What is the appropriate initial management of a right quadriceps tendon rupture?

Initial Management of Right Quadriceps Tendon Rupture

Immediate surgical repair is the definitive treatment for complete quadriceps tendon rupture, and should be performed as soon as possible—ideally within 48-72 hours of injury—to achieve optimal functional outcomes and minimize complications. 1, 2

Immediate Diagnostic Confirmation

While clinical diagnosis is typically straightforward, confirm the complete rupture through:

• Physical examination findings: Loss of active knee extension (extensor mechanism deficit), palpable suprapatellar gap, and inability to perform straight leg raise 2
• Imaging confirmation: Ultrasound or radiography can confirm the diagnosis when clinical findings are equivocal, though imaging is not mandatory when clinical diagnosis is clear 3, 1
• MRI is not routinely necessary for acute complete ruptures with obvious extensor mechanism loss 2

Surgical Timing: Critical Decision Point

Surgery must be performed urgently—delayed repair beyond 48-72 hours is associated with significantly worse outcomes, increased complications, and decreased return to pre-injury function. 1, 2

• Repairs performed within the first 48-72 hours achieve the best functional recovery 1
• Delayed operative treatment (>6 weeks) requires more complex reconstruction techniques rather than simple repair, with inferior outcomes 1, 4
• Patient delay in seeking treatment accounts for 55% of chronic cases that require reconstruction rather than repair 4

Surgical Technique Selection

Two primary techniques are equally effective for acute repair:

Transosseous Tunnel Technique

• Most commonly utilized method for quadriceps tendon repair 2
• Nonabsorbable suture passed through the tendon in locked Krackow pattern, then through longitudinal bone tunnels in the patella 2
• Lower cost compared to suture anchors 2

Suture Anchor Technique

• Increasingly popular alternative with equivalent biomechanical strength and clinical outcomes 2
• Uses knotless anchors (e.g., SwiveLock) with FiberTape in Krackow configuration 2
• Advantages: Shorter operative time and smaller incision 2
• Disadvantages: Higher cost and more complex revision if deep infection occurs 2

Both techniques yield equivalent results—choose based on surgeon preference and available resources, as no significant difference exists in range of motion, return to function, or patient-reported outcomes. 2

Repair Augmentation Considerations

For poor tissue quality or significant retraction:

• Consider augmentation with wire reinforcement, cancellous screws, Scuderi technique, Codivilla technique, tensor fasciae latae reinforcement, or MERSILENE tape 2
• Always identify and repair concomitant medial/lateral retinacular tears, which commonly occur with complete quadriceps ruptures 2

Immediate Post-Surgical Protocol

Immobilization Phase (0-3 weeks)

• Immobilize in hinged knee brace or cast in full extension for 3 weeks 3, 2
• Non-weight bearing during this initial period 3

Early Mobilization Phase (3-6 weeks)

• Begin active knee movement at 3 weeks postoperatively 3
• Initiate protected weight-bearing with knee cage/brace at 3 weeks 3
• Full weight-bearing without crutches by 6 weeks 3
• Remove knee brace at 6 weeks 3

Rehabilitation Focus

• Early aggressive physical therapy is safe with modern repair techniques 3, 2
• Address quadriceps atrophy (most common complication) through progressive strengthening 1, 2

Expected Outcomes and Monitoring

Over 90% of patients return to pre-injury function and work following timely surgical repair. 2

• Near-full range of motion recovery (typically <5° deficit compared to contralateral limb) 2
• Return to sports and daily activities by 24 months in most cases 3
• Majority report satisfactory patient-reported outcomes 2

Complications to Monitor

• Quadriceps atrophy and knee stiffness: Most common complications, managed with proper rehabilitation 1, 2
• Re-rupture rate: Only 2% with appropriate surgical technique 1
• Infection: Superficial (1.2%) and deep (1.1%) infection rates are low 1
• Thromboembolic events: DVT/PE occurs in 2.5% of cases—consider prophylaxis 1
• Heterotopic ossification: Occurs in 6.9% of patients 1

Critical Pitfall to Avoid

The single most important factor determining outcome is surgical timing—do not delay repair. Patient deferral in seeking treatment is the most common reason for chronic ruptures requiring complex reconstruction rather than simple repair, with significantly inferior functional outcomes. 1, 4