Simultaneous Contralateral Quadriceps Tendon and Patellar Tendon Rupture in a Patient with Chronic Kidney Disease and HCV Infection: A Rare Case Report

Introduction

The knee extensor mechanism, comprising the quadriceps tendon, patella, and patellar tendon, is essential for active knee extension and normal gait. Disruption of this mechanism is uncommon but can result in significant functional disability if not diagnosed and treated promptly [1]. Quadriceps tendon ruptures are typically seen in middle-aged and elderly individuals, whereas patellar tendon ruptures are more common in younger patients following high-energy trauma [2, 3].

Simultaneous involvement of the extensor mechanism is rare, and asymmetric patterns such as contralateral quadriceps tendon rupture with patellar tendon rupture are exceedingly uncommon [4]. These injuries are frequently associated with systemic comorbidities that predispose to tendon degeneration. Chronic kidney disease (CKD) is a well-recognized risk factor, with metabolic disturbances such as secondary hyperparathyroidism, uremia, and altered calcium phosphate metabolism leading to weakening of the osteotendinous junction [5,6]. In addition, systemic inflammatory conditions, including chronic infections like hepatitis C virus (HCV), may impair collagen integrity and contribute to tendon degeneration [7].

Such pathological changes can result in tendon rupture even after trivial trauma, making diagnosis challenging. Early recognition and timely surgical intervention are crucial for optimal functional recovery. We report a rare case of simultaneous contralateral quadriceps tendon and patellar tendon rupture in a patient with CKD and hepatitis C infection.

Case Report

A 51-year-old male presented with complaint of pain and swelling over bilateral knee since 2 days with inability to walk and inability to actively extend both knees following a trivial fall while getting out from his bed. He was a known case of CKD and chronic HCV managed with medical therapy for 2 years.

On clinical examination, a palpable suprapatellar gap was noted in the right knee suggestive of quadriceps tendon rupture, while an infrapatellar gap was appreciated in the left knee indicating patellar tendon rupture. Active straight leg raising was not possible bilaterally. Radiographs (Fig. 1) revealed patella baja on the right side and patella alta on the left side. The patient was given bilateral long knee braces and admitted to the ward with proper limb elevation. Magnetic resonance imaging (MRI) of both knees was performed which showed complete rupture of the quadriceps tendon on the right side and patellar tendon on the left side (Fig. 2).

The patient underwent surgical management on the 3rd day after trauma with open repair of both tendons. Through a midline incision, the torn ends were identified and freshened. The quadriceps tendon on the right side and the patellar tendon on the left side were repaired using transosseous tunnels and non-absorbable Ethibond sutures (Fig. 3). Retinacular tears were also repaired. A schematic diagram of transosseous suture repair is shown in (Fig. 4).

Postoperatively, both knees were immobilized in extension for a period of 1 month. However, the patient was allowed to walk with a brace during this time. This was followed by gradual flexion of the knee with closed-chain knee range of motion (ROM) exercises and static quadriceps exercises under supervised physiotherapy. At 3-month follow-up, the patient demonstrated satisfactory functional recovery with restoration of active knee extension and no significant extensor lag. Follow-up radiographs (Fig. 5) were satisfactory and showed maintained alignment with an intact extensor mechanism repair. At 1 year of follow up patient had full ROM of knee with no extensor lag, walking full weight bearing and doing all activities of daily living comfortably (Fig. 6).

Discussion

Extensor mechanism injuries of the knee are uncommon and most often occur unilaterally. Bilateral or asymmetric involvement is rare, with contralateral quadriceps and patellar tendon rupture representing an extremely unusual injury pattern [1,8]. Recent literature continues to emphasize the rarity of such presentations, with only a limited number of case reports describing this entity [4, 9].

Systemic diseases play a crucial role in tendon vulnerability. CKD is one of the most frequently implicated conditions, due to metabolic disturbances such as secondary hyperparathyroidism, uremia, and calcium metabolic disturbance in the contralateral quadriceps and patellar tendon [6]. Previous studies have identified CKD as a major risk factor for bilateral or simultaneous tendon ruptures [10]. Patients on long-term dialysis are particularly susceptible to spontaneous or low-energy tendon ruptures [11]. Recent evidence further supports this association, with increased incidence of extensor mechanism injuries reported in CKD patients undergoing dialysis [6].

Hepatitis C infection may further contribute through chronic inflammation and alterations in collagen metabolism, leading to reduced tendon strength [7]. The coexistence of CKD and HCV in our patient likely created a synergistic effect, predisposing to tendon rupture even after trivial trauma.

Recent reports have described injury patterns similar to our case. Radaideh et al. reported successful management of simultaneous contralateral quadriceps and patellar tendon rupture in a patient with chronic renal failure [4]. Similarly, Zhang et al. described spontaneous quadriceps tendon rupture in a CKD patient following trivial trauma, reinforcing the role of metabolic derangements in tendon degeneration [12].

Other rare variants, such as the tendon rupture in a simultaneous ipsilateral quadriceps and patellar tendon rupture, have also been described, further highlighting the spectrum of extensor mechanism injuries [13].

Clinically, patients present with acute pain, swelling, palpable defects, and inability to actively extend the knee. However, diagnosis may be delayed, particularly in asymmetric cases. Radiographic findings such as patella alta and patella baja can aid in diagnosis, while MRI is highly sensitive for confirming tendon rupture and is particularly useful in equivocal or complex cases [1,14].

Early surgical repair remains the cornerstone of management. Techniques such as transosseous suturing using non-absorbable material provide strong fixation and favorable outcomes [15]. Recent studies continue to report favorable functional outcomes with early intervention and structured rehabilitation protocols [16,17]. In contrast, delayed treatment may lead to poor outcomes and require more complex reconstructive procedures.

The rarity of this injury pattern makes it clinically significant. While several reports have described bilateral or ipsilateral tendon ruptures, asymmetric contralateral involvement remains exceedingly uncommon, with only a limited number of cases reported [4,9]. Our case adds to the growing body of evidence linking systemic diseases, particularly CKD, with complex extensor mechanism injuries and highlights the importance of early diagnosis and prompt surgical management.

Conclusion

Simultaneous contralateral quadriceps tendon and patellar tendon rupture is a rare injury pattern, particularly in patients with systemic comorbidities such as CKD and hepatitis C infection. These conditions predispose to tendon degeneration and increase the risk of rupture even after trivial trauma. A high index of suspicion, careful bilateral knee examination, and prompt surgical intervention are essential for early diagnosis and optimal functional outcomes.

Clinical Message

In patients with chronic kidney disease, trivial trauma may lead to rare asymmetric extensor mechanism ruptures; careful bilateral evaluation and early surgical repair are key to successful outcomes and prevent long-term disability.

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About the Authors

• 

  Saurabh Satyanarayan Kunwar

• 

  Akshay Vilas Pawar

• 

  Abhi Ketan Vora

• 

  Abhishek Ganeshkumar Dussa