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803
Patellar Tendon with Underlying Disease
P Robert Morrie
Kricun1
#{149}:
Two patients with patellar One had systemic
tendon
rupture
and underlying
systemic
disease
are
lupus erythematosus and the other had chronic renal failure and secondary hyperparathyroidism. There have been I 3 other cases of patellar tendon rupture in patients with systemic disease reported in the literature and they are reviewed. Patellar tendon rupture has occurred spontaneously in more than one-half of the cases and has been associated with rupture of the contralateral extensor tendon mechanism in 87%. Although patellar tendon rupture almost always occurs at the tendinous insertion, on a rare occasion (as in one case described in this report), the tear may involve the main substance of the tendon, which is the part of the tendon with the greatest tensile strength. The relation between systemic disease and patellar tendon rupture is discussed and the clinical and radiographic findings are described. described.
E. Kricun2
George
A. Arangio3
Gabriel
S. Salzman4
Arnold
Rupture Systemic
T. Berman4
Patellan
tendon
patients with with patellar
rupture
may
occur
underlying systemic tendon rupture. One
taking oral steroids, hypenparathyroidism. radiologic features
spontaneously
disease. We had systemic
or
after
minor
examined erythematosus
trauma two
in
patients and was
and the other had chronic renal failure and secondary We report these two cases and describe the clinical and of patellar tendon rupture which to our knowledge have not
been discussed in the radiologic literature. previously reported cases of patellan tendon lupus erythematosus, the possible relation
recently lupus
chronic between
In addition, we have rupture associated
renal failure, and rheumatoid patellar tendon rupture and
arthritis these
reviewed the with systemic and discuss systemic dis-
eases. Received sion
June ,
June 2t,, 1 979;
Department
town
and Sacred
of Diagnostic Heart
after
revi-
requests
2Department
Radiology,
AllenCenter, 1 200 S. PA 181 05. Address
to R. Kricun. of Diagnostic
Radiology,
mann Medical College and Hospital, St.. Philadelphia, PA 19102. 3Department
of Orthopedic
Hahne-
230 N. Broad
Surgery, Allentown 1 200 5. Cedar
and Sacred Heart Hospital Center, Crest Blvd., Allentown, PA 1810g.
4Department of Orthopedic Surgery, Hahnemann Medical College and Hospital, 230 N. Broad St., Philadelphia, PA 19102. AJR 135:803-807, October 1980 0361 -8o3x/8o/1 354-0803 $00.00 Roentgen Ray Society
© American
Case Case
Reports 1
Hospital
Cedar Crest Blvd. , Allentown, reprint
accepted
2, 1980
A 1 9-year-old white woman was injured when she slipped on the ice and fell onto her left knee. In the emergency room, she had severe knee pain and difficulty flexing or extending the knee. She had had systemic lupus erythematosus since age 1 1 years, and had been hospitalized several times for related illnesses including lupus nephritis. She had taken prednisone in doses of 1 0-40 mg/day. Physical
examination
at admission
revealed
a cushingoid
woman
in acute
distress.
The
left knee could not be extended actively and a palpable defect was present in the infrapatellar area. Lateral radiography of the left knee showed the patella high in position and there was disruption of the infrapatellar fat and obliteration ofthe patellar tendon outline (fig. 1 B). The right knee, examined for comparison, was normal (fig. 1 A). At surgery there was rupture through the substance of the middle third of the patellar tendon with fraying of the edges of the torn tendon. The proximal and distal thirds of the
KRICUN
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804
1 . A, Normal right knee, lateral view. Normal quadriceps tendon (0). and patellar tendon (P).
Fig. 1 -Case fat (arrowhead),
tendon 10
were
intact.
weeks
without
after any
Primary
repair
surgery
the
of the
patient
tendon
was
was
AL.
infrapatellar
after
B, Left
knee
infrapatellar
and
the
performed
walking
ET
with
a walker
patellar
tendon
The
and
A 35-year-old
white
or stand
bilateral
thigh
man
after and
tissue defects The patient
nitrogen
and
serum
knees
Physical
2 years
before
admission,
he
hyperphosphatemia, levels.
examination
evidence
of
levels
acidosis this had
and On
later
along and
each
tear
located
there near
unable
revealed
that
with
uremia
1980
of patella’and
disruption
had
edges.
of
retinacular
ends
of the
were
structures using
intact.
