The increasing incidence of surgically treated quadriceps tendon ruptures

Distinct risk profiles for short-term surgical complications and venous thromboembolism exist among extensor mechanism repair procedures

PURPOSE

Extensor mechanism injuries, which comprise patella fractures, patella tendon tears and quadriceps tendon tears, are severely debilitating injuries and a common cause of traumatic knee pathology that requires surgical intervention. Risk factors for short-term surgical complications and venous thromboembolism (VTE) in this population have not been well characterised. The aim of this study was to identify perioperative risk factors associated with these short-term complications.

METHODS

The National Surgical Quality Improvement Program database was used to identify patients who underwent an isolated, primary extensor mechanism repair from 2015 to 2020. Patients were stratified by injury type. Demographic data were collected and compared. A multivariate logistic regression was used to control for demographic and comorbid factors while assessing risk factors for developing short-term complications.

RESULTS

A total of 8355 patients were identified for inclusion in this study. Overall, 3% of patients sustained short-term surgical complications and 1% were diagnosed with VTE within 30 days of surgery. Patella fracture fixation had a nearly twofold higher risk for surgical complications compared to quadriceps tendon repair (p = 0.004). Patella tendon repair had a twofold higher risk for VTE (p = 0.045), specifically deep vein thrombosis (p = 0.020), compared to patella fracture fixation. Increasing age, smoking and American Society of Anesthesiologists Classifications 3 and 4 were also found to be risk factors for surgical complications (p = 0.012, p = 0.004, p = 0.011 and p = 0.032, respectively).

CONCLUSION

This study used a nationally representative, widely validated, peer-reviewed database to provide valuable insights into risk factors for short-term postoperative complications associated with extensor mechanism repair procedures, revealing notable differences in risk profiles among distinct surgical procedures. The results of this study will inform surgeons and patients in enhancing risk assessment, guiding procedure-specific decision-making, optimising preoperative care, improving postoperative monitoring and contributing to future research of extensor mechanism injuries.

LEVEL OF EVIDENCE

Level III.

Risk Factors Associated With Poor Outcomes After Quadriceps Tendon Repair

Background

Ruptures of the quadriceps tendon present most frequently in older adults and individuals with underlying medical conditions.

Purpose

To examine the relationship between patient-specific factors and tear characteristics with outcomes after quadriceps tendon repair.

Study Design

Case-control study; Level of evidence, 3.

Methods

A retrospective review was conducted on all patients who underwent quadriceps tendon repair between January 1, 2016, and January 1, 2021, at a single institution. Patients <18 years and those with chronic quadriceps tendon tears (>6 weeks to surgery) were excluded. Information was collected regarding patient characteristics, presenting symptoms, tear characteristics, physical examination findings, and postoperative outcomes. Poor outcome was defined as a need for revision surgery, complications, postoperative range of motion of (ROM) <110° of knee flexion, and extensor lag of >5°.

Results

A total of 191 patients met the inclusion criteria. Patients were aged 58.5 ± 13.2 years at the time of surgery, were predominantly men (90.6%), and had a mean body mass index (BMI) of 32.2 ± 6.3 kg/m2. Patients underwent repair with either suture anchors (15.2%) or transosseous tunnels (84.8%). Postoperatively, 18.5% of patients experienced knee flexion ROM of <110°, 11.3% experienced extensor lag of >5°, 8.5% had complications, and 3.2% underwent revision. Increasing age (odds ratio [OR], 1.03 [95% CI, 1.004-1.07]) and female sex (OR, 3.82 [95% CI, 1.25-11.28]) were significantly associated with postoperative knee flexion of <110°, and increasing age (OR, 1.08 [95% CI, 1.04-1.14]) and greater BMI (OR, 1.14 [95% CI, 1.05-1.23]) were significantly associated with postoperative extensor lag of >5°. Current smoking status (OR, 15.44 [95% CI, 3.97-65.90]) and concomitant retinacular tears (OR, 9.62 (95% CI, 1.67-184.14]) were associated with postoperative complications, and increasing age (OR, 1.05 [95% CI, 1.02-1.08]) and greater BMI (OR, 1.08 [95% CI, 1.02-1.14]) were associated with risk of acquiring any poor outcome criteria.

