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 Table of Contents  
CASE REPORTS
Year : 2022  |  Volume : 37  |  Issue : 2  |  Page : 85-88

Neglected quadriceps tendon rupture: A case report


Speciality of Orthopaedics, Apex Trauma Center, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission31-Aug-2022
Date of Acceptance07-Sep-2022
Date of Web Publication19-Oct-2022

Correspondence Address:
Pulak Sharma
Speciality of Orthopedics, Apex Trauma Center, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226029, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_21_22

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  Abstract 

Quadriceps tendon rupture is an unusual injury, mostly occurring in the middle-aged population involved in athletic activities. Patients with such injuries present with a history of trauma, which may be direct or indirect, associated with swelling and inability to actively extend the knee. When associated with minor trauma, the concurrent presence of chronic diseases and the long-term use of certain medications should be looked for. Neglected traumatic quadriceps tendon rupture is very rare. Our patient presented with a neglected quadriceps tendon rupture of the left knee due to injury sustained 6 months. Consent was taken from him to be used as a case report. The patient had full recovery after surgery and physiotherapy. The index case report is important as the patient had delayed presentation in such a rare injury.

Keywords: Quadriceps tendon, transosseous, VY plasty


How to cite this article:
Singh S, Sharma P. Neglected quadriceps tendon rupture: A case report. J Bone Joint Dis 2022;37:85-8

How to cite this URL:
Singh S, Sharma P. Neglected quadriceps tendon rupture: A case report. J Bone Joint Dis [serial online] 2022 [cited 2022 Nov 29];37:85-8. Available from: http://www.jbjd.in/text.asp?2022/37/2/85/358799




  Introduction Top


Quadriceps tendon ruptures (QTRs) are rare injuries (1.37/100,000) that commonly present in the middle-aged and elderly population with a history of chronic illness, such as diabetes, renal failure, gout, rheumatoid arthritis, or hyperparathyroidism.[1],[2] They also result from either direct or indirect trauma and usually have unilateral presentation although bilateral injuries have also been reported.[3] These types of injuries are generally managed by surgical repair as conservative treatment usually leads to poor functional outcome.[4] Delayed repair also carries with itself the challenges of intraoperative tendon retraction and postoperative stiffness. Therefore, the management of neglected ruptures becomes a daunting task for the surgeon.

We report a case of traumatic QTRs, which was missed in the initial management and continued to be treated conservatively for 6 months on lines of multiligament injury of knee.

This case report serves two objectives: to emphasize on the importance of suspecting quadriceps tendon injury in all open wounds around the patella and, second, to share principles of managing neglected QTRs.


  Case Report Top


A 50-year-old man, construction worker, presented to us with an inability to extend his left knee from the last 6 months. He recalled that he sustained a lacerated wound to his left knee due to a fall of heavy object (direct injury) around 6 months back [Figure 1]. The lacerated wound over knee was managed with primary suturing and application of a long leg knee brace. He was kept on the brace for 1 month. After 1 month, when the brace was removed, he was unable to walk and bear weight on the left leg. The treating doctors suspected him to have multiligament injury of the knee and advised him to continue physiotherapy and brace application for another 3 months. He took 2 more months after the doctors’ deadline, hoping for recovery, but once 6 months had passed and he was unable to bear weight over affected limb or walk without support, he presented to our center for further evaluation.
Figure 1: Lacerated wound at the time of injury

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On examination, there was a healed curvilinear scar over the anterior aspect of his left knee. Active knee extension was absent, whereas passive knee extension was comparable to the right side [Figure 2]. Palpable gap felt above the superior pole of the patella.
Figure 2: Absence of active knee extension of the left knee

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Diagnostics

The review of the plain radiographs from the emergency department was negative for fractures or loose bodies. The shadow of the quadriceps tendon appeared retracted from the superior pole of the patella along with some bony flakes attached to it [Figure 3]. Magnetic resonance imaging (MRI) revealed a full-thickness quadriceps tendon tears with retraction [Figure 4].
Figure 3: Retracted shadow of quadriceps tendon along with some bony flakes

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Figure 4: Magnetic resonance imaging showing the full-thickness tears of quadriceps tendon

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Owing to the nature of the injury and the delayed presentation, we had to tackle a number of challenges like addressing retraction of the tendon, deciding on the fixation modality, and customization of the postoperative rehabilitation protocol.

