Chapter 33 Patellar and Quadriceps Tendon Repair

Greg Fives, PT, MSPT, SCS

Patellar and quadriceps tendon ruptures are both rare events in the general population. The incidence of isolated patellar tendon ruptures is fairly low. Typically, this injury occurs in the male population younger than age 40. Quadriceps tendon ruptures are also relatively infrequent, occurring more in the older population around the sixth or seventh decade of life. Patellar tendon ruptures occurred about one-third as often as quadriceps tendon ruptures.

The mechanism of injury for both quadriceps and patellar tendon ruptures is usually a violent eccentric contraction of the quadriceps resisted by a fixed position of the leg and foot with the knee in hyperflexion. More commonly, patellar tendon ruptures occur during sports or events that require significant extensor mechanism activation, such as basketball, volleyball, soccer, football, high jump, and gymnastics. Non-sports-related mechanisms of injury are usually the result of a trip-and-fall accident.

A force of approximately 17.5 times body weight can cause a rupture of the patellar tendon. Research has shown that the quadriceps tendon may be able to withstand up to 30 kg/mm of tensile force before rupturing. Spontaneous patellar or quadriceps tendon rupture can occur in patients with systemic or inflammatory conditions, such as systemic lupus erythematosus, gouty arthritis, psoriatic arthritis, hyperparathyroidism, diabetes mellitus, chronic renal failure, and rheumatoid arthritis, which weakens the involved soft tissue structures. Other risk factors include previous knee surgery, such as anterior cruciate ligament reconstruction with patellar tendon autograft and total knee replacement. Corticosteroid injections into the tendon and anabolic steroid use have also been implicated as predisposing factors to isolated patellar tendon rupture.

Progressive patellar tendonitis (jumper’s knee) and end-stage degenerative tendinopathy are also common mechanisms by which patellar tendon ruptures occur.

Some partial patellar or partial quadriceps tendon ruptures can be treated with immobilization in full extension for 4 to 6 weeks, but the treatment of choice for complete tendon rupture (quadriceps or patellar) is immediate operative repair. Immediate repair enhances postoperative outcomes for both patellar and quadriceps tendon rupture. The deleterious effects associated with delayed diagnosis and therefore delayed repairs include knee flexion ROM deficits, quadriceps atrophy, and a decreased functional outcome for the patient.

The Hospital for Special Surgery’s postoperative rehabilitation guidelines and approach to knee extensor mechanism repairs are presented here.

Surgical Overview

• The extensor mechanism of the knee consists of the quadriceps, quadriceps tendon, patella, and patellar tendon.

• The quadriceps musculature is composed of the rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius, which unite distally to form the common quadriceps tendon.

• Aponeurotic slips from both the vastus lateralis and vastus medialis form the lateral and medial retinaculi, respectively.

• The fibers of the quadriceps tendon traverse the anterior surface of the patella to form the patellar tendon.

• The patellar tendon is primarily composed of the distal central fibers of the rectus femoris, which terminate and insert into the tibial tubercle.

Patellar Tendon Repair

• Most patellar tendon ruptures occur at the osteotendinous junction, where the tendon inserts at the distal pole of the patella.

• A palpable defect is usually present below the distal pole of the patella, and the patella itself may be displaced as much as 5 cm proximally.

• Midsubstance patellar tendon tears are less common and can be more difficult to repair.

• Avulsion repairs are made by placing nonabsorbable sutures into the medial and lateral halves of the tendon.

1 A bony trough is made across the distal patella and drill holes are made into the inferior and superior patella.

2 The sutures are then passed through the inferior drill holes and are tied off at the superior pole of the patella.

3 Midsubstance repairs can be repaired with interlocking sutures that tie the proximal and distal ends of the tendon together.

4 Repairs may be reinforced or augmented, if needed, with either cerclage sutures, allograft, or surrounding knee musculature.

Quadriceps Tendon Repair

• Ruptures of the quadriceps tendon may occur at the osteotendinous junction or through the midsubstance of the tendon.

• Ruptures occur more frequently at the osteotendinous junction near the proximal pole of the patella.

1 With this scenario, the superior pole of the patella is débrided of residual tendon, and the distal end of the rectus femoris and vastus intermedius are débrided of all chronic inflammatory tissue.

2 A bony trough is made horizontally across the proximal pole of the patella.

3 Drill holes are made near the base of the trough, and sutures are passed from the tendon through the drill holes to reattach the tendon.

• Acute midsubstance tears are made by direct repair.

1 A midline incision is made and the proximal and distal ends are débrided.

2 The two ends are then approximated and tied together with nonabsorbable sutures.

• After quadriceps or patellar tendon repair, intraoperative ROM is assessed, as is patellar position (alta or baja) and tracking. Intraoperatively, 0-degree knee flexion should be obtained without significant stress to the repair.

• Postoperatively, the patient’s lower extremity is placed in a hinged rehabilitative brace locked at 0-degree extension.

• With an uncomplicated, acute extensor mechanism repair, patients are allowed to progressively weight-bear, as tolerated, with the brace locked in full extension.

Rehabilitation Overview

• Rehabilitation after quadriceps or patellar tendon repair should be initiated soon after surgery.

• Communication with the referring surgeon is essential in the care of these patients.

1 The clinician should discuss with the surgeon specific postoperative range of motion (ROM) limitations and the patient’s weight-bearing status.

2 The clinician and the surgeon need to inform the patient that the rehabilitative process is extensive following quadriceps or patellar tendon repair.

• Other factors to be considered are the patient’s age, bone and tissue quality, and the time from injury to surgery.

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