment.1-4 It is more com-mon in patients older than 40 years and often is
Trang 1Rupture of the quadriceps tendon is
a relatively infrequent but serious
injury requiring prompt diagnosis
and treatment.1-4 It is more
com-mon in patients older than 40 years
and often is associated with
under-lying medical conditions.1 The first
written description of quadriceps
tendon injury is credited to Galen,
who described it in a young
wres-tler.5,6 Even after prolonged
heal-ing, the athlete was unable to
ex-tend his knee and had difficulty
walking on inclined surfaces
Quadriceps tendon rupture may
result from either indirect or direct
mechanisms Clinical findings
typi-cally include the triad of acute pain,
inability to actively extend the knee,
and a suprapatellar gap.7-9 Various
imaging modalities, such as plain
radiographs, ultrasound, and
mag-netic resonance imaging (MRI),
may be used to evaluate quadriceps
tendon injury A spectrum of
path-ology exists that can affect the
quadriceps tendon, including (1)
incomplete rupture, (2) acute
uni-lateral rupture, (3) biuni-lateral rupture,
and (4) tendinosis, or so-called
jumper’s knee
Incomplete or partial quadriceps tendon ruptures and jumper’s knee are usually treated nonsurgically.10
Complete tendon rupture requires surgical repair for optimal results, and several techniques have been described Neglected or chronic ruptures of the quadriceps tendon present a difficult problem and can result in substantial disability for the patient More complex reconstruc-tive procedures may be necessary to repair the extensor mechanism in these cases, and good results have been reported in some series
Anatomy
The quadriceps tendon is a coales-cence of the tendinous portions of the rectus femoris, vastus inter-medius, vastus lateralis, and vastus medialis muscles (the quadriceps)
The muscle fibers from the quadri-ceps blend with its tendinous por-tion approximately 3 cm proximal
to the superior border of the patella
The rectus femoris is the most ante-rior muscle and originates from the anteroinferior iliac spine and hip
capsule, then inserts into the
superi-or bsuperi-order of the patella It continues distally over the anterior surface of the patella, becoming contiguous with the fibers of the patella tendon The rectus femoris is unique among the quadriceps muscles in that it also crosses the hip joint Deep to the rectus femoris is the vastus intermedius, which originates at the anterior midfemur and inserts into the superior border of the patella The vastus lateralis lies anterior and lateral to the vastus intermedius and originates in the femur directly below the greater trochanter and along the linea aspera The vastus lateralis has a long tendinous inser-tion at the superolateral patellar border The vastus medialis origi-nates at the anterior femur just below the level of the lesser tro-chanter, extends inferiorly, and inserts at the superomedial border
of the patella Aponeurotic fibers
Dr Ilan is Chief Resident, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases, New York, NY Dr Tejwani is Assistant Professor, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases Dr Keschner is Chief Resident, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases Dr Leibman is Resident, Department
of Orthopaedic Surgery, NYU–Hospital for Joint Diseases.
Reprint requests: Dr Tejwani, 301 East 17th Street, New York, NY 10003.
Copyright 2003 by the American Academy of Orthopaedic Surgeons.
Abstract
Rupture of the quadriceps tendon is an uncommon yet serious injury requiring
prompt diagnosis and early surgical management It is more common in older
(>40 years) individuals and sometimes is associated with underlying medical
conditions In particular, bilateral spontaneous rupture may be associated with
gout, diabetes, or use of steroids Clinical findings typically include the triad of
acute pain, impaired knee extension, and a suprapatellar gap Imaging studies
are useful in confirming the diagnosis Although incomplete tears may be
man-aged nonsurgically, complete ruptures are best treated with early surgical repair.
