Published in:
01-03-2014 | In Brief
Complications in Brief: Quadriceps and Patellar Tendon Tears
Published in: Clinical Orthopaedics and Related Research® | Issue 3/2014
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Effective treatment of knee extensor mechanism disruptions requires prompt diagnosis and thoughtful decision-making with surgical and nonsurgical approaches. When surgery is chosen, excellent surgical technique can result in excellent outcomes. Complications and failures arise from missed or delayed diagnoses and from technical problems in the operating room. In particular, inappropriate surgical timing (especially late surgery), misplaced patellar drill holes, and failure to address concomitant injuries can result in complications seen when repairing a patellar or quadriceps tendon tear. We review the complications that can occur during treatment of these injuries (Table 1).
Table 1
Errors and complications in the treatment of quadriceps and patellar tendon tears
Error/complication | Clinical effect | Prevention | Detection | Remedy |
|---|---|---|---|---|
Judgment errors | ||||
Missed diagnosis: patella tendon tear | Patient seen in the emergency room, presumed to have a patella dislocation; sent home; delay in treatment leads to chronic extensor mechanism disruption, which can cause disability and be more difficult to treat | Careful history and physical examination | (1) Physical examination Infrapatellar pain Infrapatellar gap Inability to maintain full active extension Unable to perform straight leg raise Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction (2) Radiographs Abnormal patella height (alta) (3) MRI/ultrasound | Education of physicians and ancillary staff; high index of suspicion; thorough history and physical examination |
Missed diagnosis: quadriceps tendon tear | Very common, especially in obese patients; delay in treatment leading to chronic extensor mechanism disruption, which can cause disability and be more difficult to treat | Careful history and physical examination | (1) Physical examination Suprapatellar pain Suprapatellar gap Inability to maintain full active extension Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction (2) Radiographs Abnormal patella height (baja) (3) MRI/ultrasound | Education of physicians and ancillary staff; high index of suspicion; thorough history and physical examination |
Missed diagnosis: intact retinaculum but torn quadriceps tendon | Patient able to perform weak straight leg raise as a result of intact retinaculum, but quadriceps tendon actually completely torn; lack of power leading to altered gait and joint kinematics, joint breakdown and potential subsequent traumatic injuries | (1) Careful physical examination: check for extensor lag (2) Aspirate blood from knee and inject with lidocaine; then reexamine (3) Additional imaging: MRI | (1) Palpable defect in soft tissues proximal to patella (2) MRI | Education of physicians and ancillary staff; high index of suspicion |
Missed diagnosis: multiligament knee injury, failure to recognize extensor mechanism disruption | With severe traumatic knee injuries, clinicians may focus on ligament/bony injury and may miss extensor mechanism disruption, leading to incomplete care of injuries and significant disability | (1) Careful review of imaging, particularly sagittal views (2) Thorough physical examination | (1) Palpable defect in soft tissues proximal/distal to patella (2) MRI | Education of physicians and ancillary staff; high index of suspicion; thorough history and physical examination; careful review all imaging |
Delayed diagnosis: delayed surgery | Operating too late after injury; tendon becomes scarred down and retracted; may be difficult to perform primary repair; may require tissue grafting and multiple surgeries | Performing surgery as soon as possible, preferably within first week | Proper detection and early management; if noted too late, consider V-Y or Scuderi technique | |
Incorrect diagnosis: partial tendon tear | Tendon only partially disrupted (< 10 mm separation of the tendon from bone); will heal without surgery; in one study, nonsurgical management resulted in 93% success rate [5] | (1) MRI (2) Ultrasound (3) Physical examination | (1) Patient should be able to maintain full active extension (2) Radiographs: normal patellar height | This individual can be treated nonoperatively with immobilization until the tendon has healed |
Incorrect diagnosis: retinaculum torn, but quadriceps tendon intact | As long as the tendon is intact, the retinaculum should heal nonoperatively | (1) Careful physical examination (2) Aspirate blood from knee and inject with lidocaine; then reexamine (3) Additional imaging: MRI or ultrasound | ||
Incorrect diagnosis: inability to extend knee or perform straight leg raise, but extensor mechanism is intact | Multiple reasons: (1) Femoral nerve palsy (2) Pain (3) Intraarticular pathology: locked knee (loose body, bucket handle meniscal tear, etc) | (1) Thorough history and careful physical examination (2) Additional imaging: MRI | Consider aspiration/injection of local anesthetic and reexamination | |
Potential judgment errors | ||||
Performing definitive surgery in open injury | Consider staged procedure if contaminated wound (1) Irrigation and debridement (2) Definitive fixation | Thorough history and careful physical examination | Single stage management of contaminated or chronically open injuries potentially leads to infection and repair failure | |
Failure to account for diabetes | Poor tissue quality that should be accounted for. Delayed wound and tendon healing | Thorough history and careful physical examination. Tight perioperative glycemic control | Laboratory studies. Patient’s glycemic history Consultation with patient’s primary care provider/internal medicine | Adequate diseased tendon debridement. Delayed postoperative motion to account for expected delayed healing |
