Orthopedics

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Review Article 

Quadriceps Tendon Injuries

David J. Hak, MD_MBA; Anthony Sanchez, MD; Per Trobisch, MD

Abstract

Quadriceps tendon injuries occur in a spectrum that ranges from tendinosis, to partial tears, to complete full thickness ruptures. Complete traumatic rupture of the quadriceps tendon is a relatively uncommon but disabling injury. Clinical findings usually include acute pain, inability to actively extend the knee, and a palpable suprapatellar defect in the quadriceps tendon. Incomplete tears and tendinosis (jumper’s knee) can be managed nonoperatively, but complete quadriceps tendon ruptures require surgical repair for optimal outcomes.

The knee extensor mechanism consists of the quadriceps muscle with its 4 muscle bellies (rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius). The quadriceps tendon is composed of contributions from each of these muscles, forming a common trilaminar tendon insertion at the patella. The anterior layer is formed by the tendon of the rectus femoris, the intermediate layer by the vastus medialis and lateralis, and the deep layer by the vastus intermedius. The vastus medialis and lateralis have a fibrous expansion that blends with the medial and lateral retinaculum.1

Three major vascular arcades (medial, lateral, and peripatellar arcades) provide the blood supply to the quadriceps tendon. A relatively hypovascular zone is present between 1 and 2 cm superior to the patella, making this area more susceptible to rupture.2

While tendonitis implies the presence of an acute inflammatory process, the term tendinosis is used to signify a pathology of chronic degeneration without inflammation, which is more appropriate for what is commonly seen in patients presenting with a chronic quadriceps tendon injury. Peri-patellar tendinosis is commonly referred to as jumper’s knee. It is felt to be due to an overload injury commonly seen in athletes who perform intense and repeated jumping such as in volleyball, basketball, high jumping, and long jumping. This pathological process involves microtears at the bone-tendon junction, resulting in degenerative inflammation and replacement of the tendon by scar tissue. This condition most commonly affects the insertion of the patella tendon on the patella (65%), but can also affect the quadriceps tendon insertion on the patella (25%), and the patella insertion on the tibial tuberosity (10%).3

Patients presenting with quadriceps tendinosis usually report an insidious onset of pain over the proximal pole of the patella. This is often associated with a history of an increase of change in athletic activities. Localized tenderness may be found on direct palpation of the insertion of the distal quadriceps on the proximal pole of the patella. Pain can be elicited knee extension against resistance.

Patients presenting with a partial quadriceps tendon tear usually report an acute onset of pain during sports or a fall. This injury may be associated with a knee hemarthrosis. Unlike complete quadriceps tendon ruptures, the are able to actively extend their knee against gravity. Occasionally the severity of pain may initially limit the patient’s ability to fully contract their quadriceps muscle, making differentiation from a complete tendon rupture problematic.

Complete quadriceps tendon ruptures usually result from indirect trauma, often occurring when a patient is trying to regain their balance. When a patient rapidly contracts their quadriceps muscle with their knee flexed, it places the quadriceps under its greatest tensile stress, which may exceed the tendons strength.4

Patients commonly provide a history of a sudden onset of suprapatellar pain combined with a fall, followed by inability to actively extend the knee. However, when asked precisely many will report having experienced a sudden pain and loss of stability when trying to prevent a fall with the knee extended against resistance. The tendon rupture is therefore probably not the result of the fall but of maximum quadriceps contraction with the fall being the result of a rupture.5

Quadriceps tendon injuries occur in a spectrum that ranges from tendinosis, to partial tears, to complete full thickness ruptures. Complete traumatic rupture of the quadriceps tendon is a relatively uncommon but disabling injury. Clinical findings usually include acute pain, inability to actively extend the knee, and a palpable suprapatellar defect in the quadriceps tendon. Incomplete tears and tendinosis (jumper’s knee) can be managed nonoperatively, but complete quadriceps tendon ruptures require surgical repair for optimal outcomes.

