Rehabilitation from delayed bilateral complete quadriceps tendon repairs with knee extension assist A case report

Authors: Benjamin Hewins, Sara Sparavalo, Ivan Wong

Abstract

Simultaneous bilateral quadriceps tears are rare with fewer than 150 cases reported in the literature and typically occur in male patients greater than 40 years of age. If left untreated or with delayed clinical intervention, these injuries often lead to chronic disability including pain and reduced ambulation. Typical treatments include surgical repair with considerable post-operative rehabilitation and a guarded prognosis. However, given the scarcity of these cases, a consensus on a standard course of treatment remains unclear and ultimately at the discretion of the clinician.

A 67-year-old male presented 6-months after complete, retracted tears of bilateral quadriceps tendons after a fall onto both knees in flexion. Treatment immediate bilateral quadriceps tendon repairs, immobilization, physiotherapy, and the daily use of novel tri-compartment offloader knee braces providing knee-extension assist. To our knowledge, this is the first report of a full return to independent ambulation following a delayed diagnosis and surgical intervention of complete bilateral quadriceps tendon tears.

Introduction

Simultaneous bilateral quadriceps tendon (QT) tears are rare. QT injuries represent 1.3 % of ligamentous and tendinous injuries, but the incidence of full bilateral QT tears is unreported.^1^^,^^2^ These injuries can be mistaken for stroke, rheumatoid arthritis, or neuropathy, resulting in a delayed diagnosis.^2^ QT tears are a direct result of trauma and are most common in males above the age of 40.^2^^,^^3^ Patients with delayed QT repairs typically experience chronic disability, potentially including a loss of knee extension strength (≥40 %), decreased knee range of motion (ROM) (≥20 %), knee extensor lag, severe pain during minor activities, increased reliance on ambulatory aids, difficulty traversing stairs, reduced quality of life, and reduced satisfaction with surgery.^4^ This case report will augment our understanding of best practices in surgical and rehabilitative treatment of delayed, bilateral, complete QT tears.

Case report

Mr. BM is a 67-year-old male patient with an eight-year history of patellofemoral syndrome and significant quadriceps weakness. In addition, Mr. BM suffered from chronic neuromuscular weakness and spinal cord degeneration. Six-months elapsed between his initial assessment and his official diagnosis and surgery. During his initial clinical examination, Mr. BM reported a recent fall resulting in an inability to ambulate or extend his knees. His initial diagnosis was a neurologic disorder associated with spinal cord degeneration. A subsequent spine MRI showed small degenerative disc changes. This degeneration was thought to contribute to his chronic bilateral quadriceps weakness. He was referred for physical rehabilitation to address his longstanding bilateral quadriceps weakness. However, Mr. BM demonstrated no improvements following three months of physical therapy, suggesting a need for an X-ray. The X-ray demonstrated marked bilateral patellar baja as measured using the Insall-Salvati Index (ISI) (Fig. 1).Fig. 1(A, B, C) Pre-operative AP and lateral X-ray imaging showing patella baja with left and right ISI of 0.69. (D) and (E) show pre-operative ultrasound of the left (D) and right (E) QT with an avulsed patella (p). The full-thickness QT rupture is also seen as a dark void between the red ++ and +. (Patellar length (left): 55.0mm; patellar tendon length (left): 37.9mm; patellar length (right): 55.3mm; patellar tendon length (right): 38.3mm) p = avulsed patella, ++ = distal tip of QT, + = patellar pole. ISI is a ratio calculated by dividing the patellar tendon length (A-blue line) by the pole-to-pole patella length (B-green line).Fig. 1

An ultrasound was then performed, revealing complete, bilateral tears of the QTs with a 7cm retraction of tendinous edges to the patella. These were likely acute tears of the QTs as a consequence of his reported fall. Mr. BM underwent bilateral QT repair surgery using a suture bridge technique with acellular dermal allograft augmentation (Allopatch, MTF Biologics). After midline incisions were made over the quadriceps defects, the QTs were isolated and debrided down the superior pole of the patella (Fig. 2A) where three bone tunnels were drilled. Krackow sutures were passed through the distal aspects of the QTs using two separate, high-strength sutures. These were sequentially passed through the patella and tied distally over the bone bridges, resulting in the quadriceps being reduced to their native position. The repair was augmented with allografts on both sides (Fig. 2B).Fig. 2(A) Intraoperative debridement and isolation of the QT to the superior pole of the patella and (B) placement and suturing of the graft (Allopatch, MTF Biologics). Al = Allopatch graft.Fig. 2

