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Quadriceps Tendon Rupture

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Topic updated on 08/27/13 7:12pm
Introduction
  • Rupture of the quadriceps tendon leading to disruption in the extensor mechanism.
  • Epidemiology
    • incidence
      • quadriceps tendon rupture is more common than patellar tendon rupture
    • demographics
      • usually occurs in patients > 40 years of age
      • males > females (up to 8:1)
      • occurs in nondominant limb more than twice as often
    • location of rupture
      • usually at insertion of tendon to the patella
    • risk factors
      • renal failure
      • diabetes
      • rheumatoid arthritis
      • hyperparathyroidism
      • connective tissue disorders
      • steroid use
      • intraarticular injections (in 20-33%)
  • Pathophysiology
    • mechanism
      • eccentric loading of the knee extensor mechanism
      • often occurs when the foot is planted and knee is slightly bent
      • in younger patients the mechanism is usually direct trauma
Classification
  • Rupture classified as either
    • partial
    • complete
Anatomy
  • Quadriceps tendon
    • has been described as having 2 to 4 distinct layers
      • important when distinguishing between partial and complete tear and when repairing tendon
Presentation
  • History
    • often report a history of pain leading up to rupture consistent with an underlying tendonopathy
  • Symptoms
    • pain
  • Physical exam
    • tenderness at site of rupture
    • palpable defect usually within 2 cm of superior pole of patella
    • unable to extend the knee against resistance
    • unable to perform straight leg raise with complete rupture
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of knee
    • findings
      • will show patella baja
  • MRI
    • indications
      • when there is uncertainty regarding diagnosis
      • helps differentiate between a partial and complete tear
Treatment
  • Nonoperative
    • knee immobilization in brace 
      • indications
        • partial tear with intact knee extensor mechanism
        • patients who cannot tolerate surgery
  • Operative
    • primary repair with reattachment to patella
      • indications
        • complete rupture with loss of extensor mechanism
Techniques
  • Primary repair of acute rupture
    • approach
      • midline incision to knee
    • repair
      • longitudinal drill holes in patella
      • nonabsorbable sutures in tendon in a running locking fashion with ends free to be passed through osseous drill holes  
      • retinaculum is repaired with heavy absorbable sutures
      • ideally the knee should flex to 90 degrees after repair
    • postoperative care
      • initial immobilization in brace, cast, or splint
      • eventual progressive flexibility and strengthening exercises
  • Primary repair of chronic rupture
    • approach
      • midline to knee
    • repair
      • often the tendon retracts proximally
        • ruptures >2 weeks old can retract 5cm
      • repaired with a similar technique to acute ruptures but a tendon lengthening procedure may be necessary
        • Codivilla procedure (V-Y lengthening)
      • auto or allograft tissue may be needed to secure quadriceps tendon to patella
Complications
  • Strength deficit 
    • 33%-50% of patients
  • Stiffness
  • Functional impairment
    • 50% of patients are unable to return to prior level of activity/ sports

 

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