Anatomy

The knee extensor mechanism consists of the quadriceps muscle with its 4 muscle bellies (rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius). The quadriceps tendon is composed of contributions from each of these muscles, forming a common trilaminar tendon insertion at the patella. The anterior layer is formed by the tendon of the rectus femoris, the intermediate layer by the vastus medialis and lateralis, and the deep layer by the vastus intermedius. The vastus medialis and lateralis have a fibrous expansion that blends with the medial and lateral retinaculum.1

Three major vascular arcades (medial, lateral, and peripatellar arcades) provide the blood supply to the quadriceps tendon. A relatively hypovascular zone is present between 1 and 2 cm superior to the patella, making this area more susceptible to rupture.2

Quadriceps Tendinosis

While tendonitis implies the presence of an acute inflammatory process, the term tendinosis is used to signify a pathology of chronic degeneration without inflammation, which is more appropriate for what is commonly seen in patients presenting with a chronic quadriceps tendon injury. Peri-patellar tendinosis is commonly referred to as jumper’s knee. It is felt to be due to an overload injury commonly seen in athletes who perform intense and repeated jumping such as in volleyball, basketball, high jumping, and long jumping. This pathological process involves microtears at the bone-tendon junction, resulting in degenerative inflammation and replacement of the tendon by scar tissue. This condition most commonly affects the insertion of the patella tendon on the patella (65%), but can also affect the quadriceps tendon insertion on the patella (25%), and the patella insertion on the tibial tuberosity (10%).3

Patients presenting with quadriceps tendinosis usually report an insidious onset of pain over the proximal pole of the patella. This is often associated with a history of an increase of change in athletic activities. Localized tenderness may be found on direct palpation of the insertion of the distal quadriceps on the proximal pole of the patella. Pain can be elicited knee extension against resistance.

Partial Quadriceps Tendon Tears

Patients presenting with a partial quadriceps tendon tear usually report an acute onset of pain during sports or a fall. This injury may be associated with a knee hemarthrosis. Unlike complete quadriceps tendon ruptures, the are able to actively extend their knee against gravity. Occasionally the severity of pain may initially limit the patient’s ability to fully contract their quadriceps muscle, making differentiation from a complete tendon rupture problematic.

Complete Quadriceps Tendon Ruptures

Complete quadriceps tendon ruptures usually result from indirect trauma, often occurring when a patient is trying to regain their balance. When a patient rapidly contracts their quadriceps muscle with their knee flexed, it places the quadriceps under its greatest tensile stress, which may exceed the tendons strength.4

Patients commonly provide a history of a sudden onset of suprapatellar pain combined with a fall, followed by inability to actively extend the knee. However, when asked precisely many will report having experienced a sudden pain and loss of stability when trying to prevent a fall with the knee extended against resistance. The tendon rupture is therefore probably not the result of the fall but of maximum quadriceps contraction with the fall being the result of a rupture.5

On physical examination a suprapatellar gap can be palpated in the early phase following rupture. With later examination the gap might be masked from swelling, hematoma, and fibrosis. Most patients present with inability to actively extend the knee, although in some cases intact retinaculum will allow some active extension and obscure the diagnosis. Ambulation is usually not possible due to inability to fully extend and stabilize the knee.

Some patients presenting with inability to ambulate due to bilateral quadriceps tendon ruptures are sometimes misdiagnosed as a neurologic problem resulting in delayed treatment.6 Since these patients frequently have severe associated systemic diseases, the failure to consider an orthopedic diagnosis is understandable.

Diagnostic Imaging

Radiographs, which can rule out other injuries, may show inferior displacement of the patella (Figure 1). Several criteria based on lateral knee radiographic measurements have been described to define abnormal position of the patella. The Insall-Salvatti ratio compares the length of the patellar tendon with the length of the patella.7 This ratio should normally be approximately 1.0. Citing difficulty in identifying the tibial tubercle and variation in the size of the nonarticular portion of the patella, Blackburne and Peel8 recommended using a ratio that compared the perpendicular distance between the lowest part of the articular surface and the joint line with the length of the articular surface of the patella.8 With the knee flexed 30° this ratio should normally be between 0.80 and 0.95. Bony avulsions may occasionally be seen, but are usually absent when the rupture occurs solely within the hypovascular tendinous region. Both ultrasound and MRI can assist in the diagnosis in uncertain cases. The quadriceps tendon defect can be readily visualized on ultrasound examination (Figure 2). With combination of physical examination and ultrasound 100% diagnostic sensitivity can be achieved, thus avoiding the more expensive MRI examination (Figure 3).9 Magnetic resonance imaging can be helpful in detecting additional intra-articular injuries, but considering that this is the case in <10% of="" cases="" it="" is="" only="" recommended="" if="" strong="" suspicion="" for="" additional="" injuries="">10 Partial tendon ruptures are usually hyperintense on T2-weighted images, and may sometimes be confused with a hemangioma.11

Figure 1A: Lateral radiograph showing bony avulsion associated with an acute quadriceps tendon rupture Figure 1B: A anterior superior bone spur on the patella

Figure 1: Lateral radiograph showing bony avulsion associated with an acute quadriceps tendon rupture (A). Postoperative radiograph following quadriceps tendon repair. Note the presence of a anterior superior bone spur on the patella suggesting prior injury or prior partial avulsion (B).


