The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 1

Scientific Articles | January 01, 2005

Quadriceps Tendon Rupture After Total Knee Arthroplasty: Prevalence, Complications, and Outcomes

Ryan E. Dobbs, MD¹; Arlen D. Hanssen, MD¹; David G. Lewallen, MD¹; Mark W. Pagnano, MD¹

¹ Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Jan 01;87(1):37-45. doi: 10.2106/JBJS.D.01910

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Abstract

Background: There is relatively little information about quadriceps tendon tears after total knee arthroplasty. The purpose of this study was to determine the prevalence of this condition and the outcomes of patients who had a tear of the quadriceps tendon after a total knee arthroplasty.

Methods: From a cohort of 23,800 primary total knee arthroplasties, we identified twenty-four patients who had a rupture of the quadriceps tendon postoperatively. Ten additional patients had the total knee arthroplasty done elsewhere and were referred for care after sustaining a tear of the quadriceps tendon. Thus, the study group consisted of thirty-four patients, and all had at least two years of follow-up. Eleven patients had a complete tear, and twenty-three had a partial tear.

Results: The prevalence of a quadriceps tendon tear after total knee arthroplasty was 0.1% (twenty-four of 23,800). Seven patients with a partial tear were treated nonoperatively, and all had a satisfactory outcome. One patient with a complete tear was treated nonoperatively and had an unsatisfactory result. Of the ten patients treated operatively after a complete tear, four subsequently had rerupture of the repaired tendon and four had a satisfactory outcome. Of the sixteen patients with a partial tear treated operatively, only one had rerupture and twelve had a satisfactory outcome. Complications occurred in eleven of the twenty-six patients managed operatively.

Conclusions: The prevalence of complications was high, and the outcomes were poor for seven of the eleven patients who had a complete quadriceps tendon tear after total knee arthroplasty. Patients who sustained a partial tear and were treated nonoperatively had no complications and had uniformly good outcomes.

Level of Evidence: Prognostic study, Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Rupture of the extensor mechanism after a total knee arthroplasty is a devastating complication. Usually these ruptures occur distally as a tear or an avulsion of the patellar tendon insertion into the tibial tubercle^1-6. Tears of the quadriceps tendon following total knee arthroplasty are less common, and few reports have addressed this complication^4,5,7,8. While a single traumatic episode may result in a quadriceps tendon tear, systemic diseases, such as rheumatoid arthritis, diabetes mellitus, chronic renal failure, obesity, and hyperthyroidism, may predispose an individual to this injury^2-5,9. Local factors such as prior knee arthroplasty, arthrotomy, multiple steroid injections into the knee, poor patellar positioning, and lateral retinacular release at the time of the total knee arthroplasty have been associated with tears of the quadriceps tendon after total knee arthroplasty^2,4,5.

For knees without a total knee replacement, the results of primary operative repair of complete quadriceps tendon tears have been quite good^9-11. Similarly, the results following nonoperative management of partial quadriceps tendon tears, with immobilization in extension for four to six weeks, have been satisfactory^9,10. In patients with a total knee replacement, however, the results after primary repair of a complete quadriceps tendon tear have been less predictable and, to our knowledge, no recommendations for the treatment of a partial quadriceps tear following total knee arthroplasty have been proposed^2,4,5,8. The purpose of this study was to determine the prevalence and outcome of both complete and partial tears of the quadriceps tendon after total knee arthroplasty.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Between 1976 and 2002, 23,800 primary condylar total knee arthroplasties were performed at our institution. Twenty-four patients who had sustained a tear of the quadriceps tendon after a total knee arthroplasty were identified. We also treated ten patients who had a total knee arthroplasty done elsewhere and subsequently had a rupture of the quadriceps tendon. The study group thus comprised these thirty-four patients, all of whom were followed for a minimum of two years (mean, 4.8 years; range, two to nineteen years) (see Appendix).

The mean age of the thirty-four patients was seventy years (range, thirty-eight to eighty-seven years) at the time of the quadriceps tendon rupture. The diagnosis leading to total knee arthroplasty was osteoarthritis in twenty-five patients, rheumatoid arthritis in eight patients, and posttraumatic arthritis in one patient. The mean interval from the time of the total knee arthroplasty to the quadriceps tendon tear was thirty-two months (range, two days to 200 months). Twenty-three patients had a partial tear of the quadriceps tendon, and eleven had a complete tear. The partial tears were diagnosed by the presence of a new extensor lag and a palpable defect in the quadriceps tendon but maintenance of active, although weak, extension of the knee from a flexed position.

