Management of chronic quadriceps rupture with novel “chariot suture technique”: A case report and review

Abstract

Quadriceps tendon is one of the important segment of knee extensor mechanism. Acute ruptures are more common than chronic ruptures and have better outcomes. Chronic ruptures are rare with lot of surgical challenges including tendon retraction, fibrosis, degenerative calcification. We present a rare case of a 48 year old male diabetic patient with history of fall eight months ago and chief complaint of inability to actively extend his left knee. Diagnosis was made clinically and was confirmed radiologically with MRI. Surgical management was done with the use of novel “Chariot Suture Technique”. It involves use of three Krakow whipstitches with Ethibond No. 5 suture across the distal ruptured end of quadriceps tendon and their intraosseous passage through patella in longitudinal fashion followed by tying knot at the distal pole of patella. The formation of Chariot makes the construct stable. At one year follow up patient was actively able to extend the knee with good range of motion. The technique is relatively cost effective, has no donor site morbidity, easy to learn and practice.

1. Introduction

Quadriceps tendon ruptures are very uncommon presentation in routine orthopaedic practice. Its incidence has been reported to be 1.37/lakh every year.¹ The usual clinical presentation is usually a male patient with age >40 years with significant history of indirect trauma or fall followed by pain over knee associated with swelling and inability to extend the knee. Diagnosis can be confirmed by ultrasonography and MRI. Early surgical repair has the best clinical outcomes.² Missed injuries and neglected trauma leads to chronic quadriceps tendon rupture and poor clinical management outcomes. Written informed consent was obtained from the patient for use of all the pictures and clinical data for scientific research and its publication.

2. Case report

A 48 year old male patient presented to our outpatient department with chief complaint of inability to walk independently without putting hand over his left distal thigh since last eight months following a road traffic accident. Patient was a known diabetic since last seven years. On examination, he was not able to bear weight over his left lower limb with knee fully extended. Active knee extension and Straight led raising was also not possible. Passive flexion and extension of left knee was possible. There was significant wasting of the left thigh and calf muscles. A gap was palpable anteriorly just above the superior edge of patella in the continuity of Quadriceps muscle. Left knee radiograph depicted patella baja and uneven soft tissue shadow superior to patella anteriorly. MRI of left knee was done which depicted a break in continuity of Quadriceps tendon 1 cm above the superior edge of patella and a diagnosis of chronic quadriceps rupture was made.

Patient was planned for surgical reconstruction of knee extensor mechanism under spinal anaesthesia. Patient was laid supine and anterior incision was given in midline from distal one third of left thigh to 3 cm below the distal pole of patella. After soft tissue dissection, 6 cm gap in the continuity of quadriceps tendon was identified proximal to superior pole of patella (Fig. 1a–b). Debridement of the fibrous intervening tissue along with edges of quadriceps tendon was done. Mobilization of the proximal ruptured portion of the quadriceps tendon was done till mid thigh to achieve better excursion of the tendon. The superior edge of the proximal pole patella was debrided and roughened. Three Krokow whipstitches were taken with the help of No. 5 non absorbable Ethibond sutures from lateral (vastus lateralis), middle (rectus femoris and vastus intermedius) and medial (vastus medialis) aspects of the quadriceps tendon. Three longitudinal drill holes lateral, middle and medial were made using 2.5 mm drill bit along the length of patella. The respective sutures were passed through intraosseous tunnel in patella to the distal pole of patella. There was no significant distal stump, and repair of proximal stump was done with superior pole of patella. In full extended position of the knee these sutures were tensioned and tied with each other forming a Chariot type formation at the distal pole of patella. That is why we have named this technique as “Chariot suture technique” (Fig. 2). Closure of incision was done in layers without any negative suction drain.

Fig. 1.

a: Quadriceps tear just above the superior pole of patella in knee extension. b: Tear length increases with passive knee flexion, showing trochlear notch of distal femur.

Fig. 2.

Three Krakow whipstitches (lateral, middle and medial) passed through patellar intraosseous tunnel to distal pole of patella. (Chariot formation).

After tying of these sutures, patellar retinaculum was repaired medially and laterally to strengthen this fixation along with epitendinous sutures with absorbable No. 1 vicryl (Fig. 3). A cylindrical POP slab was given to the patient for three weeks. Weight bearing was allowed only up to 50% of the body weight till six weeks. Hinged knee brace was used after removal of slab for active and passive knee exercise up to 40° gradually for the next three weeks. Full weight bearing and further quadriceps exercises were allowed 6 weeks after the surgery as per patient compliance. At final follow up at one year, patient was able to walk with bipedal unassisted normal gait. Active knee extension and straight leg raising was possible. Final knee range of motion was from 0° to 120° (Fig. 4a–c).

Fig. 3.

Repair of quadriceps tear with chariot suture technique and retinacular repair with multiple epitendinous sutures.

Fig. 4.

a: Full extension of left knee from front showing healed surgical scar mark. b: Active full extension of left knee from side at one year follow up. c: Active flexion of left knee from side, showing good range of motion at one year follow up.

3. Discussion

Quadriceps tendon is one of the important segment of knee extensor mechanism. The tendon is structurally very strong and can withstand high load without rupture.³ Quadriceps tear classically occur at a relative hypovascular zone 1–2 cm above proximal pole of patella.⁴ Acute quadriceps injuries are more common than chronic injuries, with acute injuries having far better outcome in terms of management and rehabilitation. Chronic quadriceps tear is usually result of a missed acute injury and are commonly associated with challenging management and poorer outcomes compared to acute injuries.² The challenges associated with chronic quadriceps tear are tendon retraction, soft tissue fibrosis, degenerative calcification and decreased tendon end vascularity.⁵ Such ruptures have also being associated with underlying systemic disease such as renal failure, rheumatoid arthritis, diabetes mellitus, hyperthyroidism, connective tissue disorders, long term fluoroquinolone and corticosteroid use which leads to fatty infiltration and weakening of the tendon.⁶ Some surgical techniques have been described for the management of chronic quadriceps tendon like tendon lengthening using V–Y plasty and the Codvilla technique, hamstring grafting techniques, synthetic ligament implantation and hamstring tendons along with a prolene mesh and autologous platelet rich plasma augmentation as salvage procedure.^{7, 8, 9, 10}

Our patient was a rare case of neglected quadriceps tendon rupture leading to the chronic rupture. The chief complaint of this patient was basically a hand on knee gait due to loss of active knee active extension. Inability to bear weight over the involved knee was also due to instability of knee joint due to loss of locking mechanism. This novel “Chariot suture technique” for management has been found to be very effective. The advantage includes no requirement of any synthetic graft, autograft, allograft for this procedure. The chariot formation provides a strong construct to the repair.

In conclusion, the chronic neglected quadriceps tendon injury is a very rare injury along with requiring high surgical skill and accuracy. We have used a novel “Chariot suture Technique” with good outcomes. This technique has provided very promising results probably due to high construct stability due to chariot formation. The technique is relatively cost effective, has no donor site morbidity, easy to learn and practice.

Appendix A. Supplementary data

The following is the Supplementary data to this article: