(aspects of sports medicine)

Floating : Combined Quadriceps , Retinacula, and Ruptures in a High-Performance Elite Athlete Phillip R. Langer, MD, and F. Harlan Selesnick, MD

Abstract association exists with numerous occurs during falls. The estimated Simultaneous quadriceps and patellar systemic diseases and prior degen- force required to disrupt the exten- tendon rupture is rare. To our knowl- erative changes in the extensor sor mechanism has been reported edge, we present the first known case mechanism. Various conditions, to be as high as 17.5 times body of simultaneous quadriceps tendon, such as hyperparathyroidism, weight. With the knee flexed, the patella tendon, and retinacula rupture 1 in the ipsilateral knee of a high-per- chronic renal failure, mel- patellar tendon undergoes more formance elite athlete. This disabling litus, systemic lupus erythemato- stress than the quadriceps tendon 2 injury in the active person results sus (SLE), and steroid abuse, can does, and the tensile load is much in an inability to actively obtain and damage the tendon vascular supply higher at the insertion sites than maintain full knee extension. When or disrupt the tendon structure. in the midsubstance of the ten- the do not heal properly, at the correct length and tension, knee range of motion and strength can “ become significantly altered, leading Bilateral ruptures are highly correlated to early fatigue, patellofemoral pain, with systemic disease but have been and possible instability, preventing return to preinjury status. Immediate reported in Protectedhealthy patients who do not surgical repair is recommended ” for optimal return of knee function have predisposing factors. and power. Ruptures most often occur unilat- don. Therefore, the patellar tendon uptures of the patellar erally. Bilateral ruptures are highly most commonly ruptures near its or quadriceps tendon are correlated with systemic disease proximal end, off the inferior pole rare injuries that require but have been reported in healthy of the patella. In patients with immediate repair to re- patients who do not have predis- systemic disease, however, the R 3-8 establish knee extensor continuity posing factors. patellar tendon tends to tear in and to allow early motion. A strong Ruptures of the quadriceps ten- the midsubstance rather than at don occur relatively infrequently the osseotendinous junction. Dr. Langer is Assistant Team Physician and usually in patients older than Quadriceps tendon ruptures, on and Orthopedic Surgeon for the Atlanta 40 years.9 Patellar tendon ruptures the other hand, usually occur Falcons and the Atlanta Thrashers, are less common than quadriceps distally 0 to 2 cm from the superior Atlanta Sports Medicine & Orthopedic ruptures and tend to occur in pole of the patella, through patho- Center, Atlanta, Georgia. 9 Dr. Selesnick is Head Team Physician and patients younger than 40 years. In logic tissue. Orthopedic Surgeon for the Miami Heat, rare cases, partial ruptures of the Simultaneous quadriceps and Orthopedic Institute of South Florida, quadriceps tendon occur in young patellar tendon rupture is rare. Coral Gables, Florida. athletes with end-stage jumper’s Mechanical factors and coexisting knee.10-13 Jumper’s knee usually systemic and local factors are taken Address correspondence to: Phillip R. Langer, MD, Atlanta Sports Medicine involves the patellar tendon; in 25% into consideration in the pathogen- & Orthopedic Center, 3200 Downwood of cases, the quadriceps is involved. esis of these ruptures. In patients CopyrightCir, Suite 500, Atlanta, GA 30327 (tel, Quadriceps and patellar tendon with some chronic systemic diseas- 404-352-4500; fax, 404-350-0722; e-mail, ruptures usually occur during a es, simultaneous rupture can occur [email protected]). rapid, violent, eccentric contrac- spontaneously or with minor trau- 14 Am J Orthop. 2010;39(9):446-449. tion of the quadriceps muscle with mas. Several cases of simultane- Copyright Quadrant HealthCom Inc. 2010. the planted and the knee par- ous rupture in patients with chronic All rights reserved. tially flexed. This injury commonly renal failure on hemodialysis15-17

446 The American Journal of Orthopedics® P. R. Langer and F. H. Selesnick

ening of the tendon, which can reflect tendonitis. Additional prior surgical histo- ry included a living related donor kidney transplantation (December 2003) for focal segmental glomeru- lar sclerosis (diagnosed in October 2000). Pertinent pharmacologic interventions include brief (weeks) steroid treatment immediately after transplantation (2000) and again 6 months after transplantation during a mild rejection episode. Because the patient was an active, high-per- formance elite athlete, the treating nephrologists used almost no ste- A B roids in his regimen over approxi- Figure 1. Lateral (A) and anteroposterior (B) radiographs of injured extremity. mately 4 years. Before the traumatic episode that led to the patient’s or with SLE18 have been docu- Examination at that time was con- latest presentation, he was taking mented. In addition, the first case sistent with a high-riding patella tacrolimus 3 mg orally twice daily of simultaneous quadriceps tendon tendon, a small avulsion fracture and sirolimus 2 mg orally once daily. and contralateral patellar tendon of the patella, inability to extend These medications kept his serum rupture was reported in a healthy against gravity, a significant 2+ levels between 5 and 10 ng/mL, athlete.15 To our knowledge, in this effusion, and no instability of the which is therapeutic for a transplan- article, we present the first known knee—consistent with a patel- tation patient. He had been at these case of simultaneous quadriceps lar tendon rupture. Preoperative dosages for several years, and his tendon, patellar tendon, and reti- radiographs showed a patella alta kidney function was stable through- nacula rupture in the ipsilateral (Figures 1A, 1B). Protectedout the changes in his immunosup- knee of a high-performance elite Relevant prior surgical history pressive medications. He was not athlete. The patient provided writ- of the right knee included repair taking quinolone antibiotics. The ten informed consent for print and of a partial tear of the patellar only other medication therapy was electronic publication of this case tendon (October 1998), and rele- thyroid hormone replacement. report. vant nonsurgical history of the knee After a thorough discussion of included extracorporeal shockwave the risks and benefits of surgi- Case Report treatments for patellar tendinosis cal and nonsurgical treatment, the The patient, a 37-year-old pro- (June 2005 and May 2007). The patient was brought to surgery on fessional basketball player, pre- patient had been asymptomatic at December 20, 2007. After initial sented with acute right knee pain his preseason physical examina- exposure with a standard mid- on December 19, 2007. He had tion (September 2007), though rou- line approach to the knee, marked sustained a noncontact traumatic tine preseason magnetic resonance scarring was noted over the patel- injury to the knee when it buck- imaging (MRI) had revealed post- lar tendon and prepatellar bursa, led during play in a professional surgical changes in the proximal which was totally scarred to the regular season basketball game. patellar tendon and diffuse thick- tendon. This was dissected free, Copyright

A B C

Figure 2. (A) Patellar tendon rupture. (B) Patellar tendon with Fiberwire No. 2 sutures interwoven before transpatellar placement. (C) Transpatellar repair of patellar tendon rupture. September 2010 447 Floating Patella: Combined Quadriceps Tendon, Retinacula, and Patellar Tendon Ruptures