Conclusion

Patient-specific characteristics-such as increasing age, greater BMI, female sex, retinacular involvement, and current smoking status-were found to be risk factors for poor outcomes after quadriceps tendon repair. Further studies are needed to identify potentially modifiable risk factors that can be used to set patient expectations and improve outcomes.

Patellar and quadriceps tendon rupture are associated with hip fracture in hemodialysis patients with severe hyperparathyroidism

Spontaneous rupture of the patellar (PTR) and quadriceps (QTR) tendon is infrequent. Systemic diseases such as diabetes mellitus, CKD, and secondary hyperparathyroidism (SHPT) are risk factors. The present cohort study aimed to evaluate risk factors associated with tendon rupture in hemodialysis (HD) patients with SHPT, as well as outcomes including surgical complications, re-ruptures, and fracture. Baseline clinical, laboratorial data, and radiographs were analyzed. Patients were followed up from March 2012 to March 2020. One-hundred thirty-one patients (≥18 yr of age, on HD ≥ 6 mo, with SHPT) were included. Incidence rates of PTR and QTR were 2.3 and 1.7/10000 HD patients/yr, respectively. The mean age of patients with tendon rupture was 44.0 ± 11.2 yr. These patients exhibited higher serum levels of phosphorus (6.3 ± 1.5 mg/dL vs 5.6 ± 1.1 mg/dL; P = .005), PTH (2025.7 ± 667.6 pg/mL vs 1728.4 ± 684.8 pg/mL; P = .035), and C-reactive-protein (35.4 ± 32.9 mg/dL vs 17 ± 24.5 mg/dL; P = .002) compared to the group without tendon rupture. The mean follow-up was 56.7 ± 27.1 mo. No patient required a new surgical approach or experienced re-rupture. Of all patients, 31% experienced hip fracture: 50% in the group with rupture (29.5 ± 17.4 mo after the tendon rupture) vs 26% without tendon rupture (P = .015). After adjustment, the hazard ratio for hip fracture was 2.87 (95% CI, 1.27-6.49; P = .012). Patients with SHPT and high levels of phosphorus, PTH, and inflammatory markers were at greater risk for tendon rupture. Surgical complication rates were low. However, results suggest that tendon rupture of knee extensor mechanism in HD patient with SHPT should be regarded as a "red flag" for future hip fracture.

Chronic quadriceps tendon rupture: quadriceps tendon reconstruction using ipsilateral semitendinosus tendon graft

Ruptures of the quadriceps tendon (QTRs) are uncommon. If the rupture is not diagnosed, chronic ruptures may develop. Re-ruptures of the quadriceps tendon are rare. Surgery is challenging because of tendon retraction, atrophy and poor quality of the remaining tissue. Multiple surgical techniques have been described. We propose a novel technique in which the quadriceps tendon is reconstructed using the ipsilateral semitendinosus tendon.

Trends and epidemiology of knee extensor mechanism injuries presenting to United States emergency departments from 2001 to 2020

OBJECTIVES

Injuries to the native extensor mechanism (EM) of the knee are potentially disabling and often require surgical treatment. Large-scale, updated epidemiological data on these injuries is lacking. The objective of the current study was to examine recent trends in EM injuries presenting to United States (US) Emergency Departments (EDs) over the last 20 years using a nationally representative sample.

METHODS

This study retrospectively analyzed the National Electronic Injury Surveillance System (NEISS) database to identify cases of EM injuries (defined as either a quadriceps tendon rupture, a patella fracture, or a patellar tendon rupture) presenting to EDs in the US from 2001 to 2020.

RESULTS

During the study period, an estimated 214,817 EM injuries occurred in an at-risk population of 6,183,899,410 person-years for an overall incidence rate of 3.47 per 100,000 person-years. Patella fractures (PFs) were the most common injury type, representing 77.5% of all EM injuries (overall incidence rate: 2.69), followed by patellar tendon ruptures (PTRs; 13.5%; incidence: 0.48) and quadriceps tendon ruptures (QTRs; 9%; incidence: 0.31). Demographic characteristics and mechanisms of injury differed between injury types. Annual incidence rates increased significantly during the study period for all EM injury types, with PTRs demonstrating the largest relative increase (average annual percent increase: PF, 2.8%; PTR, 7.2%; QTR, 5.3%). Accounting for population growth yielded an increasing incidence of all EM injuries combined from 3.65 in 2001 to 4.9 in 2020. The largest relative increases in incidence rates were observed in older age groups.

