MRI visualization of bilateral quadriceps tendon rupture in a patient with secondary hyperparathyroidism: implications for diagnosis and therapy

Bilateral spontaneous quadriceps tendon rupture: a case report and literature review

Bilateral spontaneous quadriceps tendon rupture is a rare condition characterized by the simultaneous tear of the fibrous tissue connecting the quadriceps muscle to the patella bone. Prompt diagnosis is crucial for appropriate treatment and optimal outcomes. We present a case of a 70-year-old male with bilateral knee pain and an inability to walk, resulting from a trivial fall. Despite initial misdiagnosis, a thorough evaluation, including physical examination and imaging, revealed bilateral quadriceps tendon rupture. Surgical repair was performed, followed by a comprehensive rehabilitation program. At the four-month follow-up, the patient showed significant improvement in pain and function. This article provides a comprehensive review of the existing literature on bilateral quadriceps tendon rupture, emphasizing the challenges in the diagnosis and management of this rare condition. Early diagnosis, prompt surgical intervention, and a tailored rehabilitation program are crucial for successful outcomes.

Bilateral Quadriceps Tendon Rupture and Femoral Neck Fracture After Generalized Tonic-Clonic Seizures: A Case Report

CASE

We report on a 19-year-old male renal transplant patient with multiple medical issues who sustained simultaneous bilateral quadriceps tendon ruptures and bilateral femoral neck fractures after 2 generalized tonic-clonic seizures. The quadriceps tendon ruptures were detected early surgically repaired; the femoral neck fractures were not detected and managed with bilateral total hip arthroplasty for almost 2 weeks.

CONCLUSION

Tonic-clonic seizures can be associated with unique and complex acute orthopaedic injuries that can be initially missed. Physicians should be cognizant of the need for a thorough medical history and physical examination to avoid orthopaedic postseizure missed diagnoses.

Bilateral Simultaneous Quadriceps Tendon Rupture in a 24-Year-Old Obese Patient: A Case Report and Review of the Literature

Introduction. Simultaneous bilateral quadriceps tendon ruptures (SBQTR) are uncommon knee injuries and most frequently occur in male patients, over 50 years of age. It can be associated with one or more predisposing risk factors like obesity, steroids use, and hyperparathyroidism. The main focus of this paper is to review SBQTR in obese patients. Case Report. We are reporting the youngest patient in the literature to date, a 24-year-old obese male patient, who presented to the emergency department complaining of bilateral knee pain and inability to walk after a fall during a basketball game. His clinical examination revealed the presence of a palpable suprapatellar gap and loss of knee extension bilaterally. Magnetic resonance imaging (MRI) confirmed that both of his quadriceps tendons were ruptured. A day after his diagnosis, the patient underwent successful operative repair followed by rehabilitation. At the two-year follow-up, the patient had full strength of both quadriceps muscles with no extension lag. Conclusion. The diagnosis of SBQTR can be challenging. Early diagnosis and treatment are associated with better functional outcome compared to delayed treatment. Physicians should have a high index of clinical suspicion in order not to miss such an injury and achieve favourable outcomes.

Real-time sonoelastography of the quadriceps tendon in patients undergoing chronic hemodialysis

OBJECTIVES

This study aimed to compare sonoelastographic findings for the quadriceps tendon in patients with chronic renal failure who were in a dialysis program to findings in a control group.

METHODS

Fifty-three randomly allocated patients (mean age, 54.3 years; range, 27-86 years) with chronic renal failure who were in a dialysis program 3 days a week between January and May 2012 were included. The measurements were performed in both knees of 53 patients undergoing dialysis and 25 individuals in the control group. The tendons were classified as follows: type 1, very stiff tissue (blue); type 2, stiff tissue (blue-green); and type 3, intermediate tissue (green-yellow) according to color mapping.

RESULTS

The mean quadriceps tendon thicknesses in the patient group were 4.9 mm (range, 1.9-6.5 mm) for the right knee and 4.9 mm (1.4-6.5 mm) for the left knee; the values in the control group were 5.4 mm (3.6-7.0 mm) for the right knee and 5.4 mm (3.4-7.0 mm) for the left knee. The mean elasticity scores in the patient group were 3.14 (1.03-5.23) for the right knee and 3.33 (1.29-5.00) for the left knee; in the control group, the values were 3.79 (1.73-5.23) and 3.69 (1.23-5.53) for the right and left knees, respectively (right knee, P = .025; left knee, P = .018; Mann-Whitney U test). The quadriceps tendons were significantly thinner in the patient group (right knee, P = .054; left knee, P = .015; Mann-Whitney U test).

CONCLUSIONS

Quadriceps tendons in patients with chronic renal failure are thinner and have lower elasticity scores compared to controls.

Quadriceps Tendon Rupture due to Postepileptic Convulsion

We present a case of quadriceps tendon (QT) rupture. QT ruptures can occur in all ages. The cause is mostly traumatic in origin. Spontaneous ruptures that are thought to result from predisposing conditions are rare. Post-convulsion QT ruptures lacking traumas in their history can be overlooked in clinical examinations. This should be born in mind by the attending physician, as early diagnosis and treatment of the condition can lead to satisfactory outcomes.

