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Rupture of the Quadriceps

- See: Extensor Mechanism Injuries of the Knee:
- Discussion:
    - rupture of quadriceps tendons is most common in the 6th & 7th decades, and is probably associated w/decreased  vasculature;
    - Male:female  8:1
    - more common w/ cortisone injections, diabetes, chronic renal failure; hyperthyroidism, and gout;
    - tear may involve either portion of trilaminar tendon or its entirety;
    - usually the tear is initiated centrally and progresses peripherally;
    - tendon usually ruptures transversely at the osteotendinous junction;
    - rupture often extends thru the vastus intermedius tendon, proximal to the rupture of the rectus femoris tendon;        
    - its level usually corresponds to amount of flexion at time of injury;
           - superficial and deep tears rarely involve the trilaminar structure at the same level;
    - unlike the achilles tendon rupture, the quadriceps disruption is usually associated w/ intense pain, although in cases of chronic tendon  
           atrition (as from renal failure) pain may be minimal;

- Clinical Presentation:
    - large hemarthrosis
    - freely mobile patella and an impressive loss of extensor function with intact knee flexion;
    - patient is unable to walk;
    - look for palpable defect(suprapatellar gap) swelling 2nd to hemarthrosis, pt unable to extend the knee;
    - hemarthrosis/swelling may mask defect; aspiration or knee flexion may widen the gap by shortening the rectus
    - quad tendon usually ruptures transversely just proximal to patella;
    - partial tears
           - an extensor lag usually is present;
           - in these patients, MRI may delineate the extent of injury.
           - partial tears of quadriceps tendon may be treated nonsurgically w/ immobilization and early range of motion. 

- Radiographs:

    - may show patella in a lower position than normal, use contralateral patella for comparison;
    - Insall-Salvati method for determining patella alta/baja
           - Constant relationship  length of patella (P) and length of the patellar tendon (T)
           - Normal (T/P) = 0.80 - 1.2
           - Patella Infera/Baja < .80  possible Quad tendon rupture 
           - Patella Alta   > 1.2  possible Patella tendon rupture 

- Surgical Treatment:

   - rupture is repaired within 7 days if possible;
   - early intervention allows end-to-end repair of the tendon as well as tendon to bone anchorage;
   - make anterior longitudinal incision in midline of extremity;
   - transossoeous repair:
           - fibers of rectus femoris tendon are sutured to superior pole of patella through drill holes, as is done for
                    patellar tendon ruptures;           
           - roughen the surface of the patella to promote healing;
           - take care not to place the drill holes too close to the anterior patellar surface, (in order to avoid patellar tilt);
           - place drill holes in center of patella (with respect to AP), so bias the drill hole slightly toward to the articular surface;
           - No 5 Ethibond/Fiberwire suture is then passed thru the quadriceps tendon (using the Krachow or Becker technique)
                    and then is passed thru the drill holes;
           - because rupture nearly always takes place early thru an area of degeneration, consider reinforcement of
                    sutures w/ fascia strips; 
           - if the repair is strong, consider not repairing the lateral retinaculum (if it is torn) inorder to avoid patellar subluxation; 
    - references:
            - Primary repair of quadriceps tendon ruptures. Results of treatment.
            - Transpatellar refixation of acute quadriceps tendon ruptures close to the proximal patella pole using FiberWire
            - A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report

    - Scuderi technique:
           - triangular tongue of tissue distally from the anterior surface of the proximal tendon;
                 - from anterior surface of proximal part of tendon fashion triangular flap 2-3 mm thick, 7.5 cm long on each side, and 5 cm wide;
           - the base of the flap is left attached 5 cm above the rupture;
           - the proximal tip of the flap is then turned over the rupture and is sutured in place;
           - turn down triangular distally and suture it in place across rupture;
    - Codivilla technique:
           - indicated for chronic ruptures where the tendon edges cannot be opposed;
           - create a full thickness inverted V flap which ends 1.5 cm above the rupture;
           - the tendon edges are repaired w/ heavy suture;
           - the proximal portion of the inverted V is closed down (coverting it to a verticle line);

- Post Operative Care:
    - immobilize for 4-6 weeks, and then begin ROM, followed by crutch walking for 6-8 weeks 
    - patients passive and active flexion is limited by a hinged brace set to 30 deg. for 2 weeks, then increased to 60 deg for 2-4 weeks, and then
           to 90 deg for weeks for 4-6 weeks post op;
           - patiens are allowed full body weight being;
    - references:
           - Postoperative functional rehabilitation after repair of quadriceps tendon ruptures: a comparison of two different protocols.
           - A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report.

Bilateral simultaneous rupture of the quadriceps tendons. A report of four cases and review of the literature.
Ruptures of the extensor mechanism of the knee joint.
Outcomes following repair of quadriceps tendon ruptures
Complications in Brief: Quadriceps and Patellar Tendon Tears.