Distinct risk profiles for short-term surgical complications and venous thromboembolism exist among extensor mechanism repair procedures.

PURPOSE: Extensor mechanism injuries, which comprise patella fractures, patella tendon tears and quadriceps tendon tears, are severely debilitating injuries and a common cause of traumatic knee pathology that requires surgical intervention. Risk factors for short-term surgical complications and venous thromboembolism (VTE) in this population have not been well characterised. The aim of this study was to identify perioperative risk factors associated with these short-term complications. METHODS: The National Surgical Quality Improvement Program database was used to identify patients who underwent an isolated, primary extensor mechanism repair from 2015 to 2020. Patients were stratified by injury type. Demographic data were collected and compared. A multivariate logistic regression was used to control for demographic and comorbid factors while assessing risk factors for developing short-term complications. RESULTS: A total of 8355 patients were identified for inclusion in this study. Overall, 3% of patients sustained short-term surgical complications and 1% were diagnosed with VTE within 30 days of surgery. Patella fracture fixation had a nearly twofold higher risk for surgical complications compared to quadriceps tendon repair (p = 0.004). Patella tendon repair had a twofold higher risk for VTE (p = 0.045), specifically deep vein thrombosis (p = 0.020), compared to patella fracture fixation. Increasing age, smoking and American Society of Anesthesiologists Classifications 3 and 4 were also found to be risk factors for surgical complications (p = 0.012, p = 0.004, p = 0.011 and p = 0.032, respectively). CONCLUSION: This study used a nationally representative, widely validated, peer-reviewed database to provide valuable insights into risk factors for short-term postoperative complications associated with extensor mechanism repair procedures, revealing notable differences in risk profiles among distinct surgical procedures. The results of this study will inform surgeons and patients in enhancing risk assessment, guiding procedure-specific decision-making, optimising preoperative care, improving postoperative monitoring and contributing to future research of extensor mechanism injuries. LEVEL OF EVIDENCE: Level III.

Reconstruction of chronic quadriceps tendon rupture using autologous semitendinosus tendon graft: A case report.

INTRODUCTION: Chronic quadriceps tendon rupture is a relatively rare injury that can be challenging to treat. Several techniques have been described for chronic quadriceps tendon repair, including the use of autografts, allografts, and synthetic mesh. We reported a case of 17-year-old male with chronic quadriceps tendon rupture treated using autologous semitendinosus tendon graft. CASE PRESENTATION: A 17-year-old male presented with left knee pain since 8 months ago after he fell into a ditch. Physical examination demonstrated palpable gap on suprapatellar region. Magnetic resonance imaging demonstrated quadriceps discontinuity and hyperintensity surrounding the insertion of the quadriceps tendon. The patient underwent quadriceps tendon reconstruction using ipsilateral autologous semitendinosus graft. After 3 weeks the patient was sent for physiotherapy to regain his left knee's range of motion. At final follow up at six months, the 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 0° to 130°. DISCUSSION: In this case, we demonstrated a successfully treated chronic quadriceps tendon rupture using autologous semitendinosus tendon graft. For cases of chronic quadriceps tendon rupture with tissue loss, it is advisable to utilise an autologous graft for the purpose of repairing and restoring the structure and function of the quadriceps tendon. CONCLUSION: Surgical treatment of chronic quadriceps tendon rupture is challenging and lacks evidence-based guidelines. We propose the use of ipsilateral semitendinosus tendon autograft as choice for chronic quadriceps tendon rupture in this report, as it leads to favorable outcomes postoperatively.

Floating patella: Ipsilateral and simultaneous rupture of the quadriceps and patellar tendons in a young individual (a surgical case report).