The mechanism of injury for the tendon tear was a fall for sixteen patients; walking without major trauma for seven patients; rising from a low chair for three patients; climbing stairs for two patients; physical therapy for two patients; and horseback riding, transferring, kneeling, and lifting a heavy object for one patient each. The potential risk factors predisposing to quadriceps tendon rupture were identified in twenty-six of the thirty-four patients (Tables I and II).

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TABLE I Data on Patients with a Complete Tear

Gender, Age	Diagnosis	Prosthesis^*	Duration from Arthroplasty to Tear (mo)	Mechanism of Injury	Systemic or Local Factors	Treatment	Complications
F, 77	Osteoarthritis	Unknown	5	Kneeling	None	Late suture repair, revision total knee arthroplasty	Recurvatum, knee instability
M, 87	Osteoarthritis	Unknown	1.5	Fall	None	Early suture repair	None
F, 86	Osteoarthritis	AGC	0.5	Walking	Morbid obesity	Late suture repair augmented with Marlex	None
F, 73	Osteoarthritis	Press-Fit Condylar Sigma	31	Fall	Gout	Early suture repair	None
F, 70	Osteoarthritis	Press-Fit Condylar Sigma	3	Fall	Diabetes mellitus, Parkinson disease	Late suture repair augmented with Marlex	Rerupture
F, 40	Rheumatoid arthritis	Kinematic condylar	144	Rising from a chair	Steroids	Late suture repair	Rerupture, periprosthetic infection
F, 38	Rheumatoid arthritis	Porous-coated anatomic	2	Rising from a chair	Steroids	None	Missed diagnosis
F, 71	Rheumatoid arthritis	Unknown	36	Walking	Steroids, scleroderma, previous quadriceps tendon rupture	Late suture repair and patellectomy	None
M, 73	Osteoarthritis	Total Condylar III	0.5	Physical therapy	Multiple prior knee surgeries, steroid injections	Early suture repair	Periprosthetic infection
M, 69	Osteoarthritis	Cruciate condylar	11	Fall	Lateral release	Late suture repair	Rerupture
F, 69	Posttraumatic arthritis	Murray	6	Fall	Multiple previous knee surgeries	Late suture repair	Rerupture

AGC = Anatomic Graduated Component.

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TABLE I Data on Patients with a Complete Tear

Gender, Age	Diagnosis	Prosthesis^*	Duration from Arthroplasty to Tear (mo)	Mechanism of Injury	Systemic or Local Factors	Treatment	Complications
F, 77	Osteoarthritis	Unknown	5	Kneeling	None	Late suture repair, revision total knee arthroplasty	Recurvatum, knee instability
M, 87	Osteoarthritis	Unknown	1.5	Fall	None	Early suture repair	None
F, 86	Osteoarthritis	AGC	0.5	Walking	Morbid obesity	Late suture repair augmented with Marlex	None
F, 73	Osteoarthritis	Press-Fit Condylar Sigma	31	Fall	Gout	Early suture repair	None
F, 70	Osteoarthritis	Press-Fit Condylar Sigma	3	Fall	Diabetes mellitus, Parkinson disease	Late suture repair augmented with Marlex	Rerupture
F, 40	Rheumatoid arthritis	Kinematic condylar	144	Rising from a chair	Steroids	Late suture repair	Rerupture, periprosthetic infection
F, 38	Rheumatoid arthritis	Porous-coated anatomic	2	Rising from a chair	Steroids	None	Missed diagnosis
F, 71	Rheumatoid arthritis	Unknown	36	Walking	Steroids, scleroderma, previous quadriceps tendon rupture	Late suture repair and patellectomy	None
M, 73	Osteoarthritis	Total Condylar III	0.5	Physical therapy	Multiple prior knee surgeries, steroid injections	Early suture repair	Periprosthetic infection
M, 69	Osteoarthritis	Cruciate condylar	11	Fall	Lateral release	Late suture repair	Rerupture
F, 69	Posttraumatic arthritis	Murray	6	Fall	Multiple previous knee surgeries	Late suture repair	Rerupture

AGC = Anatomic Graduated Component.