The
were
crutches
tears
structures injuries
repaired
when
first
necrotic
were
to the and
seen
Both
disrupted the
but
patellar patient
in follow-up
the
tendons was
fully
clinic.
to
of
began
and soft-
at age
the
to the
21
and initiation
elevated
blood
urea
radiographic
ruptures
At
site
both
of attachment
hypocalcemia,
nitrogen
examination
of
Patellar
and
serum
of the
hands,
radiography
of both
occurs tamed
to the
tendons inferior
with pole
least when knees
tendon patella patellar the
patellar
of
Rupture
fracture of the patella, patellar of the tibial tubercle. Of these,
against The
to be displaced upward infrapatellar soft tissue
Tendon
Disruption of the extensor mechanism of the knee may be caused by one of four injuries: quadriceps tendon rupture,
the anemia,
hyperparathyroidism.
were
hypertension led
Discussion
swell-
admission. hypertension,
knees, lateral views showed both patellae and there was disruption of the normal structures (fig. 2). surgery,
was
He complained
of chronic interstitial nephritis with bilateral made at age 29. Steadily rising blood urea
creatinine
At this
and
running.
knee joints with diffuse ecchymoses knee. There were bilateral palpable
metabolic
of dialysis
had
both
while
in the infrapatellar region. had a history of renal disease
of severe
creatinine
pain.
both either
years, and a diagnosis end-stage kidneys was signs
injured
he tripped knee
ing in and around inability to extend
At
position
October
2
walk
he
High
retinacular
tendons
ambulatory Case
distal
lateral
quadriceps and
rupture.
1 35,
fat (arrowhead).
patella.
medial
difficulty.
AJR:
flexed
mental
and
the body weight patellan tendon
[4]
but
McMasten
work
that
also [5]
rupture
rupture, or fracture of the patellar tendon
[1 ]. This injury lands unexpectedly contracts
the
is most often on his feet quadriceps
suswith
violently
in an effort to prevent a fall [1 -3]. is a continuation of the quadriceps
attaching proximally and distally to the tendon occurs most
patella
tubercle.
frequently the patient
tendon rupture
to the inferior borden of the tibial tubencle. Rupture of the commonly at the attachment to
occurs
at the
concluded
does
insertion
from
not
occur
clinical
through
to the and
tibial
expeni-
the
main
AJR:135,
October
PATELLAR
1980
TENDON
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I
..
:
RUPTURE
S
WITH
SYSTEMIC
DISEASE
805
,,
.
.l1. .1
Fig. 2.-Case 2. Lateral views of right (A) and left (B) knees (arrowhead), and accumulation of fluid in retropatellar region.
after
substance
strength
unless
of a tendon the
tendon
degenerative
due
has
been
process.
significant
indirect
to its great weakened
Without
injury
will
by a destructive
such leave
tensile
bilateral
previous the
or
weakening
main
a
substance
of
patellar
tendon
Posterior infrapatellan
rupture.
to
High
the tendon fat. Rupture
infrapatellar
the inferior aspect may be visualized.
tear of the Rupture
cludes
and
inability
reveal
to extend
a high
patella
the
knee.
radiographic
examination
the
care
pain,
Physical
and a palpable
patellar tendon. However, the ability of the examiner the
The causes
cnepitation,
examination
defect
swelling and hematoma to diagnose this disorder, particularly
may
at the site of the may limit making
important.
In ad-
of patella,
of the
differential the
very
appears clinically tella [6], but the infrapatellar defect The method of
of infrapatellar
tendon and disruption a small bone fragment
patella
diagnosis rare
disruption
is a homogenous quadrangle of the patellar tendon causes
of the outline of the fat. Occasionally,
litenation
the tendon intact and will result instead in a tear of the tendon at its insertion, a fracture of the adjacent bone, or a adjacent muscle. of the patellan tendon
position
of
superior
on from patellan
the tendon
dislocation
and radiognaphically patellar tendon is present. Insall and
Salvati
tibial
of obof the from
tubencle rupture
of the
patella.