J Am Acad Orthop Surg 2003;11:192-200
Doron I Ilan, MD, Nirmal Tejwani, MD, Mitchell Keschner, MD, and Matthew Leibman, MD
Trang 2from both the vastus lateralis and
medialis contribute to the lateral and
medial retinacula, respectively.1,11
The articularis genu muscle, an
anatomic variant, occasionally
con-tributes fibers to the quadriceps
ten-don This muscle arises deep to the
vastus intermedius, originating on
the distal anterior femoral diaphysis
and inserting into the superior
cap-sule.11 The quadriceps is innervated
by the femoral nerve (L2-4)
The four muscles that form the
quadriceps unite into one common
tendon that incorporates the patella
This tendinous insertion is
com-posed of three distinct planes The
superficial, or anterior, plane
con-tains the rectus femoris; the second,
or middle, plane contains the vastus
lateralis and medialis; the third, or
deep, plane contains the vastus
in-termedius Deep to these layers is
the synovium, which, when torn,
accounts for the large hemarthrosis
associated with quadriceps tendon
rupture.1
Biomechanics
The extensor mechanism is
com-posed of the quadriceps tendon,
patella, and patellar tendon During
active knee extension, forces
gen-erated in the quadriceps muscle
group are transferred in a
conver-gent fashion via the patellar tendon
and retinacula to the tibial tubercle
The anterior location of the patella
enables it to act as a fulcrum, which
increases the lever arm of the
quad-riceps (the distance between the
joint center of rotation and the
quadriceps mechanism).11
The transmission of force from
the quadriceps to the patellar tendon
is complex The relative force in
each tendon varies with the degree
of knee flexion and is modulated by
the ability of the patella to tilt in the
sagittal plane Huberti et al12
dem-onstrated increased forces on the
quadriceps tendon in relation to the
patellar tendon at increasing knee flexion angles The force in the quadriceps is 30% less than the force
in the patellar tendon at a knee flex-ion angle of 30°, whereas the forces are equal at 50° of flexion At these flexion angles, the patellofemoral contact area is located at the distal end of the patella, giving the quadri-ceps tendon a mechanical advantage during active knee extension As the knee is flexed beyond 90°, the force
in the quadriceps tendon is 30%
greater than the force in the patellar tendon The patellofemoral contact area shifts proximally with increas-ing knee flexion, givincreas-ing the patellar tendon a mechanical advantage dur-ing active knee extension.12
The quadriceps muscle may con-tract concentrically (as the muscle shortens) or eccentrically (as the muscle lengthens) Markedly higher forces can be generated during an eccentric contraction, which is when most quadriceps muscle and tendon injuries occur.13
Healing Potential of Tendons
Tendons have excellent healing potential when the torn ends are reasonably approximated Tendon healing begins with an
inflammato-ry phase characterized by fibroblast migration Granulation tissue then proliferates around the injury site, resulting in randomly oriented col-lagen fibrils The density of the fibroblasts increases with time, pro-ducing more collagen Optimal ten-don healing depends on surgical apposition and mechanical stabi-lization of the tendon ends Once a tendon has been repaired, the su-ture material holds the tendon ends together, allowing fibroblasts to produce sufficient amounts of colla-gen to form a tendon callus The strength of the repaired tendon depends on the orientation of the collagen fibrils and the overall
colla-gen concentration Over 3 to 6 months, the collagen remodels into
an organized, longitudinal structure that resembles normal tendon.14 In contrast with approximated tears, neglected ruptures with retraction
of the proximal portion of the ten-don heal with scar tissue, resulting
in a lengthened, weakened musculo-tendinous unit Poor muscle func-tion will result without restorafunc-tion
of normal tendon length.15 Studies
of tendon healing have indicated that early controlled motion and tensile stress applied to a repaired tendon promote earlier organization and remodeling of collagen fibers, decreased scar tissue, and increased strength compared with tendon immobilization.14
Etiology and Mechanism
of Injury
The normal, healthy quadriceps ten-don is a remarkably strong structure that is extremely resistant to tearing and can bear high loads without rupture.16 Even when the extensor mechanism is under loads sufficient
to disrupt it, it usually fails at a loca-tion other than the quadriceps ten-don.1 In an early study, McMaster16
