Clinical Orthopaedics and Related Research®

, Volume 472, Issue 3, pp 1050–1057

Complications in Brief: Quadriceps and Patellar Tendon Tears

  • W. Robert Volk
  • Gautam P. Yagnik
  • John W. Uribe
In Brief

DOI: 10.1007/s11999-013-3396-6

Cite this article as:
Volk, W.R., Yagnik, G.P. & Uribe, J.W. Clin Orthop Relat Res (2014) 472: 1050. doi:10.1007/s11999-013-3396-6

Abstract

Effective treatment of knee extensor mechanism disruptions requires prompt diagnosis and thoughtful decision-making with surgical and nonsurgical approaches. When surgery is chosen, excellent surgical technique can result in excellent outcomes. Complications and failures arise from missed or delayed diagnoses and from technical problems in the operating room. In particular, inappropriate surgical timing (especially late surgery), misplaced patellar drill holes, and failure to address concomitant injuries can result in complications seen when repairing a patellar or quadriceps tendon tear. We review the complications that can occur during treatment of these injuries (Table 1).
Table 1

Errors and complications in the treatment of quadriceps and patellar tendon tears

Error/complication

Clinical effect

Prevention

Detection

Remedy

Judgment errors

 Missed diagnosis: patella tendon tear

Patient seen in the emergency room, presumed to have a patella dislocation; sent home; delay in treatment leads to chronic extensor mechanism disruption, which can cause disability and be more difficult to treat

Careful history and physical examination

(1) Physical examination

 Infrapatellar pain

 Infrapatellar gap

 Inability to maintain full active extension

 Unable to perform straight leg raise

 Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction

(2) Radiographs

 Abnormal patella height (alta)

(3) MRI/ultrasound

Education of physicians and ancillary staff; high index of suspicion; thorough history and physical examination

 Missed diagnosis: quadriceps tendon tear

Very common, especially in obese patients; delay in treatment leading to chronic extensor mechanism disruption, which can cause disability and be more difficult to treat

Careful history and physical examination

(1) Physical examination

 Suprapatellar pain

 Suprapatellar gap

Inability to maintain full active extension

 Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction

(2) Radiographs

 Abnormal patella height (baja)

(3) MRI/ultrasound

Education of physicians and ancillary staff; high index of suspicion; thorough history and physical examination

 Missed diagnosis: intact retinaculum but torn quadriceps tendon

Patient able to perform weak straight leg raise as a result of intact retinaculum, but quadriceps tendon actually completely torn; lack of power leading to altered gait and joint kinematics, joint breakdown and potential subsequent traumatic injuries

(1) Careful physical examination: check for extensor lag

(2) Aspirate blood from knee and inject with lidocaine; then reexamine

(3) Additional imaging: MRI

(1) Palpable defect in soft tissues proximal to patella

(2) MRI

Education of physicians and ancillary staff; high index of suspicion

 Missed diagnosis: multiligament knee injury, failure to recognize extensor mechanism disruption

With severe traumatic knee injuries, clinicians may focus on ligament/bony injury and may miss extensor mechanism disruption, leading to incomplete care of injuries and significant disability

(1) Careful review of imaging, particularly sagittal views

(2) Thorough physical examination

(1) Palpable defect in soft tissues proximal/distal to patella

(2) MRI

Education of physicians and ancillary staff; high index of suspicion; thorough history and physical examination; careful review all imaging

 Delayed diagnosis: delayed surgery

Operating too late after injury; tendon becomes scarred down and retracted; may be difficult to perform primary repair; may require tissue grafting and multiple surgeries

Performing surgery as soon as possible, preferably within first week

 

Proper detection and early management; if noted too late, consider V-Y or Scuderi technique

 Incorrect diagnosis: partial tendon tear

Tendon only partially disrupted (< 10 mm separation of the tendon from bone); will heal without surgery; in one study, nonsurgical management resulted in 93% success rate [5]

(1) MRI

(2) Ultrasound

(3) Physical examination

(1) Patient should be able to maintain full active extension

(2) Radiographs: normal patellar height

This individual can be treated nonoperatively with immobilization until the tendon has healed

 Incorrect diagnosis: retinaculum torn, but quadriceps tendon intact

As long as the tendon is intact, the retinaculum should heal nonoperatively

(1) Careful physical examination

(2) Aspirate blood from knee and inject with lidocaine; then reexamine

(3) Additional imaging: MRI or ultrasound

  

 Incorrect diagnosis: inability to extend knee or perform straight leg raise, but extensor mechanism is intact

Multiple reasons:

(1) Femoral nerve palsy

(2) Pain

(3) Intraarticular pathology: locked knee (loose body, bucket handle meniscal tear, etc)

(1) Thorough history and careful physical examination

(2) Additional imaging: MRI

Consider aspiration/injection of local anesthetic and reexamination

 

Potential judgment errors

 Performing definitive surgery in open injury

Consider staged procedure if contaminated wound

(1) Irrigation and debridement

(2) Definitive fixation

Thorough history and careful physical examination

 

Single stage management of contaminated or chronically open injuries potentially leads to infection and repair failure

 Failure to account for diabetes

Poor tissue quality that should be accounted for. Delayed wound and tendon healing

Thorough history and careful physical examination. Tight perioperative glycemic control

Laboratory studies. Patient’s glycemic history

Consultation with patient’s primary care provider/internal medicine

Adequate diseased tendon debridement.