Mr. BM's pre-surgical International Knee Documentation Committee subjective knee evaluation form (IKDC) score was 35.6 for his left knee and 44.8 for his right knee. Following surgery, he was prescribed bilateral tricompartment offloader (TCO) knee braces for all day use. One-year post-operatively, Mr. BM reported morning knee stiffness; however, when wearing the TCO knee braces, he was able to ambulate around his home without pain. Two years following surgery, Mr. BM's IKDC improved to 66.7 and 73.6 for the left and right knee, respectively, and he showed increased strength, and ROM (Table 1). His two-year post-operative x-rays showed a notable patellar shift from baja (L: 0.69; R: 0.69) to normal (L: 0.98; R: 0.95) (Fig. 3). Post-operative rehabilitation consisted of varying levels of bodyweight exercises, supported by the TCO braces (Fig. 4). Due to strong compliance, Mr. BM was advised to reduce use of the braces to 3 hours per day.Table 1Post-operative outcomes, strength, ROM, and rehabilitation regime for Mr. BM, including the frequency and duration in which his bilateral TCO braces were used.Table 1TimepointSideIKDC ScoreRange of Motion (°)Strength (lbs)RehabilitationExtensionFlexionPre-opL/R35.6/44.8–––Physiotherapy twice per week, six weeks of knee immobilizers6-weeks post-opL–090–Removal of immobilizers, PT therapy reduced to once every three weeks with isometric strengthening and band work. Home exercises to continue with wheeled walker and bilateral TCO bracesR–090–5-months post-opL28.70110–Assistive walker discarded. Patient instructed to continue wearing TCO braces all day as primary assistive device and to attend in-person physiotherapy once every three months while at home exercises continued.R25.30120–1-year post-opL43.70119Flexion: 27.3Recommended to continue therapy on exercise bike while continuing exercise from home program, as well as wearing the TCO braces during ADLs. Exercises included prone quads stretching, bridges, 10lbs hamstring curls, 10 lbs quad extensions, and step-ups.Extension: 97.7R37.90123Flexion: 26.6Extension: 83.32-years post-opL66.70130Hamstring: 37.8Continuing to attend in-person physiotherapy consults once every three months. The exercises included lunges, curtsies, stretching, and spin bike supplemented with TCO braces. The patient reported wearing his TCO braces throughout the day except while sleeping or sitting for prolonged periods. At this point, Mr. BM could ambulate freely. It was suggested that TCO use was reduced to 3 hours/day and to complete physiotherapy exercises without brace.Extension: 111.8R73.60140Hamstring: 29.6Extension: 88.6Fig. 3Post-operative AP and lateral x-ray imaging showing the more normal location of the patient's patella. Blue line/A = patellar tendon length; green line/B = pole-to-pole patellar length. Right ISI ratio = 0.95 and the left = 0.98. (patellar length (left): 49.9mm; patellar tendon length (left): 50.7mm; patellar length (right): 50.5mm; patellar tendon length (right): 48.0mm).Fig. 3Fig. 4(A, B) Post-operative images demonstrating Mr. BM in a squatting position while wearing the TCO braces.Fig. 4

Discussion

Mr. BM was an especially unique case. Due to his older age, chronic neuromuscular weakness, the bilateral nature of the QT tears, and the six-month delay to surgery, this case had a relatively low prognosis.

Remarkably, Mr. BM reported that his post-operative levels of ambulation and strength exceed his pre-injury levels while also surpassing our expected post-operative outcomes.4, 5, 6 Mr. BM's post-operative strength, ROM, activities of daily living, and overall ability to ambulate is comparable to younger patients without pre-injury comorbidities who underwent timely surgical repair.^1^^,^^4^^,^^5^ At his most recent clinical follow-up, Mr. BM was able to reach a full squat and also expressed interest in returning to riding his motorcycle, which was not possible for the last ten years.

Based on patient reports and measured clinical outcomes, the TCO braces appear to have expedited and enhanced the clinical improvements for this patient, as opposed to the poor prognosis.^4^^,^^7^ It is likely the braces resulted in significant improvement in strength, pain management, and ROM that would not have been realized without their aid.

This is the first report of a full return to pre-injury level and independent ambulation following delayed diagnosis and surgical repair of full-thickness, bilateral QT tears. This case may serve as a clinical guide for the diagnostic, surgical, and rehabilitative management of complicated uni- and bilateral full-thickness QT tears. This case further underscores the importance of early brace selection and its central role in the rehabilitation process.