Figure 2: Ultrasound of a ruptured and a nonruptured quadriceps tendon

Figure 2: Ultrasound of a ruptured and a nonruptured quadriceps tendon.


Figure 3: MRI of a chronic quadriceps tendon rupture

Figure 3: MRI of a chronic quadriceps tendon rupture showing a lack of quadriceps tendon attachment to the superior patella.

Epidemiology

An epidemiologic study from the United Kingdom reported an incidence of 1.37/100,000 per year, with a mean age of 50.5 in males and 51.7 in females.12 Quadriceps tendon ruptures are more common in patients older than 40 years, with a peak incidence seen in the sixth and seventh decade of life. Men are affected 4 to 8 times as often as women.4,12 Racial differences also have been described with a >10 times increased risk of major tendon ruptures in black men.13,14

Etiology

The quadriceps tendon is normally remarkably strong and resistant to rupture. It has been commonly accepted that quadriceps tendon ruptures rarely occur in the absence of some pre-existing degeneration of the tendon. However, a recent study found that only 64% of cases analyzed showed histologic abnormalities.15 Histologic analysis of ruptured quadriceps tendons found the most frequent pathological change to be hypoxic degeneration and focal regions with decreased collagen fiber thickness.16,17 However, degeneration alone may not completely explain the rare incidence of this injury, since cadaveric studies observed degenerative changes in up to 100% even in nonruptured tendons.2,18 Most quadriceps tendon ruptures are located in the hypovascular zone, which is 1 to 2 cm superior to the patella.2,19

Patients with certain systemic diseases that may cause pathologic degeneration of the quadriceps tendon have an increased risk of quadriceps tendon ruptures. These systemic diseases include renal disease, diabetes, rheumatoid arthritis, gout, obesity, hyperparathyroidism, systemic lupus erythematosis, and osteomalacia. Systemic diseases have been reported to be present in 10% to 20% of patients sustaining a quadriceps tendon rupture.4,20 In addition the use of steroids or fluroquinolone antibiotics has been reported in patients sustaining quadriceps tendon ruptures.21 Iatrogenic weakening of the quadriceps muscle and quadriceps tendon, which can be the case in quadriceps release for total knee arthroplasty or in patella lateralization, have also been reported to result in a quadriceps tendon rupture.22,23 While bilateral quadriceps tendon ruptures occur in <5% of="" cases,="" associated="" systemic="" disease="" such="" as="" renal="" insufficiency,="" diabetes,="" or="" chronic="" steroid="" use="" is="" almost="" universal="" in="" these="">4,20,24-26

Treatment

Quadriceps Tendinosis

The mainstay of quadriceps tendinosis treatment is rest, activity modification, and a physical therapy program that focuses on aggressive hamstring stretching. Additional treatment modalities include ice, massage, ultrasound, iontophoresis and phonophoresis.

Some surgeons have promoted the use of platelet rich plasma injections into injured tendons, proposing that the growth factors present in the concentrated plasma are beneficial in tendon healing and recovery.27 Another proposed treatment is directed at the hypervascularity of the affected tendon, which is oblitered by injection of a sclerosing agent.28

Surgical treatment of quadriceps tendinosis is rarely needed, but may be considered in selected patients who fail conservative therapy. The location and extent of the affected tendon can be imaged with an MRI. The degenerative tissue is excised, along with any calcifications.29 If a significant portion of tissue is excised, reattachment of the quadriceps tendon to the patella may be required.

Partial Quadriceps Tears

Incomplete tears are usually treated nonoperatively. Evacuation of the intra-articular hemarthrosis has been recommended to reduce pain and promote faster recovery.4 Rest, ice, compression, and anti-inflammatory medication are commonly recommended. However, the use of anti-inflammatory medications may delay or impair the tendon healing process, so it is recommended to minimize or avoid their use. The patient’s knee is commonly immobilized in full extension. Duration of immobilization is controversial, but 6 weeks is a commonly chosen duration of immobilization. A shorter period of immobilization may be feasible for smaller tears and while allow more rapid rehabilitation. To determine whether to discontinue immobilization, the patients comfort and ability to perform a straight leg raise are assessed. If the patient’s recovery is deemed satisfactory progressive knee range of motion and strengthening exercises are begun.

