Simultaneous bilateral patellar tendon rupture without predisposing systemic disease or steroid use: a case report

There is a dearth of case reports describing simultaneous bilateral patellar tendon ruptures in the medical literature.These ruptures are often associated with systemic disorders such as lupus erythema...     

Tendon rupture of the extensor muscles of the knee

Five cases of rupture of the quadriceps tendon and two cases of rupture of the patellar ligament form the authors' own patient material (1975-1984) are reviewed. It seems we must differentiate between rupture of the quadriceps tendon (namely, rupture in an elderly patient with degeneratively changed tendon in trivial traumas) on the one hand, and rupture of the patellar ligament (rupture in the young patient with considerable trauma, as in sports) and hence a more or less purely traumatically caused rupture, on the other. Except for one case of spontaneous rupture associated with cortison treatment for several years, the four remaining quadriceps tendon ruptures were based on the same accident mechanism, the average age of these patients being 65 years: on trying to stabilize themselves while stumbling, the quadriceps muscle was suddenly tensed. In both cases of rupture of the patellar tendon, rupture occurred while jumping off a springboard during sports activities. The authors advocate protecting the tendon suture in quadriceps tendon rupture via a walking cast of the femur; in rupture of the patellar ligament, it is recommended to effect wire cerclage between patella and tuberositas tibiae. In each case, functional exercise should be initiated as early as possible.     

Ruptures of the extensor mechanism of the knee joint. Clinical results and patellofemoral articulation

The functional results of 28 cases of rupture of the quadriceps and patellar tendons are reported. Excellent or good results were noted in 15 of 18 quadriceps and 7 of 10 patellar tendons. Radiographic comparison with the opposite knee disclosed incongruences between the patella and the femoral groove in the tangential view and/or cranial-caudal position of the patella in the lateral view in 13 of the quadriceps tendon ruptures and seven of the patellar tendon ruptures. Patients with residual pain had patellofemoral incongruity but since two-thirds of the patients with incongruity were asymptomatic, incongruity alone may not be the cause of the symptoms. There was no positive correlation to muscular strength or range of movement. Nevertheless, exact adaptation of the patellar tendon and periarticular tissue seems necessary to obtain correct patello-femoral articulation. Reinforcement of the tendon with a wire cerclage is recommended to decrease the tension on the suture line and the consequent risk of a secondary rupture. In acute ruptures of the quadriceps tendon end-to-end sutures are sufficient.     

A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report

The quadriceps tendon and patellar tendon (ligament) were repaired with a Dacron vascular graft used as a tension suture material. In cases of quadriceps tendon ruptures, the Dacron graft is passed transversely through the patellar ligament just below the patella and crossed transversely at the level of the musculotendinous junction with two loops applying tension to the tendon, which brings the tendon ends together by creating a solid structure. In cases of patellar ligament ruptures, the Dacron graft is passed through a hole in the tibia posteriorly to the tibial tuberosity instead of through the patellar ligament below the patella. This technique enables early mobilization on the first day after surgery. The technique was first tested on six dogs with severed quadriceps tendons and patellar ligaments that were repaired with this suture method. All of the animals recovered from surgery and walked and ran normally on the repaired legs within 27 days and with only mild limping after 17 days. The technique was then used on six patients, four with complete quadriceps tendon rupture and two with complete tear (avulsion) of the patellar ligament (tendon). In all of the patients, excellent surgical results were obtained and leg immobilization was virtually eliminated. Physical therapy was prescribed the first day after surgery. The rehabilitation period was significantly reduced.     

Quadriceps and patellar tendon ruptures

Ruptures of the quadriceps as well as the patellar tendon occur in low frequency, but cause major functional deficits of the leg. These injuries usually require operative treatment. Acute quadriceps tendon ruptures are treated by suture repair, using heavy sutures guided through bone tunnels in the patella. Chronic defects and neglected cases require a local tendon transfer, either by a quadriceps tendon turn-down or by a V-Y-plasty of the quadriceps tendon. Ruptures of the patellar tendon are treated by suture of the tendon stumps plus an reinforcement procedure protecting the tendon and avoiding secondary patella alta. Patello-tibial fixation may be achieved by a cerclage technique using wire or an autologous tendon strip, alternatively a patello-tibial external fixator can be applied. In chronic and neglected cases, patellar tendon reconstruction is performed with autologous tendon grafts or with soft tissue allografts. The graft must be protected by a patello-tibial fixation for the first weeks.     

