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J Knee Surg 2013; 26(05): 301-308
DOI: 10.1055/s-0033-1353989
Special Focus Section
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Quadriceps and Patellar Tendon Ruptures

Dennis Lee
1   Division of Orthopedic Trauma, Department of Orthopedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
,
Daniel Stinner
1   Division of Orthopedic Trauma, Department of Orthopedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
,
Hassan Mir
1   Division of Orthopedic Trauma, Department of Orthopedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
› Author Affiliations
Further Information

Publication History

01 July 2013

08 July 2013

Publication Date:
16 August 2013 (online)

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Abstract

The diagnosis of quadriceps and patellar tendon ruptures requires a high index of suspicion and thorough history-taking to assess for medical comorbidities that may predispose patients to tendon degeneration. Radiographic assessment with plain films supplemented by ultrasound and magnetic resonance imaging when the work-up is equivocal further aids diagnosis; however, advanced imaging is often unnecessary in patients with functional extensor mechanism deficits. Acute repair is preferred, and transpatellar bone tunnels serve as the primary form of fixation when the tendon rupture occurs at the patellar insertion, with or without augmentation depending on surgeon preference. Chronic tears and disruptions following total knee arthroplasty are special cases requiring reconstructions with allograft, synthetic mesh, or autograft. Rehabilitation protocols generally allow immediate weight-bearing with the knee locked in extension and crutch support. Limited arc motion is started early with active flexion and passive extension and then advanced progressively, followed by full active range of motion and strengthening. Complications are few but include quadriceps atrophy, knee stiffness, and rerupture. Outcomes are excellent if repair is done acutely, with poorer outcomes associated with delayed repair.

