A simultaneous bilateral quadriceps and patellar tendons rupture in patients with chronic kidney disease undergoing long-term hemodialysis: a case report

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.

Acidosis induces significant changes to the murine supraspinatus enthesis organic matrix

Rotator cuff pathology is a common musculoskeletal condition that disproportionately affects older adults, as well as patients with diabetes mellitus and chronic kidney disease. It is known that increased age and kidney dysfunction have been correlated to acidotic states, which may be related to the increased incidence of rotator cuff injury. In order to investigate the potential relationship between acidosis and rotator cuff composition and mechanics, this study utilizes a 14-day murine model of metabolic acidosis and examines the effects on the supraspinatus tendon-humeral head attachment complex. The elastic matrix in the enthesis exhibited significant changes beginning at day 3 of acidosis exposure. At day 3 and day 7 timepoints, there was a decrease in collagen content seen in both mineralized and unmineralized tissue as well as a decrease in mineral:matrix ratio. There is also evidence of both mineral dissolution and reprecipitation as buffering ions continually promote pH homeostasis. Mechanical properties of the tendon-to-bone attachment were studied; however, no significant changes were elicited in this 14-day model of acidosis. These findings suggest that acidosis can result in significant changes in enthesis composition over the course of 14 days; however, enthesis mechanics may be more structurally mediated rather than affected by compositional changes.

Simultaneous Bilateral Patellar Tendon Rupture: A Systematic Review

The extensor mechanism of the knee can be damaged due to various modes of injury, which, in most cases, will require urgent surgical intervention for repair. Single patellar tendon ruptures are uncommon, but simultaneous bilateral events are even rarer and have been scarcely reviewed in English literature. Research in this area is mainly confined to case series, with some literature reviews but no evidence of more substantial analysis. Therefore, this systematic review was done to analyse the existing literature on bilateral simultaneous patellar tendon ruptures and propose a systematic and standardised approach to diagnosing and managing these injuries. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search terms included 'bilateral patellar tendon rupture', 'bilateral', 'patellar', 'tendon' and 'rupture'. Three independent reviewers conducted searches in PubMed, OvidSP for Medline, Embase and the Cochrane Library using the same search strategy. The eligibility criteria included studies on bilateral concomitant patellar tendon rupture published in English. Bilateral simultaneous patellar tendon ruptures of traumatic and atraumatic origin in human patients were included. The study types comprised case reports and literature reviews. The key limitation of this study was the low number of patients covered by the eligible literature. Patellar tendon ruptures are a rare and scarcely documented injury, and there is a need for studies with a high level of evidence, especially regarding surgical treatment choice and methods, as well as post-operative management, which could potentially lead to improved outcomes in the management of this injury.

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.

Quantitative evaluation of the Achilles tendon and supraspinatus tendon in end-stage kidney disease patients: A potential tool for predicting spontaneous tendon rupture

Many cases of spontaneous tendon rupture in end-stage kidney disease (ESKD) patients have been reported worldwide. Quantitative assessment of tendon has become an important way to improve the prognosis of patients. In the recruited healthy volunteers and ESKD patients, the thickness and shear wave velocity (SWV) of supraspinatus tendons and Achilles tendons were measured and compared among groups. Potential factors related to the tendon SWV of ESKD patients were screened in multiple linear regression. There was no significant difference in the tendon thickness and supraspinatus tendon SWV among groups. SWV of Achilles tendons in long-term dialysis ESKD patients were significantly lower than those in healthy volunteers (5.1 vs. 5.6 m/s, p < 0.01). Ca²⁺ , creatinine, body mass index, and genders are the significant factors related to the tendon SWV. Shear wave elastography can be used as a potential tool for predicting spontaneous tendon rupture in ESKD patients.

A Simultaneous Rupture of the Patellar Tendon and the Con-tralateral Quadriceps Tendon in a Patient with Chronic Renal Failure Undergoing Long Term Hemodialysis

Background:

Quadriceps or patellar tendon rupture incidence is relatively low, especially simultaneous bilateral rupture, which usually reported as a complication of chronic systemic disorders such as renal failure.

