F1000ResearchF1000Research2046-1402F1000 Research LimitedLondon, UK10.12688/f1000research.155799.2Clinical Practice ArticleArticlesBreaking point: Case series of tendon ruptures in Hemodialysis patients
[version 2; peer review: 3 approved, 1 approved with reservations]
NazeerMuhammed EhsanConceptualizationData CurationFormal AnalysisInvestigationWriting – Original Draft PreparationWriting – Review & Editinghttps://orcid.org/0000-0003-4355-6861a1HaphizDr AskharConceptualizationInvestigationWriting – Original Draft PreparationWriting – Review & Editing2NazeerDr MuhammedConceptualizationInvestigationMethodologyProject AdministrationSupervision3MoniDr PradeepWriting – Original Draft PreparationWriting – Review & Editing4MuraleedharanDr PraveenSupervision5
Trauma and Orthopaedics, North Cumbria integrated care trust,, Cumberland Infirmary, Carlisle, England, UK
Trauma and arthroscopy, MS Orthopedicsorthopaedics, P.B.No.1, Anayara P.O, Trivandrum, KIMSHEALTH, Thiruvananthapuram, Kerala, 695029, India
Consultant, Trauma and Group coordinator orthopaedics, MS Orthopedics, P.B.No.1, Anayara P.O, FRCS (Glasgow) KIMSHEALTH, Trivandrum, Kerala, 695029,, India
Resident, Trauma and orthopaedics, MBBS, P.B.No.1, Anayara P.O,, KIMSHEALTH, Thiruvananthapuram, Kerala, 695029, India
Nephrology, Senior consultant, DM Nephrology P.B.No.1, Anayara P.O, – Kerala, India, KIMSHEALTH, Trivandrum, Kerala, 695029, Indiam.ehsannazeer@gmail.com
Spontaneous tendon ruptures in end stage kidney disease patients have the potential to cause long- term morbidity, and timely intervention is required to prevent complications that can severely affect the functional status of the patient.
Case presentation
A series of six tendons (two triceps tendons and two bilateral patellar tendons) in three patients with ESKD undergoing hemodialysis is discussed in this case series. Patients were aged 61, 44 and 26 years, and on hemodialysis for 5, 10 and 5 years, respectively.
Conclusion
End -stage kidney disease is associated with a multitude of physiological changes, and the musculoskeletal system is no exception to this. Spontaneous tendon rupture is a multifactorial complication of ESKD, with serious implications for mobility and quality of life. As a result, these patients require a multifaceted approach to ensure optimum results and an early return to activity. We report a series of 6 spontaneous tendon ruptures in 3 patients with ESKD at our institution. We would like to outline the methods of repair for each case and further attempt to assess biochemical parameters that may have contributed to the disease process.
ESRDQuadricepsHyperparathyroidismTendon ruptureHemodialysisCase seriesThe author(s) declared that no grants were involved in supporting this work.Amendments from Version 1
This updated version of the article addresses the following revisions, based on reviewer feedback and further clarification of clinical findings:
Abstract: The case presentation was revised to correctly describe the patellar tendon as the involved structure instead of the quadriceps tendon, as the injury was infrapatellar rather than suprapatellar.
Case 2: The description of the triceps tear was updated from "grade 0" to a more precise explanation of the clinical presentation, highlighting an inability to activate the elbow extensor mechanism. While the triceps muscle could contract upon attempted activation, the tear prevented complete movement.
Additionally, the section on page 3 clarifies that no radiological or histopathological investigations were performed. Clinical diagnosis was considered sufficient in this instance. As authors, we acknowledge the value of histopathological analysis and will consider it in future similar cases.
Figures and Legends:
On page 5, the legend for Figure 5 has been corrected to identify the patellar tendon instead of the quadriceps tendon, aligning with the described injury.
On page 6, Figure 6 now includes annotations for the cranial and caudal ends of the specimen for improved clarity.
