Chronic quadriceps rupture repair: Chambat technique or sardine tin technique

Introduction

Quadriceps tendon ruptures are uncommon injuries of the extensor apparatus and account for fewer than 2% of knee tendon injuries.[1] Saragaglia D, Pison A, Rubens-Duval B. Acute and old ruptures of the extensor apparatus of the knee in adults (excluding knee replacement). Orthop Traumatol Surg Res. 2013;99(1 Suppl):S67-76. doi:10.1016/j.otsr.2012.12.002 As with all extensor apparatus tears, they have serious functional limitations due to the inability to lock the knee when walking. The incidence of quadriceps tendon ruptures is three times lower than that of patellar tendon ruptures.[2] Garner MR, Gausden E, Berkes MB, Nguyen JT, Lorich DG. Extensor Mechanism Injuries of the Knee: Demographic Characteristics and Comorbidities from a Review of 726 Patient Records. J Bone Joint Surg Am. 2015;97(19):1592-1596. doi:10.2106/JBJS.O.00113 Patients are usually aged over 40 years. Nearly three quarters of cases have a predisposition, whether metabolic (diabetes, chronic kidney injury, hyperparathyroidism, uremia), inflammatory (polyarthritis, tendinopathy) or due to medication use (corticosteroids, quinolines).[3], Shah MK. Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. South Med J. 2002;95(8):860-866.[4], Meyer Z, Ricci WM. Knee Extensor Mechanism Repairs: Standard Suture Repair and Novel Augmentation Technique. J Orthop Trauma. 2016;30 Suppl 2:S30-31. doi:10.1097/BOT.0000000000000604[5] Muratli HH, Celebi L, Hapa O, Biçimoğlu A. Simultaneous rupture of the quadriceps tendon and contralateral patellar tendon in a patient with chronic renal failure. J Orthop Sci. 2005;10(2):227-232. doi:10.1007/s00776-004-0868-2 The rupture is usually traumatic due to eccentric contraction of the quadriceps when flexed. There have also been a few rare reports of non-traumatic ruptures.[6], Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-937.[7] Ramsey RH, Muller GE. Quadriceps tendon rupture: a diagnostic trap. Clin Orthop Relat Res. 1970;70:161-164.