Chronic rupture of a patellar tendon: A technique for reconstruction with achilles allograft

Chronic ruptures of the patellar tendon fortunately are an uncommon event. These ruptures are often difficult to repair because they are generally accompanied by quadriceps muscle contracture and a great deal of scar tissue formation. We report the case of a repair of a chronic patellar tendon rupture. The patient's right patellar tendon was reconstructed approximately 10 months after the injury using quadricepsplasty and an Achilles tendon allograft with a suprapatellar wire for tension release. Four weeks postoperatively, he had attained 60° of flexion and full active extension. At 8 weeks, the suprapatellar wire was removed allowing the distribution of stresses on the reconstructed patellar tendon. At 6 months, the patient had 130° of flexion and full extension, but showed a persistent 40% deficit in right quad strength. The technique accomplished the preoperative goals of restoring quadriceps function, restoring the anatomic position of the patella, and allowing early mobilization after surgery. Although the use of a suprapatellar wire to reduce tension on the reconstructed tendon required a second operation for removal, it allowed early mobilization and better healing of the repair.     

Neglected patellar tendon rupture: preserve the fat pad

Management of neglected patellar tendon ruptures remains a difficult therapeutic endeavor, as complications such as adhesions, proximal patellar migration, and quadriceps contracture occur. Treatment goals include restoration of extensor mechanism, both structurally and functionally, which allows active knee extension. Few cases of neglected patellar tendon rupture have been reported in the literature, however, all have used preoperative or additional intraoperative procedures to relocate the patella or to provide additional support to the reconstructed tendon. This article presents a case of a 25-year-old man whose diagnosis of patellar tendon rupture was delayed by 1 year. The patella was mobile and could be brought down to its original position manually. The patellar tendon was successfully reconstructed with autogenous semitendinosus and gracilis tendon graft. No preoperative or intraoperative traction was used on the patella. Quadriceps lengthening was not performed and no hardware was used between the patella and the tibia to augment the reconstruction. Scar tissue was not excised and was used to cover the hamstring tendons. The patient achieved a good functional result after 5 months of rehabilitation. At 14-month follow-up, the patient had returned to his pre-injury level of work with no deterioration of knee function.     

Simultaneous bilateral spontaneous rupture of the quadriceps tendons compared with unilateral traumatic rupture

A rare case of simultaneous, bilateral and spontaneous rupture of the quadriceps tendons is described in a 59-year-old man without systemic disease or traumatic lesions. For comparison, we report the case of a young woman with complete traumatic, unilateral rupture of the quadriceps tendon. The more or less normal degenerative changes of the ligament structure were considered to be the additional etiological reasons for both ruptures. A review of the literature is given.     

Extensor mechanism complications following total knee arthroplasty

Extensor mechanism complications following 281 knee arthroplasties that included patellar resurfacing, performed by two surgeons in one hospital over a 6-year period, were reviewed. The mean follow-up period was 42 months. There were 28 (10%) extensor mechanism complications: 3 quadriceps tendon ruptures, 5 patellar fractures, 4 patellar tendon ruptures, 11 recurring patellar subluxations, 4 cases of patellar pain, and 1 malrotated patella. Nine (3%) required further surgery. Surgical technique may have contributed to the tendon ruptures; patellar fractures occurred mainly in patients who had rheumatoid arthritis. Patients with patellar subluxation had abnormal preoperative valgus deformities of their knees and presented with this subluxation problem an average of 4 months after surgery, but it appeared to cause them less discomfort with time. Patellar resurfacing as part of a knee arthroplasty procedure is recommended but should be performed with care to the integrity and vasculature of the extensor mechanism.     