INTRODUCTION AND IMPORTANCE: The phenomenon of a floating patella or ipsilateral bifocal rupture of the extensor apparatus is an extremely rare injury, with few cases reported in the literature. The aim of this case study is to report an unprecedented event: the simultaneous trans-tendinous rupture of both quadriceps and patellar tendons in a young adult without predisposing factors, emphasizing the need for awareness in diagnosis and management, and suggesting a new avenue for research in prevention and rehabilitation. CASE PRESENTATION: We report the case of a 35-year-old patient with no significant medical history, who experienced this injury following a sudden start in a sprint without prior warm-up. The clinical examination revealed a swollen, painful knee with active extension deficit, patellar ascent, and a sub patellar hiatus. Magnetic Resonance Imaging (MRI) confirmed a trans-tendinous rupture of both the patellar and quadriceps tendons. CLINICAL DISCUSSION: Tendon repair was performed using end-to-end sutures and a figure-8 reinforcement with the semitendinosus tendon, along with gracilis plastie to strengthen the patellar tendon repair. This methodological approach is discussed in the context of its effectiveness and potential implications for future surgical management of similar injuries. CONCLUSION: After a 12-month follow-up, the patient exhibited highly satisfactory results, resuming both professional and sporting activities. To our knowledge, this is the first published case of a trans-tendinous rupture of the extensor apparatus tendons. This observation serves as a reference in understanding the mechanism and surgical management of such lesions, emphasizing the need for further research and clinical vigilance in similar cases.

Bilateral spontaneous quadriceps tendon rupture: a case report and literature review.

Bilateral spontaneous quadriceps tendon rupture is a rare condition characterized by the simultaneous tear of the fibrous tissue connecting the quadriceps muscle to the patella bone. Prompt diagnosis is crucial for appropriate treatment and optimal outcomes. We present a case of a 70-year-old male with bilateral knee pain and an inability to walk, resulting from a trivial fall. Despite initial misdiagnosis, a thorough evaluation, including physical examination and imaging, revealed bilateral quadriceps tendon rupture. Surgical repair was performed, followed by a comprehensive rehabilitation program. At the four-month follow-up, the patient showed significant improvement in pain and function. This article provides a comprehensive review of the existing literature on bilateral quadriceps tendon rupture, emphasizing the challenges in the diagnosis and management of this rare condition. Early diagnosis, prompt surgical intervention, and a tailored rehabilitation program are crucial for successful outcomes.

Chronic Quadricep Tendon Rupture Reconstruction with Poly-Tape and Achilles' Tendon Allograft: A Case Report and Review of the Literature.

Introduction: Chronic rupture of the quadriceps tendon is an uncommon but debilitating injury, seen only in 1.37/100,000 patients per annum. The problems associated with this injury are the inability to walk due to disruption of the extensor mechanism and pain. There is limited literature on the reconstruction methods for this injury. This study aims to provide a case report and review of similar cases, using artificial tape and allograft. Case Report: A 60-year-old male patient was operated on for chronic quadriceps tendon rupture after falling on his knee with forced flexion. The surgical management in our case consisted of mobilization of the proximal quadriceps tendon and muscle belly with a V-Y tendon plasty, advancement of the tendon, and repair using the Krakow technique through intraosseous patellar tunnels, augmented with Poly-Tape (Neoligaments©) and an Achilles' tendon allograft. This was used due to poor patient tissue quality and the extent of the defect. We also searched the literature for chronic quadriceps tendon ruptures reconstruction using poly tape or Achilles' tendon allograft. Conclusion: Chronic quadriceps tendon rupture repairs have relatively poor outcomes, and no surgical procedure has been proven to be the gold standard treatment. We believe the novel combination of Poly-Tape supplemented with Achilles' tendon allograft produces a structurally competent reconstruction in patients with poor tissue quality and large defects and produced good results in our case report.

Peripheral Nerve Stimulator for Chronic Pain From Quadriceps Tendon Rupture: A Case Report.

Chronic pain from quadriceps tendon rupture (QTR) presents a significant challenge for both orthopedic surgeons and pain management physicians. Current treatment options include physical therapy and medication management. Patients with refractory pain often end up using opioids and suffer from a prolonged disability that affects the quality of their life. A peripheral nerve stimulator is a novel treatment option for QTR. It is a minimally invasive treatment option that can be used to manage refractory cases in the future. We report a case of successful management of chronic pain in a patient with bilateral QTR with a femoral peripheral nerve stimulator.

