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

Abstract

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.

Keywords: Secondary hyperparathyroidism; Spontaneous quadriceps tendon rupture; ligament reconstruction; parathyroidectomy; secondary hyperparathyroidism; uremia; uremia quadriceps tendon rupture.

Figure 1

Diagram of the QT repair surgery. (A). Five parallel longitudinal trans-osseous tunnels with diameters of 2.0 mm were made in the upper pole of the patella using a drill. (B). A figure-of-eight suture was performed through each of the adjacent bone tunnels and simple trans-osseous sutures were achieved through the bone tunnels on both sides. (C). Tears in the retinaculum and deep fascia on the surface of the patella were repaired using an overlapping tightening suture with absorbable suture material.

Figure 2

(A) x-ray of the right knee taken at the initial consultation showing severe osteoporosis. (B) Lateral radiograph showing the patella baja and calcification in the ruptured end of the QT (arrow). (C) Lateral T2-weighted MRI of the right knee showing a complete disruption of the QT at the patellar insertion sites. (D) The QT peel off from the upper pole of the patella. (E,F) Radiography after QT repair showing the regular positioning of the patella. (G,H) Radiography one year after PTX showed BMD had significantly increase compared to pre-PTX levels. (I,J) One year after PTX, the ROM of the right knee was 0–130° and in the left knee was 0–140°. (K) The patient undergoing IMS tests.

Figure 3

(A) 99mTc-MIBI dual-phase planar imaging. The early phase (15 min) planar images showed MIBI uptake in the inferior pole of the right thyroid lobe. (B) The delayed phase (2 h) planar images showed MIBI uptake in the inferior and upper pole of the bilateral thyroid lobes. (C) 99mTc-MIBI SPECT/CT imaging showing small soft-tissue masses with MIBI uptake in the back of the inferior Poles of both bilateral thyroid lobes.