What is the recommended management, including timing of surgical repair, for a quadriceps tendon rupture in an adult over 40 with risk factors such as diabetes, chronic renal failure, or chronic steroid use sustained by a sudden forceful knee flexion injury?

Quadriceps Tendon Rupture Management

Immediate Surgical Repair is Essential

Complete quadriceps tendon ruptures require prompt surgical intervention to restore extensor mechanism function and achieve optimal outcomes, with repair ideally performed within 48-72 hours of injury. 1, 2

Diagnosis and Clinical Presentation

• Suspect quadriceps tendon rupture in adults over 40 with risk factors including diabetes mellitus, chronic renal failure, chronic steroid use, rheumatoid arthritis, systemic lupus erythematosus, gout, secondary hyperparathyroidism, and peripheral vascular disease 2, 3, 4

• The classic presentation includes inability to actively extend the knee with a palpable suprapatellar defect following sudden forceful knee flexion during a fall or eccentric loading 2, 3

• MRI is the gold-standard diagnostic test with sensitivity, specificity, and positive predictive value of 1.0, though clinical examination alone often suffices for diagnosis 2

• Plain radiographs may show patella baja with suprapatellar calcifications in chronic cases 4

Surgical Timing: Critical for Outcomes

Surgical repair must be performed as soon as possible—ideally within 48-72 hours—to minimize complications and achieve optimal functional recovery. 1, 2

• Delayed operative treatment is associated with significantly worse outcomes and increased complication rates 1

• Early repair allows for direct end-to-end tendon approximation without need for complex reconstruction 1, 3

• Neglected ruptures (>2 months) require more difficult reconstructive procedures with lengthening plasty and have inferior outcomes 4

• Even repairs delayed 8 years can achieve functional restoration, though this is far from ideal 5

Surgical Technique Options

Primary Repair Methods

Two primary surgical techniques are recommended: transosseous tunnel repair and suture anchor repair, with no significant difference in clinical outcomes between methods. 1

Transosseous Tunnel Technique (Most Common)

• Pass nonabsorbable sutures through the quadriceps tendon in locked Krackow pattern 1, 3
• Create three parallel longitudinal bone tunnels through the patella 1
• Tension sutures with knee in full extension and tie at distal patella 1

Suture Anchor Technique (Increasingly Popular)

• Pass FiberTape through tendon in Krackow pattern 1
• Place knotless SwiveLock anchors into proximal patella 1
• Advantages include decreased operative time and smaller incision 1
• Disadvantages include higher cost and more complex revision if deep infection occurs 1

Augmentation Considerations

• If primary construct appears unstable, augment with wire reinforcement, cancellous screws, Scuderi technique, Codivilla technique, tensor fasciae latae reinforcement, or MERSILENE tape 1

• Identify and repair concomitant medial and lateral retinaculum tears, which commonly occur with complete ruptures 1

Postoperative Rehabilitation

Early functional mobilization with full weight-bearing and progressive range-of-motion exercises is recommended immediately following surgical repair. 2

• Avoid complete immobilization as it leads to muscle atrophy and deconditioning 6

• Serial rehabilitation programs are essential for recovery of active extension 4

• Most patients (>90%) return to pre-injury function and work levels 1

• Near-full range of motion recovery is expected, with <5° deficit compared to contralateral limb 1

Expected Outcomes and Complications

Excellent Prognosis with Timely Repair

• The vast majority of patients report satisfactory results on patient-reported outcome measures 1
• Approximately 80% of tendon injuries fully recover within 3-6 months with appropriate treatment 6

Common Complications

• Knee stiffness and quadriceps muscle atrophy are most common but can be managed with proper rehabilitation while maintaining adequate knee function 1

Rare Severe Complications (<3%)

• Deep venous thrombosis/pulmonary embolism 1
• Superficial or deep infection 1
• Tendon rerupture 1

Critical Pitfalls to Avoid

• Do not delay surgery for medical optimization in patients with diabetes or renal failure—these conditions increase rupture risk but should not postpone repair 2, 4

• Do not misdiagnose as partial tear or patellar tendinopathy—complete ruptures with extensor mechanism deficit require immediate surgery, not conservative management 1

• Do not attempt nonoperative treatment for complete ruptures—this is reserved only for partial tears with intact extensor mechanism or patients unfit for surgery 1

• Ensure proper Krackow stitch tensioning by removing all slack before each tissue pass 1