Rotura traumática simultánea y bilateral del tendón del cuádriceps en un paciente fisicoculturista: informe de caso y revisión de la literatura / Simultaneous bilateral traumatic quadriceps tendon rupture in a bodybuilding patient: case report and literature review

La rotura traumática, simultánea y bilateral del tendón cuadricipital es una lesión infrecuente, generalmente asociada a otras enfermedades sistémicas tales como insuficiencia renal o trastornos endocrinos. Presentamos el caso de un varón sano y atleta de 38 años que sufrió esta lesión mientras realizaba una sentadilla en el gimnasio. (AU)

The traumatic bilateral and simultaneous quadriceps tendon rupture is a rare injury, usually associated with other systemic diseases such as renal insufficiency or endocrine disorders. We present the case of a 38-year-old healthy male athlete who sustained this injury while performing a squat at the gym. (AU)

Use of the forgotten joint score (FJS)-12 to evaluate knee awareness after quadriceps tendon reconstruction.

BACKGROUND: Quadriceps tendon rupture (QTR) is a severe injury of the knee extensor apparatus. The study aims to validate the use of forgotten joint score (FJS-12) for functional outcome assessing after surgical treatment of QTR. METHODS: Fifty-seven patients who underwent surgery for QTR with transosseous suture reconstruction in a single orthopaedic surgery and traumatology center between 2015 and 2020 were eligible for enrolment in this retrospective case series. The demographic data and other pre-operative details such as age, gender, comorbidities and medication use also were extracted from the medical records. Patient reported outcome measures (PROMs) were gathered in the form of Western Ontario and McMaster Universities Arthritis Index Score (WOMAC), Tegner Activity Score (TAS), Lysholm Score and FJS-12 at a mean follow-up time of 49.84 months ± 20.64 months. The FJS-12 was validated by correlation with WOMAC, TAS and Lysholm Score. RESULTS: The mean age of all patients were 69.2 ± 13.6 years with 51 (89.5%) males and 6 (10.5%) females. The mean time from injury to surgery was 3.39 ± 5.46 days. All patients reported satisfactory functional outcomes after surgery on FJS-12, WOMAC and Lysholm scores, except the TAS, which decreased slightly from pre-operative level. There was a high negative correlation between WOMAC and FJS-12, but moderate positive correlations between FJS-12 and TAS and Lysholm scores. The Cronbach's alpha value was 0.96 for 12 items in FJS-12. CONCLUSION: This study has found that FJS-12 is a reliable and easy to assess tool for functional outcomes after QTR reconstruction. It has shown moderate to strong correlation with other commonly used outcome measures (WOMAC, TAS and Lysholm).

Bilateral Quadriceps Tendon Rupture in a Healthy Individual Following a Motor Vehicle Accident: A Case Report.

Bilateral quadriceps tendon rupture (QTR) is a rare injury that typically affects middle-aged men presenting underlying medical conditions, while only a few cases have been reported in healthy individuals. The gold standard treatment of such injuries is prompt surgical repair, followed by postoperative immobilization and physiotherapy. We present the case of a 51-year-old previously healthy man who experienced bilateral, simultaneous, and complete QTR following a high-velocity motor vehicle accident. Physical examination revealed bilateral extensor mechanism disruption and palpable defects at the superior poles of the patellae. MRI confirmed the diagnosis, and the patient underwent surgical repair using three anchor sutures on each side. Postoperative management involved a brief period of immobilization followed by progressive passive motion exercises and protected weight bearing. At a six-month follow-up, the patient had excellent functional outcomes and was satisfied with the treatment.

Simultaneous bilateral quadriceps tendon rupture in a healthy young male: a case report.

BACKGROUND: Simultaneous bilateral quadriceps tendon rupture is rare, particularly in young individuals with no prior medical history. We present the case of a young man who presented with bilateral quadriceps tendon rupture. CASE PRESENTATION: A 27-year-old Japanese man missed a step while descending a flight of stairs, stumbled, and became aware of severe pain in both knees. He had no past medical history, but was severely obese, with a body mass index of 43.7 kg/m2 (height 177 cm, weight 137 kg). Five days after injury, he was referred to our hospital for examination and treatment. Bilateral quadriceps tendon rupture was diagnosed based on magnetic resonance imaging, and quadriceps tendon repair with suture anchor was performed on both knees 14 days after injury. The postoperative rehabilitation protocol was to immobilize both knees in extension for 2 weeks, then to gradually proceed with weight-bearing and gait training using hinged knee braces. Both knees obtained a range of motion from 0° to 130° without any extension lag by 3 months postoperatively. One year postoperatively, tenderness was evident at the suture anchor in the right knee. That suture anchor was therefore removed in a second operation, and histological evaluation of the tendon of the right knee revealed no pathological changes. As of 19 months after the primary surgery, the patient showed a range of motion from 0° to 140° in both knees, did not complain of any disability, and had fully returned to normal daily activities. CONCLUSIONS: We experienced simultaneous bilateral quadriceps tendon rupture in a 27-year-old man with no past medical history other than obesity. Suture anchor repair was performed for both quadriceps tendon ruptures and achieved a favorable postoperative outcome.