Authors describe numerous techniques for repairing recent quadriceps ruptures, involving either trans osseous reinsertion or suture anchor fixation.[6], Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-937.[8], Ciriello V, Gudipati S, Tosounidis T, Soucacos PN, Giannoudis PV. Clinical outcomes after repair of quadriceps tendon rupture: a systematic review. Injury. 2012;43(11):1931-1938. doi:10.1016/j.injury.2012.08.044[9] Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg. 2003;11(3):192-200. doi:10.5435/00124635-200305000-00006Surgical treatment for acute injuries is associated with excellent functional outcomes and a low failure rate of around 2%.[6], Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-937.[8], Ciriello V, Gudipati S, Tosounidis T, Soucacos PN, Giannoudis PV. Clinical outcomes after repair of quadriceps tendon rupture: a systematic review. Injury. 2012;43(11):1931-1938. doi:10.1016/j.injury.2012.08.044[9] Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg. 2003;11(3):192-200. doi:10.5435/00124635-200305000-00006 In contrast, chronic injuries or failed reinsertions are much more complex and there is a lack of consensus due to the retraction of the tendon and the difficulties in getting the tendon stump to reach down to the proximal patella.[11], Rasul AT, Fischer DA. Primary repair of quadriceps tendon ruptures. Results of treatment. Clin Orthop Relat Res. 1993;(289):205-207.[12], Rizio L, Jarmon N. Chronic quadriceps rupture: treatment with lengthening and early mobilization without cerclage augmentation and a report of three cases. J Knee Surg. 2008;21(1):34-38. doi:10.1055/s-0030-1247789[13], Katzman BM, Silberberg S, Caligiuri DA, Klein DM, DiPaolo P. Delayed repair of a quadriceps tendon. Orthopedics. 1997;20(6):553-554. doi:10.3928/0147-7447-19970601-12[14], Leopardi P, Vico G di, Rosa D, Cigala F, Maffulli N. Reconstruction of a chronic quadriceps tendon tear in a body builder. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):1007-1011. doi:10.1007/s00167-006-0044-7[15], McCormick F, Nwachukwu BU, Kim J, Martin SD. Autologous hamstring tendon used for revision of quadiceps tendon tears. Orthopedics. 2013;36(4):e529-532. doi:10.3928/01477447-20130327-36[16], Rehman H, Kovacs P. Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repair of chronic quadriceps tendon rupture. Knee. 2015;22(6):664-668. doi:10.1016/j.knee.2015.04.006[17], Forslund J, Gold S, Gelber J. Allograft Reconstruction of a Chronic Quadriceps Tendon Rupture with Use of a Novel Technique. JBJS Case Connect. 2014;4(2):e42. doi:10.2106/JBJS.CC.M.00230[18], Lee SH, Song EK, Seon JK, Woo SH. Surgical Treatment of Neglected Traumatic Quadriceps Tendon Rupture with Knee Ankylosis. Knee Surg Relat Res. 2016;28(2):161-164. doi:10.5792/ksrr.2016.28.2.161[19] Li PL. Acute bilateral rupture of the quadriceps tendon--an obvious diagnosis? Injury. 1994;25(3):191-192. doi:10.1016/0020-1383(94)90162-7 Published articles describe techniques involving either lengthening surgery[16], Rehman H, Kovacs P. Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repair of chronic quadriceps tendon rupture. Knee. 2015;22(6):664-668. doi:10.1016/j.knee.2015.04.006[10], Scuderi C. Ruptures of the quadriceps tendon; study of twenty tendon ruptures. Am J Surg. 1958;95(4):626-634. doi:10.1016/0002-9610(58)90444-6[12], Rizio L, Jarmon N. Chronic quadriceps rupture: treatment with lengthening and early mobilization without cerclage augmentation and a report of three cases. J Knee Surg. 2008;21(1):34-38. doi:10.1055/s-0030-1247789[13] Katzman BM, Silberberg S, Caligiuri DA, Klein DM, DiPaolo P. Delayed repair of a quadriceps tendon. Orthopedics. 1997;20(6):553-554. doi:10.3928/0147-7447-19970601-12autografts [14], Leopardi P, Vico G di, Rosa D, Cigala F, Maffulli N. Reconstruction of a chronic quadriceps tendon tear in a body builder. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):1007-1011. doi:10.1007/s00167-006-0044-7[15], McCormick F, Nwachukwu BU, Kim J, Martin SD. Autologous hamstring tendon used for revision of quadiceps tendon tears. Orthopedics. 2013;36(4):e529-532. doi:10.3928/01477447-20130327-36[16] Rehman H, Kovacs P. Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repair of chronic quadriceps tendon rupture. Knee. 2015;22(6):664-668. doi:10.1016/j.knee.2015.04.006 or allografts [17], Forslund J, Gold S, Gelber J. Allograft Reconstruction of a Chronic Quadriceps Tendon Rupture with Use of a Novel Technique. JBJS Case Connect. 2014;4(2):e42. doi:10.2106/JBJS.CC.M.00230[18] Lee SH, Song EK, Seon JK, Woo SH. Surgical Treatment of Neglected Traumatic Quadriceps Tendon Rupture with Knee Ankylosis. Knee Surg Relat Res. 2016;28(2):161-164. doi:10.5792/ksrr.2016.28.2.161. We propose a direct tendon reinsertion technique reinforced with a metal frame to help lower the retracted tendon down to the proximal end of patella without the need for these other tricks.

