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Quadriceps Tendon Rupture: Treatment

Medical Therapy
Conservative treatment is indicated for partial tears. Immobilize the knee in full extension for 3-6
weeks. Straight-leg raises are started late in the immobilization phase. If these can be performed
without discomfort for 10 days, immobilization can be progressively discontinued. Range-of-motion
(ROM) exercises are then initiated and quadriceps strengthening is continued until the strength of
the injured leg is equal to that of the contralateral leg.
Surgical Therapy
Early surgical repair yields the best results for complete quadriceps tendon ruptures. 29 , 30 Many
techniques have been described for the repair and augmentation of acute and neglected tears, including
the following:

Use of kangaroo tendon
Free fascial grafts
Traction sutures
Vastus lateralis flaps 31
Carbon fiber 32
Mersilene sutures
Dacron graft
Polyester graft
Autograft of the central third of the patellar tendon

Suture anchors also have come into use. However, 3 main types of repair continue to be the most
popular: direct repair of the tendon to the patella, the Scuderi technique for acute tears, and the
Codivilla tendon-lengthening and repair technique for chronic ruptures.
Intraoperative Details
Direct repair of the tendon can be performed for most acute ruptures and for some neglected
ruptures. A midline longitudinal incision is made exposing the rupture (see image below). The tear site
is irrigated, and the torn tendon edges are debrided back to healthy tissue. Occasionally, if adequate
tendon remains distally, an end-to-end repair can be performed. Several heavy, nonabsorbable mattress
sutures are placed through the tendon, and absorbable sutures are used to re-approximate the
retinaculum. Some authors advocate leaving the lateral retinaculum open for better patellar tracking.

Exposure of a tendon rupture.
Usually, insufficient tendon remains distally or the tear is at the osteotendinous junction. In these
cases, the tendon is repaired to a bony trough in the patella. Again, the proximal tendon edge is
freshened. The superior pole of the patella is debrided of any remaining tendon, and a transverse bony
trough is made. The trough should not be made near the anterior surface of the patella, to avoid
patellar tilt. Three or 4 longitudinal holes are drilled about 1 cm apart from the bony trough to the
inferior pole of the patella (see image below).

The free suture ends are passed through the drill holes from proximal to distal with a suture passer (see image below). the sartorius rotational flap. Tendon pulled down into the patellar bony trough with sutures. apply a cylinder cast with the knee in full extension. 7.Additionally.0 cm proximal to the tear. Secure the sutures with a hemostat. The apex of the triangle is folded distally and sutured over the repair site. exiting the skin distally. The tendon and retinaculum then are advanced distally until re-approximation is possible. Pull-out wires are recommended to protect the repair. Suturing is performed as previously described. and assess patellar rotation and tracking throughout the ROM of the knee. with the base about 5 cm proximal to the tear. and artificial graft material. the Codivilla tendon lengthening technique can be used. the base of the flap is more distal. The Bunnell-type weave and Krackow whipstitches are popular. running from the quadriceps tendon to the patellar tendon. The proximal aspect of the open triangle is repaired with absorbable suture. has been advocated. about 1. Finished repair. Passing suture through patellar drill holes. If the tendon cannot be reapproximated to the patella.5-2. Repair using patellar drill holes. If satisfactory. the knee is cast in full extension. interlocked stitches are placed medial and lateral in the tendon using 5-0 nonabsorbable suture. The tendon then is pulled by the sutures distally into the trough (see image below). options for additional augmentation include the vastus lateralis strip.Following wound closure. Running. the repair may be reinforced with extra tissue by using the Scuderi technique. The posterior portion of the tendon is left intact. tie the sutures distally and repair the retinaculum with absorbable sutures (see image below).5 cm long on each side.Drill holes through the patella. If a defect remains following Codivilla lengthening. as well as simple excision of the scar tissue and closure. If a long course of conservative management for partial quadriceps tendon ruptures fails. except that the flap consists of the full thickness of the tendon. For chronic ruptures. The flap should be roughly 3-4 mm thick. surgery may be necessary. and 5 cm wide at its base. A triangular flap from the anterior portion of the tendon is fashioned. if a significant vastus intermedius stump remains. If necessary. this may be used to augment the repair posteriorly. a direct repair with augmentation using the Scuderi technique (if necessary) is attempted. Bunnell pull-out wires are placed medially and laterally.The quadriceps tendon and muscle are freed from adhesions. Also. The flap is folded distally and sutured over the repair. fascia lata grafts.After routine subcutaneous and skin closure. A triangular flap is fashioned similar to that used in the Scuderi technique. .

