Tailored Rehabilitation Program and Dynamic Ultrasonography After Surgical Repair of Bilateral Simultaneous Quadriceps Tendon Rupture in a Patient Affected by Gout: A Case Report

Abstract

Spontaneous quadriceps tendon rupture is a very rare occurrence, notably for bilateral simultaneous ruptures. Its occurrence is commonly linked to an underlying condition that may weaken the tendons leading to rupture. We report the case of a 68-year-old Caucasian male afflicted with long-term gout who presented a bilateral simultaneous quadriceps tendon rupture (BSQTR). We showcase the clinical presentation, the surgical intervention, rehabilitation program, dynamic sonographic monitoring, and home-based rehabilitation techniques of this injury, which aimed to improve activities of daily living (ADL) and quality of life (QoL). The patient was included in a 9-week post-surgical rehabilitation program and a home-based rehabilitation program with subsequent pain management and gait reacquisition. The outcome measures included right and left knee active range of motion (AROM), pain intensity measured on Visual Analogue Scale (VAS), functioning measured through ADL score, and gait assessment on Functional Ambulation Categories (FAC). All endpoints were measured at different time points, scoring significant improvement at discharge compared to baseline (e.g., AROM increased from 0 degrees to 95 degrees, while VAS decreased from 7 to 1, ADL score increased from 6 to 10, and FAC increased from 1 to 5). Moreover, some of these outcomes continued to improve after discharge, and the effects of home-based rehabilitation program and a single hip joint manipulation were assessed at 6-month follow-up. Musculoskeletal ultrasound findings showed mature tendon structure, consistent dynamic glide, and no scarring.

Keywords: bilateral quadriceps tendon rupture; dynamic sonography; home-based rehabilitation; joint manipulation; simultaneous quadriceps tendon rupture.

Figure 1

(A) Left knee lateral view on X-ray (preoperative, performed immediately after the incident) showing the low position of the patella. (B) Right knee lateral view on X-ray showing the low position of the patella (preoperative, performed immediately after the incident). (C) Sagittal T2 left knee MRI image (preoperative, performed 1 day after the incident) showing complete rupture of the quadriceps tendon at the level of the patellar insertion with 40 mm retraction. (D) Sagittal T2 right knee MRI image (preoperative, performed 1 day after the incident) showing complete rupture of the quadriceps tendon at the level of the patellar insertion with 24 mm retraction cranially.

Figure 2

(A) Intraoperative image showing complete rupture of the quadriceps tendon. (B) Intraoperative image showing the reinsertion of the quadriceps at the level of the upper pole of the patella using fixation anchors.

Figure 3

(A) Patient wearing a bilateral functional brace (unhinged ROM knee brace adjustable with extended support) for 6 weeks to keep the lower limbs in full extension (the picture was taken at 5 weeks post-surgery). (B) Patient walking with the aid of crutches at 8 weeks post-surgery on even surface and without crutches at discharge (9 weeks).

Figure 4

Serial dynamic sonography for left and right lower limbs assessed at different time points (T0, T1, T2) post-surgery. (A1,A2) Relatively non-homogeneous, hypoechoic left and right quadriceps tendon with loss of fibrillar pattern and thickened appearance, associated with the presence of peritendinous calcifications and subcutaneous tissue edema (baseline evaluation). (B1,B2) Relatively homogeneous, echogenic left and right quadriceps tendon with fibrillar pattern, several peritendinous calcifications and reduced subcutaneous tissue edema (sonographic evaluation at 6 weeks post-surgery). (C1,C2) Homogeneous, hyperechoic left and right quadriceps tendon with fibrillar pattern, presenting several peritendinous calcifications and resorption of the subcutaneous tissue edema (sonographic evaluation at 6 weeks post-surgery). T0: baseline sonographic assessment at admission; T1: sonographic assessment at 6 weeks post-surgery.; T2: sonographic assessment at 9 weeks post-surgery (at discharge).