Introduction
Spontaneous tendon rupture is rare in the general population. Most cases of tendon rupture occur secondary to trauma or degenerative changes resulting from obesity or old age. Other etiologies of tendon rupture include pathological alterations in the substance of the tendon itself, such as gout,
1 autoimmune arthritis,
1 and end stage renal disease.
2 Long-term use of drugs such as statins, quinolones and steroids
3 constitute yet another often implicated cause of spontaneous tendon ruptures.
Literature on spontaneous tendon ruptures in patients with ESKD undergoing hemodialysis is uncommon and studies on the exact underlying mechanism and management guidelines for such patients are sparse.
The objective of this case series was to report a series of patients on hemodialysis for ESKD who experienced spontaneous tendon ruptures with emphasis on the methods and results of surgical management. An assessment of laboratory parameters was also performed to identify risk factors for the same.
Case reportsCase 1
A 61 year old male suffering with ESKD due to nephrosclerosis on hemodialysis for the last 5 years presented to the emergency department with complaints of acute onset pain and swelling in both knees while attempting to stand up from a sitting position. Examination revealed effusion in both knees with a palpable defect in the bilateral patellar tendons and bilateral extension lag. Lateral radiographs showed bilateral patella alta with calcified patellar tendons (
Figure 1).
Patella alta noted with calcified patellar tendon.
Surgical repair was performed in a staged fashion with an interval of 2.5 weeks in view of his physiological status. Surgical exploration revealed friable tendon edges with partial avulsion and mid substance tear patterns. The degenerated tissue was excised, and the ends of the tendon were reattached to the patella using suture anchors and non-absorbable sutures, followed by closure of the defects in the medial and lateral paratenon using bioabsorbable sutures (
Figure 2).
Post operative radiographs after fixation of tendons with suture anchors.
Post operatively the knees were immobilized in full extension for 6 weeks. DVT prophylaxis was administered using low molecular weight heparin (40 mg, sub-cutaneous injections, once daily) during the hospital stay and Rivaroxaban on Discharge. He was started on active Knee ROM and quadriceps strengthening exercises at six weeks.
He complained of left elbow extension weakness in his review for suture removal on the second knee, and further evaluation revealed a spontaneous rupture of the triceps tendon. This was likely caused by sustained forces while using a walker to assist ambulation. He has been advised to undergo surgical repair, for which he is yet to be reported.
Follow-up examinations at 8 and 8.5-months post-op respectively, examination revealed a knee ROM of 0-120 degrees with bilateral full extension and no residual weakness in the quadriceps mechanism.
End stage renal disease was managed by our nephrology department with thrice weekly hemodialysis sessions and regular monitoring of renal parameters. The patient has been receiving hemodialysis for the past five years.
Case 2
A 44-yr old male with ESRD secondary to immunoglobinA nephropathy with a history of allograft rejection during three weekly hemodialysis sessions for 10 years presented with complaints of right elbow extension weakness following trivial trauma. Physical examination revealed swelling of the right elbow with inability to activate the elbow extensor mechanism. Radiographs showed an avulsed triceps tendon (
Figure 3).
Anteroposterior and lateral radiographs of Case 2 with avulsed triceps tendon.
He underwent open repair of the triceps tendon with a suture anchor inserted in the olecranon after excision of the devitalized tongue of the tissue (
Figure 4). The elbow was immobilized in an above elbow slab at approximately 110° for 6 weeks, after which active mobilization was started. The last follow-up at 7 months revealed grade 5/5 power with full elbow ROM.
Post-operative radiographs after fixation of tensons using suture anchors.
Case 3
A 26-year-old male, suffering from lupus nephritis presented to ER with acute loss of extension in both knees and inability to ambulate following a fall while descending stairs at his house. The treatment history was significant for the intake of methylprednisolone for the last 3 months and twice weekly hemodialysis for ESKD for a duration of 5 years.