A retrospective case series of the treatment of spontaneous quadriceps tendon rupture in patients with uremia and secondary hyperparathyroidism.

Background: Spontaneous quadriceps tendon rupture (QTR) is a rare complication of uremia. Secondary hyperparathyroidism (SHPT) is considered the leading cause of QTR in uremia patients. QTR in patients with uremia and SHPT are treated with active surgical repair along with the treatment of SHPT using medication or parathyroidectomy (PTX). The impact of PTX for SHPT on tendon healing remains unclear. The purpose of this study was to introduce surgical procedures for QTR and to determine the functional recovery of the repaired quadriceps tendon (QT) after PTX. Methods: Between Jan 2014 and Dec 2018, eight uremia patients underwent PTX after a ruptured QT was repaired by figure-of-eight trans-osseous sutures with an overlapping tightening suture technique. Biochemical indices were measured before and one year after PTX to evaluate the control of SHPT. The changes in bone mineral density (BMD) were determined by comparing x-ray images at pre-PTX and during follow-up. The assessment of the functional recovery of the repaired QT was conducted at the last follow-up using multiple functional parameters. Results: Eight patients (fourteen tendons) were retrospectively evaluated at an average follow-up of 3.46 ± 1.37 years after PTX. ALP and iPTH levels one year after PTX were significantly lower than at pre-PTX (P = 0.017, P < 0.001, respectively). Although there was no statistical differences compared to pre-PTX, serum phosphorus levels decreased and returned to normal one year after PTX (P = 0.101). BMD significantly increased at the last follow-up compared to pre-PTX. The average Lysholm score was 73.5 ± 11.07 and the average Tegner activity score was 2.63 ± 1.06. The active knee ROM after repair averaged an extension of 2.85 ± 3.78° to a flexion angle of 113.21 ± 10.12°. The quadriceps muscle strength was grade IV and the mean Insall-Salvati index was 0.93 ± 0.10 in all of the knees with tendon ruptures. All patients were able to walk without external help. Conclusions: Figure-of-eight trans-osseous sutures with an overlapping tightening suture technique is an economical and effective treatment for spontaneous QTR in patients with uremia and SHPT. PTX may promote tendon-bone healing in patients with uremia and SHPT.

Inferior results at long-term follow-up after extensor mechanism allograft reconstruction in septic compared to aseptic revision total knee arthroplasty.

PURPOSE: Extensor mechanism lesion after total knee arthroplasty (TKA) is a catastrophic complication. Reconstruction with extensor mechanism allograft (EMA) has been described as a sound salvage procedure. Its effectiveness at long term and in septic cases is still under scrutiny. The long-term results of EMA reconstruction for chronic extensor mechanism failures following aseptic and septic revision TKA have been analysed. METHODS: From the institutional database, 35 patients with a revision TKA (RevTKA) undergoing EMA reconstruction from 2005 to 2015 have been retrospectively identified. A history of periprosthetic joint infection (PJI) was found in 13 (37%) patients. The mean follow-up was 81.2 months (± 34.7, range 3-120). EMA failures were considered for lag more than 20°, Knee Society Score (KSS) less than 60 points, and/or in the case of revision of the allograft. RESULTS: The mean KSS improved from 35.9 (± 16.9, range 0-54) to 86.6 (± 10.4, range 54-99) points in the aseptic group (p < 0.001) and from 27.5 (± 11.6, range 10-44) to 79.4 (± 16.3, range 48-94) points in the septic group (p < 0.001). The extensor lag changed from 48.4° (± 14.5, range 30-90) to 4.6° (± 10.8, range 0-50) in the aseptic group (p < 0.001) and from 56.5° (± 20.8, range 30-90) to 6.1° (± 6.8, range 0-20) in the septic group (p < 0.001). The mean postoperative flexion was 105.2° (± 13.2, range 75-130) in the aseptic group and 102.7° (± 12.5, range 80-120) in the septic group (p = 0.32). Three failures (14% of the cases) occurred in the aseptic group and five in the septic group (38% of the cases). The overall survivorship at 10 years was 83.3% (22 cases, CI95 94.2-121.7) vs 58% (13 cases, CI95 67.2-111.7) in the aseptic and septic group, respectively (p = 0.01). CONCLUSIONS: EMA reconstruction after extensor mechanism disruptions in TKA is a reliable salvage procedure. The septic nature of the revision decreased the functionality of the knee joint after EMA, but it did not represent a risk factor for re-ruptures or recurrence of infection. LEVEL OF EVIDENCE: Level III.

