Quadriceps Tendon Rupture Treatment & Management

Updated: Jun 08, 2021
  • Author: James Edwin Lyle, MD; Chief Editor: Thomas M DeBerardino, MD  more...
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Treatment

Approach Considerations

Early operative repair is indicated for all acute complete quadriceps tendon ruptures, provided that the patient is a suitable surgical candidate. Surgery is also indicated for most chronic complete quadriceps ruptures. [50] Although repair/reconstruction is technically more difficult and results are inferior to those of early repair, successful results have been reported with surgery performed even as late as 1 year following injury. Partial tears may be treated nonoperatively unless they are refractory to a long course of conservative management.

No contraindications for acute repair of quadriceps tendon ruptures exist, provided that the patient is an adequate surgical candidate. For delayed repair/reconstruction, no contraindications for surgery appear to exist up to 1 year following injury. The authors are unaware of any literature on operative management performed later than 1 year following rupture.

With the growing popularity of suture-anchor fixation in other aspects of orthopedic surgery, more research will probably follow to better define the role of this technique in quadriceps tendon ruptures. [41, 51, 52]

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Medical Therapy

Conservative treatment is indicated for partial tears. [53] The knee should be immobolized 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. [54]

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Surgical Therapy

Choice of surgical approach

Early surgical repair yields the best results for complete quadriceps tendon ruptures. [55, 56, 57, 58, 59, 60] 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 flaps [61]
  • Carbon fiber [62]
  • Mersilene sutures
  • Dacron graft
  • Polyester graft
  • Autograft of the central third of the patellar tendon

Suture anchors also have come into use, [41, 51, 52] and a suture bridge technique has been reported to be effective in restoring function in cases of quadriceps tendon rupture. [63] However, the following three main types of repair continue to be the most popular:

  • Direct repair of the tendon to the patella
  • Scuderi technique for acute tears
  • Codivilla tendon-lengthening and repair technique for chronic ruptures

A small (N = 4) pilot study by Severyns et al described a technique method for arthroscopic reattachment of the quadriceps tendon with suture anchors. [64] The authors reported no wound healing complications, infectious complications, or repeat tears. 

Operative 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 the image below).

Exposure of a tendon rupture. Exposure of a tendon rupture.

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 reapproximate 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. To avoid patellar tilt, the trough should not be made near the anterior surface of the patella. Three or four longitudinal holes are drilled about 1 cm apart from the bony trough to the inferior pole of the patella (see the image below).

Drill holes through the patella. Drill holes through the patella.

Running interlocked stitches are placed medially and laterally in the tendon with 5-0 nonabsorbable suture. The Bunnell-type weave and Krackow whip stitches are popular. The free suture ends are passed through the drill holes from proximal to distal with a suture passer (see the image below).

Passing suture through patellar drill holes. Passing suture through patellar drill holes.

The tendon then is pulled by the sutures distally into the trough (see the image below).

Tendon pulled down into the patellar bony trough w Tendon pulled down into the patellar bony trough with sutures.

Secure the sutures with a hemostat, and assess patellar rotation and tracking throughout the ROM of the knee. If the assesment is satisfactory, tie the sutures distally and repair the retinaculum with absorbable sutures (see the image below).

Finished repair. Finished repair.

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 pullout 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 reapproximated to the patella, the Codivilla tendon-lengthening technique can be used. A triangular flap is fashioned that resembles the flap used in the Scuderi technique, except that the Codivilla flap consists of the full thickness of the tendon. Also, the base of the Codivilla flap is more distal, about 1.5-2.0 cm proximal to the tear.

The tendon and retinaculum then are advanced distally until reapproximation 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. Pullout wires are recommended to protect the repair.

If a defect remains after 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.

Repeat rupture

If a repeat rupture occurs after surgical repair or reconstruction of a quadriceps tendon rupture, reconstruction is mandatory. Several techniques are available for this purpose (see above).

Maffulli et al described a surgical approach to patellar and quadriceps tendon reconstruction that makes use of an ipsilateral hamstring autograft. [65] In this technique, once the hamstring tendon has been harvested, its ends are prepared by using a whip stitch, and a transverse tunnel is drilled in the middle of the patella. The graft is then advanced through the patella, and sutures are placed to secure it firmly to the openings of the transverse patellar tunnel.

Polyethylene terephthalate tape augmentation has been suggested as a potential solution in recurrent quadriceps tendon ruptures. [66]

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Postoperative Care

Sutures or staples are removed at 2-3 weeks. Pullout wires are removed at 3 weeks. Most authors prefer cylinder casting for 4-6 weeks. Immediate postoperative weightbearing 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. [67]

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.

Several authors have advocated immediate postoperative ROM exercises and delayed weightbearing to potentially increase ultimate ROM. Studies also have shown that mobilized tendons heal faster and attain greater strength than immobilized tendons do. In two studies, artificial graft was used to augment the repair and to allow early motion. Konrath et al reported successful immediate motion without routine augmentation. [19]  However, other studies have shown that ROM is routinely regained after up to 6 weeks of immobilization.

Rougraff et al found that nearly all patients (including patients with delayed repairs) regained motion to within 2º of their uninjured leg. [18]  Additionally, this study provided the only comparison of immobilization and immediate motion in the literature up to that point; however, the immediate motion group was very small. No significant difference existed in the ultimate ROM between the groups. Further research comparing larger groups of patients treated with immobilization and early motion is needed to help resolve this issue.

For repair of chronic ruptures, 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.

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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.

Care must be taken to restore normal alignment during surgery, because malalignment can lead to degenerative changes of the patellofemoral joint. Repeat rupture occurs infrequently. Rougraff et al reported two repeat ruptures in 53 repairs, [18] whereas Konrath et al observed one repeat rupture in 50 repairs. [19]

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Long-Term Monitoring

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
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