Quadriceps tendon rupture through a superolateral bipartite patella

We report a case of a quadriceps tendon rupture through a bipartite patella. Although quadriceps tendon ruptures and patella fractures are common, rupture through a bipartite patella fragment is rare. This case was managed similar to a quadriceps rupture with an excellent result.     

Patellar and quadriceps tendon ruptures

Ten cases of rupture of quadriceps tendon and seven cases of rupture of the patellar ligament were studied. All patients were reexamined. One must differentiate between rupture of the quadriceps tendon (tendon ruptures in elderly patients with degeneratively changed tendon in trivial trauma) and rupture of the patellar tendon (tendon rupture in younger patients with considerable trauma). All the patients were discussed with regard to accident mechanism, histology, underlying systemic and local diseases, therapy and results. There were good results in all patients with rupture of the patella tendon. In seven of the ten patients with quadriceps tendon rupture, we noted also good results. Three patients had residual pain and restricted motion and function of the knee. In two of these cases, diagnosis and reconstruction was delayed for months, the other patient had an infection of an implanted knee endoprosthesis in the injured knee.     

Chronic patellar tendon rupture: surgical reconstruction technique using 2 Achilles tendon allografts

Delayed reconstruction of chronic patellar tendon ruptures classically has yielded suboptimal results. Quadriceps contracture, distal patella mobilization, quadriceps lengthening (eg, V-Y lengthening), prolonged postoperative immobilization, residual quadriceps weakness, surgical macro failure, and loss of knee flexion are some of the complications associated with treatment for chronic patellar tendon rupture. Reinforcement hardware (eg, cerclage wire) may necessitate subsequent removal and the possibility of breaking with migration through the body. This article details the use and short-term success of a surgical technique using 2 Achilles tendon allografts for reconstruction of a chronic patellar tendon rupture.     

Intra-operative patellar fracture during chronic patellar tendon rupture reconstruction: salvage and prophylactic modified techniques

Management of chronic neglected patellar tendon rupture represents a challenging condition for the orthopedic surgeons to deal with due to many factors such as quadriceps muscle atrophy, superior migration of the patella, e.g., patella alta, peri-patellar adhesions and patellar tendon atrophy. Such difficulties might be further complicated by intra-operative patellar fracture during patellar tendon reconstruction. In the current article, the authors report (1) a salvage procedure for such devastating intra-operative complication, based on bypassing the patella and gaining the advantage of the quadriceps tendon for structural and functional restoration of the knee extensor mechanism, and (2) prophylactically a technical modification of patellar tendon reconstruction guarding against such inadvertent patellar fracture.

     

Spontaneous ruptures of the extensor system of the knee following joint replacement in patients with rheumatoid arthritis

Spontaneous ruptures of the quadriceps tendon and the patellar ligament following total knee arthroplasty in two patients with rheumatoid arthritis are reported. Degenerative and steroid-induced changes of tendinous tissue, circulation problems as well as mechanical changes to the patellofemoral joint by resurfacing the patella are discussed being possible causes of these complications of the extensor mechanism of the knee.     

Partielle Quadrizepssehnenruptur bei einem sechsjährigen Jungen

In children, avulsion fractures of the patella are observed more frequently than ruptures of the quadriceps tendon. In cases of suspected lesions of the quadriceps tendon, conventional x-ray imaging and ultrasound comparison of both patellae is recommended. Arthroscopy is helpful for diagnosing concomitant intra-articular knee lesions and permits evacuation of the hemarthrosis.     

Adult native knee extensor mechanism ruptures

Extensor mechanism rupture is a serious event requiring prompt diagnosis and treatment. Patella fractures are reportedly six times more frequent than soft tissue injuries such as quadriceps or patella tendon ruptures. Classically quadriceps and patella tendon ruptures are seen more in males, with those over 40 predominantly suffering from quadriceps tendon ruptures, often associated with an underlying condition, whereas patella tendon ruptures are mostly associated with sport injuries and are commonly seen in the under 40s. Almost all types of extensor mechanism ruptures benefit from early management which typically involves surgery.Diagnosis can be deemed easy to make by demonstrating inability to actively extend the knee, this however can be easily overlooked and missed in a busy emergency department leading to a late diagnosis and necessitating more complex surgery. Earlier surgical intervention and rehabilitation tend to produce improved outcomes.     