These problems were tackled sequentially. The patient was operated in a supine position under spinal anesthesia. An electric pneumatic tourniquet was applied to the operating extremity. The retracted tendon was approached through a vertical midline incision. The scar tissue debrided [Figure 5] till normal-appearing tissue was encountered. VY plasty of the retracted quadriceps tendon was done to bring the freshened end close to the superior pole of the patella. Krakow sutures were passed through the mobilized quadriceps tendon using 1.8-mm fiber tape. Two transosseous vertical tunnels were made in the patella. The free ends of the fiber tape were retrieved through the tunnels using standard shuttling techniques and were tied on the lower pole of the patella [Figure 6].
Figure 5: Debridement of the scar tissue

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Figure 6: VY plasty and transosseous suture repair

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Postoperative rehabilitation protocol consisted of the application of knee immobilizer for 6 weeks with an initiation of gradual weight bearing after 3 weeks over brace. The range of motion brace given after 6 weeks [Figure 7], 0°–30° initially and henceforth 20°, increased after every 1 week. Knee range of motion started without brace after 12 weeks [Figure 8]. [Figure 9] is depicting clinical outcome following surgery along with range of motion of knee joint.
Figure 7: Eight-week follow-up

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Figure 8: Twelve-week follow-up

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Figure 9: Six-month follow-up

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At 6-month follow-up, the patient had regained knee movements comparable to the other extremity and was able to do independently perform all activities such as driving, climbing stairs, and running.


  Discussion Top


Quadriceps rupture is a rare injury, most commonly occurring in males older than 40 years.[5],[6] QTRs are more common than patellar tendon ruptures, but are more likely to be misdiagnosed.[5],[7]

QTRs are described as either traumatic or idiopathic and can be associated with various systemic diseases. QTRs have also been reported as a complication of various surgical procedures of the knee, for example, after proximal quadriceps release in total knee arthroplasty, lateral retinacular release, meniscectomy, and anterior cruciate ligament reconstruction with a central-third patellar tendon graft.

Tendons are most prone to rupture if tension is applied quickly and obliquely, and the highest forces are seen during eccentric muscle contraction.[8] Hasenoehrl et al. demonstrated that approximately 30 kg/mm2 of longitudinal stress has to be applied to the normal quadriceps tendon prior to failure. Therefore, tendon rupture usually occurs through a pathologic area of the tendon, which explains why many ruptures occur after relatively trivial trauma.[9] MRI is useful in differentiating complete from partial quadriceps tendon tears, but it is expensive and, in Indian setting, less readily available than ultrasound.

Early surgical (primary end to end) repair usually yields the best results for complete QTRs, and delayed surgery has an inverse affect over the functional outcome.[10] All surgical methods can be expected to give comparable results, provided that surgery is undertaken within 1 week of the injury.[6],[10] Most patients with repaired quadriceps tendon can expect a good range of motion and return to their previous occupation. Delaying passive knee flexion up to 6 weeks would prevent the risk of early inadvertent stretching and failure of the repair. This delay is also helpful in minimizing the discomfort and pain.

We are not aware of any study that details the results of quadriceps repair done after 6 months of initial assault. In conclusion, this is a very unusual case of a chronic, full-thickness QTRs in a healthy male with a history of antecedent trauma. It has been generally assumed that healthy tendons do not rupture, which makes this case a unique addition to the literature as it was missed during the primary presentation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Clayton RA, Court-Brown CM The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 2008;39:1338-44.  Back to cited text no. 1
    
2.
Lombardi LJ, Cleri DJ, Epstein E Bilateral spontaneous quadriceps tendon rupture in a patient with renal failure. Orthopedics 1995;18:187-91.  Back to cited text no. 2
    
3.
Neubauer T, Wagner M, Potschka T, Riedl M Bilateral, simultaneous rupture of the quadriceps tendon: A diagnostic pitfall? Report of three cases and meta-analysis of the literature. Knee Surg Sports Traumatol Arthrosc 2007;15:43-53.  Back to cited text no. 3
    
4.
Scuderi C Ruptures of the quadriceps tendon; study of twenty tendon ruptures. Am J Surg 1958;95:626-34.  Back to cited text no. 4
    
5.
Holm C Bilateral traumatic quadriceps tendon rupture. Eur J Orthop Surg Traumatol 1999;9:31-3.  Back to cited text no. 5
    
6.
Siwek CW, Rao JP Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am 1981;63:932-7.  Back to cited text no. 6
    
7.
Khan KM, Cook JL, Maffulli N Patellar tendinopathy and patellar tendon rupture. In: Maffulli N, Leadbetter W, Renstrom P, editors. Tendon Injuries: Basic Sciences and Clinical Medicine. London: Springer; 2005. p. 166-77.  Back to cited text no. 7
    
8.
Fyfe I, Stanish WD The use of eccentric training and stretching in the treatment and prevention of tendon injuries. Clin Sports Med 1992;11:601-24.  Back to cited text no. 8
    
9.
Plesser S, Keilani M, Vekszler G, Hasenoehrl T, Palma S, Reschl M, et al. Clinical outcomes after treatment of quadriceps tendon ruptures show equal results independent of suture anchor or transosseous repair technique used—A pilot study. Plos One 2018;13:e0194376.  Back to cited text no. 9
    
10.
Rougraff BT, Reeck CC, Essenmacher J Complete quadriceps tendon ruptures. Orthopedics 1996;19:509-14.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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