Rectus Femoris Tendon Research Articles

Effect of exercise intervention on thigh muscle volume and anatomical cross‐sectional areas—Quantitative assessment using MRI

The objective of this study was to evaluate the location-specific magnitudes of an exercise intervention on thigh muscle volume and anatomical cross-sectional area, using MRI. Forty one untrained women participated in strength, endurance, or autogenic training for 12 weeks. Axial MR images of the thigh were acquired before and after the intervention, using a T1-weighted turbo-spin-echo sequence (10 mm sections, 0.78 mm in-plane resolution). The extensor, flexor, adductor, and sartorius muscles were segmented between the femoral neck and the rectus femoris tendon. Muscle volumes were determined, and anatomical cross-sectional areas were derived from 3D reconstructions at 10% (proximal-to-distal) intervals. With strength training, the volume of the extensors (+3.1%), flexors (+3.5%), and adductors (+3.9%) increased significantly (P < 0.05) between baseline and follow-up, and with endurance training, the volume of the extensor (+3.7%) and sartorius (+5.1%) increased significantly (P < 0.05). No relevant or statistically significant change was observed with autogenic training. The greatest standardized response means were observed for the anatomical cross-sectional area in the proximal aspect (10-30%) of the thigh and generally exceeded those for muscle volumes. The study shows that MRI can be used to monitor location-specific effects of exercise intervention on muscle cross-sectional areas, with the proximal aspect of the thigh muscles being most responsive.

Evaluation of therapeutic effects on sacroiliitis and enthesopathy in ankylosing spondylitis patients by color ultrasound

To explore the value of color Doppler ultrasound in evaluating the therapeutic effects on ankylosing spondylitis (AS) patients. Color Doppler high-frequency ultrasound images and blood flow in 30 healthy volunteers and 50 AS patients, changes of high-frequency ultrasound images and blood flow of involved sites in AS patients pre- and after-Etanercept treatments, as well as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and the Bath AS disease activity indices pre- and post-treatment were compared. Positive rates were significantly different between healthy volunteers and AS patients in terms of sacroiliac joints, Achilles tendon attachments, patellar ligament attachments, and rectus femoris tendon attachments by ultrasonograph (P < 0.05); and the fibular collateral ligament attachments positive rates had no significant difference with those at pre-treatment (P > 0.05). There was significant difference between patients with Bath AS disease activity index (BASDAI) ≥ 4 and those with BASDAI < 4 with respects to peripheral enthesis positive rate, Bath AS functional index (BASFI), patient's global assessment VAS (PGA), nocturnal back pain and general back pain VAS, morning stiffness duration, ESR and CRP (P < 0.05). Positive rates of sacroiliac joints, Achilles tendon attachments, patellar ligament attachments and rectus femoris tendon by ultrasonograph significantly decreased at Weeks 12 and 24 at post-treatment compared to that at pre-treatment (P < 0.05); there was significant difference for patient's BASDAI, BASFI, ESR and CRP at pre-treatment and weeks 12 and 24 post-treatment (P < 0.05). Ultrasound can sensitively detect the pathological changes of joint synovium and entheses so that it may be used as a routine method of monitoring diseases in these soft tissues, following up AS patients and evaluating clinical efficacy.

US-Guided Therapy of Calcific Tendinopathy: Clinical and Radiological Outcome Assessment in Shoulder and Non-Shoulder Tendons

To analyze the effectiveness and complication rate of ultrasound (US)-guided perforation and lavage using a two-needle technique with 16 - 18 G needles in the treatment of patients with calcific tendinopathy in the shoulder, elbow, hip, and knee by radiological and clinical follow-up. A retrospective chart review was performed and 40 patients (13 male, 27 female; mean age, 53.5 years; range 24 -74 years) were identified as having received US-guided perforation and lavage due to symptomatic calcific tendinopathy of the rotator cuff tendons, triceps, extensor and flexor tendons at the elbow, rectus femoris tendon and patellar tendons. The radiographic outcome was assessed by comparison of the size and quality of the calcification before and 6 weeks after the procedure. On US images, the quality of the acoustic shadow was assessed, together with other alterations of the tendon and surrounding tissue. Patients were interviewed by telephone to assess the clinical outcome regarding pre-treatment and post-treatment pain and tendon function. 34 shoulder tendons and 6 non-shoulder tendons were identified. The mean calcium reduction was 39.9 mm(2) (range, 0 - 215; p < 0.001), while 80 % of patient showed a resolution of more than 60 % resulting in good clinical improvement. A very low complication rate was found (1 partial tear). The US-guided perforation and lavage technique is an effective and safe treatment for rotator cuff calcifications as well as for other body tendons. Although the two-needle technique and large needles were used in this study, a very low complication rate was detected.