A B Figure 3. On subsequent inspection, Figure 4. (A) Quadriceps tendon with significant tearing (longitudinal rent, transverse completely torn medial and lateral reti- deep tear). (B) Primary repair with Ethibond No. 2. nacula are seen extending back at least 6 cm medially and 4 cm laterally. Primary repair with Fiberwire No. 2 suture. point, medial and lateral retinacula mus dosing regimen remained con- were closed, after copious irriga- stant after surgery. Throughout the and the patellar tendon rupture tion, with a Vicryl 0 suture, first change in medications, the patient’s was obvious (Figures 2A–2C). The medially and then laterally. The kidney function was stable. pathologic report of this tissue was patella tracked well through a range By 12 months after surgery, tendon with areas of degenerative of motion (ROM) of 0° to 100°. the patient had returned to his change, fibrosis, and mild chronic No tension was noted on the patel- preinjury level of function. Final inflammation, consistent with rup- lar tendon or quadriceps tendon examination of the affected extrem- ture bursa showing chronic mild repairs with appropriate balancing ity revealed it to be symmetric to . Next, the edge of the patellar and anatomical placement of the the contralateral side in terms of was débrided to create a bleed- patella (Figure 5). After copious ROM, strength, and gait pattern. ing surface for reattachment of the irrigation, the surgical wound was From an orthopedic standpoint, patellar tendon. Subsequent inspec- closed in standard fashion, and the the patient was cleared to return to tion found the medial and lateral operative extremity was placed in a professional basketball. However, retinacula completely torn, extend- well-molded long leg cast.Protectedhe retired secondary to his pre- ing back at least 6 cm medially and After surgery, the patient was existing renal condition. 4 cm laterally (Figure 3). At this kept in the long leg cast for 2 weeks, point, a Fiberwire No. 2 suture was at which point the cast was convert- Discussion woven into the tendon, first later- ed to a locked hinged knee brace. In cases of complete extensor ally, then centrally. Subsequently, Four weeks after surgery, the knee mechanism ruptures, early diagno- another Fiberwire No. 2 suture was brace was unlocked to allow ROM sis and repair are essential for best placed medially and then centrally. of 0° to 20° and some isometric outcomes.19 When intervention is The patellar tendon was noted to strengthening. Every 3 days, ROM delayed, repair is more difficult, be free of scar and well mobilized. was increased another 10°. A formal and results may be compromised. Then the quadriceps tendon was program was insti- Early surgical repair yields the best examined; it had significant tear- tuted 6 weeks after surgery. Three results for complete quadriceps and ing, with a longitudinal rent and a months after surgery, the patient patellar tendon ruptures.20 This dis- transverse deep tear (Figures 4A, was pain-free and had ROM of 0° abling injury in the active person 4B). The edges of these tears were to 130° and appropriate strength of débrided and primarily repaired the extensor mechanism. with Ethibond No. 2 suture, first The pharmacologic regimen was to the quadriceps tendon and then carefully adjusted by the patient’s to the patella. Three longitudinal nephrologists. Although sirolimus holes were then drilled parallel to has not been shown to cause ten- one another in the patella. The free don weakness, it has been shown ends of the Fiberwire No. 2 sutures to impair wound healing, so after interwoven in the patella tendon surgery it was switched to myco- Copyrightwere brought through the tunnels phenolate mofetil. Six weeks after in the patella and tied superiorly surgery, and with careful discus- over the bony bridge. In addition, a sion between the patient and his Figure 5. Patella tracks well (range of motion, 0° to 100°). No tension noted on 2.7-mm bone anchor was placed to treating nephrologist, mycopheno- patellar tendon or quadriceps tendon further reinforce the repair, creat- late mofetil was discontinued and repairs with appropriate balancing and ing a tension-free construct. At this sirolimus reinitiated. The tacroli- anatomical placement of patella. 448 The American Journal of Orthopedics® P. R. Langer and F. H. Selesnick