Examination revealed bilateral patella alta and boggy swelling in both knees with grade 0 power in bilateral knee extension. Imaging revealed isolated patella alta without any avulsed bony edges (
Figure 5).
Patella Alta noted in case 3 due to patellar rupture.
He was diagnosed with bilateral patellar tendon rupture and underwent open repair during which severe fraying of the tendons was noted (
Figure 6). Robust repair was performed using non-absorbable sutures in a mattress pattern (
Figure 7). He was given bilateral long knee immobilizers for 6 weeks to protect the repair, following which he was started on assisted ambulation with walker support over the next 4 weeks. At the final review at 6 months, he had grade 5/5 power in both his knee extensors with no appreciable lag on either side.
Frayed ends of patellar tendon noted in case 3.
Post operative radiographs of 3 after patellar tendon repair.
Discussion
Normal tendons are strong, with Ultimate Tensile Strengths ranging from 45 to 125 MPa which exceed three times the strain caused by muscle contraction.
4 The tendency for spontaneous tendon ruptures in patients with ESKD has often been attributed to five main factors:
elastosis secondary to chronic acidosis,
5
chronically elevated blood urea levels,
1
amyloidosis with beta 2 microglobulin deposition,
6
increased cortical bone resorption because of secondary hyperparathyroidism,
2
high circulating calcium levels resulting in dystrophic calcification of the tendon.
7
This contrasts with other cases of spontaneous tendon rupture, which is a condition of middle-aged overweight patients, with bilaterality being an exception rather than the norm.
8
A quick diagnosis is paramount because early surgical intervention is a key factor in ensuring optimal results.
9 This rare diagnosis should always be considered when dealing with sudden unexplained motor deficits in the lower limbs. Hemarthrosis can further complicate the matter by making it difficult to identify infrapatellar defects. Such cases warrant the use of incongruous techniques, such as ultrasound and MRI to confirm the diagnosis.
A prolonged duration of hemodialysis appears to be a reliable risk factor for the development of spontaneous tendon ruptures.
10 The markedly elevated PTH and ALP levels in our patients were also concurrent with the existing literature and explain the avulsed tendon ends noted both intraoperatively and radiographically in 2 cases in our series (
Table 1).
Lab results of cases showing elevated PTH and ALP levels.
Parameter
Case 1
Case 2
Case 3
Normal range
Hemoglobin
7.6
11.2
8.4
13-16 g/dL
Calcium
8.2
8.3
8.1
8.6-10.2 mg/dL
PTH
1101
1826
1220
15-65 pg/mL
Phosphorous
5.5
4.5
4.9
2.7-4.5 mg/dL
Albumin
3.2
4.4
3.3
3.5-5.2 g/dL
ALP
200
1399
866
40-129 U/L
The repairs were performed as soon as fitness could be obtained, in view of the compromised physiological status of the patients. No additional procedures were required to compensate for retraction or shortening of tendons. Repair was performed using suture anchors and heavy non absorbable sutures. The patients attained full active extension in all cases at an average of 2 months from the date of surgery with no re-ruptures or residual weakness at a minimum 6 months follow up.
Although the exact mechanism of injury remains unknown, most existing studies implicate sub-tendon bone resorption due to secondary hyperparathyroidism,
2 in addition to chronic inflammation, as evidenced by reduced serum hemoglobin and albumin levels, which was noted in 50% of cases.
Conclusion
Spontaneous tendon rupture in patients with ESKD remains a significant complication with considerable potential to cause disability. Robust repair with adequate immobilization and protection during the healing phase is instrumental in ensuring reliable results. Moreover, these patients require cautious physio rehabilitation, including careful walker- assisted mobilization to prevent further tendon ruptures during the postoperative period.
Optimization of renal parameters, such as hyperparathyroidism and hypoalbuminemia, may help improve outcomes and prevent recurrence. Overall, a high index of suspicion for spontaneous tendon rupture is advised in patients with ESKD presenting with acute-onset limb weakness to prevent long-term morbidity.