Prepatellar Quadriceps Continuation: MRI of Cadavers with Gross Anatomic and Histologic Correlation

The "prepatellar quadriceps continuation" is the appropriate designation for the deepest soft-tissue layer that lies anterior to the patella, related to the deep rectus femoris tendinous fibers. The purpose of this study was to define and investigate the prepatellar quadriceps continuation and its relationship with the patella in cadavers using MRI and gross anatomic and histologic analyses. MRI of 12 fresh-frozen knee specimens was performed using T1-weighted sequences in the axial and sagittal planes. Specimens were then sectioned in 3-mm-thick slices to correspond precisely with the MR images. Histologic analysis was performed in two specimens. The MR images were compared with findings seen on anatomic sectioning and histology. In addition, the layered organization of the patellar tendon was analyzed in 29 embalmed knee specimens obtained from human cadavers of both sexes. The normal prepatellar quadriceps continuation was seen as a band of low signal intensity in the MR images. This structure could not be differentiated easily from the low signal intensity of the patellar cortical bone. The sagittal plane was the most optimal plane for visualization of the attachment site of this continuation to the patella. Gross anatomic dissections revealed that at the proximal pole of the patella, the quadriceps tendon was formed by the rectus femoris and vastus intermedius muscles. The entire quadriceps tendon had an average thickness of 8.54 mm in this region. The thickness of the quadriceps tendon fibers extending over the anterior patellar surface measured, on average, 0.68 mm, and the average thickness of those fibers inserting into the proximal patellar pole was 7.87 mm. Histologic analysis showed that the attachment site of the prepatellar quadriceps continuation was formed by the distal extension of the deep longitudinal fibers of the rectus femoris tendon. At the border zone between the tendons and the patella, the tendinous fibers gradually were transformed into fibrocartilage. This so-called chondroapophyseal type of attachment was found to cover the entire anterior surface of the patella. The average thickness of the fibrocartilage at the insertion of the quadriceps tendon, patellar tendon, and prepatellar quadriceps continuation measured 0.136, 0.023, and 0.004 mm, respectively. The prepatellar quadriceps continuation is formed by fibers of the rectus femoris tendon and connects the quadriceps and patellar tendons. All tendons are attached through formation of a chondroapophyseal zone and are therefore transformed into a seam of fibrocartilage. Based on these anatomic features, separation of the prepatellar quadriceps continuation from the patella in the absence of more extensive abnormalities of the quadriceps mechanism is plausible.

Quadriceps cross-sectional area changes in young healthy men with different magnitude of Q angle

Knee pain and dysfunction have been often associated with an ineffective pull of the patella by the vastus medialis (VM) relative to the vastus lateralis (VL), particularly in individuals with knee joint malalignment. Such changes in muscular behavior may be attributed to muscle inhibition and/or atrophy that precedes the onset of symptoms. The aim of this study was to investigate possible effects of knee joint malalignment, indicated by a high quadriceps (Q) angle (HQ angle >15 degrees ), on the anatomic cross-sectional area (aCSA) of the entire quadriceps and its individual parts, in a group of 17 young asymptomatic men compared with a group of 19 asymptomatic individuals with low Q angle (LQ angle <15 degrees ). The aCSA of the entire quadriceps (TQ), VM, VL, vastus intermedius (VI), rectus femoris (RF), and patellar tendon (PT) were measured during static and dynamic magnetic resonance imaging (MRI) with the quadriceps relaxed and under contraction, respectively. A statistically significant lower aCSA was obtained in the HQ angle group, compared with the LQ angle group, for the TQ, VL, and VI in both static (TQ = 9.9%, VL = 12.9%, and VI = 9.1%; P < 0.05) and dynamic imaging (TQ = 10.7%, P < 0.001; VL = 13.4%, P < 0.01; and VI = 9.8%, P < 0.05) and the aCSA of the VM in dynamic MRI (11.9%; P < 0.01). The muscle atrophy obtained in the HQ angle group may be the result of a protective mechanism that inhibits and progressively adapts muscle behavior to reduce abnormal loading and wear of joint structures.