determined the tensile strength and points of rupture of the quadriceps tendon in adult rabbits Values also were determined for tendons that had been crushed or partially sev-ered or that had been ligated in an effort to obstruct the blood supply and produce aseptic necrosis Ap-proximately 50% of a tendon’s fibers had to be severed for rupture
to occur, even when subjected to extremely high forces (Under nor-mal physiologic stresses, approxi-mately 75% of the tendon’s fibers must be cut before rupture occurs.) Rupture was possible under lesser loads at the osteotendinous and musculotendinous junctions or through muscle substance.1,16 These data suggest that rupture of the
Trang 3quadriceps tendon requires a
weak-ened tendon The tendons
subject-ed to vascular insult also ruptursubject-ed
at lesser loads, suggesting that
vas-cular disturbance may play a role in
tendon rupture.16
Degenerative changes, such as
fatty and cystic degeneration,
myx-oid degeneration, microangioblastic
dysplasia, decreased collagen, and
calcification, occur within tendons
with age All of these changes alter
the tendon architecture1,5,17,18 and
may weaken it However,
quadri-ceps tendon rupture is rare even in
older populations Thus, other
fac-tors may make the tendon
suscepti-ble to rupture In fact,
approximate-ly one third of patients presenting
with bilateral spontaneous rupture
and 20% of those with unilateral
rupture have a systemic medical
condition that may accelerate
degen-eration of the healthy tendon.2,19
An array of pathologic conditions
can affect the quadriceps tendon and
contribute to its subsequent rupture
by accelerating fatty degeneration or
tendon infiltration or by decreasing
collagen content Renal disease and
uremia can weaken the quadriceps
mechanism by causing muscle fiber
atrophy Patients with chronic renal
failure may develop changes within
the collagen structure itself.20
Dia-betes has been shown to precipitate
vascular changes within the
ten-don.21 Rheumatoid arthritis causes
chronic inflammatory changes
re-sulting in synovitis and diffuse
fibrosis.22 Gout can lead to
topha-ceous synovitis and fibrinoid
necro-sis of the tendon.23 Obesity causes
fatty degenerative changes in the
tendon.7 Hyperparathyroidism,
sys-temic lupus erythematosus,
osteo-malacia, and use of steroids can
cause microscopic damage to the
vascular supply, altering the normal
architecture of the tendon and thus
increasing the susceptibility to
com-plete rupture.22,24-26 These findings
suggest that it is necessary to search
for an underlying medical condition
in any patient presenting with bilat-eral spontaneous rupture of the quadriceps tendon
Most traumatic ruptures of the quadriceps tendon occur during attempts to regain balance to avoid a fall The quadriceps muscle rapidly contracts against the individual’s body weight (eccentric contraction) while the knee is in a semiflexed position, placing the quadriceps tendon under its greatest tensile stress.5,16 Although rare, direct
trau-ma or a penetrating injury can result
in disruption of the quadriceps ten-don
Clinical Presentation
The diagnosis of quadriceps tendon rupture is largely based on a careful history and physical examination
There is usually the diagnostic triad
of pain, inability to actively extend the knee, and a suprapatellar gap.7-9
The pain is often described as an immediate, intense tearing sensation
at the time of rupture Immobili-zation of the extremity in extension results in pain relief On examina-tion, the patient is unable to actively extend the knee and maintain exten-sion against gravity Knee aspiration with an intra-articular anesthetic injection can help relieve the pain and allow the physician to more accurately assess the extensor mech-anism Active knee flexion typically remains intact A suprapatellar gap,
a palpable depression just superior
to the patella, is pathognomonic for quadriceps tendon rupture
Despite these relatively apparent signs and symptoms, the diagnosis
of quadriceps tendon rupture may sometimes initially be missed Diag-nosis may be more difficult when the injury is accompanied by a hemar-throsis, which can mask the presence
of a suprapatellar gap As a result, diagnostic failure rates of 10% to 50%
have been reported, with delays in diagnosis ranging from days to
months.2,6,8,9 When the suprapatellar gap is not readily apparent because
of local fluid accumulation, the sign may be elicited by having the patient actively flex the hip while in the supine position This maneuver causes active shortening of the rectus femoris muscle, which draws the remaining portions of the quadriceps superiorly, thus widening the defect