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TABLE II Data on Patients with a Partial Tear

Gender, Age	Diagnosis	Prosthesis	Duration from Arthroplasty to Tear (mo)	Mechanism of Injury	Systemic or Local Factors	Treatment^*	Early or Late Complications
F, 68	Osteoarthritis	Press-Fit Condylar Sigma	0.25	Walking	Diabetes mellitus	Early use of crutches, non-weight-bearing	None
M, 73	Osteoarthritis	Press-fit condylar	105	Climbing stairs	Diabetes mellitus	Early suture repair	None
F, 71	Osteoarthritis	Press-Fit Condylar Sigma	3	Fall	Diabetes mellitus	Early suture repair	None
M, 72	Osteoarthritis	Cruciate condylar	16	Fall	Lateral release	Early suture repair	Rerupture
F, 82	Osteoarthritis	Cruciate condylar	108	Fall	Open excision of calcium deposits in quadriceps tendon	Early cast	None
M, 80	Osteoarthritis	Unknown	24	Fall	Renal insufficiency	Early knee immobilizer	None
F, 65	Rheumatoid arthritis	Kinematic condylar	3	Fall	Steroids	Early suture repair	None
F, 75	Rheumatoid arthritis	Kinematic stabilizer	18	Fall	Steroids	Early suture repair	Periprosthetic infection
F, 45	Rheumatoid arthritis	Polycentric	95	Walking	Steroids, multiple knee surgeries	Early suture repair	Recurrent knee instability
F, 52	Rheumatoid arthritis	Total condylar	9	Rising from a chair	Steroids, steroid injections, multiple knee surgeries	Early suture repair	None
M, 85	Osteoarthritis	Genesis	1	During transfer	None	Early physical therapy	None
F, 69	Osteoarthritis	Press-fit condylar	0.75	Fall	None	Early suture repair	None
M, 68	Osteoarthritis	Press-fit condylar	48	Lifting	None	Early suture repair	None
F, 83	Osteoarthritis	Unknown	120	Fall	None	Early knee immobilizer	None
F, 71	Osteoarthritis	Press-fit condylar	0.75	Fall	None	Early knee immobilizer	None
F, 60	Osteoarthritis	Unknown	0.05	Fall	Diabetes mellitus, venous stasis, varus deformity, morbid obesity	Late suture repair, revision total knee arthroplasty	Popliteal artery laceration
M, 69	Osteoarthritis	NexGen	3	Fall	Diabetes mellitus	Late suture repair	None
F, 78	Osteoarthritis	Press-Fit Condylar Sigma	3	Physical therapy	Knee in excessive valgus	Late suture repair, polyethylene exchange, lateral release	None
F, 68	Osteoarthritis	Total Condylar III	15	Walking	Multiple knee surgeries	Late suture repair and vastus medialis advancement	Intraoperative fracture of medial femoral condyle
F, 74	Osteoarthritis	Press-Fit Condylar Sigma	9	Walking	Previous knee surgery	Late suture repair, lateral release	None
M, 70	Osteoarthritis	Press-fit condylar	48	Horseback riding	None	Chronic suture repair, lateral release, patellar revision	None
F, 63	Rheumatoid arthritis	Total condylar	200	Walking	Steroids, previous knee surgery	Late suture repair, patellar revision	None
F, 80	Osteoarthritis	Press-fit condylar	2	Climbing stairs	Steroid injections	None	Missed diagnosis

Treatment administered within two weeks after the quadriceps tear was deemed early, and treatment administered more than two weeks after the tear was deemed late.