Diagnosis

Patients usually describe a history of trauma involving eccentric contraction of the quadriceps and hyperflexion. Immediate after the event there is often haemarthrosis, a visible indentation above the patella (Fig. 1) and a loss of active extension.[9], Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg. 2003;11(3):192-200. doi:10.5435/00124635-200305000-00006[19], Li PL. Acute bilateral rupture of the quadriceps tendon--an obvious diagnosis? Injury. 1994;25(3):191-192. doi:10.1016/0020-1383(94)90162-7[20], MacEachern AG, Plewes JL. Bilateral simultaneous spontaneous rupture of the quadriceps tendons. Five case reports and a review of the literature. J Bone Joint Surg Br. 1984;66(1):81-83. doi:10.1302/0301-620X.66B1.6693484[21] Kaneko K, DeMouy EH, Brunet ME, Benzian J. Radiographic diagnosis of quadriceps tendon rupture: analysis of diagnostic failure. J Emerg Med. 1994;12(2):225-229. doi:10.1016/0736-4679(94)90703-x

A late diagnosis is reported in 10–50% of cases due partly to the haemarthrosis which can mask the hollow[6], Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-937.[19], Li PL. Acute bilateral rupture of the quadriceps tendon--an obvious diagnosis? Injury. 1994;25(3):191-192. doi:10.1016/0020-1383(94)90162-7[22] Konrath GA, Chen D, Lock T, et al. Outcomes following repair of quadriceps tendon ruptures. J Orthop Trauma. 1998;12(4):273-279. doi:10.1097/00005131-199805000-00010, and partly to the continued ability to lock out the knee if the rupture was only partial or if the medial and lateral retinacula are still intact. Asymmetry in active extension compared to the healthy knee is another diagnostic sign.[9], Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg. 2003;11(3):192-200. doi:10.5435/00124635-200305000-00006[19] Li PL. Acute bilateral rupture of the quadriceps tendon--an obvious diagnosis? Injury. 1994;25(3):191-192. doi:10.1016/0020-1383(94)90162-7

In chronic forms, patients commonly complain of anterior pain and instability when walking on sloped ground. A physical examination will reveal a loss of active extension and a indentation above the patella.

Imaging

A strict lateral x-ray will help the diagnosis by revealing signs of pre-existing tendinopathy or a low-riding baja.[6] Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-937. The existence of a suprapatellar mass will sometimes indicate and help evaluate the tendon retraction (Fig. 2).

If there is any doubt, ultrasonography can be used to confirm the diagnosis and the extent of the retraction.[23] Heyde CE, Mahlfeld K, Stahel PF, Kayser R. Ultrasonography as a reliable diagnostic tool in old quadriceps tendon ruptures: a prospective multicentre study. Knee Surg Sports Traumatol Arthrosc. 2005;13(7):564-568. doi:10.1007/s00167-004-0576-7Likewise, an MRI can evaluate the extent of the retraction and any associated fatty atrophy of quadriceps.[13], Katzman BM, Silberberg S, Caligiuri DA, Klein DM, DiPaolo P. Delayed repair of a quadriceps tendon. Orthopedics. 1997;20(6):553-554. doi:10.3928/0147-7447-19970601-12[21], Kaneko K, DeMouy EH, Brunet ME, Benzian J. Radiographic diagnosis of quadriceps tendon rupture: analysis of diagnostic failure. J Emerg Med. 1994;12(2):225-229. doi:10.1016/0736-4679(94)90703-x[24] O’Shea K, Kenny P, Donovan J, Condon F, McElwain JP. Outcomes following quadriceps tendon ruptures. Injury. 2002;33(3):257-260. doi:10.1016/s0020-1383(01)00110-3

Surgical technique

The surgery is performed under general or spinal anaesthesia. The patient is placed in a supine position with a pneumatic tourniquet at the proximal end of the thigh. A counter-support is placed against the lateral thigh and a knee bar used to position the knee at 90° flexion. A second bar can be placed more distally to flex the knee to about 30° and make the skin closure easier at the end of the operation without placing excessive strain on the repaired tendon (Figs. 3 and 4). In fact, the retraction of the tendon usually means that flexing the joint will pull on the sutures at the end of the procedure.

A 10–15 cm anterior longitudinal incision is made, centred over the proximal end of patella. The subcutaneous layers are opened. The adhesions are cut to expose and then strip the proximal and distal ends of the quadriceps tendon (Figures 5 and 6).