Anterior Thigh Pain in a Collegiate Basketball Player

HISTORY: A 21 year old college student was playing basketball when he sustained an injury to his right thigh. He jumped up for a rebound and when he landed, he felt a pop and experienced pain over his right anterior thigh. He was unable to continue playing. He developed ecchymosis over the injured site. The pain was gradually improving when he sought medical attention four weeks later. He had not yet returned to playing basketball. He denied any numbness, tingling, or paresthesias. He denied low back pain or knee pain. By the time of his follow-up examination five weeks later, he had resumed playing basketball. He denied any further pain, however he occasionally experienced weakness and instability of his right knee. PHYSICAL EXAM: On initial examination, he was ambulating with a normal gait. He had no gross deformity or atrophy, no palpable tenderness or defect over his quadriceps muscle, and no appreciable soft tissue swelling or ecchymosis. He had no pain to active quadriceps resistance. Knee and hip range of motion were normal with no pain to resistive testing. Distal neurovascular exam was intact. On follow-up examination he had a grossly visible and palpable deformity over the anterior proximal thigh with tightening of quadriceps/VMO. The deformity was soft, non-tender and mobile. DIFFERENTIAL DIAGNOSIS: Quadriceps strain/rupture Hematoma Sarcoma Myositis Deep venous thrombosis TEST AND RESULTS: MRI right thigh: Myofascial muscular strain involving the rcctus femoris with suspicion for a tear of the tendon. A fluid component was seen around the inferior portion of the muscle extending down along the course of the expected tendon. MRI right knee: Small joint effusion. Extensor mechanism at level of the knee was intact. Equivocal findings for sprain of anterior cruciate ligament. FINAL WORKING DIAGNOSIS: Rectus femoris tendon tear TREATMENT AND OUTCOMES: Non-operative management with supervised physical therapy. Returned to playing basketball less than 4 weeks post injury.

“Ciprofloxacin-Induced” Bilateral Rectus Femoris Tendon Rupture

“Ciprofloxacin-Induced” Bilateral Rectus Femoris Tendon Rupture

Comparison of rectus femoris transposition with traditional transfer for treatment of stiff knee gait in patients with cerebral palsy

To assess the outcome of children with cerebral palsy following reposition of the distal rectus femoris tendon for treatment of stiff knee gait. Children with cerebral palsy with stiff knee gait who underwent rectus femoris transfer were studied retrospectively. Inclusion criteria were cerebral palsy of diplegic or quadriplegic type, preoperative and 1 year postoperative three-dimensional motion analysis, and no other surgery except rectus femoris transfer at the time of study. The patients were separated into two groups: in group I, the rectus femoris was transferred to the distal medial hamstring tendons, either the gracilis or the semitendinosus; in group II, the distal tendon of the rectus femoris was transposed laterally and attached to the iliotibial band/intermuscular septum. Peak knee flexion during swing phase, total dynamic knee range of motion, knee range of motion during swing phase, and time to peak knee flexion during swing phase were all improved in both groups. Hip and pelvic kinematics were not influenced by the surgery. Velocity, stride length, and cadence were all improved following the surgery. There was no difference between the transfer group and the transposition group. These findings suggest that distal transfer of the rectus femoris is effective in improving swing phase knee function by diminishing the mechanical effect of the dysphasic swing phase activity of the rectus femoris, not by converting the rectus femoris to an active knee flexor.

Return to Play Following Muscle Strains

To assess return to play strategies following muscle strains with the desired outcomes of decreased competition play lost and minimized risk for recurrent injury. Literature review of previous studies that examine return to play criteria for the commonly seen muscle strain injuries in sport. There have been no studies directly comparing different return to play approaches. Studies have instead concentrated on recurrence risk factors and prognosis assessment, particularly for hamstring injuries. There is some literature support for risk factors for recurrence such as persisting strength deficits, larger injuries seen on diagnostic imaging, players in high-risk positions or sports, inability to complete functional tasks without pain, and strains of specific high-risk muscles (biceps femoris, central tendon of rectus femoris, medial head of gastrocnemius, adductor longus or magnus). There are no consensus guidelines or agreed-upon criteria for safe return to sport following muscle strains that completely eliminate the risk for recurrence and maximize performance. At this time, it may be a sensible strategy to allow earlier return to play in team sports and accept a low to moderate injury recurrence rate. Improved prognostic assessment of muscle strains with injury identification (MRI) and injury assessment (isokinetic testing) may be assist practitioners to lower, but not eliminate, recurrent injuries.

