Chapter 12
Acute and Chronic Rupture of the Quadriceps Tendon Treated with Direct Repair
Robert E. Booth and Frank P. Femino
Rupture of the quadriceps tendon after total knee arthroplasty is rare and there is scant information in the literature regarding this problem.1–3 In the nonimplant population, quadriceps tendon rupture is the more common malady in the older patient and patel- lar tendon rupture in the younger patient.4–6The reverse seems to be true after knee replacement despite the older average age of this population.
The causes of quadriceps rupture in the total knee arthroplasty patient are multiple. They include mechanical, systemic, and local factors. Mechanically, the tensile forces generated across the quadriceps tendon are very high, with values approaching 3000 newtons. They are greater than the forces in the patellar tendon at 90 and 120 degrees of flexion but less at 60 degrees of flexion.7In the setting of soft tissue compromise and with such large forces being sustained by the extensor mechanism, it is not surprising that rupture of the quadriceps tendon can occur after a total knee arthroplasty. Vascular and soft tissue compromise following surgi- cal procedures such as a lateral retinacular release or a Roux- Goldthwaite procedure can lead to rupture and several cases have also been reported.2,3
In a patient with a total knee arthroplasty there is little con- traindication to directly repairing the acutely ruptured quadriceps tendon. If there is minimal soft tissue compromise, the techniques used in nonarthroplasty patients are perfectly valid. These tech- niques are widely described in the literature and include end-to- end repair alone or with supplemental fixation.4,5,8 The problem arises when, as is often the case in the total knee arthroplasty patient, there is structural compromise of the quadriceps tendon.
This can make re-rupture common. Whether the rupture is acute or chronic often makes little difference. Therefore, reinforcement of the repair and augmentation of the soft tissue is advised. Tech-
niques are described using various reinforcement techniques such as a quadriceps turndown flap (Fig. 12.1, Scuderi turndown tech- nique).6,9 In the chronic situation, the Codivilla technique of quadriceps lengthening may be necessary due to shortening of the extensor mass (Fig. 12.2, Codivilla technique of tendon lengthen- ing and repair).10
The results for early repair of acute quadriceps tendon ruptures in nonarthroplasty patients have been excellent.4,11The functional outcome in the patient with a total knee arthroplasty has been con- sistently inferior. Extensor lag and quadriceps weakness are common and may require bracing.1,2,12The repair should be pro- tected for several months.1,3A series of three repairs reported by Lynch and colleagues resulted in one re-rupture after 6 weeks, leaving a 35-degree permanent extension lag, as well as limited flexion and significant extension lag in the other two.3The only
12. ACUTE AND CHRONIC RUPTURE OF THE QUADRICEPS TENDON TREATED 155
FIGURE12.1. The Scuderi technique for repairing acute tears of the quadri- ceps tendon. (A) The torn edges of the quadriceps tendon are debrided and repaired. (B) A triangular flap of the proximal tendon is developed, folded distally over the rupture, and sutured in place. (C) Pullout sutures are then placed in the medial and lateral retinaculum.
exception is a case reported by Fernandez-Baillo and associates13 in which he repaired a traumatic rupture of the quadriceps tendon occurring over 1 month after a total knee replacement. He used the technique described by Scuderi and reinforced the repair with Dacron tape. The functional result was good after 1 year, with no pain, a range of motion of 0 to 110 degrees, and almost normal quadriceps strength.13
It is our recommendation to perform the repair as soon as pos- sible, because acute repair will minimize further quadriceps atrophy and shortening. We prefer the technique as described by Scuderi with the discretionary use of Dacron tape reinforcement, based on intraoperative assessment. Postoperative treatment con- sists of full weight-bearing in a cylinder cast for 6 weeks. The cast is then removed and gradual flexion is begun in a protective hinged brace. Physical therapy for strengthening is started. Our goal is to reach 90 degrees of flexion at 3 months with minimal extensor lag.
Maximum results can be expected between 6 and 12 months.
References
1. Gustillo RB, Thompson R. Quadriceps and patellar tendon ruptures following total knee arthroplasty. In: Rand JA, Dorr LD, eds. Total Arthroplasty of the Knee. Rockville, Maryland: Aspen, 1987:45.
156 R.E. BOOTH AND F.P. FEMINO
FIGURE12.2. The Codvilla quadriceps tendon lengthening and repair for chronic ruptures. (A) The torn tendon edges are debrided and repaired. (B) An inverted V is cut through the proximal tendon. (C) The flap is brought distally and sutured in place. The upper portion on the V defect is then repaired.
2. Doolittle KH, Turner RH. Patellofemoral problems following total knee arthroplasty. Orthop Rev. 1988; 17:696–702.
3. Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism complica- tions following total knee arthroplasty. J Arthroplasty. 1987; 2:135–140.
4. Siwek CW, Rao JO. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg. 1981; 63A:932–937.
5. Larsen E, Lund PM. Ruptures of the extensor mechanism of the knee joint. Clin Orthop. 1986; 213:150–153.
6. Murzic WJ, Hardaker WT, Goldner JL. Surgical repair of extensor mechanism ruptures of the knee. Complic Orthop. 1992; 7:276–279.
7. Huberti HH, Hayes WC, Stone JL, Shybut GT. Force ratios in the quadriceps tendon and ligamentum patellae. J Orthop Res. 1984; 2:
49–54.
8. Walker LG, Glick H. Bilateral spontaneous quadriceps tendon ruptures.
Orthop Rev. 1989; 18:867–871.
9. Scuderi C. Ruptures of the quadriceps tendon. Am J Surg. 1958; 95:
626–634.
10. Scuderi C, Schrey EL. Ruptures of quadriceps tendon; study of 14 tendon ruptures. Arch Surg. 1950; 61:42–54.
11. Rasul AT, Fischer DA. Primary repair of quadriceps tendon ruptures.
Clin Orthop. 1993:205–207.
12. MacCollum MS, Karpman RR. Complications of the PCA anatomic patella. Orthopedics. 1989; 12:1423–1428.
13. Fernandez-Baillo N, Garay EG, Ordonez JM. Rupture of the quadriceps tendon after total knee arthroplasty: a case report. J Arthroplasty.
1993:331–333.
12. ACUTE AND CHRONIC RUPTURE OF THE QUADRICEPS TENDON TREATED 157
