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Updated: Apr 2 2024

Quadriceps Tendon Rupture

Images rupture.jpg
  • summary
    • A quadriceps tendon rupture is a traumatic injury of the quadriceps insertion on the patella leading to a disruption in the knee extensor mechanism.
    • Diagnosis is made clinically with a palpable defect 2 cm proximal to the superior pole of the patella with inability to perform a straight leg raise and presence of patella baja on knee radiographs. 
    • Treatment may be nonoperative in patients with partial tears and intact extensor mechanism. Operative repair is indicated if there is disruption of the extensor mechanism.
  • Epidemiology
    • Incidence
      • quadriceps tendon rupture is more common than patellar tendon rupture
    • Demographics
      • usually occurs in patients > 40 years of age
      • males > females (up to 8:1)
      • occurs in nondominant limb more than twice as often
    • Anatomic location
      • usually at insertion of tendon to the patella
    • Risk factors
      • renal failure
      • diabetes
      • rheumatoid arthritis
      • hyperparathyroidism
      • connective tissue disorders
      • steroid use
      • intraarticular injections (in 20-33%)
  • Etiology
    • Pathophysiology
      • mechanism
        • eccentric loading of the knee extensor mechanism
        • often occurs when the foot is planted and knee is slightly bent
        • in younger patients the mechanism is usually direct trauma
  • Classification
    • Rupture classified as either
      • partial
      • complete
  • Anatomy
    • Quadriceps tendon
      • has been described as having 2 to 4 distinct layers
        • important when distinguishing between partial and complete tear and when repairing tendon
  • Presentation
    • History
      • often report a history of pain leading up to rupture consistent with an underlying tendonopathy
    • Symptoms
      • pain
    • Physical exam
      • tenderness at site of rupture
      • palpable defect usually within 2 cm of superior pole of patella
      • unable to extend the knee against resistance
      • unable to perform straight leg raise with complete rupture
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral of knee
      • findings
        • will show patella baja
    • MRI
      • indications
        • when there is uncertainty regarding diagnosis
        • helps differentiate between a partial and complete tear
  • Treatment
    • Nonoperative
      • knee immobilization in brace
        • indications
          • partial tear with intact knee extensor mechanism
          • patients who cannot tolerate surgery
    • Operative
      • primary repair with reattachment to patella
        • indications
          • complete rupture with loss of extensor mechanism
  • Techniques
    • Primary repair of acute rupture
      • approach
        • midline incision to knee
      • repair
        • longitudinal drill holes in patella
        • nonabsorbable sutures in tendon in a running locking fashion with ends free to be passed through osseous drill holes
        • repair with suture anchors has been shown to have decreased gap formation and increased ultimate loads to failure
        • retinaculum is repaired with heavy absorbable sutures
        • ideally the knee should flex to 90 degrees after repair
      • postoperative care
        • initial immobilization in brace, cast, or splint
        • eventual progressive flexibility and strengthening exercises
    • Primary repair of chronic rupture
      • approach
        • midline to knee
      • repair
        • often the tendon retracts proximally
          • ruptures >2 weeks old can retract 5cm
        • repaired with a similar technique to acute ruptures but a tendon lengthening procedure may be necessary
          • Codivilla procedure (V-Y lengthening)
        • auto or allograft tissue may be needed to secure quadriceps tendon to patella
  • Complications
    • Strength deficit
      • 33%-50% of patients
    • Stiffness
    • Functional impairment
      • 50% of patients are unable to return to prior level of activity/ sports
    • Re-rupture 
      • Risk is increased in the setting of pre-existing inflammatory arthropathy
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