Technical errors | ||||
Positioning and preparing | (1) Supine, bump under ipsilateral hip to internally rotate lower extremity (2) Consider full muscle paralysis to aid in reduction | |||
Inadequate exposure | Generous midline incision needed to see extent of injury (retinacular injury) and define injury pattern (midsubstance tear versus avulsion from patella) | |||
Failure to identify correct injury pattern: patellar tendon | Three injury patterns based on location: (1) Avulsion (with/without bone) from inferior pole patella (2) Midsubstance rupture (3) Distal avulsion from tibial tubercle | (1) Preoperative imaging (2) Adequate exposure | Correctly identifying injury pattern will dictate fixation method | |
Failure to identify correct injury pattern: quadriceps tendon | Three injury patterns based on location: (1) Avulsion (with/without bone) from superior pole patella (2) Midsubstance rupture (3) Mixed | (1) Preoperative imaging (2) Adequate exposure | Correctly identifying injury pattern will dictate preoperative planning and fixation method | |
Failure to débride patella/quadriceps tendon stump | Failure to débride scar or devascularized tissue may predispose to failure of the repair and/or chronic weakness | Rongeur scar tissue from patella | Prepare bleeding bone bed: curette or burr a trough | |
Failure to débride/prepare patella bone bed | Failure to débride patella bone bed may predispose to poor healing | Rongeur scar tissue from patella | Prepare bleeding bone bed: curette or burr a trough | |
Tendon repair: inadequate tissue for repair of midsubstance ruptures | Can be challenging, especially with severely disrupted patella tendons | Consider augmentation with contralateral hamstring autograft or allograft; role for other biologics (dermal patches, etc)? | ||
Tendon repair: appropriate tension for midsubstance ruptures | Can be challenging, especially with severely disrupted patella tendons | Lateral radiograph of contralateral leg can help determine appropriate tension | ||
Transosseous tendon repair: divergent tunnels | Divergent tunnels lead to asymmetric reduction of tendon to bone; may lead to poor contact and therefore poor healing or maltracking | (1) Adequate exposure of entire patella (2) Parallel pin drill guide (3) Consider use of fluoroscopy | ||
Transosseous tendon repair: tunnel penetration into articular surface | Iatrogenic articular cartilage injury | (1) Adequate exposure of entire patella (2) Parallel pin drill guide | ||
Transosseous tendon repair: drill breakage | Broken drill bit in tunnel | (1) Careful drilling technique (2) Do not attempt to change direction of drill hole once started drilling (3) Do not torque drill (4) Use stout drill bit | ||
Transosseous tendon repair: anterior placement of tunnels | May lead to downward tilting of the patella and increase patellofemoral contact forces and pain | (1) Place drill holes in center of patella (with respect to AP) (2) If have to cheat, cheat toward articular surface | ||
Transosseous tendon repair: overtightening repair | May lead to patella alta or baja | (1) Prepare opposite leg to assist with tensioning (2) Obtain intraoperative radiograph and compare with contralateral side | ||
Transosseous tendon repair: undertightening repair | (1) May lead to patella alta or baja (2) Poor tendon to bone contact may interfere with healing | (1) When tying knots, make sure to remove all the slack and that the tendon is pulled snuggly into patella bone trough (2) Adequate retinacular repair | ||
Transosseous tendon repair: prominent proximal suture knots | May lead to skin irritation | Attempt to bury knots and cover with surrounding soft tissue | ||
Suture anchor tendon repair | Advantages: (1) Less dissection (2) Decreased surgical time (3) More accurate suture placement (4) Low profile | |||
Suture anchor tendon repair: anchor pullout | Causes: (1) Poorly placed anchors (2) Poor bone quality (3) Weak anchors | (1) Anchors should be placed in center of patella [2] (2) Not to be used in osteoporotic bone (3) Two 5.0-mm corkscrew titanium anchors (equivalent pullout to transosseous tunnels) [1] | ||
Suture anchor tendon repair: proud anchors | Proud anchors will not allow the tendon edge to be pulled into the bone trough in the patella, possibly leading to a gap at the bone-tendon junction and poor healing | Anchors should be slightly countersunk to pull tendon firmly into bone trough in patella | ||
Failure to repair retinacular tissue | May lead to increased stress on central repair | (1) Adequate exposure (2) Suture medial and lateral retinaculum | ||
Additional complications | ||||
Infection | (1) Open injury (2) Comorbidities Diabetes Smoking Chronic disease | (1) Irrigation and debridement (consider delayed repair) (2) Timely administration preoperative antibiotics (3) Tight glucose control (4) Smoking cessation | ||
Wound complications | (1) Open injury (2) Comorbidities Diabetes Smoking Chronic disease (3) Prominent sutures | (1) Irrigation and débridement (consider delayed repair) (2) Timely administration preoperative antibiotics (3) Tight glucose control (4) Smoking cessation | ||
Nerve injury | Extremely rare | |||
Rehabilitation complications | ||||
Prolonged immobilization | Leads to stiffness and decreased ROM | Intraoperative assessment of maximum flexion before gapping between bone and tendon is observed | Early ROM (10–14 days): active flexion, passive extension to limits determined intraoperatively | |
Inadequate immobilization | (1) Wound complications (2) Failure of repair | ROM bracing locked in extension | ||
Overly aggressive physical therapy | Need time for tendon-to-bone healing to occur | No forced flexion or active extension in first 6 weeks | ||