Neglected Spontaneous Bilateral Quadriceps Tendon Rupture: An Uncommon But Important Complication Of A Chronic Kidney Disease: A Case Report And Review Of Literature

Abstract

Introduction: Spontaneous tendon ruptures involving quadriceps, triceps, and finger tendons, characterizing uremic tendinopathy, are seen in about 15% of patients with chronic kidney disease (CKD) on hemodialysis. Weakness and rupture of tendons in CKD are correlated with the duration of renal failure and length of treatment with hemodialysis. The resulting malnutrition, ß2 -amyloidosis, and accumulation of uremic toxins have been suggested to be causative factors for spontaneous tendon rupture. The unknown and untreated nature of renal failure with elevated serum PTH and low pH stresses the role of hyperparathyroidism and metabolic acidosis, the classical complications of renal failure, in the pathogenesis of uremic tendinopathy. This is a challenging condition that requires specialized treatment and management.

Case Presentation: We report a 40-year-old female with neglected spontaneous bilateral quadriceps rupture with chronic kidney disease. The patient experienced pain, swelling and sudden weakness in both her knees while climbing stairs 2 months before coming to the hospital. She felt pain in the upper area of both knees for around three months before falling. The patient was later referred to our hospital for an MRI examination, which showed bilateral quadriceps tendon rupture. The patient was treated with bilateral transosseous repair of the quadriceps tendon. The patient could lift her leg one 1 month later and walk normally without aid 3 months later. The KOOS score of this patient was 78%, and the Kujala score was 79% in the fifth month after surgery.

Discussion: Quadriceps tendon ruptures usually occur during a rapid, eccentric contraction of the quadriceps muscle, with a planted foot and partially flexed knee due to a fall or direct blow. Bilateral ruptures are very rare and strongly associated with systemic illnesses like hyperparathyroidism, renal failure, rheumatoid arthritis, gout, obesity, systemic lupus erythematosus steroid use, and diabetes mellitus. Metabolic acidosis may result in tendon degeneration due to disruption of the structure of the protein-polysaccharide complex, which is responsible for collagen maturation. Early operative repair is indicated for all acute complete quadriceps tendon ruptures. The transosseous suture technique has been the most used treatment for the disorder. As most quadricep injuries in this group of individuals occur at the tendon insertion, there is no distal stump for the direct suture to be safely performed.

Conclusions: Spontaneous quadriceps rupture is a rare condition many chronic diseases can cause. Proper medication and surgery should be performed early. However, successful results have been reported in chronic cases with surgery performed as late as 1 year after injury