Bilateral Extensor Mechanism Allograft Reconstruction for Chronic Spontaneous Rupture: A Case Report and Review of the Literature

Chronic Quadriceps Tendon Rupture-Surgical Treatment and Outcomes: A Systematic Review

Quadriceps tendon ruptures (QTR) lead to significant lower extremity weakness, gait abnormalities, and disability. Outcomes following surgical management of chronic QTR remain largely unknown. This study aimed to systematically review the management of chronic QTR to better understand the incidence, indications for repair versus reconstruction, complications, and outcomes. Studies published in PubMed, EMBASE, and the Cochrane Library reporting on patients with chronic QTR were identified. Inclusion criteria consisted of patients with chronic QTR (injuries ≥6 weeks) undergoing operative management, with reported injury mechanism, tear characteristics, surgical repair versus reconstruction, graft type (if used), postoperative complications, and outcomes. A total of 26 studies, consisting of 44 patients undergoing repair or reconstruction for chronic QTR, were identified. The mean patient age was 48.5 (range, 15-80) years, with 83% (n = 33/40) of patients being male. The mean interval between injury and surgery was 17.2 months (range, 6 weeks-303 months). Falls were the most frequently reported injury mechanism (59%, n = 16/27). Patient-related factors-primarily patient delay in seeking treatment-accounted for delayed management in 55% (n = 11/20) of patients. Tendon reconstruction using graft augmentation was performed in 46% (n = 20/44), most frequently with hamstring autograft (40%; n = 8/20). Quadriceps atrophy (n = 3) and superficial wound infection (n = 3) were the most commonly reported adverse outcomes, while no subsequent re-ruptures, revisions, or additional surgeries were reported. Postoperative active range of motion (ROM) was comparable in patients undergoing repair versus reconstruction (mean ROM = 0.0-124.4 degrees vs. 4.3-120.5 degrees, respectively). Chronic QTR was identified in 44 patients undergoing operative management, an average of 17.2 months following injury. The majority of patients were males, with a mean age of 48.5 years. Falls comprised the majority of injuries, while patient deferral in seeking treatment represented the most common reason for delay. Reconstruction was performed in 46% of cases, most commonly utilizing hamstring autograft. ROM was comparable irrespective of surgical management. Quadriceps atrophy and wound infection were the most commonly reported adverse outcomes, with no reported re-ruptures or revision procedures.

Sartorius muscle transfer for chronic quadriceps tendon rupture: A prospective study

BACKGROUND

Quadriceps tendon rupture (QTR) is an uncommon injury. In chronic QTR there may be a large defect and direct repair is not possible with sutures or transosseous anchors. There is no gold standard surgical procedure for the treatment of chronic QTR. We propose a novel technique in which the quadriceps tendon (QT) is reconstructed using a transfer of ipsilateral sartorius tendon.

METHODS

Between January 2002 and April 2020, 19 patients undergoing sartorius muscle transfer for chronic QTR were prospectively recruited. The Knee Society Score (KSS), range of motion (ROM), and Medical Research Council (MRC) Scale for QT muscle strength were collected preoperatively and at a minimum of 2 years follow up.

RESULTS

The mean age of our cohort was 53.4 ± 9.8 years with a female patient count of 12 (54%). The mean body mass index recorded was 28.5 ± 3.2 kg/m2 (range 23-30). At the mean follow up of 53.4 ± 28.1 months the mean KSS was 90.9 ± 6.3 (range 80-100) (P < 0.05), the mean ROM was 119.5 ± 9.9° for flexion (range 100-130) (P < 0.05) and the mean extension lag was 3.8 ± 5.1° (range 0-15) (P < 0.05). The mean MRC scale was 4.5 ± 0.7 (range 3-5) (P < 0.05). The most frequent complication was QT hypotrophy; it was noted in 14 patients.

CONCLUSION

Satisfactory clinical outcomes of ipsilateral sartorius muscle transfer for chronic QTR can be expected a mean of 4.4 years after surgery.

Clinical Outcomes are Similar Between Graft Types Used in Chronic Patellar Tendon Reconstruction: A Systematic Review

Purpose

To compare clinical outcomes between graft types and techniques used to repair chronic patellar tendon injuries to help surgeons make evidence-based decisions.

Methods

Medline, Embase, and Cochrane libraries were searched through January 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Inclusion criteria were surgical treatment of chronic patellar tendon injury (defined as >6 weeks old), article available in English, and human subjects, minimum 1-year follow-up, and level of evidence I-IV. Studies describing chronic patellar tendon ruptures in the setting of total knee arthroplasty were excluded. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal tools for case reports and case series.

Results

A total of 642 studies were identified through the initial search with 9 studies meeting all inclusion criteria. All studies included were case series encompassing 96 patients with follow-up ranging from 21 months to 7.2 years. Reconstruction techniques included the use of semitendinosus and/or gracilis tendon(s), Achilles tendon, bone-patellar tendon-bone (BTB), or direct repair. The most common graft choice was semitendinosus and/or gracilis tendon(s). Each reconstruction method yielded improvement in respect to range of motion (ROM), extensor lag, quadriceps strength, and patient-reported outcome measures (PROMs). Commonly reported complications were pain and numbness with only one reported instance of graft failure.

Conclusions

In this study, we found that all reconstructive methods described in the literature can produce satisfactory outcomes with improved function, strength, and minimal complications after chronic patellar tendon ruptures. Because of study heterogeneity and low levels of evidence, consensus cannot be reached on a single superior reconstruction method.

Level of Evidence

Level IV, systematic review of level IV studies.