CONCLUSION

Extensor mechanism injuries of the knee are increasing in the US, which likely reflects an aging and more active population. These types of injuries are associated with substantial functional impairment and recent increases in incidence rates highlight the need for injury prevention and management strategies.

Suture Anchor-Based Quadriceps Tendon Repair May Result in Improved Patient-Reported Outcomes but Similar Failure Rates Compared to the Transosseous Tunnel Technique

PURPOSE

The purpose of this study was to compare failure rates and patient-reported outcomes between transosseus (TO) suture and suture anchor (SA) quadriceps tendon repairs.

METHODS

Following institutional review board approval, patients who underwent primary repair for quadriceps tendon rupture with TO or SA techniques between January 2009 and August 2018 were identified from an institutional database and retrospectively reviewed. Patients were contacted for satisfaction (1-10 scale), current function (0-100 scale), failure (retear), and revision surgeries; International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were also collected to achieve a minimum of 2-year follow-up.

RESULTS

Sixty-four patients (34 SA, 30 TO) were available by phone or e-mail at a mean of 4.81 ± 2.60 years postoperatively. There were 10 failures, for an overall failure rate of 15.6%. Failure incidence did not significantly differ between treatment groups (P = .83). Twenty-seven patients (47% of nonfailed patients) had completed patient-reported outcomes. The SA group reported higher subjective function (SA: 90 [85-100] vs TO: 85 [60-93], 95% CI of difference: -19.9 to -2.1 × 10^-5, P = .042), final IKDC (79.6 [50.0-93.6] vs 62.1 [44.3-65.5], 95% CI of difference: -33.0 to -0.48, P = .048), KOOS Pain (97.2 [84.7-97.2] vs 73.6 [50.7-88.2], 95% CI of difference: -36.1 to -3.6 × 10^-5, P = .037), Quality of Life (81.3 [56.3-93.8] vs 50.0 [23.4-56.3], 95% CI of difference: -50.0 to -6.2, P = .026), and Sport (75.0 [52.5-90.0] vs 47.5 [31.3-67.5], 95% CI of the difference: -45.0 to -4.1 × 10^-5, P = .048).

CONCLUSIONS

There is no significant difference in failure rate between transosseus and suture anchor repairs for quadriceps tendon ruptures (P = .83). Most failures occur secondary to a traumatic reinjury within the first year postoperatively. Despite the lack of difference in failure rates, at final follow-up, patients who undergo suture anchor repair may report significantly greater subjective function and final IKDC, KOOS Pain, Quality of Life, and Sport scores.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Repair of Bilateral Quadriceps Tendon Rupture Using a Modified Knotless Suture Anchor and Internal Brace Technique: Surgical Technique and Case Report

BACKGROUND

Quadriceps tendon rupture (QTR) is a rare clinical condition often caused by indirect injury in healthy people. In addition, spontaneous and bilateral ruptures can occur in patients with predisposing factors, such as endocrine or rheumatic disease. Currently, several QTR repair techniques have been proposed; however, no consensus exists about the best repair technique.

CASE PRESENTATIONS

A 55-year-old man with renal failure secondary to glomerulonephritis suffered from spontaneous bilateral quadriceps tendon ruptures. Based on a knotless suture anchor and internal brace, a novel double-row suture-bridge configuration surgical approach was used to treat the patient. At 11-month follow-up, the patient maintained excellent function, with a Lysholm score of 91 for both knees.

CONCLUSIONS

This technique may be an effective method for repairing ruptured quadriceps tendons.

Midterm outcome and strength assessment after quadriceps tendon refixation with suture anchors

PURPOSE

Quadriceps tendon ruptures (QTR) occur predominantly in middle-aged patients through violent eccentric contraction that occurs either when trying to regain balance or during a fall on the hyperflexed knee. The aim of this study was to quantify midterm postoperative results, including strength potential measured via standardized strength tests following acute (< six weeks) quadriceps tendon refixation using suture anchors.