Operative treatment may be indicated if nonoperative management is unsuccessful. With >1 of the 3 tendon layers intact, ruptures involving only 1 portion can usually be treated with excision of the scar tissue and side-to-side closure of the tendon.30 If more extensive debridement results in removal of the majority of the tendon, then suture repair to the patella should be considered.31

Complete Quadriceps Tendon Ruptures

Complete quadriceps tendon ruptures require open repair or reconstruction, since nonoperative treatment results in poor outcomes. Early repair is recommended because delay in surgery is correlated with retraction and atrophy of the quadriceps muscle resulting in decreased functional outcome.32 No consensus exists on what constitutes “early” repair and in different reports has ranged from 24 hours to 1 month following the rupture.19,33,34

During surgical repair the patient is positioned supine after induction of general or regional anesthesia. The use of a tourniquet is optional. A midline incision beginning just distal to the superior patellar pole and extending proximally for approximately 5 cm is used (Figure 4). The quadriceps tendon rupture is exposed, and hematoma and fibrous granulation tissue debrided. A tissue sample for histologic analysis may be taken to identify the degree of preexisting degeneration.

Figure 4A: Quadriceps tendon rupture Figure 4B: Repair of medial and lateral retinaculum

Figure 4: Intraoperative photograph of quadriceps tendon rupture. Note associated disruption of medial and lateral joint capsule (A). Following repair of quadriceps tendon rupture using #5 FiberWire (Arthrex, Naples, Florida) passed through longitudinal drill holes in the patella, and repair of medial and lateral retinaculum (B).

Several surgical techniques for repair of quadriceps tendon ruptures have been described (Figure 5A). The most common used method is a transosseous suture through vertical patellar drill holes. Alternatively, some surgeons have advocated placing the transosseous suture through a transverse drill hole through the patella (Figure 5B). Some form of locking suture technique, such as those described by Kirchmayr, Krakow, Bunnell or a figure of eight technique is used to anchor the quadriceps tendon.

Figure 5A: Diagram of longitudinal transosseous quadricepts tendon repair Figure 5B: Diagram of transverse transosseous quadricepts tendon repair

Figure 5: Diagram of longitudinal (A) and transverse (B) transosseous quadricepts tendon repair.

Different suture materials have been used, with most authors recommending use of a nonabsorbable material, however good results have also been reported with the use of absorbable polydioxane (PDS).32,34-36 Additional repair of the medial and lateral retincaculum, which are torn in most cases, should be performed. It is often easiest to place the retinacular repair sutures in position before repairing the quadriceps tendon. More proximal ruptures in which a portion of intact tendon remains attached to the patella, can occasionally be repaired with end-to-end sutures. Ruptures occurring at the patella insertion often have avulsion bone fragments attached to the tendon. In this situation the bone fragments should be maintained to achieve bone to bone healing. A horizontal trough can be made in the superior border of the patella and suture repair completed as described above.

Alternative methods of repair include additional use of wire cerclages, screw augmentation, or suture anchors instead of drill holes.26,37-39 Some surgeons recommend placement of a circumferential suture that encompasses and “protects” the repair and might provide additional strength if early postoperative mobilization is planned.40 Such a circumferential suture is usually places with the knee in 30° of flexion. Prior to skin closure, a “stress test” of the repair should be performed by passively flexing the knee to at least 60°.

Scuderi19 advocated reinforcement of the defective tendon zone by turning down a flap of the proximal, and presumably nondegenerative, quadriceps tendon. Following direct repair of the tendon rupture, a triangular flap approximately 1/8-inch thick can be elevated from the anterior portion of the distal quadriceps tendon and turned down to reinforce the weakened area. By using only the superficial portion of the tendon the remainder of the tendon is not substantially weakened.

As result of anatomical and biomechanical studies promoting early mobilization to improve tendon healing and maintain joint motion, many authors have recently advocated passive flexion between 30° and 90° starting on the first postoperative day.35,41,42 Controversy exists regarding postoperative weight bearing with most authors recommending partial weight bearing for 6 weeks.32,37,39,40

Chronic Ruptures

The treatment of a chronic rupture can be significantly more challenging because tendon retraction and scarring may preclude direct repair. The quadriceps tendon must be mobilized by resecting adhesions and elevating the quadriceps muscle off the femur. A lateral and medial quadriceps release can help in tendon mobilization.43 If the quadriceps tendon can be approximated to the patella then the above-mentioned techniques of primary repair can achieve good results.44

If primary approximation of the tendon is not possible reconstruction with a hamstring graft, V-shaped turn down flap and Leeds-Keio ligament, which is a synthetic device that has the ability to induce a collagen rich capsule around it, have all shown acceptable results.4,45-48

The Codvilla quadriceps lengthening technique has been recommended when direct primary repair is not possible. A full-thickness inverted “V” is made in the mid-substance of the proximal quadriceps tendon, ending approximately 2 cm proximal to the rupture zone. The triangular flap is turned down distally and attached to the patella. The upper portion of the quadriceps tendon where the triangular flap was taken is repaired in a side to side manner.19

Outcome Following Repair of Complete Quadriceps Tendon Ruptures

A number of relatively small retrospective studies have reviewed the outcome of patients following quadriceps tendon repairs (Table). Slightly different repair techniques and postoperative protocols were used. Most studies used 6 weeks of postoperative immobilization, but some allowed immediate limited range of motion from 55° to 90°.35,40,49 Patients generally reported satisfactory results following their surgical repair.