Rupture of the quadriceps tendon: an association with a patellar spur

We reviewed the records of 107 consecutive patients who had undergone surgery for disruption of the knee extensor mechanism to test whether an association existed between rupture of the quadriceps tendon and the presence of a patellar spur. The available standard pre-operative lateral radiographs were examined to see if a patellar spur was an indicator for rupture of the quadriceps tendon in this group of patients. Of the 107 patients, 12 underwent repair of a ruptured patellar tendon, 59 had an open reduction and internal fixation of a patellar fracture and 36 repair of a ruptured quadriceps tendon. In the 88 available lateral radiographs, patellar spurs were present significantly more commonly (p < 0.0005) in patients operated on for rupture of the quadriceps tendon (79%) than in patients with rupture of the patellar tendon (27%) or fracture of the patella (15%). In patients presenting with failure of the extensor mechanism of the knee in the presence of a patellar spur, rupture of the quadriceps tendon should be considered as a possible diagnosis.     

Neglected spontaneous bilateral rupture of the patellar tendon: a case report

A patient taking corticosteroids for rheumatoid arthritis experienced a spontaneous bilateral rupture of the patellar tendon. Initially neglected, the rupture was repaired surgically by tendinoplasty using the semitendinous tendon for the right knee and inversion of the quadriceps tendon for the left. Functional results were similar. On the right knee, the wire cerclage loosened leading to posterior sagittal displacement of the patella, pointing out the difficulties encountered when repairing neglected rupture of the patellar tendon. Due to the small number of cases and difficulties in assessing the techniques proposed, no large-scale series has been reported in the literature.     

Quadrizeps- und Patellasehnenrupturen

Ruptures of the quadriceps or patellar tendon are uncommon but extremely relevant injuries. Early diagnosis and surgical treatment with a stable suture construction are mandatory for a good postoperative clinical outcome. The standard methods of repair for quadriceps and patellar tendon injuries include the placement of suture loops through transpatellar tunnels. Reinforcement with either a wire cerclage or a PDS cord is used in patellar tendon repair. The PDS cord can also be applied as augmentation in quadriceps tendon repair. In secondary patellar tendon repair an autologous semitendinosus graft can be used. For chronic quadriceps tendon defects a V-shaped tendon flap with a distal footing is recommended. The different methods of repair should lead to early functional postoperative treatment. The clinical outcome after surgical treatment of patellar and quadriceps tendon ruptures is mainly good.     

Eine vereinfachte Methode zur Therapie der Quadrizepssehnenruptur mittels transpatellarer PDS-Kordel

Quadriceps tendon ruptures are relatively unusual injuries caused by direct or more frequently indirect trauma. Since complete ruptures lead to loss of active extension of the knee joint, operative treatment is usually indicated. Several techniques are described in the literature. However, relatively little is known about the functional outcome after operative treatment of acute quadriceps tendon ruptures. We present a new operative technique using a 1.3-mm PDS cord passed through a transverse drill hole in the proximal pole of the patella. We operated ten consecutive cases of complete quadriceps tendon ruptures with the technique described between January 2000 and June 2003. Eight of ten patients were evaluated after a mean follow-up time of 38 months by physical examination, IKDC Subjective score, Lysholm and Tegner score as well as an isokinetic test of the quadriceps strength. No complications were noted in this period. The average postoperative scores were 87 (IKDC), 98 (Lysholm), and 4.5 (Tegner). Isokinetic testing showed an average of 25% quadriceps strength deficit. The operative treatment of complete quadriceps tendon ruptures using a PDS cord through a drill hole in the patella is a safe and effective technique permitting functional postoperative treatment.