SIMULTANEOUS RUPTURE OF THE PATELLAR AND CONTRALATERAL QUADRICEPS TENDONS IN A NEPHROPATHY PATIENT

ABSTRACT Simultaneous rupture of the patellar and contralateral quadriceps tendons in patients with chronic renal failure is an extremely rare condition, with few cases described in the medical literature. Several systemic pathological conditions that lead to a decline in kidney function can predispose individuals to spontaneous tendon rupture, such as rheumatological and endocrine diseases, and even gestational conditions, such as eclampsia. Objective: In this case report, we describe the case of a 39-year-old woman with chronic renal failure on dialysis due to a previous history of eclampsia that caused the simultaneous rupture of the patellar and contralateral quadriceps tendons. Methods: Data were collected by interviews, direct observation, and medical examinations, and include information about the case history, the patient’s characteristics, the former interventions, and the results obtained. Results: The surgery to repair the patellar and contralateral quadriceps tendons was performed by transosseous tunnels and the Krackow technique with nonabsorbable sutures was used. The semitendinosus tendon was removed and used as reinforcement. Conclusion: Patient under follow-up with good functional results in both knees. Level of Evidence V, Expert Opinion.


ABSTRACT
Simultaneous rupture of the patellar and contralateral quadriceps tendons in patients with chronic renal failure is an extremely rare condition, with few cases described in the medical literature. Several systemic pathological conditions that lead to a decline in kidney function can predispose individuals to spontaneous tendon rupture, such as rheumatological and endocrine diseases, and even gestational conditions, such as eclampsia. Objective: In this case report, we describe the case of a 39-year-old woman with chronic renal failure on dialysis due to a previous history of eclampsia that caused the simultaneous rupture of the patellar and contralateral quadriceps tendons. Methods: Data were collected by interviews, direct observation, and medical examinations, and include information about the case history, the patient's characteristics, the former interventions, and the results obtained. Results: The surgery to repair the patellar and contralateral quadriceps tendons was performed by transosseous tunnels and the Krackow technique with nonabsorbable sutures was used. The semitendinosus tendon was removed and used as reinforcement.

INTRODUCTION
Quadriceps tendon rupture is a condition with a higher incidence in older patients, aged around the 60th and 70th decades of life, due to degenerative conditions in the tendon caused or aggravated by falls and low-impact trauma. 1,2 Patellar tendon rupture usually occurs in patients aged under 40 years due to intra-and periarticular applications of corticosteroids as a result of previous patellar tendinitis and/or sports practices that increase the risk of this type of injury. 3 Simultaneous rupture of the patellar and contralateral quadriceps tendons in patients with chronic renal failure is an extremely rare condition, with few cases described in the medical literature. 4 In this case report, we describe the case of a 39-year-old woman with chronic renal failure on dialysis due to a previous history of eclampsia that caused the simultaneous rupture of the patellar and contralateral quadriceps tendons.

CASE REPORT
A 39-year-old female patient was admitted to our service with bilateral functional disability in the knees and mild pain on palpation, referring to a sudden onset of weakness when walking, which led to a fall from her standing height. On physical examination, during inspection, she had significant swelling in both knees, with areas of ecchymosis over the patella in the right knee and in the peripatellar region in the left knee. In the dynamic inspection, we observed inability to actively extend the knees bilaterally. During palpation, we found a gap in the suprapatellar region on the right and an infrapatellar gap on the left, with patella alta (Figure 1). During anamnesis, the patient reported a history of chronic renal failure on dialysis resulting from a previous history of eclampsia nine years ago, when she was pregnant with her last child. Laboratory tests showed altered creatinine levels (5.9 mg/dL) and increased urea (79 mg/dL) and mild anemia (hemoglobin 8.1 g/dL). Radiological examination of the knees showed no fractures, but patella alta on the left side and patella baja on the right side ( Figure 2). Ultrasound examination confirmed quadriceps tendon rupture in the right upper pole and patellar tendon rupture in the left knee ( Figure 3). As a result of the condition, the patient was admitted and hospitalized, and seven days elapsed from injury to surgery. Intraoperatively, we confirmed injury to the right quadriceps tendon and left patellar tendon. As a synthesis method, we performed transosseous tunnels and raffia using the Krackow technique with nonabsorbable sutures. 5,6 Moreover, the semitendinosus tendon was removed and used to reinforce the left patellar tendon. (Figure 4) Postoperative imaging studies showed a bilateral return of patellar height to normal parameters ( Figure 5). As a post-surgical indication, we prescribed the use of a long knee immobilizer brace for 60 days. After three weeks, the patient started isometric exercises and early mobilization bilaterally. After six weeks, we recommended partial load using Canadian crutches associated with active mobilization. Three months after surgery, the patient started walking with full weight bearing, but still using crutches.

DISCUSSION
Several systemic pathological conditions that lead to a rapid decline in kidney function 7 can predispose individuals to spontaneous tendon rupture, such as rheumatological and endocrine diseases, medications, and even gestational conditions, such as eclampsia. [8][9][10] Simultaneous rupture of the patellar and contralateral quadriceps tendons in patients with chronic renal failure is an extremely rare condition, with few cases described in the medical literature. 4 We could not find any cases identical to the one described in this article, related to chronic renal failure due to a previous history of eclampsia. However, we found cases resulting from chronic renal failure 4,5 and other pathological conditions: amyloidosis; 10 rheumatological diseases, such as lupus; 9 endocrinological diseases, such as hyperparathyroidism; 11 and uremia. We also found cases related to the use of medications, such as intra-articular corticosteroids and quinolones. On the other hand, the literature also includes few reports of this type of injury in healthy patients without systemic diseases. 1,3 Some explanations suggest that spontaneous tendon rupture in dialysis patients results from several complications, such as renal osteodystrophy and amyloidosis. 12,13 This is associated with the hemodialysis process, which promotes, among dysfunctions, musculoskeletal manifestations, such as flexor tenosynovitis in the hands and carpal tunnel syndrome. In turn, osteodystrophy is as a condition secondary to hyperparathyroidism that can lead to osteoporosis, weakness of the osteotendinous junctions, and increased subperiosteal resorption. 14

CONCLUSION
Osteotendinous complaints in patients with chronic kidney disease deserve careful evaluation and investigation. Early diagnosis and treatment of the underlying condition can prevent osteotendinous pathologies and injuries, ensuring a better quality of life. Patients with blood pressure disorders during pregnancy should be monitored periodically and have adequate management of renal function. The authors understand that prevention and early diagnosis can reduce morbidity and future complications in the knees, as well as in other segments of the body.