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TABLE II Data on Patients with a Partial Tear

Gender, Age	Diagnosis	Prosthesis	Duration from Arthroplasty to Tear (mo)	Mechanism of Injury	Systemic or Local Factors	Treatment^*	Early or Late Complications
F, 68	Osteoarthritis	Press-Fit Condylar Sigma	0.25	Walking	Diabetes mellitus	Early use of crutches, non-weight-bearing	None
M, 73	Osteoarthritis	Press-fit condylar	105	Climbing stairs	Diabetes mellitus	Early suture repair	None
F, 71	Osteoarthritis	Press-Fit Condylar Sigma	3	Fall	Diabetes mellitus	Early suture repair	None
M, 72	Osteoarthritis	Cruciate condylar	16	Fall	Lateral release	Early suture repair	Rerupture
F, 82	Osteoarthritis	Cruciate condylar	108	Fall	Open excision of calcium deposits in quadriceps tendon	Early cast	None
M, 80	Osteoarthritis	Unknown	24	Fall	Renal insufficiency	Early knee immobilizer	None
F, 65	Rheumatoid arthritis	Kinematic condylar	3	Fall	Steroids	Early suture repair	None
F, 75	Rheumatoid arthritis	Kinematic stabilizer	18	Fall	Steroids	Early suture repair	Periprosthetic infection
F, 45	Rheumatoid arthritis	Polycentric	95	Walking	Steroids, multiple knee surgeries	Early suture repair	Recurrent knee instability
F, 52	Rheumatoid arthritis	Total condylar	9	Rising from a chair	Steroids, steroid injections, multiple knee surgeries	Early suture repair	None
M, 85	Osteoarthritis	Genesis	1	During transfer	None	Early physical therapy	None
F, 69	Osteoarthritis	Press-fit condylar	0.75	Fall	None	Early suture repair	None
M, 68	Osteoarthritis	Press-fit condylar	48	Lifting	None	Early suture repair	None
F, 83	Osteoarthritis	Unknown	120	Fall	None	Early knee immobilizer	None
F, 71	Osteoarthritis	Press-fit condylar	0.75	Fall	None	Early knee immobilizer	None
F, 60	Osteoarthritis	Unknown	0.05	Fall	Diabetes mellitus, venous stasis, varus deformity, morbid obesity	Late suture repair, revision total knee arthroplasty	Popliteal artery laceration
M, 69	Osteoarthritis	NexGen	3	Fall	Diabetes mellitus	Late suture repair	None
F, 78	Osteoarthritis	Press-Fit Condylar Sigma	3	Physical therapy	Knee in excessive valgus	Late suture repair, polyethylene exchange, lateral release	None
F, 68	Osteoarthritis	Total Condylar III	15	Walking	Multiple knee surgeries	Late suture repair and vastus medialis advancement	Intraoperative fracture of medial femoral condyle
F, 74	Osteoarthritis	Press-Fit Condylar Sigma	9	Walking	Previous knee surgery	Late suture repair, lateral release	None
M, 70	Osteoarthritis	Press-fit condylar	48	Horseback riding	None	Chronic suture repair, lateral release, patellar revision	None
F, 63	Rheumatoid arthritis	Total condylar	200	Walking	Steroids, previous knee surgery	Late suture repair, patellar revision	None
F, 80	Osteoarthritis	Press-fit condylar	2	Climbing stairs	Steroid injections	None	Missed diagnosis

Treatment administered within two weeks after the quadriceps tear was deemed early, and treatment administered more than two weeks after the tear was deemed late.

Each of the twenty-four patients who had the index total knee arthroplasty done at our institution was entered prospectively into our total joint registry. They were asked to return for a follow-up examination at six weeks and at one year, two years, five years, and ten years after the index total knee arthroplasty. The ten patients who had the primary total knee arthroplasty done elsewhere were followed from the time of our diagnosis of the quadriceps tendon tear. Knee function was assessed with the Knee Society clinical rating system¹².

Results

Materials and Methods | Results | Discussion | Appendix | References

Complete Tears of the Quadriceps Tendon

Eleven patients had a complete tear of the quadriceps tendon. Nine of them had an identifiable predisposing systemic or local factor that may have contributed to the tear (Table I). Only four of these eleven patients ultimately rated the outcome as satisfactory.

Ten of the eleven patients with a complete tear of the quadriceps tendon had a primary operative repair. The repairs were done with direct suture fixation of the tendon, with or without drill-holes in the patella¹³. In two of the ten patients, the repair was augmented with synthetic material (Marlex mesh; C.R. Bard, Murray Hill, New Jersey). One patient had revision of the total knee replacement at the time of the repair. Four of the ten patients had a rerupture of the quadriceps tendon after operative repair. Two patients had a deep periprosthetic infection develop, and the total knee replacement was resected. One of those two patients later had an above-the-knee amputation to control the infection. One additional patient had development of a recurvatum deformity and substantial knee instability (Table I). The active range of motion before a complete tear of the quadriceps tendon averaged 2° (range, 0° to 8°) of extension and 106° (range, 95° to 135°) of flexion. At the time of the last follow-up, the active range of motion averaged 3° (range, 0° to 10°) of extension and 101° (range, 60° to 125°) of flexion.