Keywords

extensor mechanism - tendon rupture - quadriceps tendon - patellar tendon
 

  • References

  • 1 Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 2008; 39 (12) 1338-1344
    CrossrefPubMedGoogle Scholar
  • 2 Ramsey RH, Muller GE. Quadriceps tendon rupture: a diagnostic trap. Clin Orthop Relat Res 1970; 70: 161-164
    PubMedGoogle Scholar
  • 3 Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am 1991; 73 (10) 1507-1525
    PubMedGoogle Scholar
  • 4 Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am 1981; 63 (6) 932-937
    PubMedGoogle Scholar
  • 5 O'Shea K, Kenny P, Donovan J, Condon F, McElwain JP. Outcomes following quadriceps tendon ruptures. Injury 2002; 33 (3) 257-260
    CrossrefPubMedGoogle Scholar
  • 6 Loehr J, Welsh RP. Spontaneous rupture of the quadriceps tendon and patellar ligament during treatment for chronic renal failure. Can Med Assoc J 1983; 129 (3) 254-256
    PubMedGoogle Scholar
  • 7 Lombardi LJ, Cleri DJ, Epstein E. Bilateral spontaneous quadriceps tendon rupture in a patient with renal failure. Orthopedics 1995; 18 (2) 187-191
    PubMedGoogle Scholar
  • 8 Ramseier LE, Werner CM, Heinzelmann M. Quadriceps and patellar tendon rupture. Injury 2006; 37 (6) 516-519
    CrossrefPubMedGoogle Scholar
  • 9 Stinner DJ, Orr JD, Hsu JR. Fluoroquinolone-associated bilateral patellar tendon rupture: a case report and review of the literature. Mil Med 2010; 175 (6) 457-459
    PubMedGoogle Scholar
  • 10 Ribbans WJ, Angus PD. Simultaneous bilateral rupture of the quadriceps tendon. Br J Clin Pract 1989; 43 (3) 122-125
    PubMedGoogle Scholar
  • 11 Kelly DW, Carter VS, Jobe FW, Kerlan RK. Patellar and quadriceps tendon ruptures—jumper's knee. Am J Sports Med 1984; 12 (5) 375-380
    CrossrefPubMedGoogle Scholar
  • 12 Boublik M, Schlegel T, Koonce R, Genuario J, Lind C, Hamming D. Patellar tendon ruptures in National Football League players. Am J Sports Med 2011; 39 (11) 2436-2440
    CrossrefPubMedGoogle Scholar
  • 13 el-Khoury GY, Wira RL, Berbaum KS, Pope Jr TL, Monu JU. MR imaging of patellar tendinitis. Radiology 1992; 184 (3) 849-854
    PubMedGoogle Scholar
  • 14 Shah M, Jooma N. Simultaneous bilateral quadriceps tendon rupture while playing basketball. Br J Sports Med 2002; 36 (2) 152-153 , discussion 153
    CrossrefPubMedGoogle Scholar
  • 15 Ismail AM, Balakrishnan R, Rajakumar MK, Lumpur K. Rupture of patellar ligament after steroid infiltration. Report of a case. J Bone Joint Surg Br 1969; 51 (3) 503-505
    PubMedGoogle Scholar
  • 16 Benner RW, Shelbourne KD, Urch SE, Lazarus D. Tear patterns, surgical repair, and clinical outcomes of patellar tendon ruptures after anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft. Am J Sports Med 2012; 40 (8) 1834-1841
    CrossrefPubMedGoogle Scholar
  • 17 Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism complications following total knee arthroplasty. J Arthroplasty 1987; 2 (2) 135-140
    CrossrefPubMedGoogle Scholar
  • 18 Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture after total knee arthroplasty. Prevalence, complications, and outcomes. J Bone Joint Surg Am 2005; 87 (1) 37-45
    CrossrefPubMedGoogle Scholar
  • 19 Parker DA, Dunbar MJ, Rorabeck CH. Extensor mechanism failure associated with total knee arthroplasty: prevention and management. J Am Acad Orthop Surg 2003; 11 (4) 238-247
    PubMedGoogle Scholar
  • 20 Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg 2003; 11 (3) 192-200
    PubMedGoogle Scholar
  • 21 Rauh M, Parker R. Patellar and quadriceps tendinopathies and ruptures. In: DeLee JC, , ed. DeLee and Drez's Orthopaedic Sports Medicine. Philadelphia, PA: Saunders; 2009: 1513-1577
    Google Scholar
  • 22 Matava MJ. Patellar Tendon Ruptures. J Am Acad Orthop Surg 1996; 4 (6) 287-296
    PubMedGoogle Scholar
  • 23 Arnoczky SP. Blood supply to the anterior cruciate ligament and supporting structures. Orthop Clin North Am 1985; 16 (1) 15-28
    CrossrefPubMedGoogle Scholar
