Elsevier

Injury

Volume 43, Issue 11, November 2012, Pages 1931-1938
Injury

Review
Clinical outcomes after repair of quadriceps tendon rupture: A systematic review

https://doi.org/10.1016/j.injury.2012.08.044Get rights and content

Abstract

The existing evidence regarding the management of quadriceps tendon rupture remains obscure. The aim of the current review is to investigate the characteristics, the different techniques employed and to analyse the clinical outcomes following surgical repair of quadriceps tendon rupture. An Internet based search of the English literature of the last 25 years was carried out. Case reports and non-clinical studies were excluded. The methodological quality of the included studies was assessed using the Coleman Methodology Score. All data regarding mechanism and site of rupture, type of treatment, time elapsed between diagnosis and repair, patients’ satisfaction, clinical outcome, return to pre-injury activities, complications and recurrence rates were extracted and analysed. Out of 474 studies identified, 12 met the inclusion criteria. The average of Coleman Methodology Score was 50.46/100. In total 319 patients were analysed with a mean age of 57 years (16–85). The mean time of follow-up was 47.5 months (3 months to 24 years). The most common mechanism of injury was simple fall (61.5%). Spontaneous ruptures were reported in 3.2% of cases. The most common sites of tear were noted between 1 cm and 2 cm of the superior pole of the patella and, in the older people, at the osseotendinous junction. The most frequently used repair technique was patella drill holes (50% of patients). Simple sutures were used in mid-substance ruptures. Several reinforcement techniques were employed in case of poor quality or retraction of the torn ends of tendon. The affected limb was immobilised in a cast for a period of 3–10 weeks. Quadriceps muscular atrophy and muscle strength deficit were present in most of the cases. Worst results were noted in delayed repairs. Reported complications included heterotopic ossifications in 6.9% of patients, deep venous thrombosis or pulmonary embolism in 2.5%, superficial infection in 1.2% and deep infection in 1.1%. It appears that the type of surgical repair does not influence the clinical results. The majority of the studies reported good or excellent ROM and return to the pre-injury activities. The overall rate of re-rupture was 2%.

Introduction

Quadriceps tendon rupture (QTR) is a relative uncommon injury with an incidence of 1.37/100,000 patients per year, affecting predominantly middle aged males (M:F = 4.2:1, mean age: 51.1 years).1 This disabling condition is the result of direct or indirect trauma.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Spontaneous ruptures, even sometimes bilaterally, have been reported in people with predisposing conditions such as chronic renal failure, rheumatoid arthritis, diabetes, gout, steroids abuse and other conditions13 or in healthy subjects during sporting activity.14 In case of traumatic injury, indirect and violent eccentric contraction is the most frequent cause of QTR.15 Patients usually report the experience of an intense pain felt during attempts to regain balance while avoiding a fall.15 Clinical history and physical examination usually suffice for the diagnosis of QTR. The clinical diagnostic triad includes: acute pain, inability to active extend the knee and a palpable suprapatellar gap.16 In case of a suspected tendon rupture, radiological investigations, such as ultrasound scan or MRI are used to confirm the diagnosis.17

QTR requires a prompt surgical repair to avoid poor outcomes previously reported in neglected or chronic ruptures.15, 18 Many surgical techniques have been described in the literature15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 to repair QTR, but no studies have been published to the best of our knowledge to compare the outcome of the different techniques.

The aim of this review therefore is to analyze the available evidence regarding the effectiveness of different techniques for the surgical repair of complete traumatic QTR, and to evaluate the potential influence of the timing of surgery on the functional outcome.

Section snippets

Materials and methods

All the studies dealing with quadriceps tendon rupture management, performed on adult patients (more than 16 years old), with a minimum follow-up of 12 months, published in a peer-reviewed journal in English language, within the last 25 years were eligible for inclusion. Case reports, biomechanical, animal or cadaveric studies, literature reviews, technical notes, letters to editor, editorials and instructional course lectures were excluded. An Internet-based search of the MEDLINE, EMBASE and

Features of the included studies and Coleman Methodology Score

The literature search yielded 474 studies and out of potentially 34 articles that were relevant to the objectives of this study, 1216, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 met the inclusion criteria. All the included studies were retrospective cohort studies published from 198116 to 2008.24 The mean CMS was 50.46 (range: 3328 to 7224). The lowest scores reported were relevant to the type of study (0 for every study) and the study size (mean: 3, ranging from 023, 28, 29 to 718) (Table 1,

Discussion

Quadriceps tendon is a very strong structure contributing to the extensor mechanism of the knee. The structural and biomechanical properties of the quadriceps tendon allow it to sustain very high loads without rupture.30 The tendon tissue response to loads consists of three phases33: the first phase or the “toe” phase, in which the initial deformation, till 2% of load, depends only on flattening of the crimp pattern of collagen fibres. Beyond this point and up to 4% of the strain, tendon

Conflict of interest

None to declare.

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