Trends and epidemiology of knee extensor mechanism injuries presenting to United States emergency departments from 2001 to 2020.

OBJECTIVES: Injuries to the native extensor mechanism (EM) of the knee are potentially disabling and often require surgical treatment. Large-scale, updated epidemiological data on these injuries is lacking. The objective of the current study was to examine recent trends in EM injuries presenting to United States (US) Emergency Departments (EDs) over the last 20 years using a nationally representative sample. METHODS: This study retrospectively analyzed the National Electronic Injury Surveillance System (NEISS) database to identify cases of EM injuries (defined as either a quadriceps tendon rupture, a patella fracture, or a patellar tendon rupture) presenting to EDs in the US from 2001 to 2020. RESULTS: During the study period, an estimated 214,817 EM injuries occurred in an at-risk population of 6,183,899,410 person-years for an overall incidence rate of 3.47 per 100,000 person-years. Patella fractures (PFs) were the most common injury type, representing 77.5% of all EM injuries (overall incidence rate: 2.69), followed by patellar tendon ruptures (PTRs; 13.5%; incidence: 0.48) and quadriceps tendon ruptures (QTRs; 9%; incidence: 0.31). Demographic characteristics and mechanisms of injury differed between injury types. Annual incidence rates increased significantly during the study period for all EM injury types, with PTRs demonstrating the largest relative increase (average annual percent increase: PF, 2.8%; PTR, 7.2%; QTR, 5.3%). Accounting for population growth yielded an increasing incidence of all EM injuries combined from 3.65 in 2001 to 4.9 in 2020. The largest relative increases in incidence rates were observed in older age groups. CONCLUSION: Extensor mechanism injuries of the knee are increasing in the US, which likely reflects an aging and more active population. These types of injuries are associated with substantial functional impairment and recent increases in incidence rates highlight the need for injury prevention and management strategies.

Management of Extensor Mechanism Disruption After Total Knee Arthroplasty.

Extensor mechanism disruptions following total knee arthroplasty are devastating injuries with complication rates following surgical intervention ranging from 25% to 45%. Primary repair with and without augmentation is appropriate in certain limited clinical settings. Allograft reconstruction has been a popular option; however, synthetic grafts are showing promise and good results. In this article the authors discuss an algorithm for treating these difficult injuries as well as detail the surgical techniques for each approach.

Extensor mechanism ruptures.

Native patellar tendon injuries are seen in younger patients compared to quadriceps tendon ruptures. Up to a third of the patients may have local (antecedent tendinopathy and cortisone injections) or systemic risk factors (obesity, diabetes, hyperparathyroidism, chronic renal failure, fluoroquinolone or statin use) of injury, these are more frequent in bilateral disruptions. Complete extensor mechanism disruptions should be repaired surgically. Although isolated primary repair has been reported to have good outcomes in younger patients with acute tears and good tendon quality, augmentation of the repair with autograft, allograft or synthetic material should be considered in patients with poor tendon quality, chronic tears or tendon defects. High rates of return to work/sports have been reported in native patellar and quadriceps tendon tears, with re-rupture rates <5%. Extensor mechanism disruptions in patients with a total knee arthroplasty are challenging due to older age, systemic co-morbidities and poor local conditions, resulting in inferior outcomes compared to native extensor mechanism injuries. Some form of augmentation with autograft, allograft or synthetics is advisable in all cases. Salvage procedures such as whole extensor mechanism allografts provide acceptable outcomes in multiply operated knees with extensive bone and soft tissue deficits.

