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Year : 2014  |  Volume : 14  |  Issue : 2  |  Page : 161-164

Bilateral spontaneous rupture of quadriceps tendon in a case of gout

1 Diploma Orthopedic Surgery, DNB Orthopaedic Trainee, Shalby Hospitals, Ahmedabad, Gujarat, India
2 M.S. Orthopaedic Surgery, The Spine Clinic, Shalby Hospitals, Ahmedabad, Gujarat, India

Date of Web Publication9-Oct-2014

Correspondence Address:
Prateek S Joshi
H/102 Shaligram Flora, Near Sangeeni bungalows, Opposite shaligram-3, Thaltej, Ahmedabad - 380 054, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-6308.142376

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Introduction: Bilateral and spontaneous quadriceps tendon rupture is a very rare phenomenon in clinical scenario. It is usually associated with trivial trauma superimposed on pathological and weakened quadriceps tendon due to various conditions. Because of its uncommon nature it is frequently misdiagnosed and mistreated. Case Report : A 57-year-old gentleman developed bilateral spontaneous quadriceps tendon rupture following a trivial fall. Further evaluation revealed that he was suffering from gout. Bilateral quadriceps tendon tears were surgically repaired with Krackow technique. He was started on treatment for hyperuricemia. He achieved good functional results at 20-week follow-up. Conclusion : Bilateral spontaneous quadriceps tendon rupture occurs in pathologically weakened tendon due to various disease processes. Correct diagnosis and early treatment provides best functional results.

  Abstract in Arabic 

التمزق العفوي الثنائي فى وتر عضلة الفخذ (quadricepstendon) في حالة النقرس
ان التمزق العفوي الثنائي وتر عضلات الفخذ هو ظاهرة نادرة جدا في الطب السريرى. وعادة ما ينتج ذلك من صدمة خفيفة تحدث فى وتر عضلات الفخذ اضعفتها حالات مرضية مختلفة ونعرض فى المقال حالة مريض فى السابعة والخمسين من عمره حدث له تمزقا عفويا ثنائيا فى وتر عضلات الفخذ بعد وقعة بسيطة. وعند الكشف اتضح أنه يعاني من النقرس وتمزقا ثنائيا فى عضلات الفخذ. تم إصلاح الوتر فى الجانبين جراحيا باستخدام تقنية Krackow. واعطى المريض العلاج المناسب لفرط حمض يوريك الدم. حققت هذه الخطة العلاجية نجاحا جيدا عند المتابعة لفترة عشرين اسبوعا
الاستنتاج: ان التمزق العفوى لعضلات الفخذ قد ينتج عنه تمزقا في وتر العضلة المعتلة نتيجة أمراض مختلفة.

Keywords: Bilateral quadriceps tendon rupture, gout, primary quadriceps tendon repair, spontaneous quadriceps tendon rupture

How to cite this article:
Joshi PS, Shah VB, Saxena PB. Bilateral spontaneous rupture of quadriceps tendon in a case of gout . Saudi J Sports Med 2014;14:161-4

How to cite this URL:
Joshi PS, Shah VB, Saxena PB. Bilateral spontaneous rupture of quadriceps tendon in a case of gout . Saudi J Sports Med [serial online] 2014 [cited 2023 Dec 8];14:161-4. Available from: https://www.sjosm.org/text.asp?2014/14/2/161/142376

  Introduction Top

Bilateral quadriceps tendon rupture is an uncommon injury. It finds infrequent mention in literature [1],[2] with only 105 cases published till date. [3] It is associated with various conditions such as old age, obesity, [4] chronic renal failure, [4],[5] gout, [6] systemic lupus erythematosus, [7] diabetes, [8] rheumatoid arthritis, [9] secondary hyperparathyroidism, [10] steroid treatments, [11] pseudo gout, [12] amyloidosis [13] and simvastatin therapy. [14] Trivial trauma superimposed on pathologically weakened quadriceps tendon due to above mentioned causes leads to spontaneous bilateral rupture. [15] These patients require timely and adequate surgical intervention to prevent permanent loss of knee functions. [16]

  Case report Top

A 57-year-old gentleman presented to us with history of injury to both knees after slip and trivial fall on consecutive days two and half months back. He complained of severe pain, swelling around superior aspect of knees, inability to straighten knees and difficulty in walking [Figure 1]. He gave history of an episodic pain on his right foot great toe (first tarso-metatarsal joint). His evaluation revealed higher levels of blood uric acid for which he was put on Tab. allopurinol 300 mg once a day regime since last two months. He presented to us two and half months from the time of injury. On general examination, his body mass index (BMI) was 29.4. His right foot first tarso-metatarsal joint was mildly swollen and tender. There were palpable defects in quadriceps tendon bilaterally with supra-patellar swelling on left side.
Figure 1: Clinical photograph showing supra-patellar swelling and palpable supra-patellar step