  • 24 Huberti HH, Hayes WC, Stone JL, Shybut GT. Force ratios in the quadriceps tendon and ligamentum patellae. J Orthop Res 1984; 2 (1) 49-54
    CrossrefPubMedGoogle Scholar
  • 25 Garrett Jr WE. Injuries to the muscle-tendon unit. Instr Course Lect 1988; 37: 275-282
    PubMedGoogle Scholar
  • 26 Zernicke RF, Garhammer J, Jobe FW. Human patellar-tendon rupture. J Bone Joint Surg Am 1977; 59 (2) 179-183
    PubMedGoogle Scholar
  • 27 Blazina ME, Kerlan RK, Jobe FW, Carter VS, Carlson GJ. Jumper's knee. Orthop Clin North Am 1973; 4 (3) 665-678
    PubMedGoogle Scholar
  • 28 Evans EJ, Benjamin M, Pemberton DJ. Variations in the amount of calcified tissue at the attachments of the quadriceps tendon and patellar ligament in man. J Anat 1991; 174: 145-151
    PubMedGoogle Scholar
  • 29 Insall J, Salvati E. Patella position in the normal knee joint. Radiology 1971; 101 (1) 101-104
    CrossrefPubMedGoogle Scholar
  • 30 Yu JS, Petersilge C, Sartoris DJ, Pathria MN, Resnick D. MR imaging of injuries of the extensor mechanism of the knee. Radiographics 1994; 14 (3) 541-551
    PubMedGoogle Scholar
  • 31 Zeiss J, Saddemi SR, Ebraheim NA. MR imaging of the quadriceps tendon: normal layered configuration and its importance in cases of tendon rupture. AJR Am J Roentgenol 1992; 159 (5) 1031-1034
    CrossrefPubMedGoogle Scholar
  • 32 Spector ED, DiMarcangelo MT, Jacoby JH. The radiologic diagnosis of quadriceps tendon rupture. N J Med 1995; 92 (9) 590-592
    PubMedGoogle Scholar
  • 33 Konrath GA, Chen D, Lock T , et al. Outcomes following repair of quadriceps tendon ruptures. J Orthop Trauma 1998; 12 (4) 273-279
    CrossrefPubMedGoogle Scholar
  • 34 Rougraff BT, Reeck CC, Essenmacher J. Complete quadriceps tendon ruptures. Orthopedics 1996; 19 (6) 509-514
    PubMedGoogle Scholar
  • 35 Wiesel S , ed. Operative Techniques in Orthopaedic Surgery. Vol. 1. Philadelphia, PA: Lippincott Williams & Wilkins; 2001
    Google Scholar
  • 36 Scuderi C. Ruptures of the quadriceps tendon; study of twenty tendon ruptures. Am J Surg 1958; 95 (4) 626-634
    CrossrefPubMedGoogle Scholar
  • 37 Stannard J, Schmidt A, Kregor P. Surgical Treatment of Orthopaedic Trauma. New York, NY: Thieme Medical Publishers; 2007
    Google Scholar
  • 38 Bushnell BD, Whitener GB, Rubright JH, Creighton RA, Logel KJ, Wood ML. The use of suture anchors to repair the ruptured quadriceps tendon. J Orthop Trauma 2007; 21 (6) 407-413
    CrossrefPubMedGoogle Scholar
  • 39 Maniscalco P, Bertone C, Rivera F, Bocchi L. A new method of repair for quadriceps tendon ruptures. A case report. Panminerva Med 2000; 42 (3) 223-225
    PubMedGoogle Scholar
  • 40 Richards DP, Barber FA. Repair of quadriceps tendon ruptures using suture anchors. Arthroscopy 2002; 18 (5) 556-559
    CrossrefPubMedGoogle Scholar
  • 41 Lighthart WA, Cohen DA, Levine RG, Parks BG, Boucher HR. Suture anchor versus suture through tunnel fixation for quadriceps tendon rupture: a biomechanical study. Orthopedics 2008; 31 (5) 441
    PubMedGoogle Scholar
  • 42 McLaughlin HL. Repair of major tendon ruptures by buried removable suture. Am J Surg 1947; 74 (5) 758-764
    CrossrefPubMedGoogle Scholar
  • 43 Fujikawa K, Ohtani T, Matsumoto H, Seedhom BB. Reconstruction of the extensor apparatus of the knee with the Leeds-Keio ligament. J Bone Joint Surg Br 1994; 76 (2) 200-203
    PubMedGoogle Scholar
  • 44 Levy M, Goldstein J, Rosner M. A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report. Clin Orthop Relat Res 1987; (218) 297-301
    PubMedGoogle Scholar
  • 45 Miskew DB, Pearson RL, Pankovich AM. Mersilene strip suture in repair of disruptions of the quadriceps and patellar tendons. J Trauma 1980; 20 (10) 867-872
    CrossrefPubMedGoogle Scholar
  • 46 Hsu KY, Wang KC, Ho WP, Hsu RW. Traumatic patellar tendon ruptures: a follow-up study of primary repair and a neutralization wire. J Trauma 1994; 36 (5) 658-660
    CrossrefPubMedGoogle Scholar
  • 47 Marder RA, Timmerman LA. Primary repair of patellar tendon rupture without augmentation. Am J Sports Med 1999; 27 (3) 304-307