Objective:

Herein, we report a case of bilateral knee extensor mechanism ruptured in a patient with chronic renal failure on long standing hemodialysis.

Case presentation:

A 38-year-old white male, a known case of chronic renal failure on long term hemodialysis, presented to our clinic with clinical signs of bilateral simultaneous knee extensor tendons rupture. After proper workup simultaneous quadriceps and contralateral patellar tendons rupture diagnosis was made. The patient was managed with surgical repair of the tendons and within few days after the surgery he started physiotherapy and rehabilitation program, using walking crutches partial weight bearing mobilization was allowed, and a gradual increase of knee flexion within brace was applied. He used the knee braces and the walking crutches for two months, to ensure complete healing of the repaired tendon with a sufficient strength to allow full weight bearing. At four-year follow-up, complete bilateral knee extensor tendons healing and both knees functional outcome was satisfactory.

Conclusion:

A simultaneous rupture of quadriceps and contralateral patellar tendons is a rare event in patients with chronic renal failure undergoing long term hemodialysis. With early surgical intervention and good physiotherapy, the patient usually has good recovery of both knees function.

Complex ruptures of the quadriceps tendon: a systematic review of surgical procedures and outcomes

Background

Chronic ruptures, ruptures following total knee arthroplasty (TKA), and re-ruptures of the quadriceps tendon (QT) are rare. A systematic review of the current literature was conducted on their treatment and outcome to provide evidence-based indications for their management.

Methods

We searched published articles in English on chronic ruptures of QT, QT ruptures that occurred after TKA, and re-ruptures in PubMed, Scopus, and Google Scholar up to January 2021. Twenty-five articles were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Data from 25 articles (97 patients) with a mean age of 57 were retrieved. Patients were classified into three groups depending on the type of rupture: 16 patients suffered chronic QTR, 78 a QTR after a TKA, and 9 patients reported a re-rupture. The most frequent surgical approaches were different for each group: Codivilla’s Y-V technique and end-to-end sutures were the most commonly used in the chronic tears group (62.5%), synthetic MESH was the most frequent choice in QTR after a TKA group (38 patients, 53%), while end-to-end sutures were the first choice in the re-rupture group (4 patients, 44%).

Conclusions

Complex ruptures of the QT can be chronic ruptures, re-ruptures, or ruptures occurring after TKA. The choice of the best surgical technique depends on the macroscopic quality of the tendon stumps rather than the timing of intervention. Evidence-based preventive and therapeutic strategies should be developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02696-9.

Uremic Toxins and Ciprofloxacin Affect Human Tenocytes In Vitro

Tendinopathy is a rare but serious complication of quinolone therapy. Risk factors associated with quinolone-induced tendon disorders include chronic kidney disease accompanied by the accumulation of uremic toxins. Hence, the present study explored the effects of the representative uremic toxins phenylacetic acid (PAA) and quinolinic acid (QA), both alone and in combination with ciprofloxacin (CPX), on human tenocytes in vitro. Tenocytes incubated with uremic toxins +/- CPX were investigated for metabolic activity, vitality, expression of the dominant extracellular tendon matrix (ECM) protein type I collagen, cell-matrix receptor β1-integrin, proinflammatory interleukin (IL)-1β, and the ECM-degrading enzyme matrix metalloproteinase (MMP)-1. CPX, when administered at high concentrations (100 mM), suppressed tenocyte metabolism after 8 h exposure and at therapeutic concentrations after 72 h exposure. PAA reduced tenocyte metabolism only after 72 h exposure to very high doses and when combined with CPX. QA, when administered alone, led to scarcely any cytotoxic effect. Combinations of CPX with PAA or QA did not cause greater cytotoxicity than incubation with CPX alone. Gene expression of the pro-inflammatory cytokine IL-1β was reduced by CPX but up-regulated by PAA and QA. Protein levels of type I collagen decreased in response to high CPX doses, whereas PAA and QA did not affect its synthesis significantly. MMP-1 mRNA levels were increased by CPX. This effect became more pronounced in the form of a synergism following exposure to a combination of CPX and PAA. CPX was more tenotoxic than the uremic toxins PAA and QA, which showed only distinct suppressive effects.