Musculoskeletal manifestations of endocrine disorders

Endocrine disorders can lead to disturbances in numerous systems within the body, including the musculoskeletal system. Radiological evaluation of these conditions can demonstrate typical appearances of the bones and soft tissues. Knowledge of these patterns can allow the radiologist to suggest a diagnosis that may not be clinically apparent. This review will highlight the typical musculoskeletal findings of acromegaly, hypercortisolism, hyperthyroidism, hypothyroidism, hyperparathyroidism, pseudo- and pseudopseudohypoparathyroidism, and diabetes mellitus. The radiological manifestations of each of these endocrine disorders, along with a brief discussion of the pathophysiology and clinical implications, will be discussed.

Bilateral quadriceps tendon rupture as the presenting manifestation of chronic kidney disease

Bilateral painful knees with loss of extension in a patient with chronic kidney disease (CKD) may be due to spontaneous quadriceps tendon rupture. This rare complication is usually seen in patients on long term dialysis. We present a case of bilateral spontaneous quadriceps tendon rupture demonstrated by magnetic resonance imaging in a 20-year-old woman who on evaluation was found to have CKD.

Spontaneous rupture of the patellar and contralateral quadriceps tendons associated with secondary hyperparathyroidism in a patient receiving long-term dialysis

Although spontaneous rupture of the extensor tendon of the knee is more likely to occur in uremic patients with secondary hyperparathyroidism, simultaneous ruptures of bilateral knee extensor tendons is a rarely reported condition. We describe a 30-year-old man with uremia who underwent subtotal parathyroidectomy because of secondary hyperparathyroidism with very high serum parathyroid hormone (PTH) level (1940.4 pg/mL). Two weeks later, he complained of a sharp pain in both knees without trauma when he walked downstairs with his left knee forward and right knee behind. Spontaneous simultaneous ruptures of the right patellar tendon and the left quadriceps tendon were diagnosed and surgically repaired. The mechanism of spontaneous tendon rupture in uremic patients with secondary hyperparathyroidism seems to be related to high PTH level which results in osteolytic bone resorption at the tendon insertion site. Early surgical repair, control of secondary hyperparathyroidism, early use of vitamin D analogs, and total parathyroidectomy with or without autotransplantation of part of the parathyroid gland, can treat and prevent tendon rupture or re-rupture with satisfactory results.

Bilateral, simultaneous rupture of the quadriceps tendon: a diagnostic pitfall? Report of three cases and meta-analysis of the literature

Bilateral, simultaneous quadriceps tendon rupture (QTR) represents a rare entity and delay in establishing the correct diagnosis is not uncommon. Another three cases are reported here and in all the correct diagnosis was missed initially. A review of the English and German literature retrieved 105 cases of bilateral, simultaneous QTR and in 32 patients (30.5%) the correct diagnosis was established with delay. In 28 cases--representing 25 men (89.3%) and 3 women (10.7%)--sufficient data was available for further analysis. In the majority of patients (n = 19/28; 67.9%) rupture was associated with trauma, while no trauma was reported in 9/28 cases (32.1%). No direct correlation between age and the kind of rupture form (traumatic/spontaneous) could be detected (P = 0.35). Most partients (n = 18/28; 64.3%) presented risk factors associated with QTR and obesity (n = 6/28; 21.4%) was most frequently encountered. A direct association between the rate of risk factors and the rupture form was not seen (P = 0.5). Overall diagnostic delay lasted 64.7 days on an average (traumatic ruptures 67.7 days/spontaneous ruptures 58.7 days) with this period being longer than 2 weeks in 51.9% and longer than 3 months in 33.3% of patients. Delay varied distinctly in different medical institutions as this period lasted in hospital departments 93.9 days, in ambulances 24 days and in General Practitioners 7.6 days on an average. Initially 25 incorrect diagnoses were established in 21/28 (75%) patients, while 7/28 cases (25%) were discharged initially without any diagnosis. Clinical examination revealed most often palpable suprapatellar gaps (n = 17/24) and effusions (n = 13/24), while the classic trias of painful swelling, suprapatellar gap and loss of knee extension was found in only 58.3% of reported patients (n = 14/24). The correct diagnosis of bilateral QTR was established in 60.7% (n = 17/28) by history and clinical examination alone. In 10.7% (n = 3/28) clinical suspect was supported by sonography and in 14.3% (n = 4/28) by MRT; in 14.3% (n = 4/28) the correct diagnosis represented a by chance finding during diagnostic or operative procedures of other indication. In 52 tendons detailed information about repair was provided and most often transosseous fixation (n = 30/52; 57.7%) and direct repair (n = 14/52; 26.9%) were used, while a tenoplasty was performed in only 15.4% (n = 8/52). Only 34.6% of patients (n = 9/26) with follow-up data (n = 26/28) reported a full recovery with a trend that early surgical repair (limit 2 weeks) improves the final outcome.

