Ruptures of the patellar tendon and quadriceps tendon almost always require surgical repair. But does one tendon injury have a better chance of recovery than the other? As it turns out, neither tendon repair has particularly good outcomes, according to a Cleveland Clinic study.
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The research, published in the Journal of Knee Surgery, is the first large prospective study to look at risk factors associated with recovery from these two types of injuries.
“I thought that patellar tendon repair would perform a little better than quad tendon repair,” says orthopaedic surgeon Kurt Spindler, MD, Director of Clinical Research and Outcomes at Cleveland Clinic Florida and principal investigator of the study. “It goes to show you, impressions can be wrong.”
Patients with patellar tendon injuries tend to be younger and healthier than patients with quad tendon injuries. (Patellar tendon ruptures are generally caused by traumatic injury rather than wear and tear.) However, the study did not find a difference in outcomes between the two groups of patients. Rather, it found that both types of injuries require significant rehabilitation time, and many patients never fully recover.
According to Dr. Spindler, the study findings are a reality check for physicians and patients. The data may change expectations for recovery and reinforce the need for long-term rehabilitation after surgery.
“The fact is, these are massive injuries,” he says. “In spite of repairing and healing, the tendons often don’t come back anywhere near normal, and patients still have significant disability.”
Difficult paths to recovery
The study followed 59 patients with patellar tendon injuries and 82 patients with quadriceps tendon injuries through surgery and for one year afterward.
Patellar patients were younger, with a median age of 45 compared to 60 for quadriceps patients. Researchers looked at a variety of risk factors and used Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain and physical function to measure recovery outcomes.
Across both surgeries, researchers found that women and people of color had more pain after surgery, while people with higher education (a stand-in for higher socioeconomic status) had less pain and better outcomes. People who reported higher levels of pain before surgery also were more likely to have higher levels of pain after surgery, as did patients who had worse mental health status before surgery.
But, Dr. Spindler noted, the biggest takeaway was that all patients had a difficult path to recovery, scoring around 83 (out of 100) for pain and approximately 71 (out of 100) for function one year after surgery.
“These operations are often assumed to be easy and very successful,” says Dr. Spindler. “Unfortunately, the data do not support those assumptions. When asking patients about their Patient Acceptable Symptom State, 25% said their symptoms were not acceptable. Clearly we have room to improve.”
Managing patient expectations
Physicians should use this information for patient education, and to help manage expectations around how much function patients truly will regain after surgery, he adds.
“Patients should understand that a ruptured patellar or quad tendon is a big injury,” says Dr. Spindler. “It’s going to take a long time to regain function, and patients may not ever get back to the way they were before the rupture.”
Physicians can help by stressing the need for rehabilitation after surgery.
“To give patients the best opportunity for recovery, physicians should prescribe extensive physical therapy and follow the patient for 12 months, encouraging them to do all their exercises and recovery work,” he says.
Next, the research team plans to gather enough patient data to explore whether surgery technique makes a difference in outcomes and recovery.
“There are newer methods of doing these tendon repairs, and we want to know whether they may help improve outcomes,” Dr. Spindler concludes.