Consent
The patients have given their informed consent for the case series to be published. Written consent was obtained for the same.
Data availability
All data underlying the results are available as part of the article and no additional source data are required.
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10.1016/j.fjmd.2010.12.00510.5256/f1000research.174955.r353382Reviewer response for version 2VasukuttyNijil1Referee
United Lincolnshire Hospitals NHS Trust, Lincoln, England, UK
Competing interests: No competing interests were disclosed.
In this paper, the authors report on a series of six cases with spontaneous tendon ruptures due to chronic renal disease
The have reported on a variety of cases with the involvement of quadriceps and triceps.
This is not an easily recognised condition and a high index of suspicion will be required to diagnose this in a timely fashion.
Any delay in diagnosis will make the surgical procedure technically challenging and the outcomes suboptimal.
The authors do give a brief description of their diagnostic methods, surgical procedures and post-operative rehabilitation with intermediate term outcomes.
There is a section on the biochemical mechanism behind tendon rupture in end stage renal disease
This paper will form a valuable addition to the literature on this subject as they look at a different ethology to this difficult problem.
This is a short series but that would be expected as this is not a common problem.
The first line of introduction may be revised as most degenerate ruptures do occur spontaneously like in the Achilles and these are not rare .
Avoid using abbreviations the first time this term is referred to as in ESKD
Case reports
Could the authors clarify whether they used any three dimensional imaging like MRI or ultrasound before undertaking surgery or did they just depend on plain x-rays?
In case three the authors are report that the end of the patella tendon were frayed . In such a situation were the frayed ends excised and if so, how did they make up the lost length as the patella tendon may not be amenable to stretching.
In the discussion session it may be helpful to add a short paragraph on other causes of spontaneous tendon rupture like use of Ciprofloxacin and degenerate tendon rupture.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Yes
Is the background of the cases’ history and progression described in sufficient detail?
Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Yes
Is the conclusion balanced and justified on the basis of the findings?
Yes
Reviewer Expertise:
Trauma and Orthopaedics
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
10.5256/f1000research.174955.r348090Reviewer response for version 2VijayanSandeep1Referee
Additional Professor, Department of Orthopaedics, Kasturba Medical College Manipal,, Manipal Academy of Higher Education, Manipal, India
Competing interests: No competing interests were disclosed.
Add (ESKD) after it is mentioned first time in the introduction.
Correct spelling of tendon in figure 4 legend
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is the background of the cases’ history and progression described in sufficient detail?
Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Yes
Is the conclusion balanced and justified on the basis of the findings?
Yes
Reviewer Expertise:
NA
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
10.5256/f1000research.174955.r348092Reviewer response for version 2AbramowitzMatthew1Refereehttps://orcid.org/0000-0001-6984-9799
Albert Einstein College of Medicine, Bronx, New York, USA
Competing interests: No competing interests were disclosed.
Lack of description of the dialysis prescriptions remains a limitation.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
No
Is the background of the cases’ history and progression described in sufficient detail?
No
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the conclusion balanced and justified on the basis of the findings?
Yes
Reviewer Expertise:
physical function, muscle physiology in CKD
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
10.5256/f1000research.171011.r335309Reviewer response for version 1AbramowitzMatthew1Refereehttps://orcid.org/0000-0001-6984-9799
Albert Einstein College of Medicine, Bronx, New York, USA
Competing interests: No competing interests were disclosed.
This case series brings attention to the risk of tendon rupture in patients with ESKD. There are several areas in which it could be strengthened:
1. To improve the generalizability of this report to other patients with ESKD, it would be helpful to present details of the patients’ dialysis prescriptions, such as use of high flux dialyzers (which would reduce the likelihood of beta-2 microglobulin as an etiologic factor), pre-dialysis bicarbonate levels, Kt/V, dialysate settings (especially bicarbonate), and treatment of hyperparathyroidism. If beta-2 microglobulin levels were measured, those data should be presented.