METHODS

All consecutive patients with QTR who underwent surgical suture anchor refixation between 2012 and 2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Tegner Activity Scale (TAS), Lysholm score, International Knee Documentation Committee subjective knee form (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, return to work rates, and Visual Analog Scale (VAS) for pain. Additionally, a standardized clinical examination and an isometric strength assessment of knee extension and flexion were performed.

RESULTS

A total of 17 patients (median age 61.0 [25-75% IQR 50.5-72.5]) were available for final assessment at a mean follow-up of 47.1 ± SD 25.4 months. The majority of patients were male (82.4%) and most injuries occurred due to a fall on the hyperflexed knee (76.5%). The average time interval between trauma and surgery was 12.7 ± 7.5 days. Patients achieved a moderate level of activity postoperatively with a median TAS of 4 (3-5.5) and reported good to excellent outcome scores (Lysholm score: 97 (86.5-100); IKDC: 80.7 ± 13.5; KOOS subscales: pain 97.2 (93.1-100), symptoms 92.9 (82.5-100), activities of daily living 97.1 (93.4-100), sport and recreation function 80 (40-97.5) and knee-related quality of life 87.5 (62.5-100). All patients were able to fully return to work and reported little pain [VAS: 0 (0-0)]. No postoperative complications were reported. Strength measurements revealed a significant deficit of knee extension strength in comparison to the contralateral side (p = 0.011).

CONCLUSION

Suture anchor refixation of acute QTR leads to good functional results and high patient satisfaction without major complications. Isometric knee extension strength, however, may not be fully restored compared to the unaffected side.

Extensor Mechanism Ruptures and Reruptures: Perioperative Opioid Management

The purpose of this study was to determine (1) the correlation between preoperative and postoperative opioid use and (2) risk factors associated with rerupture in patients undergoing open extensor mechanism repair. A retrospective review of patients who underwent operative repair of quadriceps or patellar tendon rupture was performed. Patients were classified as opioid nonusers if they had not received any opioid medications in the 3 months before surgery, or as acute users or chronic users if they received at least one opioid prescription within 1 month or 3 months preceding surgery. Clinical records were reviewed for postoperative opioid use within a year after surgery as well as rerupture rates. A total of 144 quadriceps tendon and 15 patellar tendon repairs were performed at a mean age of 56.8 ± 15.1 years and body mass index of 33.2 ± 7.1. The overall rerupture rate was 6%. Diabetes was a significant risk factor for rerupture (56 vs. 19%, p = 0.023). Chronic preoperative opioid users were more likely to continue to use opioids beyond 1 month postoperatively (p < 0.001) as compared with acute or nonopioid users. Chronic preoperative opioid users (relative risk [RR]: 3.53, 95% confidence interval [CI]: 2.11-5.90) and patients with longer anesthesia time (RR: 1.39, 95% CI: 1.00-1.93) required more monthly opioid refills, whereas tourniquet use required fewer opioid refills each month (RR: 0.57, 95% CI: 0.37-0.88). Compared with patients without a rerupture, each additional prescription refill after the initial repair in the rerupture group was associated with a 22% higher risk of tendon rerupture (RR: 1.22, 95% CI: 1.07-1.39). The chronicity of preoperative opioid intake was found to have a significant effect on postoperative opioid use. This study suggests that there is a higher prevalence of rerupture in patients with prolonged opioid use postoperatively and among diabetics.

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.

Early, Bilateral Re-Rupture of Quadriceps Tendon After Previous Bone-Anchor Repair for Simultaneous, Low-Energy, Bilateral Quadriceps Rupture: A Case Report and Literature Review

Patient: Male, 42-year-old

Final Diagnosis: Bilateral quadriceps tendon re-rupture

Symptoms: Disability • pain

Medication: —

Clinical Procedure: —

Specialty: Orthopedics and Traumatology

Considerations in spontaneous quadriceps tendon rupture repair in end-stage renal disease patients: A case report

INTRODUCTION

Spontaneous quadriceps tendon rupture (SQTR) is a rare injury to the knee extensor mechanism that is usually associated with systemic diseases such as end stage renal diseases (ESRD) and it is more prevalent in the elderly. Due to the underlying pathology, quadriceps tendon rupture warrants special considerations and management in its repair.