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Dreyer's test (ability to raise leg straight after stabilizing quadriceps tendon) was positive bilaterally. His HB was 13.8 gm%, TLC-6430/cmm, ESR-12, Uric acid - 5.9, 5.8, 5.0 mg/dl on different accounts while on allopurinol treatment. Laboratory investigations for hyperparathyroidism, lupus, renal functions, diabetes, and rheumatoid arthritis were normal. There was no history of prolonged steroid treatment. X-ray revealed soft tissue discontinuity with swelling and forward tilted patella. Ultrasound of knees suggested discontinuity of quadriceps tendons bilaterally with cystic fluid collection in surroundings. MRI scan showed torn quadriceps tendons with gap of two cm on right side and four cm on left side with cystic fluid collection [Figure 2].
Figure 2: MRI showing defect in quadriceps tendon with fluid collection

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On 19 September 2012 he was operated. There was brownish turbid fluid collection with debris (organized hematoma) and granular material surrounding rounded torn edges of tendon with stump of 2.5 cm at patellar insertion site [Figure 3].
Figure 3: Intra-operative picture showing degenerative tear of tendon with organized hematoma

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Tendon was repaired primarily with Krackow technique, [17] using a non-absorbable material and deep muscular fascia was used as reinforcement to the repair [Figure 4].
Figure 4: Repair by Krackow technique[17]

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Muscle biopsy revealed fibrinoid necrosis with fibrin deposits and cyst wall surrounded by flattened cells with lymphocytes, plasma cells and histiocytes, suggestive of chronic inflammation. Analysis for crystal deposition could not be done because material was formalin fixed.

Postoperatively both the knees were immobilized using knee brace locked in extension for three weeks [Figure 5]. Static quadriceps strengthening exercises were initiated in first week with limited weight bearing with walker. After three weeks from surgery active knee flexion, passive knee extension and SLR exercises were started with patella mobilization. At the time of discharge (four weeks from surgery) patient's right and left knee ROM was 20-35° and 20-30°, respectively with extensor lag of 20° on both sides. Knee brace was continued for six weeks. At six weeks his right and left knee ROM was 15-50° and 15-40°, respectively. At 20 weeks right and left knee ROM was 10-95° and 10-90°, respectively. Repeat USG scan showed intact continuity of tendons on both sides.
Figure 5: Knee-brace immobilization

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  Discussion Top

In 1949, Steiner and Palmer reported the first case of bilateral, simultaneous rupture of the quadriceps tendon. [18] Rupture of the quadriceps tendon occur relatively infrequently and usually occur in patients older than 40 years. [1],[2],[3] Shah et al. [15] analyzed 66 cases published from 1949 to 2002 and Neubauer et al. [3] performed a meta-analysis of 105 published cases in the English and German literature from 1949 to 2004.

According to Ribbans and Angus two distinct categories individuals have been described. [19] Younger age group is associated with rapid, eccentric contraction of the quadriceps muscle during sports activity. Older age group is associated with pathologically weakened tendon due to chronic renal failure with long-term dialysis, obesity, leukemia, hyperparathyroidism, diabetes, rheumatoid arthritis, systemic lupus, gout, anabolic steroid use, pseudogout, alkaptonuria, simvastatin therapy, prolonged immobilization and severe osteomalacia. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

In chronic renal failure and chronic metabolic acidosis, tendon collagen content alteration and elastosis result in pathological weakening of tendon, whereas in hyperparathyroidism calcification of the tendon and sub-periostal bone re-absorption make it prone for rupture. Steroid usage alters collagen cross-linking, especially in conjunction with exercise, and can lead to dysplasia and excess build up of collagen fibers. In patients with gout, there is fibrinous necrosis as with diabetes and chronic inflammatory reactions, leading to similar tendon content modifications, which ultimately predispose the patient to tendon rupture. [20],[21],[22]

In most cases a complete rupture of the quadriceps tendon develops at the tendon-osseous junction but in our case there was a 2.5 cm stump at patellar insertion site bilaterally. Hence tendon was repaired primarily with Krackow technique [17] using non-absorbable material and deep muscular fascia from vastus lateralis was used as reinforcement to the repair.

  Conclusion Top

Due to its rare incidence, simultaneous bilateral quadriceps tendon rupture is often misdiagnosed as osteoarthritis, strokes, rheumatoid arthritis, [23],[24] hence high index of suspicion, correct timely diagnosis and early treatment provide best functional results.

  Clinical message Top

Weakness in knee spontaneously or after trivial injury in predisposed group of patients should alert clinician about possibility of pathological quadriceps tendon rupture. It should be treated surgically as soon as possible with treatment of predisposing factor for better functional outcomes.