Repeat rupture occurs infrequently. Konrath and associates found that 83% of patients returned to their previous occupations. including patella alta. and the mechanism of injury do not appear to affect the results. painless ROM. Although uncommon. 51% were unable to return to their pre-injury activity levels.Postoperative care for partial tear repairs requires minimal immobilization and a shorter period of rehabilitation. Rougraff and colleagues reported 2 repeat ruptures in 53 repairs. Complications The most common complications are loss of motion and extensor mechanism weakness. malalignment of the patella. 34 The type of repair. Most patients can return to their previous occupation. 17 Patients had a mean thigh atrophy of 1. with flexion gradually increased over time. such as football. because malalignment can lead to degenerative changes of the patellofemoral joint. the location of the tear. For chronic repairs. Most authors prefer cylinder casting for 4-6 weeks. basketball. postoperative treatment is similar. In a large study.A few authors have advocated immediate postoperative ROM exercises and delayed weight bearing. Follow-up Athletes treated for partial or complete ruptures may return to play when several conditions are met. Therapy is continued until strength and motion are comparable to those of the uninjured leg. ROM exercises are initiated along with continued quadriceps strengthening. including the following:    The patient should have nearly full. Isometric quadriceps exercises may be started in the cast. but protection of the repair and rehabilitation can be longer. 33 A hinged knee brace may be used. wound compromise. or tennis. and 53% had persistent quadriceps strength deficits (>20% compared with the uninjured leg). but many cannot return to their pre-injury activity level. Outcome and Prognosis Studies generally have reported good results following early repair of complete unilateral and bilateral quadriceps tendon ruptures. while Konrath and associates observed 1 repeat rupture in 50 repairs. the patient's age and sex. and skin breakdown from casting occasionally occur. When the cast is removed. .5 cm compared with that of the uninjured leg. and patellar subluxation. Immediate postoperative weight bearing as tolerated with a walker or crutches is allowed by many authors. soccer. Infection. is possible.Postoperative Details Sutures or staples are removed at 2-3 weeks. Pull-out wires are removed at 3 weeks. Knee strength should be at least 85-90% of the other knee. Take care to restore normal alignment during surgery. Completion of a sport-specific agility program is highly recommended for athletes involved in vigorous sports. but some persistent quadriceps weakness is fairly common. Good ROM usually can be regained. The goal of therapy is to obtain full extension and flexion. patellar tilt.

care must be taken to educate all physicians on the importance of testing the integrity of the extensor mechanism in the injured knee. other studies have shown that ROM is routinely regained after up to 6 weeks of immobilization. their study provided the only comparison of immobilization and immediate motion in the literature to date. lower satisfaction scores.Several studies have shown markedly worse results with delayed repairs. . 19 Future and Controversies Several authors advocate immediate postoperative motion to potentially increase ultimate ROM. 17 However. It is hoped that physician awareness will lead to fewer cases of misdiagnosis of extensor mechanism injuries. Konrath and associates reported successful immediate motion without routine augmentation. the immediate motion group was very small. artificial graft was used to augment the repair and to allow early motion. In 2 studies. Future research comparing larger groups of patients treated with immobilization and early motion is needed to help resolve this issue. With the growing popularity of suture anchor fixation in other aspects of orthopedic surgery. Studies also have shown that mobilized tendons heal faster and are stronger than are immobilized tendons. Rougraff and colleagues reported significantly poorer functional results. Finally. 16 Additionally. however. more research will probably follow to better define the role of this technique in quadriceps tendon ruptures. and lower isokinetic data in patients with delayed repair. 16 Raatikainen and coworkers reported good results from simple debridement and repair of partial quadriceps tendon ruptures. No significant difference existed in the ultimate ROM between the groups. Rougraff and colleagues found that nearly all patients (including patients with delayed repairs) regained motion to within 2 º of their uninjured leg.