CASE REPORT

We present two cases of quadriceps tendon rupture in end-stage renal disease (ESRD) patients. The first case; a 57 years old female who had bilateral SQTR and is undergoing hemodialysis. The second patient, a 26 years old male had unilateral quadriceps tendon rupture caused by minimal trauma. The first patient had a trans-osseous repair by direct suturing the quadriceps tendon stump to the proximal pole patella. The second patient was repaired with a modified Bunnel suture and anchor placement on the proximal pole patella. The first case had a re-rupture of the right quadriceps tendon and the second case has recovered with improved outcomes.

DISCUSSION

Spontaneous quadriceps tendon rupture is usually underlined by degenerative changes of the tendons. Special care is needed to address the pathologic tendon underlying SQTR. The current surgical literature still lacks the statistical data that shows which surgical approach is most optimal for SQTR in ESRD patients.

CONCLUSION

SQTR rupture is generally an injury of brittle tendons caused by underlying diseases. A multidisciplinary and comprehensive approach including a proper surgical approach and postoperative managements are crucial for good functional outcomes of the extensor mechanism.

Bringing tendon biology to heel: Leveraging mechanisms of tendon development, healing, and regeneration to advance therapeutic strategies

Tendons are specialized matrix-rich connective tissues that transmit forces from muscle to bone and are essential for movement. As tissues that frequently transfer large mechanical loads, tendons are commonly injured in patients of all ages. Following injury, mammalian tendons heal poorly through a slow process that forms disorganized fibrotic scar tissue with inferior biomechanical function. Current treatments are limited and patients can be left with a weaker tendon that is likely to rerupture and an increased chance of developing degenerative conditions. More effective, alternative treatments are needed. However, our current understanding of tendon biology remains limited. Here, we emphasize why expanding our knowledge of tendon development, healing, and regeneration is imperative for advancing tendon regenerative medicine. We provide a comprehensive review of the current mechanisms governing tendon development and healing and further highlight recent work in regenerative tendon models including the neonatal mouse and zebrafish. Importantly, we discuss how present and future discoveries can be applied to both augment current treatments and design novel strategies to treat tendon injuries.

Suture Tape Reduces Quadriceps Tendon Repair Gap Formation Compared With High-Strength Suture: A Cadaveric Biomechanical Analysis

PURPOSE

To compare the biomechanical differences between quadriceps tendon (QT) repair with high-strength suture (HSS) versus suture tape (ST) with varying number of suture passes.

METHODS

In total, 28 fresh-frozen QTs were randomized into 2 groups: (1) HSS; or (2) ST; specimens were then further randomized into subgroups of either 4 or 6 suture passes. Specimens were secured within a materials testing system and a 150-N preload was applied for 10 seconds followed by a cyclic loading protocol between 50 N and 250 N for 1000 cycles. Video was used to follow tracking markers used to calculate the magnitude of tendon displacement. Two-way univariate analysis of variance was used to determine the effect of suture type and passes on the displacement after preloading and mixed repeated-measures analysis of variance was used to determine the effect of suture type and passes on displacement following cyclic loading.

RESULTS

There were large increases in displacement following the preload across all conditions (7.82 ± 3.64 mm), with no statistically significant differences between groups. There was a significant difference in the mean (± standard deviation) displacement between the ST (5.24 ± 2.82 mm) and HSS (7.93 ± 2.91 mm) starting at 200 cycles, which became more pronounced with successive testing out to 1000 cycles (P = .021). There were no significant difference with respect to the number of suture or tape passes.

CONCLUSIONS

Following preloading at 150 N, significant displacement occurred in both QT repair groups. ST demonstrated significantly less displacement than HSS under cyclic loading and had greater ultimate failure loads.

CLINICAL RELEVANCE

When performing QT repair, emphasis should be placed on appropriate pretensioning of sutures to at least 150 N before knot-tying. In addition, where available, ST should be used over HSS to reduce further cyclic elongation and improve ultimate failure loads.

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.