Bilateral Extensor Mechanism Allograft Reconstruction in Native Knees: A Case Report

CASE

A 66-year-old man presented with chronic bilateral extensor mechanism dysfunction and profound patella baja after failed revision surgery for bilateral quadriceps tendon ruptures. Staged bilateral reconstruction with complete extensor mechanism allograft resulted in excellent two-year satisfaction and clinical outcomes.

CONCLUSION

Complete extensor mechanism reconstruction can be a successful treatment for chronic quadriceps tendon rupture with profound patella baja.

TREATMENT OF QUADRICEPS TENDON RUPTURE IN HEMODIALYSIS PATIENTS: A 2020 UPDATE

ABSTRACT Quadriceps tendon tears are uncommon injuries often associated with chronic diseases, including end-stage renal disease (ESRD). The role of secondary hyperparathyroidism as a predisposing factor for tendon tears in this group of patients is well documented, and the weakening of the tendon-bone junction is part of this context. The treatment of choice for quadriceps tendon ruptures in patients with ESRD is surgery, which should be performed as soon as possible. There are several surgical techniques to be used, but the lack of comparative studies does not allow us to conclude which one is the best option. More recent publications have preferred the association of techniques, with emphasis on the use of autologous tendon grafts as a reinforcement tool, which is the author’s procedure of choice. Recent studies reported the use of biological agents to stimulate healing and allografts, but the information seems preliminary to be routinely recommended. Level of evidence II; Obsevation of therapeutic studies.

Quadriceps reconstruction with suture anchor and Achilles allograft combination in quadriceps tendon re-rupture after primary surgical repair: A novel technique

Quadriceps ruptures are one of the pathological conditions of the knee extensor mechanism, accounting for 3% of all tendon injuries. These injuries cause substantial disability of the extensor mechanism. Primary repair is the treatment of choice in acute presentation. In the setting of chronic conditions, the treatment becomes more challenging. Available surgical options include lengthening procedures, and reconstruction with auto graft or allografts. The traditional Scuderi and Codivilla techniques are challenging to perform in degenerative or traumatic retracted ruptures. There is no standard effective treatment in these patients, which yields the best clinical and biomechanical outcomes. An 18-year-old male patient with quadriceps re-rupture after a primary repair was managed with allograft reconstruction using suture anchors. At six years of follow-up, the patient gained a full range of motion with excellent clinical outcomes. He returned to his previous work. In conclusion, quadriceps reconstruction using suture anchor and Achilles allograft combination is a feasible technique in neglected cases who present with quadriceps tendon re-rupture after primary surgical repair.

Complex ruptures of the quadriceps tendon: a systematic review of surgical procedures and outcomes

Background

Chronic ruptures, ruptures following total knee arthroplasty (TKA), and re-ruptures of the quadriceps tendon (QT) are rare. A systematic review of the current literature was conducted on their treatment and outcome to provide evidence-based indications for their management.

Methods

We searched published articles in English on chronic ruptures of QT, QT ruptures that occurred after TKA, and re-ruptures in PubMed, Scopus, and Google Scholar up to January 2021. Twenty-five articles were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Data from 25 articles (97 patients) with a mean age of 57 were retrieved. Patients were classified into three groups depending on the type of rupture: 16 patients suffered chronic QTR, 78 a QTR after a TKA, and 9 patients reported a re-rupture. The most frequent surgical approaches were different for each group: Codivilla’s Y-V technique and end-to-end sutures were the most commonly used in the chronic tears group (62.5%), synthetic MESH was the most frequent choice in QTR after a TKA group (38 patients, 53%), while end-to-end sutures were the first choice in the re-rupture group (4 patients, 44%).

Conclusions

Complex ruptures of the QT can be chronic ruptures, re-ruptures, or ruptures occurring after TKA. The choice of the best surgical technique depends on the macroscopic quality of the tendon stumps rather than the timing of intervention. Evidence-based preventive and therapeutic strategies should be developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02696-9.

Simultaneous Bilateral Patellar Tendon Rupture in a Young Adult Male: A Case Report and Review of the Literature

A bilateral patellar tendon rupture is extremely rare and has only been documented in case reports. Although the etiology remains unknown, predisposing factors include steroid usage, systemic diseases, and tendinopathies. In the present case, a healthy 33-year-old male with a prior history of bilateral patellar tendonitis and a diagnosis of Osgood-Schlatter disease during adolescence experienced simultaneous bilateral patellar tendon rupture after playing volleyball. He underwent bilateral patellar repair without complications. In the absence of trauma, spontaneous bilateral patellar tendon ruptures are associated with several predisposing factors, including systemic diseases, prior corticosteroid or fluoroquinolone usage, and history of tendinopathy. Injuries can be classified based on the location of the rupture. Bilateral patellar tendon ruptures can be misdiagnosed due to the rarity of cases and the lack of a normal comparative knee. Radiographic techniques can aid in the diagnosis, leading to early surgical treatment and improved outcomes. Early diagnosis and prompt surgical repair contribute to good functional outcomes in this potentially debilitating injury pattern.

Suture Anchor Repair with V-Y Plasty and Achilles Allograft Augmentation for Chronic Quadriceps Tendon Injury

Despite an overall incidence that remains low, quadriceps tendon injuries represent a common disorder of the knee extensor mechanism. Persistent pain, weakness, and loss of terminal extension can lead to poor clinical outcomes and significant functional impairment. In the acute setting, approach to management often includes primary repair of the injured tendon that can lead to excellent clinical outcomes. However, a delayed or missed diagnosis can bring forth a clinical scenario that can be difficult to manage thereafter. In the chronically injured tendon, challenges can be linked to limited tendon excursion, poor tissue quality, and increased risk of reinjury.