One of the eleven patients with a complete tear of the quadriceps tendon was treated nonoperatively. The index total knee arthroplasty had been done at our institution, and the patient had been doing well when evaluated six weeks after surgery. Two weeks later, that patient sustained a tear of the quadriceps tendon but failed to seek treatment. When evaluated at one year after the index arthroplasty, he had no active knee extension and a 3-cm palpable defect in the quadriceps tendon. Because of poor skin quality, high doses of systemic steroids, the large defect in the tendon, and the ten-month delay from the injury until the diagnosis, this patient was treated nonoperatively with a drop-lock knee brace. The patient had an unsatisfactory result, and the final active range of motion was 30° to 110°.

Partial Tears of the Quadriceps Tendon

Twenty-three patients had a partial tear of the quadriceps tendon. Seventeen had an identifiable factor that may have predisposed the patient to the tear (Table II). Nineteen of the twenty-three patients with a partial tear ultimately rated the outcome as satisfactory.

Seven patients with a partial rupture of the quadriceps tendon were treated nonoperatively. Six of them, who were seen early, were managed with immobilization of the knee in extension for four to six weeks (four patients), walking with use of crutches for six weeks (one patient), and gentle physical therapy (one patient). None of the six patients subsequently had a rerupture of the quadriceps tendon or had a substantial complication. The remaining patient with a partial tear was treated nonoperatively by default, as the problem was not diagnosed initially. That patient was seen at our institution one year after the injury, three years after the index total knee arthroplasty, and had an extensor lag of 10° with a palpable defect in the quadriceps tendon. No additional treatment was recommended. All seven patients who had a partial rupture of the quadriceps tendon that was treated nonoperatively had a satisfactory outcome. The active range of motion was an average of 1° (range, 0° to 5°) of extension and 99° (range, 90° to 120°) of flexion before the tear and 1° (range, 0° to 10°) of extension and 99° (range, 90° to 120°) of flexion at the final follow-up examination.

Sixteen patients had a primary operative repair of the partial tear of the quadriceps tendon. All sixteen had a direct suture repair of the tendon without augmentation. In three, a lateral release was done concurrently with the repair. Two of the sixteen patients also had the patellar component revised, and one patient had all components of the total knee replacement revised. Five of the sixteen patients had a complication, including knee instability, rerupture, intraoperative laceration of the popliteal artery, intraoperative fracture of the femoral condyle, or deep periprosthetic infection (Table II). The active range of motion in the sixteen patients before the partial tear of the quadriceps tendon averaged 4° (range, 0° to 20°) of extension and 110° (range, 90° to 130°) of flexion. The active range of motion after the operative repair averaged 7° (range, 0° to 40°) of extension and 104° (range, 90° to 130°) of flexion. Twelve patients had a satisfactory outcome.

Clinical Function

Prior to the partial or complete tear of the quadriceps tendon, the mean Knee Society knee score was 83 points (range, 60 to 97 points) and the mean Knee Society function score was 63 points (range, 40 to 100 points). At the final follow-up evaluation after treatment of the tear in the quadriceps tendon, the thirty-four patients had a mean Knee Society knee score of 74 points (range, 0 to 100 points) and a mean Knee Society function score of 44 points (range, 0 to 100 points). In a comparison of nonoperative treatment with early (less than four weeks) and late operative treatment, we found that the mean Knee Society knee and function scores at the time of the last follow-up were 92 points (range, 82 to 99 points) and 49 points (range, 0 to 100 points), respectively, for the nonoperative group; 70 points (range, 0 to 100 points) and 41 points (range, 0 to 100 points), respectively, for the group that had early operative treatment; and 77 points (range, 0 to 97 points) and 51 points (range, 0 to 90 points), respectively, for the group that had late operative treatment.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

Tears of the quadriceps tendon after total knee arthroplasty are rare^2,4,5,7,8. In contrast, the catastrophic nature of patellar tendon disruption after total knee arthroplasty has been well delineated^{1-3,5-7,14-16}. Most reported results of the operative repair of patellar tendon rupture have been discouraging. Satisfactory results have not been obtained reliably with suture fixation alone^2,16. Accordingly, efforts have focused on the use of autogenous or allograft tendon to reconstruct or augment these patellar tendon repairs^6,14,15.