Outcomes After Repair of Quadriceps Tendon Rupture in Patients Aged 40 Years and Younger.

Background: Injury to the quadriceps tendon is rare and most commonly occurs in middle-aged men. Few reports are available regarding outcomes after quadriceps tendon rupture in younger patients. Purpose/Hypothesis: To review the clinical outcomes of patients who underwent quadriceps tendon repair at age ≤40 years. We hypothesized that this cohort would experience better clinical outcomes in comparison to historical older controls. Study Design: Case series; Level of evidence, 4. Methods: Using an institutional database, we retrospectively identified patients who underwent quadriceps tendon repair between January 2009 and December 2017. Patients were included in the study if they were aged ≤40 years at the time of surgery and had sustained an isolated, complete tendon rupture. Patient and injury characteristics were recorded. Patients were contacted to complete a custom survey, the 2000 International Knee Documentation Committee (IKDC) form, the Lysholm scale, and the Tegner scale. Results: Included were 38 patients (86.8% male; mean age, 32.0 ± 6.9 years; age range, 15-40 years), with a mean follow-up of 5.9 ± 2.3 years (range, 2.4-11.3 years). At final follow-up, the mean IKDC score was 74.1 ± 22.6 (range, 26.4-100.0), and the mean Lysholm score was 85.4 ± 20.0 (range, 30-100), which were similar if not inferior to historical controls of patients >40 years. Only 16 patients (42.1%) had unchanged or higher Tegner scores after surgery, whereas 22 patients (57.9%) reported lower postoperative activity level. Overall, 91.2% (31/34) of workers returned at a mean 3.9 months after surgery, whereas 63% (12/19) of athletes were able to return to play at 8.8 months. At final follow-up, 12 patients (31.6%) reported persistent pain and stiffness in their knees. Additionally, 3 patients (7.9%) reported pain without stiffness, and 4 (10.5%) reported stiffness without pain. Patients reporting pain or stiffness had significantly lower IKDC scores, Lysholm scores, postoperative Tegner scores, and change in their Tegner score at final follow-up in comparison to those who did not report pain or stiffness. Conclusion: Although patients aged ≤40 years had satisfactory outcomes after quadriceps tendon repair, this injury resulted in significant long-term sequelae in a substantial percentage of patients, despite their youth. Further, this group did not have better outcomes compared with historical controls aged > 40 years.

A Survey of Treatment Trends for Acute Quadriceps Tendon Ruptures Among North American Surgeons.

Background: To date, little clinical evidence exists to support a specific surgical technique or postoperative rehabilitation protocol for quadriceps tendon ruptures. With a lack of evidence-based superiority, assessment of clinical practices and surgeon preferences is pertinent. Purpose: To describe the current surgical technique and rehabilitation preferences among members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine pertaining to acute quadriceps tendon rupture. Study Design: Cross-sectional study. Methods: Orthopaedic staff members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine were invited to complete an internet-based survey composed of 26 questions assessing current trends in the management and rehabilitation of acute quadriceps tendon rupture. Survey questions were developed after a thorough review of current literature. Survey responses were analyzed and reported using descriptive statistics (absolute values, frequencies, and percentages) where appropriate. Statistical comparisons and contrasts between Canadian and American surgeons were made using chi-square analyses and Student t tests. Results: A total of 264 surgeons participated in the survey (136 Canadians; 128 Americans). Canadian surgeons were more likely to obtain a preoperative ultrasound as compared with Americans (43.0% vs 6.7%; P < .00001), while American respondents were more likely to obtain magnetic resonance imaging scans (65.8% vs 10.2%; P < .00001). The transosseous drill hole technique was the most commonly utilized (70.2%); the suture anchor technique was used 20.6% of the time. Canadian respondents trended toward a higher use of transosseous tunnels; however, this was not statistically significant (75.8% vs 64.2%; P = .068). American respondents were more likely to utilize suture anchors (27.5% vs 14.1%; P = .0096). Most respondents advanced range of motion goals stepwise in 2-week intervals of 30° (Canadians, 54.0% vs Americans, 58.5%; P = .3091); timing of range of motion initiation varied. Conclusion: Among North American surgeons who responded to this study, the transosseous technique was the most commonly used, and range of motion was generally advanced in a 2-week stepwise fashion. We found several differences in practice between Canadian and American respondents, including the type of preoperative imaging and the frequency of using the suture anchor technique.

