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.     

A method of repair for Achilles tendon ruptures without cast immobilization. Preliminary report

A new technique for the repair of Achilles tendon ruptures has been developed with a Dacron vascular graft used as a tension suture material. The suture is passed through the calcaneal tuberosity and, with two loops applying tension to the tendon at the level of the musculotendinous junction, brings the tendon ends together by creating a solid structure. Post-operative immobilization and its possible adverse sequelae are eliminated by this procedure. The technique was first tested on five dogs with severed Achilles tendons of both hind legs. One side in each animal was repaired with this suture technique; the second leg was left as an untreated control. All the animals recovered from surgery and walked almost normally on the sutured leg within less than three weeks. The dogs did not walk on the unsutured legs. In a second procedure, the control leg was repaired by the same reparative procedure. Equally good results were obtained. The technique was then used on five patients with recent and neglected Achilles tendon ruptures or lacerations. In all instances excellent surgical results were obtained and leg immobilization was virtually eliminated. Physical therapy was begun in the immediate postoperative period. The rehabilitation period was significantly reduced.     

An alternative cruciate reconstruction graft: The central quadriceps tendon

The central quadriceps tendon, above the patella, is thicker and wider than the patella tendon. Using precise technique, one can obtain a tendon graft for cruciate reconstruction with 50% greater mass than a patellar tendon bone-tendonbone graft of similar width. The central quadriceps tendon graft may be harvested by a second surgeon while the first surgeon is simultaneously accomplishing notchplasty and tunnel placement for cruciate ligament reconstruction. Consequently, this cruciate ligament reconstruction graft offers time savings as well as greater tendon volume. The central quadriceps tendon graft is difficult to harvest, with significant risk of entering the suprapatellar pouch and losing knee distension during ACL reconstruction. By careful adherence to the technique described in this article, the surgeon can obtain this reconstruction graft safely. It is important to recognize the anatomic subtleties of the proximal patella, which include a curved proximal surface, dense cortical bone, and closely adherent suprapatellar pouch. Proper technique is of utmost importance in obtaining this tendon graft safely and efficiently.     

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.     

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.     

Editorial Commentary: From Lateral Release and Medial Plication to Complex Medial Patellofemoral Ligament Reconstruction Techniques: Medial Quadriceps Tendon Femoral Ligament Reconstruction Is the Most Anatomic Repair

Patella instability and dislocation are common in younger patients, and 1 in 5 patients are at risk of recurrent dislocations. Conservative treatment should be considered for first dislocations unless other concomitant injuries are present. Historically, lateral patella release and medial plication techniques were used for repair but have been superseded by medial patellofemoral ligament reconstruction. Overconstraint is a potential problem and often related to nonanatomic femoral tunnel position and graft tension, which could result in increased patellar contact pressures and graft failure. The medial quadriceps tendon–femoral ligament reconstruction technique (MQTFL) avoids patellar tunnels without the risk of patella fracture. When comparing medial patellofemoral ligament, MQTFL, and the combination of both techniques in a cadaver model, MQTFL resulted in less constraint with no differences for patellar contact pressures. Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair.     

高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂

目的 探讨陈旧性髌腱断裂的临床特点,介绍采用高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂的手术方法 和术后康复方法 .方法 2002年1月至2007年2月,收治陈旧性髌腱断裂6例,手术切断超长的瘢痕愈合髌腱组织.恢复长度后重新吻合,并在胫骨结节和髌骨两端钻骨孔,采用4根高强度聚酯纤维缝线经骨孔减张保护.术后对患者采用积极的康复锻炼方案:术后第1天即町下地直立行走及被动屈膝90°,休息和睡眠时不须支具石膏固定保护;术后3周起开始练习主动抬腿;术后6周后开始练习快走,负重2 kg直腿抬高;术后12周后开始练习上下楼梯和下蹲;术后6个月后开始正常运动以及蹬跳运动.结果 术后随访1～5年,平均3.2年.患者早期即可以活动并可以下床直立行走,所有患者均未出现再断裂.手术6个月以后,患者均恢复正常的平地行走、跑步能力等,屈膝基本达到对侧的水平,股四头肌力量良好.Lysholm评分均能达到100分.结论 高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂,创伤小,方法 简单,不须外加牵引,不须石膏固定,不须二次手术取内固定.积极的康复训练允许患者早期行走,效果可靠.     

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.     

Patellar tendon rupture repair using Dall-Miles cable

Ten patients underwent patellar tendon repair with end-to-end suture technique and medial and lateral retinacular repair, as well as reinforcement with a Dall-Miles cable through the patella and tibial tubercle. The cable was tensioned at 60 degrees of flexion to allow immediate range of motion to at least 100 degrees of flexion and to protect the repair from undue tension while healing. Accurate tendon length was obtained from a lateral radiograph of the noninvolved knee in 60 degrees of flexion. Patients were allowed to bear full weight as tolerated postoperatively. A knee immobilizer was worn for approximately 2 weeks when adequate muscular control of the leg was attained. The cable was removed 6-8 weeks postoperatively, at which time range of motion equal to the opposite extremity was sought. Full extension was obtained by 1 week postoperatively. Average postoperative knee flexion was 88 degrees at 2 weeks, 112 degrees at 1 month, 133 at 3 months, and 138 degrees at 6 months compared to flexion of 141 degrees in the noninvolved knee. Mean quadriceps muscle strength 1 year postoperatively was 72%+/-11% of the noninvolved leg. No patient had patella infera or rerupture after surgery. Repair of a patellar tendon rupture with end-to-end techniques reinforced with a Dall-Miles cable allows immediate rehabilitation without the need for prolonged immobilization. This technique allows restoration of full range of motion early postoperatively and enables patients to regain adequate quadriceps strength.     