  References Top

Geisl H. Bilateral, simultaneous, spontaneous and subcutaneous rupture of the quadriceps tendon. Aktuelle Traumatol 1983;13:201-4.  Back to cited text no. 1
Kelly BM, Rao N, Louis SS, Kostes BT, Smith RM. Bilateral, simultaneous, spontaneous rupture of quadriceps tendons without trauma in an obese patient: A case report. Arch Phys Med Rehabil 2001;82:415-8.  Back to cited text no. 2
Neubauer T, Wagner M, Potschka T, Riedl M. Bilateral, simultaneous rupture of the quadriceps tendon: A diagnostic pitfall? Report of three cases and meta-analysis of the literature. Knee Surg Sports Traumatol Arthrosc 2007;15:43-53.  Back to cited text no. 3
Wilson JN. Bilateral rupture of rectus femoris tendons in chronic nephritis. Br Med J 1957;1:1402-3.  Back to cited text no. 4
Loehr J, Welsh RP. Spontaneous rupture of the quadriceps tendon and patellar ligament during treatment for chronic renal failure. Can Med Assoc J 1983;129:254-6.  Back to cited text no. 5
Levy M, Seelenfreund M, Maor P, Fried A, Lurie M. Bilateral spontaneous and simultaneous rupture of the quadriceps tendons in gout. J Bone Joint Surg Br 1971;53:510-3.  Back to cited text no. 6
Wener JA, Schein AJ. Simultaneous bilateral rupture of the patellar tendon and quadriceps expansions in systemic lupus erythematosus. A case report. J Bone Joint Surg Am 1974;56:823-4.  Back to cited text no. 7
Bhole R, Johnson JC. Bilateral simultaneous spontaneous rupture of quadriceps tendons in a diabetic patient. South Med J 1985;78:486.  Back to cited text no. 8
Razzano CD, Wilde AH, Phalen GS. Bilateral rupture of the infrapatellar tendon in rheumatoid arthritis. Clinical Orthopaedics and Related Research 1973;91:158-61.  Back to cited text no. 9
Cirincione RJ, Baker BE. Tendon ruptures with secondary hyperparathyroidism. A case report. J Bone Joint Surg Am 1975;57:852-3.  Back to cited text no. 10
David HG, Green JT, Grant AJ, Wilson CA. Simultaneous bilateral quadriceps rupture: A complication of anabolic steroid abuse. J Bone Joint Surg Br 1995;77:159-60.  Back to cited text no. 11
Tedd RJ, Norton MR, Th omas WG. Bilateral simultaneous atraumatic quadriceps tendon ruptures associated with "pseudogout". Injury 2000;31:467-9.  Back to cited text no. 12
Masonis JL, Frick SL. Bilateral quadriceps tendon rupture as the initial presentation of amyloidosis. Orthopedics 2001;24:995-6.  Back to cited text no. 13
Rubin G, Haddad E, Ben-Haim T, Elmalach I, Rozen N. Bilateral, simultaneous rupture of the quadriceps tendon associated with simvastatin. Isr Med Assoc J 2011;13:185-6.  Back to cited text no. 14
Shah MK. Simultaneous, bilateral rupture of the quadriceps tendons: Analysis of risk factors and associations. South Med J 2002;95:860-6.  Back to cited text no. 15
Konrath GA, Chen D, Lock T, Goitz HT, Watson JT, Moed BR, et al. Outcomes following repair of quadriceps tendon ruptures. J Orthop Trauma 1998;12:273-9.  Back to cited text no. 16
Krackow KA, Thomas SC, Jones LC. A new stitch for ligament-tendon fixation. Brief note. J Bone Joint Surg Am 1986;68:764-6.  Back to cited text no. 17
Steiner CA, Palmer LH. Simultaneous bilateral rupture of the quadriceps tendon. Am J Surg 1949;78:752-5.  Back to cited text no. 18
Ribbans WJ, Angus PD. Simultaneous bilateral rupture of quadriceps tendon. Br J Clin Pract 1989;43:122-5.  Back to cited text no. 19
Trobisch PD, Bauman M, Weise K, Stuby F, Hak DJ. Histologic analysis of ruptured quadriceps tendons. Knee Surg Sports Traumatol Arthrosc 2010;18:85-8.  Back to cited text no. 20
Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am 1991;73:1507-25.  Back to cited text no. 21
Narici MV, Maffulli N, Maganaris CN. Ageing of human muscles and tendons. Disabil Rehabil 2008;30:1548-54.  Back to cited text no. 22
Wick M, Müller EJ, Ekkernkamp A, Muhr G. Missed diagnosis in delayed recognition of bilateral simultaneous rupture of the quadriceps tendons. Unfallchirurg 1997;100:320-3.  Back to cited text no. 23
Mahlfeld K, Franke J, Schaeper O, Grasshoff H. Bilateral and simultaneous rupture of the quadriceps tendon: A diagnostic problem. Ultraschall Med 2000;21:226-8.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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