The present series of thirty-four patients who had a partial or complete quadriceps tendon tear after total knee arthroplasty reinforces the debilitating nature of extensor mechanism disruption after total knee arthroplasty (Fig. 1). The prevalence of complications among the twenty-six patients treated operatively in the present series was high. Nine (35%) of them required a second operation. Three (12%) of them had development of a deep periprosthetic infection that led to the death of one patient from infection-related complications and to an above-the-knee amputation in another patient. The high rate of complications may reflect the compromised status of many patients who have a tear of the quadriceps tendon after a total knee arthroplasty.

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Fig. 1: Treatment and ultimate outcome for thirty-four patients who had a quadriceps tendon tear after total knee arthroplasty (TKA).

Similar to the early experience with operative repair of patellar tendon disruption¹⁶, the results of operative repair of a complete quadriceps tendon tear with use of suture fixation alone in the present study were unreliable in restoring extensor mechanism function, with a rerupture of the quadriceps tendon occurring in four of ten patients (Table I). Lynch et al. also reported unsatisfactory results with the direct suture repair of three quadriceps tendon tears after a total knee arthroplasty⁵. One of those repairs reruptured at six weeks, leaving the patient with a 35° extensor lag, and the other two patients had limited knee flexion to 70° and an extensor lag of 12° and 19°, respectively.

These poor results obtained with suture repair of complete quadriceps tendon tears after total knee arthroplasty contrast with the reliably good results achieved after operative repair of quadriceps tendon tears in patients without a total knee replacement^9-11,13. Siwek and Rao reported good results with primary suture repair in thirty-three patients with acute quadriceps tears treated within four weeks after the injury⁹. Larsen and Lund noted good results in fifteen of eighteen patients and stated that "in acute ruptures of the quadriceps tendon end-to-end sutures are sufficient."¹⁰ Similarly, Rasul and Fischer reported good results after treating nineteen patients with multiple sutures passed through drill-holes in the patella for ruptures that occurred at the tendon-bone junction¹¹. Part of the discrepancy in the results following operative repair of the quadriceps tendon between patients with and those without a total knee replacement may be explained by the greater age and comorbidities in the total knee replacement group. The mean age in most series of patients with an isolated quadriceps tendon tear is approximately fifty years, whereas the mean age in the present study was seventy years. Twenty-six of the thirty-four patients in the present series had a systemic disease or local factor that predisposed them to a tear of the quadriceps tendon. Reports on the operative repair of isolated quadriceps tears in patients who had not had a total knee arthroplasty have made no mention of the prevalence of predisposing factors¹⁰, have stated that all patients were otherwise healthy¹¹, or have noted only that in "several patients there were factors that could have predisposed to the rupture."⁹

In a patient managed with a total knee arthroplasty, the blood supply to the quadriceps tendon may be further reduced by the arthrotomy used to expose the joint, particularly when a lateral retinacular release also is done^17,18. That compromise of the blood supply may slow healing enough that the race between soft-tissue healing and failure of fixation is lost more frequently in patients managed with a total knee arthroplasty. This suggests a potential role for augmentation of the repair with autogenous tissue or prosthetic material to protect the quadriceps tendon until healing can occur. Several isolated case reports of quadriceps tendon tears after total knee arthroplasty have suggested that better results are achieved when the repair is reinforced with graft material. Fernandez-Baillo et al. performed a suture repair augmented with a Dacron tape (U.S. Catheter and Instrument, Glen Falls, New York) cerclage in one patient with rheumatoid arthritis who had a complete tear of the quadriceps tendon⁸. The knee was immobilized in full extension for six weeks after the repair. At one year following the repair, the patient was pain-free, was able to walk without aids, and had an active range of motion of 0° to 110°. Gustillo and Thompson advocated a similar approach with use of either synthetic graft material or autograft reinforcement of the quadriceps tendon².

On the basis of the poor results obtained with suture repair alone, we currently augment all repairs of the quadriceps tendon with either hamstring tendon autograft or with Marlex mesh. The frayed and degenerated tissue is resected back to healthy tendon, the quadriceps muscle and tendon is mobilized, and number-5 nonabsorbable suture is passed in a Krackow pattern through the quadriceps tendon and is tied through drill-holes in the patella¹⁹ (Figs. 2-A, 2-B, 2-C, 2-D, 2-E). The repair is then reinforced with either semitendinosus and gracilis tendon autograft or with Marlex mesh that is incorporated directly into the repair. At the present time, the data are not sufficient to allow us to comment on whether this type of augmentation improves the results of operative treatment of a complete tear of the quadriceps tendon after total knee arthroplasty.

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Figs. 2-A through 2-E: Repair of a complete quadriceps tendon rupture after total knee arthroplasty. Fig. 2-A A complete quadriceps tendon rupture.

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Fig. 2-B: The tissue sheath overlying the patellar tendon is mobilized.

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Fig. 2-C: The quadriceps tendon is mobilized proximally.

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Fig. 2-D: The tubularized Marlex mesh is passed through the tunnel.

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Fig. 2-E: The mesh is folded over and secured with number-5 Ethibond suture.

This report is the first, to our knowledge, to address partial tears of the quadriceps tendon after total knee arthroplasty. The results after nonoperative treatment of partial tears with immobilization of the knee in extension with either a cast or a brace were good, and no complications occurred among the seven patients treated nonoperatively. In contrast, operative repair of partial tears of the quadriceps had a substantial rate of complications (five of the sixteen patients had a complication), and yet it was not more reliable in restoring active knee motion. For that reason, we now treat partial tears of the quadriceps tendon after total knee arthroplasty nonoperatively with immobilization of the knee in extension for six to eight weeks followed by use of a brace for a six-week period to allow 30°, 60°, and then 90° of knee flexion over two-week intervals.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

A table presenting clinical data and outcomes for all patients is available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results | Discussion | Appendix | References

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Gustillo R, Thompson R. Quadriceps and patellar tendon ruptures following total knee arthroplasty. In: Rand JA, Dorr LD, editors. Total arthroplasty of the knee: proceedings of the Knee Society, 1985-1986. Rockville, MD: Aspen; 1987. 1987

Healy WL, Wasilewski SA, Takei R, Oberlander M. Patellofemoral complications following total knee arthroplasty. Correlation with implant design and patient risk factors. J Arthroplasty.1995;10: 197-201.10197 1995 [CrossRef]

Trepte CT, Kirgis A. [Spontaneous ruptures of the extensor system of the knee following joint replacement in patients with rheumatoid arthritis.] Z Orthop Ihre Grenzgeb.1988;126: 519-25. German.126519 1988 [PubMed][CrossRef]

Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism complications following total knee arthroplasty. J Arthroplasty.1987;2: 135-40.2135 1987 [CrossRef]

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Doolittle KH 2nd, Turner RH. Patellofemoral problems following total knee arthroplasty. Orthop Rev.1988;17: 696-702.17696 1988

Fernandez-Baillo N, Garay EG, Ordonez JM. Rupture of the quadriceps tendon after total knee arthroplasty. A case report. J Arthroplasty.1993;8: 331-3.8331 1993 [PubMed][CrossRef]

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Rasul AT Jr, Fischer DA. Primary repair of quadriceps tendon ruptures. Results of treatment. Clin Orthop.1993;289: 205-7.289205 1993

Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop.1989;248: 13-4.24813 1989

Scuderi C. Ruptures of the quadriceps tendon; study of twenty tendon ruptures. Am J Surg.1958;95: 626-34.95626 1958 [PubMed][CrossRef]

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Topics

tendon ; knee replacement arthroplasty ; quadriceps tendon rupture ; quadriceps

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Ryan E. Dobbs, Arlen D. Hanssen, David G. Lewallen, Mark W. Pagnano; Quadriceps Tendon Rupture After Total Knee ArthroplastyPrevalence, Complications, and Outcomes. The Journal of Bone & Joint Surgery. 2005 Jan;87(1):37-45.

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