The central quadriceps tendon graftfor cruciate ligament reconstruction

The central quadriceps tendon proximal to the patella provides an alternative source of tendon graft for cruciate ligament reconstruction. Harvesting the graft requires knowledge of the unique anatomic features of the distal quadriceps and specific surgical technique. This graft alternative is particularly important in revision cruciate surgery.     

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.     

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...     

Proximal tibia--extensor mechanism composite allograft for revision TKA with chronic patellar tendon rupture

Rupture of the patellar tendon following TKA is fortunately an uncommon complication with an incidence of 0.2-4% (Abril et al. 1995). Numerous options have been reported for treating this complication, including primary suture into a bone trough (Abril et al. 1995), autogenous tendon transfer (Cadambi and Engh 1992), and use of an artificial ligament (Fujikawa et al. 1994). Allograft patellar tendon has also been utilized either retaining the host patella and using a bone-tendon-bone graft or excising the host patella and using a quadriceps tendon-patella-patellar tendon-tibial tubercle graft (Emerson et al. 1990, Emerson et al. 1994, Zanotti et al. 1995, Booth et al. 1999). All of these techniques require structural integrity of the proximal tibia in the area of the tibial tubercle in order to attach the repair or graft to restore continuity of the extensor mechanism. When there is massive osteolysis and bone loss involving the proximal tibia, the situation becomes more complex and the previously described techniques are not advisable. In such cases, function can be obtained with a composite allograft of proximal tibia-patellar tendon-patella-quadriceps tendon. We describe a technique for dealing with this difficult clinical situation.     

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.     

Proximal tibia--extensor mechanism composite allograft for revision TKA with chronic patellar tendon rupture

Rupture of the patellar tendon following TKA is fortunately an uncommon complication with an incidence of 0.2-4% (Abril et al. 1995). Numerous options have been reported for treating this complication, including primary suture into a bone trough (Abril et al. 1995), autogenous tendon transfer (Cadambi and Engh 1992), and use of an artificial ligament (Fujikawa et al. 1994). Allograft patellar tendon has also been utilized either retaining the host patella and using a bone-tendon-bone graft or excising the host patella and using a quadriceps tendon-patella-patellar tendon-tibial tubercle graft (Emerson et al. 1990, Emerson et al. 1994, Zanotti et al. 1995, Booth et al. 1999). All of these techniques require structural integrity of the proximal tibia in the area of the tibial tubercle in order to attach the repair or graft to restore continuity of the extensor mechanism. When there is massive osteolysis and bone loss involving the proximal tibia, the situation becomes more complex and the previously described techniques are not advisable. In such cases, function can be obtained with a composite allograft of proximal tibia-patellar tendon-patella-quadriceps tendon. We describe a technique for dealing with this difficult clinical situation.     

Proximal tibia--extensor mechanism composite allograft for revision TKA with chronic patellar tendon rupture

Rupture of the patellar tendon following TKA is fortunately an uncommon complication with an incidence of 0.2-4% (Abril et al. 1995). Numerous options have been reported for treating this complication, including primary suture into a bone trough (Abril et al. 1995), autogenous tendon transfer (Cadambi and Engh 1992), and use of an artificial ligament (Fujikawa et al. 1994). Allograft patellar tendon has also been utilized either retaining the host patella and using a bone-tendon-bone graft or excising the host patella and using a quadriceps tendon-patella-patellar tendon-tibial tubercle graft (Emerson et al. 1990, Emerson et al. 1994, Zanotti et al. 1995, Booth et al. 1999). All of these techniques require structural integrity of the proximal tibia in the area of the tibial tubercle in order to attach the repair or graft to restore continuity of the extensor mechanism. When there is massive osteolysis and bone loss involving the proximal tibia, the situation becomes more complex and the previously described techniques are not advisable. In such cases, function can be obtained with a composite allograft of proximal tibia-patellar tendon-patella-quadriceps tendon. We describe a technique for dealing with this difficult clinical situation.     

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.     

Medial Patellofemoral Reconstruction Techniques for Patellar Instability

The medial patellofemoral complex (MPFC) is the term used to describe the primary soft tissue stabilizer of the patella, which consists of fibers that attach to the patella (medial patellofemoral ligament, or MPFL), and the quadriceps tendon (medial quadriceps tendon femoral ligament, or MQTFL). Despite the variability of its attachment on the extensor mechanism, the midpoint of this complex is consistently at the junction of the medial quadriceps tendon with the articular surface of the patella, indicating that either patellar or quadriceps tendon fixation can be used for anatomic reconstruction. Multiple techniques exist to reconstruct the MPFC, including graft fixation on the patella, quadriceps tendon, or both structures. Various techniques using several graft types and fixation devices have all reported good outcomes. Regardless of the location of fixation on the extensor mechanism, elements critical to the success of the procedure include anatomic femoral tunnel placement, avoiding placing undue tension on the graft, and addressing concurrent morphological risk factors when present. This infographic reviews the anatomy and techniques for the reconstruction of the MPFC, including graft configuration, type, and fixation, while addressing common pearls and pitfalls in the surgical treatment of patellar instability.     

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.     

Patellar tendon rupture and marked joint instability after total knee arthroplasty

Background Patellar tendon rupture is a rare complication of total knee arthroplasty (TKA). Multiple repair methods have been described in the literature. Methods A 66-year-old woman suffered a patellar tendon re-rupture and marked joint instability within 6 months after revision TKA. She underwent re-revision TKA and extensor mechanism reconstruction with femoral quadriceps tendon and augmentation by a Leeds-Keio ligament. Result It was fairly difficult to acquire a satisfactory range of motion as well as gain in knee extension capacity by eliminating the extension lag. Conclusion Patellar tendon ruptures after TKA should be repaired as soon as they are recognized.