at the site of rupture.8 Clinical evalu-ation also can be complicated by the presence of an intact patellar retinac-ulum so that the patient retains some ability to actively extend the leg despite complete rupture of the quadriceps tendon However, with
an intact retinaculum, the patient has weak knee extension and consider-able extensor lag Comparison with the opposite leg is essential to deter-mine whether there is a ruptured quadriceps tendon with an intact retinaculum Although a patient with a complete rupture may be able
to ambulate, the examining physi-cian should maintain a high level of suspicion for this injury in anyone presenting with acute onset of pain and inability to actively extend the knee in the presence of a fully func-tional flexor mechanism
Imaging
Several kinds of imaging studies can be useful for evaluation, includ-ing radiography, arthrography, ultrasound, and MRI Anteropos-terior and lateral radiographs should be done initially because they usually reveal several consis-tent findings In one study in 18 patients,9radiographs
demonstrat-ed obliteration of the quadriceps tendon shadow in all 18 knees; a suprapatellar mass in 12; supra-patellar calcific densities in 12; and
an inferiorly displaced patella in 10 Seventeen of 18 knees showed at least three of the previously men-tioned radiographic abnormalities The suprapatellar mass represents
Trang 4retraction of the ruptured tendon,
and the calcific densities may
repre-sent either avulsed fragments of
bone or dystrophic calcifications of
the tendon itself.9,27
Before the advent of MRI,
ar-thrography was used to confirm the
diagnosis of quadriceps tendon
rup-ture Extravasation of radiopaque
material occurred at the site of the
ruptured tendon in patients with
quadriceps tendon rupture
How-ever, arthrography has been
sup-planted by ultrasound and MRI,
both of which are less invasive.27
Ultrasound is a highly sensitive
and specific means of assessment
that delineates the location of the
rupture and helps differentiate
par-tial from complete tears With
com-plete ruptures, free ends of tendon
fibers are separated by a hypoechoic
to anechoic area representing
hema-toma Distraction of the patella
increases the gap in complete tears
but not in partial tears (Fig 1)
Ul-trasound also can be used to assess
the repaired tendon after surgery.27,28
However, its reliability is operator
dependent
MRI (Fig 2) is the most effective
means to visualize the injured
quad-riceps tendon, particularly when
extensive hematoma and edema
obscure the effectiveness of other
studies.27 MRI consistently and
accurately depicts the injury and its
location, making it a useful aid in
surgical planning.29,30 Additionally,
visualization of other pathology
within the knee is possible
How-ever, because of its cost, MRI should
be reserved for cases in which other
diagnostic methods have failed.27,29,30
Management
Incomplete Rupture
Incomplete tears are usually
managed nonsurgically, and
treat-ment should commence immediately
once a complete tear is ruled out
The patient is initially immobilized
with the knee in full extension for 6 weeks, after which protected range-of-motion and strengthening exer-cises may be started The immobi-lizer is progressively discontinued when the patient achieves good quadriceps muscle control and is able to straight-leg raise without discomfort
Traumatic hemarthrosis resulting
in knee effusion is common after quadriceps tendon rupture Jensen and Graf31showed that even small amounts of effusion decrease quad-riceps strength, thus supporting the need for aggressive treatment of knee effusion to promote rehabilita-tion Ice, compression, and anti-inflammatory medication can be used, as well as knee aspiration to evacuate the hemarthrosis Al-though no study has specifically examined the benefit of knee aspira-tion in quadriceps tendon injuries, hematoma aspiration may be of use
in reducing pain and promoting recovery To avoid difficulty once the hematoma has consolidated, aspiration should be done early
Acute Unilateral Rupture
Nonsurgical management of complete quadriceps tendon rup-ture yields poor results, including long-term disability and
weak-Quadriceps tendon Patella
Figure 1 Sagittal ultrasound of a complete tear of the quadriceps tendon without (left) and with (right) manual distraction of the patella Anechoic area (white arrows) repre-sents the rupture site and hematoma Note the increased gap with distraction of the
patel-la This gap would not change in an incomplete tear (Reproduced with permission from Bianchi S, Zwass A, Abdelwahab IF, Banderali A: Diagnosis of tears of the quadriceps
ten-don of the knee: Value of sonography AJR Am J Roentgenol 1994;162:1137-1140.)
Figure 2 Sagittal T1-weighted MRI scan demonstrating complete rupture of the quadriceps tendon (arrow).