as a high-riding remains intact and [7]
can
fat
be
inThis pano
used
to
diagnosis. Early diagnosis is important since the repair of a fresh patellan tendon rupture has good results, while late repair has less satisfactory results that may leave the patient
diagnose patella alta on the lateral radiograph of the knee by computing the ratio of patellan tendon length to the greatest diagonal length of the patella. Patella alta can be found in patients with patellar subluxation [8], recurrent patellar dislocation [9], and chondnomalacia patellae [9]. The patellan tendon remains well visualized radiognaphically
without Every
tellan fat.
dition,
this injury
primary
physician
and the radiologist
full extension effort should
may
be
unfamiliar
with
may be the first to suggest
of the knee be made
[1]. to obtain
the
in these a good
quality
lateral patellar
radiograph of the knee in flexion. In patients with tendon rupture the patella is positioned high. On the
lateral
radiograph
be visualized inferior pole
of a normal
knee,
the
patellan
as a soft-tissue density extending of the patella to the tibial tubencle
tendon from (fig.
can the 1 A).
Role
disorders
of Underlying
Rupture tients with
of the chronic
and
there
Systemic patellar renal
is no disruption
Disease tendon failure
in Tendon
of the
infrapa-
Rupture
has been reported in paand secondary hyperpara-
KRICUN
806
TABLE
1:
Systemic Type
Reported Disease
Cases of Patellar Tendon
AL.
on
AJR:135,
long-term
steroid
inflammatory
of Rupture
SLE
Unilateral Bilateral With contralateral
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Rupture with
El
tendon
Reviews
0 2
2 10
(13) (67)
alysis
revealed
1
2
0
3
(20)
tunes
including
9
4
2
15
lupus erythematosus; quadriceps tendon
CRF rupture.
chronic
-
[26,
(100)
renal
failure;
-
RA
27].
for
disease
other
have
[1 0-1
2],
were
oral
steroids
taking
tis [1 9, 20]. been
With
the
1 5 patients
an underlying 1 9-49
after
Although
sustained one-half
[3,
reported
steroid
some
of
with
ruptured
8], and
These rupture
with
that
1 5%
chronic had
the quadriceps,
All of these
their
with
The failure
in bed
1 3-1
6, 1 8-20], rupture
more
torn
[28].
Some
patients
have
had
connective
tissue
as a cause
of tendon
ne-
systemic
disease
jumping,
tendon
more than
while
performing
and 1 week knee while
while
(table 1 ), 1 0 (67%) had patellar tendon rupture
three
others
with
(20%)
had
quadriceps
patellan
tendon
[1 0, 1 2, 1 7]. Thus, 87% extensor tendon rupture
sequen[3, 1 1,
ruptures in which the patellan tendon
Tendon thnitis and tenosynovial
rupture
a tendon
in general
is thought to inflammation
don secondary culan compromise
slightly [24].
more
one-third
susceptible
to
rupture
[5].
[25]. Vasin rendering
In case
who
was
1 , a patient
taking
main
substance
which
is quite
[5], to
suggests weakening
erythematosus steroid therapy
oral
with
of the rare, that
the
third
in light
tendon by
lupus
sustained
middle
and,
caused
systemic
steroids
was the
on steroids on plays in patellan
of the
of the
phia: 2.
both. The exact tendon rupture
rendering
due
the
attachment to renal
and
this
failure
has
been
tendon
rupture
and
and was
secondary [29].
later
hypenpara-
Lippincott,
due
the
extremity:
lower
tam. Although all nine of the patients reported with systemic lupus erythematosus and patellan tendon rupture had been taking oral steroids, it must be cppreciated that no patients
: 1 1 93-1
199
and tears report
of muscles
of fifteen
cases.
and tendons of JAMA 1 933;1 00:
JA,
Wilson
CL,
Mathews
WH.
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Kelikian
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Carey
Salvati
E.
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Hughston
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:101
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patella.
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work
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underlying
of the torn erythema-
erythematosus
a tear
and near
1 . Larson
Histopathologically,
avascular changes and fibninoid degeneration tendon are seen in patients with systemic lupus tosus and with rheumatoid arthritis [3, 1 9, 20].
that pahemodi-
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