Three 2 mm longitudinal trans osseous tunnels are created at the patella between the proximal end and anterior face. Two or three large calibre sutures (e.g. Fiberwire® no. 2 (Arthrex®) or Mersuture® no. 3 (Ethicon®) are then passed over the anterior face of patella for later use. The procedure is then repeated for the quadriceps stump (Figure 7).

Two 2 mm pins are placed crosswise, one through the patella 2 cm beneath the proximal end, the other through the proximal stump of quadriceps tendon about 2 cm from the tear. The two pins are cut and their ends bent over. Two 2 mm metal wires are then passed in a loop through the ends of the pins. The knee is placed in extension and the retracted stump of quadriceps tendon is gradually moved down towards the proximal end of patella by pulling on the two metal wires (Figure 9).

Once the two stumps of the tendon are touching, the pre-prepared Fiberwire® or Mersuture® sutures from the proximal end of patella are passed through the proximal tendon stump and knotted together (Fig. 10). The procedure is completed with edge-to-edge repair of the tendon using continuous sutures and Polysorb® no. 2 (Covidien®). Stability is then tested by gradually flexing the knee. The final stage is closure of the subcutaneous and skin layers.

Post-operative recovery

The leg is immobilised in extension for 45 days using a straight brace. Preventive anticoagulant therapy is given until removal of the brace and the patient can walk fully.

Patients are allowed to stand and bear full weight on the leg, provided they wear the brace for protection, from the very first day. Physiotherapy can begin immediately, involving isometric quadriceps movements and gradual recovery of joint range of motion. Flexion is restricted to 30° for the first three weeks, then to 60° for the next three weeks.

Discussion

The time between injury and surgery appears to be a determining factor in the functional outcomes of quadriceps tendon repair. Scuderi10 reports inferior results when there was a 72-hour delay or longer after the trauma. Likewise, Rougraff [25] Rougraff BT, Reeck CC, Essenmacher J. Complete quadriceps tendon ruptures. Orthopedics. 1996;19(6):509-514. describes better functional outcomes and higher patient satisfaction for repairs performed within seven days of the rupture. Elattar26 believes the delay should be capped at 2–3 weeks to guarantee an optimum result. We therefore believe that if more than three weeks have passed since the trauma, the suture should be reinforced with a metal structure.

Numerous techniques have been described for repairing chronic quadriceps tendon ruptures, but the series all have small populations. [12], Rizio L, Jarmon N. Chronic quadriceps rupture: treatment with lengthening and early mobilization without cerclage augmentation and a report of three cases. J Knee Surg. 2008;21(1):34-38. doi:10.1055/s-0030-1247789[13], Katzman BM, Silberberg S, Caligiuri DA, Klein DM, DiPaolo P. Delayed repair of a quadriceps tendon. Orthopedics. 1997;20(6):553-554. doi:10.3928/0147-7447-19970601-12[14], Leopardi P, Vico G di, Rosa D, Cigala F, Maffulli N. Reconstruction of a chronic quadriceps tendon tear in a body builder. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):1007-1011. doi:10.1007/s00167-006-0044-7[15], McCormick F, Nwachukwu BU, Kim J, Martin SD. Autologous hamstring tendon used for revision of quadiceps tendon tears. Orthopedics. 2013;36(4):e529-532. doi:10.3928/01477447-20130327-36[16], Rehman H, Kovacs P. Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repair of chronic quadriceps tendon rupture. Knee. 2015;22(6):664-668. doi:10.1016/j.knee.2015.04.006[17], Forslund J, Gold S, Gelber J. Allograft Reconstruction of a Chronic Quadriceps Tendon Rupture with Use of a Novel Technique. JBJS Case Connect. 2014;4(2):e42. doi:10.2106/JBJS.CC.M.00230[18], Lee SH, Song EK, Seon JK, Woo SH. Surgical Treatment of Neglected Traumatic Quadriceps Tendon Rupture with Knee Ankylosis. Knee Surg Relat Res. 2016;28(2):161-164. doi:10.5792/ksrr.2016.28.2.161[27] Kerin C, Hopgood P, Banks AJ. Delayed repair of the quadriceps using the Mitek anchor system: a case report and review of the literature. Knee. 2006;13(2):161-163. doi:10.1016/j.knee.2005.11.004