2. Regarding case 3, the duration of dialysis should be presented. If the patient was not recently started on dialysis and did not have significant residual kidney function, it would be helpful to know why he was only receiving dialysis twice per week.
3. The abstract describes quadriceps tendon ruptures but the case descriptions report patella tendon ruptures. This should be clarified.
4. Abstract, Case presentation: the years on hemodialysis should be presented in the same order as the patients’ ages.
5. It would be helpful to further discuss potential mechanisms by which risk factors in ESKD may impact tendon physiology and structure.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
No
Is the background of the cases’ history and progression described in sufficient detail?
No
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the conclusion balanced and justified on the basis of the findings?
Yes
Reviewer Expertise:
physical function, muscle physiology in CKD
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
10.5256/f1000research.171011.r335311Reviewer response for version 1MaltaLuis Marcelo1Referee
Universidade Federal Fluminense, Rio de Janeiro, Brazil
Competing interests: No competing interests were disclosed.
The authors show their experience with a series of tendon ruptures on regular-based hemodialysis patients, addressing aspects of surgical treatment and functional results.
Despite the fact that it is a case series, giving it a less favorable view in terms of scientific strength or evidence, the study brings important information about the understanding and management of this unusual occurrence.
There are also some details I would like to point:
1- Abstract says that the authors report on two bilateral QUADRICEPS ruptures, but both case 1 and 3 are PATELLAR tendon ruptures. Maybe it was just a typing mistake but should be corrected to prevent confusion.
2- All cases include physical evaluation, both pre and postoperative, without clarifying which scale or functional score was used to do such measurements. I consider this is a minor but important point to address.
3- Discussion is well done but could include more recent articles at surgical repair aspects and risk factors associated with ruptures available in the literature. I consider this a major point to be revised, because there are much work documented on the field and it would make this section more complete.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is the background of the cases’ history and progression described in sufficient detail?
Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the conclusion balanced and justified on the basis of the findings?
Yes
Reviewer Expertise:
Orthopaedics / orthopedic surgery
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
10.5256/f1000research.171011.r332004Reviewer response for version 1VijayanSandeep1Referee
Additional Professor, Department of Orthopaedics, Kasturba Medical College Manipal,, Manipal Academy of Higher Education, Manipal, India
Competing interests: No competing interests were disclosed.
Abstract – case presentation: better to mention as 'patellar tendon' as the involved part is infrapatellar and not suprapatellar.
Page 3- case 2: I am not sure if it is correct to say grade 0 power. Here we are dealing with mechanical disruption of the muscle without loss in power of the muscle. Attempt to move the elbow will definitely contract the triceps muscle without the force transmitting across the tear. So, is it truly grade 0 power in the muscle ?
Page 3, case 2: was there any USG or MRI images available confirming the diagnosis and assess the quality of the tissue.
Was histopathological examination of the excised tissue performed to understand the type of degenerative changes commonly happening in tendons and ligaments in ESRD.
Page 5, figure 5 legend - better to mention as 'patellar tendon rupture'.
Page 6, figure 6- Please add cranial end and caudal end in the picture for easy understanding for the readers, The picture on the left side appear skewed (stretched horizontally). Please re-size it correctly.
Page 7- discussion - It is interesting to note that in most of the reported literatures. it the quadriceps / patellar tendon which is getting ruptured. In your review of literature, did you come across any specific reasoning from the affection of quadriceps tendon in particular.
Few more minor corrections are suggested. Same has been commented on in the main manuscript and may be accessed by opening the
manuscript with Adobe reader.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is the background of the cases’ history and progression described in sufficient detail?
Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Yes
Is the conclusion balanced and justified on the basis of the findings?
Yes
Reviewer Expertise:
NA
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.