Table: Outcome After Repair of Quadriceps Tendon Ruptures

Loss of knee motion is common following complete quadriceps tendon ruptures. Especially problematic is lack of full knee extension.4 While some studies have reported no deficit in muscle strength, most studies report long-term decreases in muscle strength in 25% to 67% of cases.26,33,34,35,49 Despite the frequency of muscle weakness most patients seem to tolerate their strength deficit well.50

In one of the largest series of patients, Konrath et al34 reported on 51 quadriceps tendon ruptures, of which 50 were treated by primary repair from 1 to 259 days after injury. The mean time from injury to surgery in 43 of the cases was 5.5 days, but in 7 cases the injury was initially missed, and mean time from injury to surgery in those cases was 60 days. Most tendon ruptures were repaired using transosseous non-absorbable sutures. Postoperative management consisted of partial weight bearing and careful flexion during physical therapy for 6 weeks. At a mean follow-up of 4 years a decrease in muscle strength could be observed in more then half of the patients. In addition to minor complications one re-rupture was reported. The authors reported that no correlation between time of surgery and functional outcome could be observed.34

Despite the frequency of medical comorbidities in many patients sustaining quadriceps tendon ruptures, few serious complications have been reported following quadriceps tendon repair. O’Shea et al26 reported 1 pulmonary embolism in 27 patients that were immobilized post-operatively and allowed partial weight bearing for 6 weeks. Wenzl et al49 reported 2 deep venous thromboses (DVTs) and 1 pulmonary embolism leading to death in 35 patients that were either immobilized or allowed up to 60° of knee flexion and partial weight bearing for 6 weeks.49 Another reported serious complication is a single documented case of acute compartment syndrome of the thigh following quadriceps tendon rupture.51

Re-rupture is a significant concern because there is usually underlying pathology within the substance of the tendon. In addition, to achieve the goal for optimal outcome, progressive postoperative therapy with early range of motion may lead to early stress of the repair. Ramseier et al33 reported 1 re-rupture in 21 patients that were immobilized in a long leg splint for 6 weeks.

Konrath et al34 observed 1 re-rupture in 39 patients with careful postoperative mobilization during physical therapy and 6 weeks of partial weight bearing. There seems to be no correlation between the specific surgical technique or the postoperative care on the rate of re-rupture. However, re-rupture rates as high as 40% have been reported in patients with total knee arthroplasty complicated by quadriceps tendon rupture.52 To date there have been no randomized controlled studies to evaluate specific surgical techniques or postoperative protocols for quadriceps tendon ruptures.

Conclusion

Complete quadriceps tendon ruptures are uncommon injuries that usually result from indirect trauma. Early diagnosis and prompt repair has been associated with the best outcomes. Fixation with transosseous patellar sutures is most common. Early range of motion within the tolerance of the repair may provide better results, but there have been no large randomized studies that have compared either the surgical technique or the postoperative treatment regimen. Some loss of muscle strength is common, however good to excellent functional results are usually achieved. Patients with associated co-morbidities may be particularly susceptible to complications, which include deep vein thrombosis, pulmonary embolism, and re-rupture.

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Authors

Drs Hak and Sanchez are from the Department of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado; and Dr Trobish is from the NYU Hospital for Joint Diseases, Department of Orthopedic Surgery, New York, New York, and the BG Trauma Center Tuebingen, Tuebingen, Germany.

The material presented in any Vindico Medical Education continuing education activity does not necessarily reflect the views and opinions of Orthopedics or Vindico Medical Education. Neither Orthopedics nor Vindico Medical Education nor the authors endorse or recommend any techniques, commercial products, or manufacturers. The authors may discuss the use of materials and/or products that have not yet been approved by the US Food and Drug Administration. All readers and continuing education participants should verify all information before treating patients or using any product.

Correspondence should be addressed to: David J. Hak, MD, MBA, 777 Bannock St, Mail Code 0188, Denver, CO 80204 (david.hak@dhha.org).

doi: 10.3928/01477447-20091124-20

10.3928/01477447-20091124-20

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