Surgical Management of Isolated Distal Rectus Femoris Tendon Avulsion Using a Suture Brace Technique

Muscle injuries of the quadriceps are relatively common in athletes, and often the rectus femoris is involved.1 Isolated avulsion of the distal rectus femoris insertion to the quadriceps tendon is a relatively uncommon but significant injury affecting the quadriceps muscle complex, particularly in athletes involved in activities requiring explosive knee extension and hip flexion, such as football and sprinting.2 These injuries can lead to significant quadriceps dysfunction, particularly in high-demand individuals, and may pose diagnostic and therapeutic challenges. The management of distal rectus femoris avulsions remains controversial, largely owing to the rarity of isolated injuries and the variability in severity, ranging from partial tendon tears to complete avulsions with tendon retraction. Nonoperative treatment, including rest, physical therapy, and gradual return to activity, has been traditionally favored in partial tears or low-demand patients, often resulting in acceptable functional outcomes.3,4 However, surgical intervention could be advocated for complete avulsions, especially in high-level athletes, to restore muscle-tendon continuity and optimize functional recovery. A few case reports describe surgical techniques aiming to reinsert the rectus femoris tendon to the quadriceps tendon,5 arguing this might reward the patient with increased strength and thus, decreased disability. Indications for surgical repair include young age, reduced strength in knee extension and pain of the anterior thigh or knee. This technical report aims to introduce a surgical technique using a suture brace in managing a distal rectus femoris avulsion. Furthermore, the postoperative rehabilitation and return-to-sport criteria are presented. TECHNIQUE A 17-year-old male, recreational football player, 3 to 4 times per week, referred by his general practitioner to the orthopedic outpatient clinic ∼6 weeks after forced extension in the right knee while kicking a football, resulting in instant pain and a snapping sensation. Initially, he was assisted off the pitch, unable to stand for the first 5 to 10 minutes. In the following 3 weeks, he regained mobility but complained of anterior thigh pain and being unable to run. His general practitioner suspected muscle injury affecting the musculus rectus femoris and initiated physiotherapy-assisted rehabilitation as well as referral to the orthopedic outpatient clinic. Clinical Findings Clinical examination in the outpatient clinic was performed at ∼6 weeks postinjury, and revealed a bulge on the anterior aspect of the right thigh proximally as well as a mid-thigh sulcus. The bulge was painful upon palpation, but the patient demonstrated a full range of motion in the right hip and knee, with sufficient muscle power to walk and fully extend the knee. In knee extension with resistance and when performing lunges, he complained of aggravating pain from the anterior thigh. Ultrasound visualized a retracted muscle belly of the rectus femoris and an absence of conjointment distally in the quadriceps tendon. The proximal retraction of the rectus femoris tendon was determined to be 8 to 10 cm from its original insertion in the quadriceps tendon by comparing to the contralateral side. The following magnetic resonance imaging, conducted 9 days after the clinical assessment, confirmed the findings at ultrasound (Fig. 1).FIGURE 1: Lateral view of the right thigh in magnetic resonance imaging showing a lesion and proximal retraction of the distal rectus femoris tendon.The patient was offered the choice between conservative management of the injury with physiotherapist-assisted rehabilitation or surgical management with reinsertion of the tendon to its origin. Surgical Management The patient is placed in a supine position with a bump under the ipsilateral hip and foot to align and fully extend the knee. The level of tendon retraction is verified by ultrasound and marked just before prepping and draping the extremity from the iliac crest to the tibial tuberosity (Fig. 2A). The level of anatomic insertion of the retracted tendon to the quadriceps tendon is assessed by comparing with the contralateral side, and a marking is made (Fig. 2B). A 7 cm longitudinal incision is made midline from the proximal marking extending distally (see Supplemental Video, Supplemental Digital Content 1, https://links.lww.com/TIO/A105 for a thorough description of the surgical steps). Dissection is carried out to the level of the rectus femoris tendon along with the underlying quadriceps tendon, incising the pseudocapsule and evacuating any potential hematoma. The rectus femoris tendon is identified and mobilized from any scar tissue and muscular adhesions with forceps and Metzenbaum scissors. A looped no. 2 braided nonabsorbable suture (Xbraid S 60 mm straight taper needle; Stryker) is used to whipstitch the distal rectus femoris tendon, before elongation of the tendon and muscle by manually applying tension for 5 minutes (Fig. 2C). Simultaneously, the dissection to identify the footprint distally on the common extensor tendon is carried out. When the footprint has been identified, one limb of the suture is passed into the common extensor tendon, while the other limb is passed in a Mason-Allen type manner (Fig. 2D). The rectus femoris tendon is then pulled distally as the knot is tensioned and locked. Acting as a suture brace, a braided flat self-tensioning suture tape (Dynatape 2.5 mm, 91 cm; DePuy Synthes) is passed twice through the rectus femoris tendon proximal to the whip stitches, crossing the 2 limbs as they are passed through the common extensor tendon distal to the knot of the loop suture (Fig. 2E). The epitendion is adapted using an absorbable no. 0 suture, and the degree of knee flexion tolerated until stressing the sutures is examined to determine the postoperative range of motion. The wound is irrigated and closed in layers, finishing with an intracutaneous suture (Fig. 2F).FIGURE 2: A–F, Sequence of surgical steps as explained in the text.Expected Outcome The patient is placed in a hinged knee brace, allowing the range of motion identified during surgery. Nonsteroid anti-inflammatory drugs are administered for 10 days postoperatively to minimize the risk of ossification in the hematoma. Weight bearing is allowed as tolerated only in full knee extension. As an advantage over previous techniques, a suture brace was added to protect the tendon repair from further elongation and re-rupture by acting as a reinforcement and relieving stress on the repair. The patient is instructed in passive and active movements by a physiotherapist 3 days after surgery, and isometric exercises at 2 weeks after surgery. The brace is allowed another 10 degrees of knee flexion every week from 2 weeks after surgery until discontinued after 6 weeks. The patient is instructed not to strain the muscle below 90 degrees of knee flexion for 3 months. The return-to-sport decision is made when range of motion and strength are within a 10% deficit of the contralateral side, typically within 4 to 5 months after surgery. COMPLICATIONS The risk of damage to the initial repair is present, as well as the risk of tendon elongation, which would decrease the muscle strength in knee extension. This is the reason the suture brace was added. The surgical site is at risk of ossification in the hematoma, and sufficient precaution must be taken postoperatively to manage this, for example, by nonsteroid anti-inflammatory drugs. Patients undergoing this procedure can expect to experience some degree of sensitivity loss in the skin at the incision site. Common risk factors related to surgery, such as swelling and risk of infection, must be taken into consideration. Lastly, patients must comply with the restrictions postoperatively to ensure sufficient healing of the repair. Ethical Approval and Consent Written informed consent was obtained from the patient for this report to include publication of the case and associated images.