A conservative, nonoperative approach is the initial management of choice when a diagnosis of partial rupture is made. Traumatic hemarthrosis and effusion have been shown to decrease quadriceps strength [48]. Early treatment should thus consist of aggressive treatment of knee effusion with ice, compression, anti-inflammatory medication, and possibly knee aspiration to evacuate the hemarthrosis and promote rehabilitation. Operative treatment may be indicated if nonoperative management fails to provide resolution of symptoms. If one or more of the tendon layers are intact, partial ruptures can be treated with excision of the scar tissue and side-to-side closure of the tendon [49].

Weakness and long-term disability associated with nonoperative management of complete quadriceps tendon ruptures have made operative repair of the ruptured tendon the treatment strategy of choice. When the diagnosis of a complete quadriceps tendon is made, prompt referral to an operative orthopedic surgeon is recommended as delay in operative repair may result in poorer outcomes secondary to retraction of the proximal tendon and atrophy of the quadriceps musculature [6, 50, 51].

The basic tenets of operative repair of quadriceps tendon ruptures including the use of suture to approximate the tendon to and through its patellar remnant have remained unchanged since the procedure was first reported in the 1880s [3]. Based on these tenets, numerous effective surgical strategies have been derived for the management of this injury; no technique has been proven to produce superior results [3, 7, 49–51]. A randomized, controlled trial comparing outcomes of quadriceps tendon ruptures repaired by the various techniques has not been completed. The type of surgical treatment is largely dependent on the location of the rupture within the tendon and surgeon preference.

For surgical intervention, the patient is placed supine on an operating room table, frequently with a bump under the involved hip to prevent external rotation of the extremity. The anatomic surgical approach shows little variability across treatment types and consists of an approximately 10 cm midline longitudinal incision over the anterior knee to expose the extensor mechanism. If hematoma is present, this is evacuated to allow visualization of the ruptured tendon ends. The tendon ends are debrided of grossly degenerative tissue to prepare them for repair.

For mid-substance tears, an end-to-end primary repair with heavy nonabsorbable suture is an effective treatment strategy. Using a No. 2 or No. 5 nonabsorbable suture, continuous running stitches are sewn up and down the lateral borders of the free proximal and distal tendon ends in a locking fashion. This is repeated along the medial borders of the free ends of the ruptured tendon, leaving four free suture ends from the proximal and distal tendon remnants. The corresponding sutures are then tied with the knee in full extension, resulting in four knots at the site of tendon rupture. The repair may be augmented with additional simple interrupted sutures at the rupture site. The medial and lateral patellar retinaculum are then reapproximated with another heavy nonabsorbable suture to complete the repair. The stability of repair and patellar tracking are then tested by taking the repaired knee through gentle range of motion.

Ruptures at or near the osteotendinous junction typically require a slightly more advanced repair strategy. Suture anchors at the superior pole of the patella or a series of three drill holes longitudinally through the patella may provide appropriate recreation of the quadriceps tendon portion of the extensor mechanism (Fig. 10.5). The transosseous technique is most commonly utilized. Two separate heavy nonabsorbable sutures are passed through the medial and lateral portions of the tendon in a locking fashion as described above, resulting in four equal-length tendon strands at the free tendon edge. A trough is made in the superior margin of the patella with a high-speed burr, thereby creating a bleeding bone bed to achieve tendon to bone healing. The trough must be created horizontally in the midpoint of the superior pole of the patella to prevent abnormal tilt when the tendon is reapproximated. A 2.0 mm drill is then used to create three parallel transosseous patella drill holes with starting points in the trough 1 cm apart. It is important that the drill holes are parallel to the patellar articular surface and each other. Convergence should be prevented as this may cause failure of the repair by suture pullout through the bone bridge. The sutures are shuttled through the patellar holes with the use of a Hewson suture passer so that one suture end passes through each of the lateral and medial holes and two pass through the medial hole. Alternatively, Beath pins can be used to create holes and shuttle the sutures. The sutures are tied distally with the knee in full extension, resulting in two knots at the inferior pole of the patella (Fig. 10.6). The medial and lateral patellar retinaculum are then reapproximated with a heavy nonabsorbable suture. Following recreation of the extensor mechanism, the knee is gently ranged from 0 to 90° to ensure absence of gapping, appropriate tension, and appropriate patellar tracking. The repair may be augmented with a cerclage suture [52]. In this technique, a heavy nonabsorbable “relaxing suture” is passed through the quadriceps tendon proximal to the locking stitches, woven down through the medial and lateral retinaculum, passed below the distal pole of the patella, and tied with the knee in 30° of flexion to reinforce the repair. Alternative approaches to repair including the use of a Leeds-Keio ligament [53], Dacron vascular graft [54], or Mersilene tape [55] have been described but are used infrequently.

Unfortunately, a delayed or missed diagnosis of a quadriceps tendon is not a rare occurrence [12, 37, 38]. Management of this subset of tears requires a different treatment approach as scarring and tendon retraction may prohibit a direct end-to-end or tendon-bone repair of the tendon. Elevation of the quadriceps from the femoral shaft provides additional length to bridge small retraction gaps, but scarring and large gaps often limits its utility. The inverted V turndown flap techniques popularized by Scuderi and Codivilla can provide reinforcement and additional length to the chronic quadriceps tendon repair (Fig. 10.7) [24]. In this technique, the ends of the quadriceps tendon are first approximated with a heavy nonabsorbable suture. This is followed by the creation of an inverted V-shaped flap (partial thickness in Scuderi technique and full thickness in Codivilla technique) of the proximal quadriceps tendon with its base 1 cm proximal to the tendon tear. The flap is then folded distally so that the body of the V overlies the rupture site and the apex of the V is distal. In the full-thickness Codivilla technique, the proximal portion of the tendon is then repaired side to side to minimize compromise of the tendon.