Reconstruction with hamstring autograft of atraumatic simultaneous ruptures of the bilateral quadriceps tendons: a novel technique: A case report

Abstract

Bilateral spontaneous quadriceps tendon rupture is a very uncommon phenomenon recorded in a few cases, but unilateral traumatic quadriceps tendon rupture is a rather common orthopedic pathology. In addition, it is related to systemic (e.g., diabetes mellitus, hyperparathyroidism, gout, pseudogout, obesity, steroid usage) and autoimmune diseases as well as most chronic renal failure (CRF). The occurrence of bilateral atraumatic simultaneous quadriceps tendon ruptures in CRF is most likely associated with the duration of renal disease and the duration of dialysis. Here we present an atraumatic spontaneous rupture of both quadriceps tendons with tendon hamstring autograft in a previously diagnosed male patient with CRF repaired using a novel reconstruction technique. This technique, which we use in quadriceps tendon repair, is an easy and effective method that shows excellent results in early rehabilitation and knee joint movements and prevent early re-rupture.

Keywords

Introduction

Bilateral spontaneous simultaneous rupture of the quadriceps tendon is very rare and almost always related to comorbidities although unilateral quadriceps tendon rupture is a relatively common injury.¹ Spontaneous tendon ruptures, characterized by uremic tendinopathy, were seen in about 15% of patients with CRF. Bilateral concurrent atraumatic quadriceps tendon ruptures in chronic kidney disease are almost certainly related to the duration of the renal disease and the duration of dialysis.²
Here we present a case of a previously diagnosed CRF male patient, repaired with the new reconstruction technique, an atraumatic spontaneous rupture of bilateral quadriceps tendons with tendon autografting.

Case Presentation

A 40-year-old male patient who had been on dialysis for 10 years due to CRF was standing after a routine dialysis session without any known trauma. As a result, a crunch from both knees was heard, as was an immediate beginning of pain. The patient was then unable to stand or ambulate after that. On physical examination at the emergency department, a severe effusion was noted in the suprapatellar space in both knees. Moreover, no active extension against gravity was feasible, and patellar reflex could not be induced on either side. A 1–1.5 cm gap was found at the attachment site of the quadriceps tendons to the superior patella on palpation in the suprapatellar region of the bilateral knees (Figure 1a). X-ray findings showed a patella Baja image in both knees. Both knees had radiographic indications of osteoarthritis, including restricted joint space, osteophyte forms, and subchondral sclerosis (Figure 1b). In both knee joints, T2-weighted magnetic resonance imaging (MRI) revealed a discontinuity between the distal quadriceps tendon and the upper pole of the patella, with the intervening region filled with hyperintense signal intensity in stark contrast to the tendon’s hypointense signal intensity. Additionally, on both sides, a minor joint effusion was observed in the suprapatellar region (Figure 1c).Surgical TechniqueThe patient was applied spinal anesthesia and was placed in the supine position. Consequently, preoperative surgical preparations were performed. Approximately 3- to 4-cm longitudinal incision was made first through the proximal and distal of the right knee patella superior pole (Figure 2a). A massive hematoma in the suprapatellar space was cleared after the dissection (Figure 2b). A large gap with full-thickness quadriceps tendon rupture at the enthesis region on the proximal pole of the patella was observed (Figure 2c). A 2- to 3-cm incision was performed at pes anserinus muscle insertion region area, and the semitendinosus and gracilis tendon grafts were removed. Both tendons were augmented with a 2/0 vicryl suture with the Krackow suture technique, and their proximal and distal ends were sutured with the Krackow technique. The distal end of the quadriceps tendon rupture line was debrided and refreshed. The central medial and lateral parts of the ruptured quadriceps tendon were sutured with 1/0 vicryl using the Krackow suture technique. These threads were tunneled to the superior center of the patella with two 1.2-mm K-wires and passed through the patella bone. These suture threads were pulled to the patella superior to the distal part of the quadriceps tendon, and tight knots were tied at the superior margin of the patella (Figure 2d). Afterward, a 4.5-mm transverse tunnel was then opened from the superior central part of the patellar bone (Figure 2e, f). A semitendinosus autograft was passed through this tunnel (Figure 2g). Moreover, the sutured ends of this autograft were passed through the distal medial and lateral portions of the quadriceps tendon and were tightly stitched on themselves (Figure 2 h, i). The same procedures were performed on the left knee using a gracilis tendon autograft.Postoperative RehabilitationThe patient recovered without incident following surgery, which included an initial phase of continuous passive movement from 0 to 30 and then complete weight-bearing mobilization with a locking knee brace. The knee brace’s flexion angle increased day by day as the patient gained control. At the end of the second month, he was able to flex the knee to 120 degrees and resumed his quadriceps-strengthening workouts. The patient was mobilized on crutches for 2 months before active weight-bearing was allowed.Postoperative OutcomesAt the end of the 12-month follow-up, the patient was nearly pain-free except for some mild discomfort while ascending or descending stairs, which was consistent with the arthritic changes, and he was able to walk without assistance. His quadriceps strength was rated 4+/ 5, and he was able to do a straight-leg lift with a range of motion of 0 to 130. He was able to perform an active extension of both knees with less than <5° of extension lag in either knee (Figure 3a, b) with a healing view on the X-rays (Figure 3c). In addition, the Lysholm score was 91points (limp=5, support=5, locking= 15, instability=20, pain=20, swelling=10, stairs=10 squatting=6), and based on the Lysholm criteria, it was an excellent result.