Delayed postoperative motion to account for expected delayed healing

Technical errors

 Positioning and preparing

(1) Supine, bump under ipsilateral hip to internally rotate lower extremity

(2) Consider full muscle paralysis to aid in reduction

   

 Inadequate exposure

Generous midline incision needed to see extent of injury (retinacular injury) and define injury pattern (midsubstance tear versus avulsion from patella)

   

 Failure to identify correct injury pattern: patellar tendon

Three injury patterns based on location:

(1) Avulsion (with/without bone) from inferior pole patella

(2) Midsubstance rupture

(3) Distal avulsion from tibial tubercle

(1) Preoperative imaging

(2) Adequate exposure

 

Correctly identifying injury pattern will dictate fixation method

 Failure to identify correct injury pattern: quadriceps tendon

Three injury patterns based on location:

(1) Avulsion (with/without bone) from superior pole patella

(2) Midsubstance rupture

(3) Mixed

(1) Preoperative imaging

(2) Adequate exposure

 

Correctly identifying injury pattern will dictate preoperative planning and fixation method

 Failure to débride patella/quadriceps tendon stump

Failure to débride scar or devascularized tissue may predispose to failure of the repair and/or chronic weakness

Rongeur scar tissue from patella

 

Prepare bleeding bone bed: curette or burr a trough

 Failure to débride/prepare patella bone bed

Failure to débride patella bone bed may predispose to poor healing

Rongeur scar tissue from patella

 

Prepare bleeding bone bed: curette or burr a trough

 Tendon repair: inadequate tissue for repair of midsubstance ruptures

Can be challenging, especially with severely disrupted patella tendons

  

Consider augmentation with contralateral hamstring autograft or allograft; role for other biologics (dermal patches, etc)?

 Tendon repair: appropriate tension for midsubstance ruptures

Can be challenging, especially with severely disrupted patella tendons

  

Lateral radiograph of contralateral leg can help determine appropriate tension

 Transosseous tendon repair: divergent tunnels

Divergent tunnels lead to asymmetric reduction of tendon to bone; may lead to poor contact and therefore poor healing or maltracking

  

(1) Adequate exposure of entire patella

(2) Parallel pin drill guide

(3) Consider use of fluoroscopy

 Transosseous tendon repair: tunnel penetration into articular surface

Iatrogenic articular cartilage injury

  

(1) Adequate exposure of entire patella

(2) Parallel pin drill guide

 Transosseous tendon repair: drill breakage

Broken drill bit in tunnel

  

(1) Careful drilling technique

(2) Do not attempt to change direction of drill hole once started drilling

(3) Do not torque drill

(4) Use stout drill bit

 Transosseous tendon repair: anterior placement of tunnels

May lead to downward tilting of the patella and increase patellofemoral contact forces and pain

  

(1) Place drill holes in center of patella (with respect to AP)

(2) If have to cheat, cheat toward articular surface

 Transosseous tendon repair: overtightening repair

May lead to patella alta or baja

  

(1) Prepare opposite leg to assist with tensioning

(2) Obtain intraoperative radiograph and compare with contralateral side

 Transosseous tendon repair: undertightening repair

(1) May lead to patella alta or baja

(2) Poor tendon to bone contact may interfere with healing

  

(1) When tying knots, make sure to remove all the slack and that the tendon is pulled snuggly into patella bone trough

(2) Adequate retinacular repair

 Transosseous tendon repair: prominent proximal suture knots

May lead to skin irritation

  

Attempt to bury knots and cover with surrounding soft tissue

 Suture anchor tendon repair

Advantages:

(1) Less dissection

(2) Decreased surgical time

(3) More accurate suture placement

(4) Low profile

   

 Suture anchor tendon repair: anchor pullout

Causes:

(1) Poorly placed anchors

(2) Poor bone quality

(3) Weak anchors

  

(1) Anchors should be placed in center of patella [2]

(2) Not to be used in osteoporotic bone

(3) Two 5.0-mm corkscrew titanium anchors (equivalent pullout to transosseous tunnels) [1]

 Suture anchor tendon repair: proud anchors

Proud anchors will not allow the tendon edge to be pulled into the bone trough in the patella, possibly leading to a gap at the bone-tendon junction and poor healing

  

Anchors should be slightly countersunk to pull tendon firmly into bone trough in patella

 Failure to repair retinacular tissue

May lead to increased stress on central repair

  

(1) Adequate exposure

(2) Suture medial and lateral retinaculum

Additional complications

 Infection

(1) Open injury

(2) Comorbidities

  Diabetes

  Smoking

  Chronic disease

  

(1) Irrigation and debridement (consider delayed repair)

(2) Timely administration preoperative antibiotics

(3) Tight glucose control

(4) Smoking cessation

 Wound complications

(1) Open injury

(2) Comorbidities

  Diabetes

  Smoking

  Chronic disease

(3) Prominent sutures

  

(1) Irrigation and débridement (consider delayed repair)

(2) Timely administration preoperative antibiotics

(3) Tight glucose control

(4) Smoking cessation

 Nerve injury

Extremely rare

   

Rehabilitation complications

 Prolonged immobilization

Leads to stiffness and decreased ROM

Intraoperative assessment of maximum flexion before gapping between bone and tendon is observed

 

Early ROM (10–14 days): active flexion, passive extension to limits determined intraoperatively

 Inadequate immobilization

(1) Wound complications

(2) Failure of repair

  

ROM bracing locked in extension

 Overly aggressive physical therapy

Need time for tendon-to-bone healing to occur

  

No forced flexion or active extension in first 6 weeks

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • W. Robert Volk
    • 1
  • Gautam P. Yagnik
    • 1
  • John W. Uribe
    • 1
  1. 1.UHZ Sports Medicine Institute, Doctors HospitalBaptist Health South FloridaCoral GablesUSA

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