Some authors suggest direct suturing [27] Kerin C, Hopgood P, Banks AJ. Delayed repair of the quadriceps using the Mitek anchor system: a case report and review of the literature. Knee. 2006;13(2):161-163. doi:10.1016/j.knee.2005.11.004if there is minimal tendon retraction and the stump can still be drawn down towards the patella. Medial and lateral retinacular release can make this easier. If there would be too much pulling on the sutures or there is a defect making it impossible for the tendon stump to reach the proximal end of patella, other authors propose a stretching V plasty [1], Saragaglia D, Pison A, Rubens-Duval B. Acute and old ruptures of the extensor apparatus of the knee in adults (excluding knee replacement). Orthop Traumatol Surg Res. 2013;99(1 Suppl):S67-76. doi:10.1016/j.otsr.2012.12.002[10], Scuderi C. Ruptures of the quadriceps tendon; study of twenty tendon ruptures. Am J Surg. 1958;95(4):626-634. doi:10.1016/0002-9610(58)90444-6[11] Rasul AT, Fischer DA. Primary repair of quadriceps tendon ruptures. Results of treatment. Clin Orthop Relat Res. 1993;(289):205-207. or a lengthening V-Y plasty [6], Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-937.[12] Rizio L, Jarmon N. Chronic quadriceps rupture: treatment with lengthening and early mobilization without cerclage augmentation and a report of three cases. J Knee Surg. 2008;21(1):34-38. doi:10.1055/s-0030-1247789. However, Siwek et al. report only a 50% success rate using the Codivilla V-Y lengthening technique. [6] Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-937. Thanks to the pins placed in the tendon stump and proximal end of patella, our technique not only makes it possible to gently and easily lower the tendon down to the patella, but also to obtain a solid primary fixation that protects the reinserted tendon until it has healed. In addition, proximal anchoring using a pin through the proximal stump of quadriceps provides a secure repair, despite the absence of transosseus fixation. In fact, we have experienced no secondary mobilisation of the proximal pin.

If the tendon is severely retracted, some authors suggest using additional support from an autograft or allograft. Leopardi [14] Leopardi P, Vico G di, Rosa D, Cigala F, Maffulli N. Reconstruction of a chronic quadriceps tendon tear in a body builder. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):1007-1011. doi:10.1007/s00167-006-0044-7 reports one case using an ipsilateral hamstring graft. Others suggest strengthening the repair by harvesting both the left and right hamstrings. The disadvantage of these techniques is the graft-related morbidity. In addition, the need to make tunnels at least 5mm wide in the patella through which to insert these grafts creates the risk of a secondary fracture. Finally, some have suggested supporting the repairs using an allograft harvested from the anterior tibial or Achilles tendon. [17], Forslund J, Gold S, Gelber J. Allograft Reconstruction of a Chronic Quadriceps Tendon Rupture with Use of a Novel Technique. JBJS Case Connect. 2014;4(2):e42. doi:10.2106/JBJS.CC.M.00230[18] Lee SH, Song EK, Seon JK, Woo SH. Surgical Treatment of Neglected Traumatic Quadriceps Tendon Rupture with Knee Ankylosis. Knee Surg Relat Res. 2016;28(2):161-164. doi:10.5792/ksrr.2016.28.2.161 As with the other autograft techniques, they require the use of tunnels that could potentially weaken the patella. In addition, there may be geographic or economic restrictions on the ability to use allografts. Our proposed technique avoids the need for a reinforcement graft, minimises the risk of patellar weakening thanks to smaller trans osseous tunnels and is readily available because it requires no special equipment.

Conclusion

Chronic quadriceps tendon ruptures are rare and there is no consensus over the correct surgical management. The Chambat or sardine tin procedure that we describe is a reliable and simple technique. Trans quadriceps tendon pins provide mechanical stability making it easy to lower the tendon stump to the proximal end of patella and secure the reinsertion, even if the tendon has retracted. They avoid the need for reinforcement autografts which have a non-negligible morbidity. It is a cost-effective technique using equipment available at all operating theatres, unlike the autograft technique.