Discussion

In this case, in addition to the primary repair of bilateral quadriceps tendon rupture by opening a hole in the patella with a parallel double-row Krackow suture technique, unlike the literature the hamstring autograft was passed through a transverse tunnel in the patella and reconstructed end-to-end to the quadriceps tendon. We used this technique to prevent quadriceps tendon rupture and to start early knee movements of the patient.
The quadriceps tendon rupture mechanism occurs most frequently as a result of a fast, eccentric contraction of the quadriceps muscle when standing on one foot and partially flexing the knee, as a result of a fall or direct blow.³ Moreover, bilateral simultaneous ruptures are extremely rare and strongly associated with systemic illnesses. In the patient of the current study, the diagnosis of CRF and quadriceps tendons were detached from the upper pole of the patella, which is similar to situations in the literature.
Surgical treatment and subsequent immobilization followed by physiotherapy protocol are the most used and recommended treatment protocols. Moreover, this treatment protocol reduces the risk of tendon rupture and the time required to return to a functional range of motion.³
In the literature, the transosseous suture method, which is passed through the tunnels opened in the patella, is the preferred choice for use, although different methods are defined in surgical treatment. Krackow described the transosseous method in which a single thread is used.⁴
Several augmentation procedures for quadriceps tendon regeneration include wire reinforcement, Mersilene tape, and Dacron vascular and carbon fiber grafts.⁵ Alternatively, autologous tissues have been used.⁶
In the study by Leopard et al.⁷ the m. semitendinosus and m. gracilis tendons were sutured together because end-to-end repair could not be performed for the quadriceps tendon. This obtained tendon was passed through the transverse tunnel in the patella and passed several times to bridge this defect in the quadriceps tendon. In another study carried out by Unlu et al.⁸ two autograft tendons were used, and the quadriceps tendon was sutured end-to-end, then passed through the patella in the same way and sutured to the patellar tendon differently after passing through the quadriceps tendon. In our case report, different from the above study, after the quadriceps tendon was sutured to the patella with the end-to-end Krackow suture technique, a single autograft tendon was used, passed transversely through the patella, and passed through the quadriceps tendon medially and laterally, and then sutured onto itself.
The Lysholm score was determined by Unlu et al. as a mean value of 89 points (good results).⁸ In addition, the range of motion (ROM) at flexion and lack of extension of the knees were 120° and 10° in the study by Unlu et al.⁸ In our case, the Lysholm score was 91 points (excellent result), and ROM at flexion and lack of extension of the knees were 130° and < -5°, respectively.
The current surgical method, which was applied to the patient of this study with a diagnosis of CRF and bilateral quadriceps tendon rupture, did not have a re-rupture after 2 years of follow-up, and nearly a full range of motion was reached. However, there are no studies in the literature with long-term results, although several repair methods have shown excellent results for bilateral quadriceps tendon ruptures.
As a result, bilateral spontaneous quadriceps tendon rupture is an extremely rare condition and can be seen in patients with systemic disease. Reinforcement with the Krackow suture method with the help of hamstring autograft has shown that this technique is an easy and effective method, which shows excellent results in early rehabilitation and knee joint movements and helps avoid early re-rupture.

Declarations

References

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