eMedicine Specialties > Orthopedic Surgery > Knee

Quadriceps Tendon Rupture: Treatment

Author: James Lyle, MD, Consulting Surgeon, Department of Orthopedic Surgery, Hughston Clinic
Contributor Information and Disclosures

Updated: Mar 7, 2008

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 flaps31
  • Carbon fiber32
  • 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 4). 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.

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 5).

Running, interlocked stitches are placed medial and lateral in the tendon using 5-0 nonabsorbable suture. The Bunnell-type weave and Krackow whipstitches are popular. The free suture ends are passed through the drill holes from proximal to distal with a suture passer (see Image 6). The tendon then is pulled by the sutures distally into the trough (see Image 7). Secure the sutures with a hemostat, and assess patellar rotation and tracking throughout the ROM of the knee. If satisfactory, tie the sutures distally and repair the retinaculum with absorbable sutures (see Image 8). Additionally, if a significant vastus intermedius stump remains, this may be used to augment the repair posteriorly. After routine subcutaneous and skin closure, apply a cylinder cast with the knee in full extension.

If necessary, the repair may be reinforced with extra tissue by using the Scuderi technique. A triangular flap from the anterior portion of the tendon is fashioned, with the base about 5 cm proximal to the tear. The flap should be roughly 3-4 mm thick, 7.5 cm long on each side, and 5 cm wide at its base. The posterior portion of the tendon is left intact. The apex of the triangle is folded distally and sutured over the repair site. Bunnell pull-out wires are placed medially and laterally, running from the quadriceps tendon to the patellar tendon, exiting the skin distally. Following wound closure, the knee is cast in full extension.

For chronic ruptures, a direct repair with augmentation using the Scuderi technique (if necessary) is attempted. The quadriceps tendon and muscle are freed from adhesions. If the tendon cannot be re-approximated to the patella, the Codivilla tendon lengthening technique can be used. A triangular flap is fashioned similar to that used in the Scuderi technique, except that the flap consists of the full thickness of the tendon. Also, the base of the flap is more distal, about 1.5-2.0 cm proximal to the tear. The tendon and retinaculum then are advanced distally until re-approximation is possible. Suturing is performed as previously described. The flap is folded distally and sutured over the repair. The proximal aspect of the open triangle is repaired with absorbable suture. Pull-out wires are recommended to protect the repair.

If a defect remains following Codivilla lengthening, options for additional augmentation include the vastus lateralis strip, fascia lata grafts, the sartorius rotational flap, and artificial graft material. If a long course of conservative management for partial quadriceps tendon ruptures fails, surgery may be necessary. Repair using patellar drill holes, as well as simple excision of the scar tissue and closure, has been advocated.

Postoperative Details

Sutures or staples are removed at 2-3 weeks. Pull-out wires are removed at 3 weeks. Most authors prefer cylinder casting for 4-6 weeks. Immediate postoperative weight bearing as tolerated with a walker or crutches is allowed by many authors. Isometric quadriceps exercises may be started in the cast. When the cast is removed, ROM exercises are initiated along with continued quadriceps strengthening.33

A hinged knee brace may be used, with flexion gradually increased over time. Therapy is continued until strength and motion are comparable to those of the uninjured leg. The goal of therapy is to obtain full extension and flexion. A few authors have advocated immediate postoperative ROM exercises and delayed weight bearing.

For chronic repairs, postoperative treatment is similar, but protection of the repair and rehabilitation can be longer. Postoperative care for partial tear repairs requires minimal immobilization and a shorter period of rehabilitation.

Follow-up

Athletes treated for partial or complete ruptures may return to play when several conditions are met, including the following:

  • The patient should have nearly full, painless ROM.
  • Knee strength should be at least 85-90% of the other knee.
  • Completion of a sport-specific agility program is highly recommended for athletes involved in vigorous sports, such as football, basketball, soccer, or tennis.

Complications

The most common complications are loss of motion and extensor mechanism weakness. Infection, wound compromise, and skin breakdown from casting occasionally occur. Although uncommon, malalignment of the patella, including patella alta, patellar tilt, and patellar subluxation, is possible.

Take care to restore normal alignment during surgery, because malalignment can lead to degenerative changes of the patellofemoral joint. Repeat rupture occurs infrequently. Rougraff and colleagues reported 2 repeat ruptures in 53 repairs, while Konrath and associates observed 1 repeat rupture in 50 repairs.17,16

More on Quadriceps Tendon Rupture

Overview: Quadriceps Tendon Rupture
Workup: Quadriceps Tendon Rupture
Treatment: Quadriceps Tendon Rupture
Follow-up: Quadriceps Tendon Rupture
Multimedia: Quadriceps Tendon Rupture
References
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References

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Further Reading

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Keywords

extensor mechanism disruption, tooth sign, patellar tendon ruptures, jumper's knee, unilateral quadriceps tendon ruptures, bilateral quadriceps tendon ruptures, quadriceps tendon tear

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Contributor Information and Disclosures

Author

James Lyle, MD, Consulting Surgeon, Department of Orthopedic Surgery, Hughston Clinic
James Lyle, MD is a member of the following medical societies: Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Medical Editor

Phillip J Marone, MD, MSPH, Clinical Professor, Department of Orthopedic Surgery, Jefferson Medical College
Phillip J Marone, MD, MSPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital
Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society
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