Les tendons : lésions traumatiques

In the recent years there has been an increase in the number of tendon tears (TT) seen in routine daily outpatient practice secondary to the increasing popularity of sport activities. Tears require early diagnosis to ensure proper treatment and reduce functional impairment. Since local pain, edema and reflex muscle contraction can significantly limit the usefulness of clinical examination, imaging is usually required to confirm the clinical diagnosis, differentiate between partial and complete tear, and localize the retracted tendon stump. Several imaging modalities can be used in the evaluation of TT. Ultrasound is an efficient, dynamic, low cost and non invasive modality that is being increasingly utilized in the evaluation of the musculoskeletal system. It is well accepted by the acutely injured patient. The aim of this review article is to describe the ultrasound findings of the most common tendon tears.

Ultrasonography as a reliable diagnostic tool in old quadriceps tendon ruptures: a prospective multicentre study

Quadriceps tendon rupture is an uncommon injury. In the majority of cases, predispositions as recurrent microtrauma or degenerative changes are present. The diagnosis of acute quadriceps tendon ruptures can usually be made by clinical examination. Ultrasonography has been shown as a reliable, inexpensive and easily available diagnostic tool to confirm the diagnosis. In this study, we evaluated the clinical value of ultrasonography for establishing diagnosis of old quadriceps tendon ruptures. In the prospective time period of 6 years (01/1998-12/2003), the delayed diagnosis of quadriceps tendon rupture was established in six patients with seven cases of old ruptures (one bilateral rupture). The mean age was 50.2 (SD+/-16.9) years in one woman and five men. The mean interval from trauma until diagnosis was 15.2 (SD+/-7.1; range 8-24) weeks. In all cases, ultrasonography represented a reliable and sensitive tool for establishing diagnosis of old quadriceps tendon rupture. We therefore recommend the use of ultrasonography in the diagnostic work up of cases with knee trauma and potential involvement of tendon injuries.

Ultrasound of tendon tears. Part 1: general considerations and upper extremity

The role of ultrasound (US) in assessing musculoskeletal disorders is persistently increasing because of its low cost, readiness, noninvasiveness, and possibility of allowing a dynamic examination. Secondary to increased sport practice, tendon tears are more frequently observed in daily medical practice. They deserve early diagnosis to allow proper treatment that can limit functional impairment. The aim of this review article is twofold: to illustrate the US appearance of normal tendons and to describe the US findings of the most common tendon tears.

Outcomes following repair of quadriceps tendon ruptures

OBJECTIVES

The purpose of this study was to examine critically the outcomes of patients sustaining a quadriceps tendon rupture and to compare outcomes in patients with bilateral simultaneous ruptures versus a unilateral rupture.

DESIGN

Retrospective review.

SETTING

Patients were treated at a Level I trauma center.

PATIENTS/PARTICIPANTS

Fifty-one quadriceps tendon ruptures in thirty-nine patients were evaluated. A mean four-year follow-up (range 13 to 204 months) was available for forty-eight tendon ruptures.

INTERVENTIONS

All patients except one were treated with operative repair of the quadriceps tendon rupture(s).

MAIN OUTCOME MEASUREMENTS

Patients were assessed by physical examination, Lysholm and Tegner scores, a functional questionnaire, quadriceps isokinetic testing, and radiographs.

RESULTS

A statistically greater number of patients in the bilateral simultaneous rupture group had a systemic illness associated with tendon rupture (p = 0.014). This result did not adversely affect outcome as compared with patients with unilateral ruptures. Mean range of motion was 123 degrees in injured knees. Eighty-four percent of working patients returned to their previous occupations. More than half the patients, however, in general the most active, could no longer participate in their preinjury recreational activities. Fifty-three percent of unilateral rupture patients had persistent quadriceps strength deficits (>20 percent) in the injured extremity. Both quadriceps and hamstring isokinetic testing correlated significantly with Lysholm and Tegner scores.

CONCLUSIONS

Most patients with bilateral simultaneous and unilateral tendon repairs can expect a good range of motion and return to their previous occupation, but many have persistent weakness and difficulty returning to higher level sporting activities.

Radiographic diagnosis of quadriceps tendon rupture: analysis of diagnostic failure

In a multi-institution study, 18 knees with complete quadriceps tendon ruptures (QTRs) were reviewed to analyze the cause of failure in radiographic diagnosis. Only 6 of the 18 knees were diagnosed correctly initially. This occurred even though almost all knee radiographs showed more than three abnormalities compatible with QTR (obliteration of quadriceps tendon, suprapatellar mass, suprapatellar calcific density, or patella baja). Of the 12 diagnostic failures, only 3 were considered to be complete failure. Nine primary reports (50%) were classified as incomplete diagnosis and could be correctly diagnosed if the attention of radiologists was focused to the quadriceps mechanism. We conclude that better understanding of radiographic abnormalities in QTR is necessary for the improvement of primary radiological diagnosis.