Trang 5ness.17,32 Delaying surgery often
complicates the repair process and
ultimately may lead to less
satisfac-tory results Without its distal
ten-dinous insertion intact, the
power-ful quadriceps apparatus begins to
retract in the first few days after
injury Beyond 72 hours, retraction
can make apposition of the torn
ends difficult and can increase the
tension along the suture lines
Al-though delayed repair does not
always lead to poor results, early
intervention is recommended.2,3,33-35
In addition, there is no evidence
that delaying repair (other than for
necessary patient or soft-tissue
fac-tors) is of any benefit
The need for surgical repair of a
complete rupture to achieve optimal
functional results is well
accept-ed.2,5,34 Many methods provide
sat-isfactory results, and no single
tech-nique clearly stands out as the most
efficient and reliable means to
return of function.33 No
random-ized, controlled studies have
direct-ly compared techniques Most
pro-cedures are variations of the general
techniques described below
Surgical Technique
A straight midline or transverse
incision is done to expose the
exten-sor mechanism Irrigation is used to
remove the hematoma and to allow
indentification and assessment of
the tear Full-thickness flaps are
ele-vated medially and laterally to
ac-cess the apex of retinacular tears
Absorbable sutures are placed in the
medial and lateral retinacula but left
untied until tendon repair is
com-plete The edges of the quadriceps
tendon are débrided of grossly
de-generative tissue and freshened for
repair
Midsubstance ruptures can be
treated with an end-to-end primary
repair if sufficient tendon exists
proximally and distally Ruptures
at or near the osteotendinous
junc-tion, the most common site of
in-jury, may be repaired through drill
holes in the patella Two heavy, nonabsorbable sutures are placed in
a locked, running (Krakow or Bunnell) arrangement through the end of the tendon, leaving four loose strands free at the distal stump (Fig 3) The superior pole of the patella is débrided and the anatomic insertion of the quad-riceps tendon is roughened to ob-tain a fresh cancellous bed that will allow tendon-to-bone healing
Three 2-mm drill holes are made parallel to each other and to the lon-gitudinal axis of the patella Using a Keith needle or a Beath pin, the free ends of the sutures are passed through the holes and tied distally with the knee in full extension
Suture anchors have been used in place of drill holes with good re-sult.36 The retinacular sutures are tied, although some surgeons prefer
to leave the lateral retinaculum open
to function as a release The knee is taken through a 0° to 90° range of motion to ensure proper patellar tracking and to observe tension on the repair Augmentation usually is not necessary2,3,6,7,19 but may be done with wire,37 Leeds-Keio liga-ment,38 Dacron vascular graft,39or Mersilene tape40 if the repair ap-pears to be tenuous
The Scuderi technique (Fig 4), or quadriceps flap turndown, is another method to repair acute ruptures of the quadriceps tendon or augment tendon ruptures that appear to be tenuous after surgical repair A partial-thickness triangular flap is fabricated from the anterior surface
of the proximal tendon that is 2
inch-es along the base and 3 inchinch-es along each side The flap is then folded distally over the rupture and su-tured in place.5
Rehabilitation
After repair, the knee is placed into a knee immobilizer for 48 hours, after which the wound is checked and the drains are discon-tinued The knee is then placed into
a locked, hinged brace, and the pa-tient is allowed complete weight bearing with the knee locked in full extension Some authors2,38,39have advocated early range of motion; however, no difference was found between early range of motion and immobilization in one study of 53 ruptures.33 With the knee brace in place, range-of-motion exercises and physical therapy are started after 4 to 6 weeks of immobiliza-tion.6,7,19,34,41 The brace is removed after 12 weeks or when the patient has good quadriceps muscle control and can straight-leg raise Good range of motion should be achieved
by 12 to 16 weeks after repair
Figure 3 Technique for quadriceps tendon
repair via drill holes in the patella Sutures (dotted lines) are passed through three par-allel drill holes and tied distally The cen-tral two suture strands are passed through the same hole and tied to the correspond-ing medial or lateral strand (Adapted with permission from Azar FM, Pickering RM: Traumatic disorders, in Canale ST