Epidemiology of Acute Extensor Mechanism Injuries in Collegiate-Level Athletes in the United States.

BACKGROUND: Extensor mechanism injuries involving the quadriceps tendon, patella, or patellar tendon can be a devastating setback for athletes. Despite the potential severity and relative frequency with which these injuries occur, large-scale epidemiological data on collegiate-level athletes are lacking. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: Knee extensor mechanism injuries across 16 sports among National Collegiate Athletic Association (NCAA) men and women during the 2004-2005 to 2013-2014 academic years were analyzed using the NCAA Injury Surveillance Program (NCAA-ISP). Extensor mechanism injuries per 100,000 athlete-exposures (AEs), operative rate, annual injury and reinjury rates, in-season status (pre-/regular/postseason), and time lost were compiled and calculated. RESULTS: A total of 11,778,265 AEs were identified and included in the study. Overall, 1,748 extensor mechanism injuries were identified, with an injury rate (IR) of 14.84 (per 100,000 AEs). N = 114 (6.5%) injuries were classified as severe injuries with a relatively higher median time loss (44 days) and operative risk (18.42%). Male athletes had higher risk of season-ending injuries in both all (3.20% vs 0.89%, P < 0.01) and severe (41.54% vs 16.33%, P < 0.01) extensor mechanism injuries. Similarly, contact injuries were more frequently season-ending injuries (4.44% vs 1.69%, P = 0.01). Women's soccer (IR = 2.59), women's field hockey (IR = 2.15), and women's cross country (IR = 2.14) were the sports with the highest rate of severe extensor mechanism injuries. CONCLUSION: Extensor mechanism injuries in collegiate athletes represent a significant set of injuries both in terms of volume and potentially to their athletic careers. Male athletes and contact injuries appear to have a greater risk of severe injuries. Injuries defined as severe had a higher risk of operative intervention and greater amount of missed playing time. CLINICAL RELEVANCE: Knowledge of the epidemiology of extensor mechanism injuries may help clinicians guide their athlete patients in sports-related injury prevention and management.

Trivial Indirect Trauma Causing Recurrent Bilateral Quadriceps Tendon Rupture in End Stage Renal Failure Patient: A Case Report.

Recurrent bilateral quadriceps tendon rupture in a young patient is a very rare incident. The underlying medical condition is always present and may have contributed to this injury. We report a recurrent bilateral quadricep tendon rupture in a 28-year-old man with underlying end-stage renal failure that occurred 10 months after the first repair. Injuries were indirect and trivial during the first and second events. Surgical repair was performed with similar technique for both incidents and he was advised to exercise extreme cautions after the second repair. He could return to his daily activities with no further recurrence at 30 months follow-up.

A Simultaneous Rupture of the Patellar Tendon and the Con-tralateral Quadriceps Tendon in a Patient with Chronic Renal Failure Undergoing Long Term Hemodialysis.

BACKGROUND: Quadriceps or patellar tendon rupture incidence is relatively low, especially simultaneous bilateral rupture, which usually reported as a complication of chronic systemic disorders such as renal failure. OBJECTIVE: Herein, we report a case of bilateral knee extensor mechanism ruptured in a patient with chronic renal failure on long standing hemodialysis. CASE PRESENTATION: A 38-year-old white male, a known case of chronic renal failure on long term hemodialysis, presented to our clinic with clinical signs of bilateral simultaneous knee extensor tendons rupture. After proper workup simultaneous quadriceps and contralateral patellar tendons rupture diagnosis was made. The patient was managed with surgical repair of the tendons and within few days after the surgery he started physiotherapy and rehabilitation program, using walking crutches partial weight bearing mobilization was allowed, and a gradual increase of knee flexion within brace was applied. He used the knee braces and the walking crutches for two months, to ensure complete healing of the repaired tendon with a sufficient strength to allow full weight bearing. At four-year follow-up, complete bilateral knee extensor tendons healing and both knees functional outcome was satisfactory. CONCLUSION: A simultaneous rupture of quadriceps and contralateral patellar tendons is a rare event in patients with chronic renal failure undergoing long term hemodialysis. With early surgical intervention and good physiotherapy, the patient usually has good recovery of both knees function.