    CrossrefPubMedGoogle Scholar
  • 48 Giles SN, Morgan-Jones R, Brown MF. The use of hinged Kirschner wires for fixation of patellar tendon rupture. Injury 1999; 30 (8) 539-540
    CrossrefPubMedGoogle Scholar
  • 49 Ho HM, Lee WK. Traumatic bilateral concurrent patellar tendon rupture: an alterative fixation method. Knee Surg Sports Traumatol Arthrosc 2003; 11 (2) 105-111
    PubMedGoogle Scholar
  • 50 Capiola D, Re L. Repair of patellar tendon rupture with suture anchors. Arthroscopy 2007; 23 (8) e1-e4
    PubMedGoogle Scholar
  • 51 Bushnell BD, Byram IR, Weinhold PS, Creighton RA. The use of suture anchors in repair of the ruptured patellar tendon: a biomechanical study. Am J Sports Med 2006; 34 (9) 1492-1499
    CrossrefPubMedGoogle Scholar
  • 52 Bushnell BD, Tennant JN, Rubright JH, Creighton RA. Repair of patellar tendon rupture using suture anchors. J Knee Surg 2008; 21 (2) 122-129
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 Larsen E, Lund PM. Ruptures of the extensor mechanism of the knee joint. Clinical results and patellofemoral articulation. Clin Orthop Relat Res 1986; (213) 150-153
    PubMedGoogle Scholar
  • 54 Larson RV, Simonian PT. Semitendinosus augmentation of acute patellar tendon repair with immediate mobilization. Am J Sports Med 1995; 23 (1) 82-86
    CrossrefPubMedGoogle Scholar
  • 55 Ecker ML, Lotke PA, Glazer RM. Late reconstruction of the patellar tendon. J Bone Joint Surg Am 1979; 61 (6A) 884-886
    PubMedGoogle Scholar
  • 56 Burks RT, Edelson RH. Allograft reconstruction of the patellar ligament. A case report. J Bone Joint Surg Am 1994; 76 (7) 1077-1079
    PubMedGoogle Scholar
  • 57 Kim TW, Kamath AF, Israelite CL. Suture anchor repair of quadriceps tendon rupture after total knee arthroplasty. J Arthroplasty 2011; 26 (5) 817-820
    CrossrefPubMedGoogle Scholar
  • 58 Cadambi A, Engh GA. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. A report of seven cases. J Bone Joint Surg Am 1992; 74 (7) 974-979
    PubMedGoogle Scholar
  • 59 Jaureguito JW, Dubois CM, Smith SR, Gottlieb LJ, Finn HA. Medial gastrocnemius transposition flap for the treatment of disruption of the extensor mechanism after total knee arthroplasty. J Bone Joint Surg Am 1997; 79 (6) 866-873
    CrossrefPubMedGoogle Scholar
  • 60 Emerson Jr RH, Head WC, Malinin TI. Reconstruction of patellar tendon rupture after total knee arthroplasty with an extensor mechanism allograft. Clin Orthop Relat Res 1990; (260) 154-161
    PubMedGoogle Scholar
  • 61 Emerson Jr RH, Head WC, Malinin TI. Extensor mechanism reconstruction with an allograft after total knee arthroplasty. Clin Orthop Relat Res 1994; (303) 79-85
    PubMedGoogle Scholar
  • 62 Leopold SS, Greidanus N, Paprosky WG, Berger RA, Rosenberg AG. High rate of failure of allograft reconstruction of the extensor mechanism after total knee arthroplasty. J Bone Joint Surg Am 1999; 81 (11) 1574-1579
    CrossrefPubMedGoogle Scholar
  • 63 Crossett LS, Sinha RK, Sechriest VF, Rubash HE. Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty. J Bone Joint Surg Am 2002; 84-A (8) 1354-1361
    PubMedGoogle Scholar
  • 64 Browne JA, Hanssen AD. Reconstruction of patellar tendon disruption after total knee arthroplasty: results of a new technique utilizing synthetic mesh. J Bone Joint Surg Am 2011; 93 (12) 1137-1143
    CrossrefPubMedGoogle Scholar
  • 65 Burnett RS, Berger RA, Paprosky WG, Della Valle CJ, Jacobs JJ, Rosenberg AG. Extensor mechanism allograft reconstruction after total knee arthroplasty. A comparison of two techniques. J Bone Joint Surg Am 2004; 86-A (12) 2694-2699
    PubMedGoogle Scholar
  • 66 Ciriello V, Gudipati S, Tosounidis T, Soucacos PN, Giannoudis PV. Clinical outcomes after repair of quadriceps tendon rupture: a systematic review. Injury 2012; 43 (11) 1931-1938
    CrossrefPubMedGoogle Scholar
  • 67 Bhargava SP, Hynes MC, Dowell JK. Traumatic patella tendon rupture: early mobilisation following surgical repair. Injury 2004; 35 (1) 76-79
    CrossrefPubMedGoogle Scholar