[ed]: Campbell’s Operative Orthopaedics, ed
9 St Louis, MO: Mosby, 1998, vol 2, p 1430.)
Trang 6Bilateral Tendon Rupture
Bilateral simultaneous rupture
of the quadriceps tendon is an
uncommon injury pattern Patients
with such injuries often have
chronic diseases and may first be
evaluated by a physician other
than an orthopaedic surgeon
These ruptures are frequently
mis-diagnosed as neurologic paralysis
or an arthritic condition
Pre-liminary workup is recommended
to rule out predisposing factors
such as gout, diabetes, or use of
steroids.6,7,19,30,41 Bilateral ruptures
should be surgically treated in a
manner similar to unilateral
rup-tures Rehabilitation regimens may
have to be adjusted to individual
needs Yilmaz et al42reported a
pa-tient who was not diagnosed with
bilateral rupture until 5 months
after injury and who was treated
surgically with the Scuderi method
The patient underwent immediate
physiotherapy with
range-of-motion exercises Full range of
motion and strong extensor
func-tion were reported at 5-year
follow-up
Chronic Tendon Rupture and Repair
Neglected or chronic rupture of the quadriceps tendon presents a dif-ficult problem in terms of reconstruc-tion Reported results of surgical management are generally less satis-factory than those after treatment of acute tears.5,33,40 When the tendon ends are able to be approximated, repair may be done as described
However, a large defect between the two ends of the tendon may occur, preventing tendon apposition
When the tendon has retracted enough to result in a large gap, the quadriceps muscle must be elevated from the femur and adhesions are released in an attempt to gain length If apposition still is not pos-sible, a Codivilla lengthening proce-dure is recommended (Fig 5) A full-thickness inverted V is devel-oped in the proximal segment of the quadriceps tendon The lower mar-gins of the inverted V should end 1.3 to 2.0 cm proximal to the site of the rupture The tendon ends are apposed and repaired with heavy nonabsorbable suture, and the
trian-gular flap is turned down distally and sutured in place The open up-per portion of the V is then sutured side to side.5
Jumper’s Knee
Tendinitis or tendinosis of the quadriceps or the patellar tendon is known as jumper’s knee, an overuse syndrome that results from repeti-tive overloading of the extensor mechanism It is common in ath-letes who participate in running and jumping sports Inflammation or degeneration occurs at the tendon insertion site, and patients typically complain of anterior knee pain and tenderness at the specific sites of in-flammation The inferior pole of the patella is involved in 65% of these injuries, while the superior pole and the tibial tubercle are involved in 25% and 10%, respectively.43
Blazina et al10developed a three-part classification system for jump-er’s knee Phase I is characterized
by pain after activity but no undue functional impairment Phase II involves pain during and after activity while retaining the ability to perform at a satisfactory level Phase III is characterized by pain during and after activity resulting in functional impairment that inter-feres with performance Radio-graphic signs of jumper’s knee in-clude elongation or fragmentation
of the pole of the patella, periosteal reaction of the anterior patellar sur-face (tooth sign), or calcification of the tendon
Patients who exhibit symptoms
of phases I and II respond well to nonsurgical treatment, such as activity modification, rest, and anti-inflammatory medication Jumping and eccentric exercises are discour-aged Functional, pain-free physio-therapy is done after resolution of symptoms Gradual return to ac-tivity is important to prevent recur-rence Cortisone injections may increase risk of rupture and thus should not be used Patients with
Figure 4 Scuderi technique of quadriceps tendon repair A, Quadriceps tendon tear
exposed B, Direct repair done with heavy nonabsorbable suture Dotted lines represent
inverted V cut (partial thickness) to be made C, Partial-thickness triangular flap (arrow)
reinforcing the repair (Adapted with permission from Scuderi C: Ruptures of the
quadri-ceps tendon: Study of twenty tendon ruptures Am J Surg 1958;95:626-635.)
Trang 7phase III jumper’s knee are treated
the same as those with phase I and
II symptoms, but the rest period is
prolonged Chronic phase III cases
may require surgical débridement.17
Results
In 1958, Scuderi5 reported good to
excellent results in 85% of patients
(11/13) treated with his method of
repair Since then, several
multi-patient, retrospective studies have
evaluated the results of various
methods of surgical repair and
post-operative protocols Siwek and
Rao3 evaluated 36 ruptures and
found that all patients treated
pri-marily had good or excellent results
based on range of motion and
strength, whereas three patients
treated after a 2-week delay had
good results and three treated at 4,
12, and 14 weeks after injury had
unsatisfactory results In another
series,483% of patients (15/18) had good or excellent results, but no cor-relation was made with the time from injury to repair Patellofem-oral congruence was evaluated radio-graphically; 13 of 18 patients had incongruence compared with the contralateral knee This did not cor-relate with range of motion or strength, but all patients with incon-gruence had residual pain