results in an inability to actively at least 85% to 90% of the other steroids. Br J Sports Med. 1995;29(2):77-79. 3. Anderson WE III, Habermann ET. Spontaneous obtain and maintain full knee exten- knee, and completion of a sport- bilateral quadriceps tendon rupture in a patient sion. When the tendons do not heal specific agility program. on hemodialysis. Orthop Rev. 1988;17(4):411- 414. properly, at the correct length and It is important to draw attention 4. Dhar S. Bilateral, simultaneous, spontaneous tension, knee ROM and strength can to the unique nature of the patient rupture of the quadriceps tendon. A report of 3 cases and a review of the literature. Injury. become significantly altered, leading described in this report. He was a 1988;19(1):7-8. to early fatigue, patellofemoral pain, professional basketball player who 5. Kaar TK, O’Brien M, Murray P, Mullan GB. Bilateral quadriceps tendon rupture—a case and possible instability, preventing had been repeatedly cleared to play report. Ir J Med Sci. 1993;162(12):502. return to preinjury status. Immediate at an elite level of athletics. Unlike 6. Kelly BM, Rao N, Louis SS. Bilateral, simul- surgical repair is recommended for in other cases of simultaneous taneous, spontaneous rupture of quadri- ceps tendons without trauma in an obese optimal return of knee function quadriceps and patellar tendon patient: a case report. Arch Phys Med Rehabil. and power. The ultimate outcome ruptures in patients with system- 2001;82(3):415-418. 18 7. MacEachern AG, Plewes JL. Bilateral simul- depends not only on the anatomical ic diseases (SLE, chronic renal taneous spontaneous rupture of the quad- riceps tendons. Five case reports and a review of the literature. J Bone Surg Br. 1984;66(1):81-83. “The ultimate outcome depends not only 8. Walker LG, Glick H. Bilateral spontaneous quadriceps tendon ruptures. A case report on the anatomical repair of the extensor and review of the literature. Orthop Rev. 1989;18(8):867-871. 9. Siwek CW, Rao JP. Ruptures of the extensor mechanism but also on the patient’s mechanism of the knee joint. J Bone Joint Surg Am. 1981;63(6):932-937. rehabilitative efforts.” 10. Adolphson P. Traumatic rupture of the quadriceps tendon in a 16-year-old girl. A case report. Arch Orthop Trauma Surg. repair of the extensor mechanism failure on hemodialysis,15-17), in 1992;112(1):45-46. 11. Kelly DW, Carter VS, Jobe FW, Kerlan but also on the patient’s rehabilitative this case, the patient’s kidney RK. Patellar and quadriceps tendon rup- efforts. It is important to empha- function had been stable for sev- tures—jumper’s knee. Am J Sports Med. 1984;12(5):375-380. size in the preoperative period the eral years, since his 2003 kidney 12. Matsumoto K, Hukuda S, Ishizawa M, importance of participating in the transplantation. It is important to Kawasaki T, Okabe H. Partial rupture of the postoperative rehabilitative protocol recognize this injury in this ath- quadriceps tendon (jumper’s knee) in a ten- year-old boy. A case report. Am J Sports Med. so that maximal ROM and strength lete, as similar injuriesProtected may occur 1999;27(4):521-525. can be achieved. more often as more athletes with 13. Walczak BE, McCulloch PC, Kang RW, Zelazny A, Tedeschi F, Cole BJ. Abnormal Unique to the present case is single organs are cleared to play findings on knee magnetic resonance imaging the simultaneous nature of the as a result of the Americans With in asymptomatic NBA players. J Knee Surg. 2008;21(1):27-33. complete disruption of the entire Disabilities Act (Public Law 101- 14. Munshi NI, Mbubaegbu CE. Simultaneous extensor mechanism complex of 336), enacted in 1990 to end dis- rupture of the quadriceps tendon with con- tralateral rupture of the patellar tendon in an the ipsilateral knee—that is, the crimination against persons with otherwise healthy athlete. Br J Sports Med. simultaneous ipsilateral quad- disabilities. 1996;30(2):177-178. riceps tendon, patellar tendon, 15. Loehr J, Welsh RP. Spontaneous rupture of the quadriceps tendon and patella and retinacula rupture. It is com- Authors’ Disclosure during treatment for chronic renal failure. Can monly believed that, after imme- Statement and Med Assoc J. 1983;129(3):254-256. 16. Muratli HH, Celebi L, Hapa O, Bicimoglu diate repair of an isolated patel- Acknowledgments A. Simultaneous rupture of the quadriceps lar tendon or quadriceps tendon The authors report no actual or tendon and contralateral patellar tendon in a patient with chronic renal failure. J Orthop Sci. rupture, most patients experience potential conflict of interest in rela- 2005;10(2):227-232. nearly full return of knee ROM, tion to this article. 17. Rysavy M, Wozniak A, Arun KP. Spontaneous and simultaneous quadriceps and patella quadriceps strength, and pre- The authors offer their sincere tendon rupture in patient on chronic hemodi- injury activity levels. Persistent thanks to the patient for his per- alysis. Orthopedics. 2005;28(6):603-605. quadriceps atrophy commonly mission to present this case to the 18. Wener JA, Schein AJ. Simultaneous bilateral rupture of the patellar tendon and quadriceps occurs but is not considered a medical community and for his expansions in systemic lupus erythemato- complication, as the atrophy does assistance with this report. sus. A case report. J Bone Joint Surg Am. 1974;56(4):823-824. not prevent return of strength. 19. Jolles BM, Garofalo R, Gillain L, Schizas Typically, athletes treated for References C. A new clinical test in diagnosing quadri- 1. Lombardi LJ, Cleri DJ, Epstein E. Bilateral ceps tendon rupture. Ann R Coll Surg Engl. partial or complete ruptures may spontaneous quadriceps tendon rupture 2007;89(3):259-261. Copyrightreturn to play when several con- in a patient with renal failure. Orthopedics. 20. Fujikawa K, Ohtani T, Matsumoto H, Seedhom 1995;18(2):187-191. BB. Reconstruction of the extensor apparatus ditions are met, including nearly 2. Liow RY, Tavares S. Bilateral rupture of the of the knee with the Leeds-Keio ligament. full, painless ROM, knee strength quadriceps tendon associated with anabolic J Bone Joint Surg Br. 1994;76(2):200-203.

September 2010 449