Rougraff et al33reviewed 53 rup-tures in which multiple surgical techniques and postoperative regi-mens were used; no differences were found based on repair tech-nique or postoperative protocol
However, patients with delayed surgery had poorer functional out-comes and decreased satisfaction scores
Using functional surveys and objective testing, Konrath et al2
studied 51 quadriceps tendon rup-tures in 39 patients They reported that 92% were satisfied and that
84% returned to their previous occupations However, 51% were unable to return to the same pre-surgery level of recreational activity There was a 12% strength loss in the quadriceps tendon and 14% in the hamstrings, as well as an 8° loss of range of motion One patient expe-rienced re-rupture, and one had an extensor lag of 10° However, there was no correlation between the length of time from tendon rupture
to surgical repair and final strength, functional score, or activity score.2
This suggests that, whether repair is done immediately or after a delay, surgical treatment can provide reli-able results However, many others have indicated that a delay may adversely affect the results of ten-don repair Patients with quadri-ceps tendon rupture older than 2 weeks may have muscle retraction
of up to 5 cm, which may result in the need for quadriceps lengthen-ing, tendon or muscle transfer, or a combination during surgery.44
Complications
Loss of knee motion is one of the most common complications after quadriceps tendon repair In partic-ular, patients have difficulty regain-ing full knee flexion Another com-plication associated with repair of the quadriceps tendon is extensor weakness, in which the quadriceps muscle undergoes atrophy, leading
to an extensor lag Siwek and Rao3
reported that 75% of their patients who underwent acute repair of rup-tured quadriceps tendons had per-sistent quadriceps atrophy of 2 to 4
cm Despite the marked atrophy, strength was adequate for normal knee function Such extensor lag usually can be corrected with ap-propriate rehabilitation
Other potential, though infre-quent, surgical complications in-clude wound infection and skin dehiscence, which are often related
Figure 5 Codivilla method of quadriceps tendon lengthening and repair A, Chronic
quadriceps tendon tear exposed Proximal retraction prevents direct apposition of the
tear Dotted lines represent inverted V cut (full thickness) to be made B, The inverted V
cut allows the tear to be approximated and repaired C, The proximal aspect of the
invert-ed V repairinvert-ed side to side A full- or partial-thickness flap may be usinvert-ed to augment the
repair, as in the Scuderi technique (Fig 4) (Adapted with permission from Scuderi C:
Ruptures of the quadriceps tendon: Study of twenty tendon ruptures Am J Surg
1958;95:626-635.)
Trang 8to the subcutaneous positioning of
wires and/or the large-caliber
non-absorbable sutures used for surgical
repair Placement of the sutures
directly in line with the incision
should be avoided to prevent
de-layed wound healing.40
Use of a postoperative closed
suc-tion drain is recommended to avoid
hemarthrosis Wire breakage may
occur, necessitating removal because
of skin irritation and wire extrusion
Patella alta or baja or patellar
incon-gruity also can occur, which may lead
to subsequent patellofemoral
degen-eration Therefore, close attention
should be paid intraoperatively to
patellar alignment when repairing the
extensor mechanism Re-rupture of
the repaired tendon may occur,
requiring revision surgery.33
Summary
Rupture of the quadriceps tendon
is an infrequent, disabling injury
that requires prompt diagnosis and surgical repair This injury can be associated with underlying medical conditions and is usually seen in patients older than 40 years
Metabolic disease, obesity, and steroid use may alter the normal architecture of the quadriceps ten-don by causing microscopic dam-age to the vascular supply, thus increasing susceptibility to rupture
However, most traumatic ruptures
of the quadriceps tendon are caused by an indirect, violent, eccentric muscle contraction; direct trauma rarely causes disruption
The hallmark of quadriceps tendon rupture on physical examination is acute onset of pain with an im-paired ability to extend the knee and a palpable suprapatellar gap
Plain radiographs, ultrasound, and MRI are used for diagnosis and evaluation
Nonsurgical management is the accepted course of treatment for incomplete quadriceps tendon
rup-tures and jumper’s knee Surgical repair is recommended to achieve optimal functional results in com-plete tendon ruptures The most common surgical repair involves placing heavy, nonabsorbable su-tures through parallel transosseous tunnels in the patella Chronic quadriceps tendon ruptures may require a lengthening procedure to address the marked retraction of the quadriceps tendon that commonly occurs
Timing of surgical repair for opti-mal outcome is unclear Some stud-ies have shown excellent and good results with immediate repair and unsatisfactory results with delayed surgical repair, while others have shown no correlation between tim-ing of repair and surgical outcomes Based on these conflicting data, quadriceps tendon ruptures should
be treated in a timely manner, thus avoiding possible suboptimal out-comes that could be attributed to surgical delay
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