Three-dimensional muscle-tendon geometry after rectus femoris tendon transfer.

Rectus femoris tendon transfer is performed in patients with cerebral palsy to improve knee flexion during walking. This procedure involves detachment of the muscle from its insertion into the quadriceps tendon and reattachment to one of the knee flexor muscles. The purpose of the present study was to evaluate the muscle-tendon geometry and to assess the formation of scar tissue between the rectus femoris and adjacent structures. Magnetic resonance images of the lower extremities were acquired from five subjects after bilateral rectus femoris tendon transfer. A three-dimensional computer model of the musculoskeletal geometry of each of the ten limbs was created from these images. The three-dimensional paths of the rectus femoris muscles after transfer demonstrated that the muscle does not follow a straight course from its origin to its new insertion. The typical muscle-tendon path included an angular deviation; this deviation was sharp (>35 degrees ) in seven extremities. In addition, scar tissue between the transferred rectus femoris and the underlying muscles was visible on the magnetic resonance images. The angular deviations in the rectus femoris muscle-tendon path and the presence of scar tissue between the rectus femoris and the underlying muscles suggest that the beneficial effects of rectus femoris tendon transfer are derived from reducing the effects of the rectus femoris muscle as a knee extensor rather than from converting the muscle to a knee flexor. These findings clarify our understanding of the mechanism by which rectus femoris tendon transfer improves knee flexion.

Magnetic resonance imaging findings after rectus femoris transfer surgery.

We describe the magnetic resonance (MR) imaging appearance of the knee flexor and extensor tendons after bilateral rectus femoris transfer and hamstring lengthening surgery in five patients (10 limbs) with cerebral palsy. Three-dimensional models of the path of the transferred tendon were constructed in all cases. MR images of the transferred and lengthened tendons were examined and compared with images from ten non-surgical subjects. The models showed that the path of the transferred rectus femoris tendon had a marked angular deviation near the transfer site in all cases. MR imaging demonstrated irregular areas of low signal intensity near the transferred rectus femoris and around the hamstrings in all subjects. Eight of the ten post-surgical limbs showed evidence of fluid near or around the transferred or lengthened tendons. This was not observed in the non-surgical subjects. Thus, MR imaging of patients with cerebral palsy after rectus femoris transfer and hamstring-lengthening surgery shows evidence of signal intensity and contour changes, even several years after surgery.

Soft-tissue anatomy anterior to the human patella.

The purpose of this anatomic study is to report the results of dissections of the soft-tissue structures anterior to the human patella. Sixty-one fresh or fresh-frozen and thawed human cadaver knees were dissected for this study. Thirty-five of the knees were from men, and twenty-six were from women. The soft-tissue structures anterior to the patella were dissected layer by layer and documented photographically. Fifty-seven (93%) of the sixty-one knees were found to have a trilaminar arrangement of fibrous soft-tissue structures anterior to the patella from superficial to deep. Those structures included a transversely oriented fascia, an obliquely oriented aponeurosis, and the longitudinally oriented fibers of the rectus femoris tendon. Between the soft-tissue fibrous layers, there were three prepatellar spaces that can be termed bursae: a prepatellar subcutaneous bursa, a prepatellar subfascial bursa, and a prepatellar subaponeurotic bursa. Four of the sixty-one knees lacked an intermediate oblique aponeurotic layer. In none of the sixty-one knees was there a potential bursal space between the rectus femoris tendon and the anterior patellar bone. These anatomic findings are at variance with descriptions in standard anatomic orthopaedic texts and periodical literature, including the Nomina Anatomica. None of those texts accurately describe the presence of a prepatellar aponeurotic layer or a prepatellar subaponeurotic bursa. Also, in contradistinction to descriptions in the anatomic literature, including the Nomina Anatomica, no prepatellar subtendinous bursa was found in any of the sixty-one knees.

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Specialized Exposure for Revision Total Knee Arthroplasty

Adequate exposure of the knee is the first step in the successful performance of a revision total knee arthroplasty. In order to safely and expeditiously remove the implants that are in place and insert trial and actual components, flexion well beyond 90 degrees (to about 110 degrees) is needed13. In addition, it is preferable to be able to evert the patella and dislocate the tibia anteriorly. If a patient has less than 80 to 90 degrees of passive flexion under anesthesia, the standard medial parapatellar approach may not provide adequate exposure. Initially, it is useful to start the midline incision more proximally than the previous incision in order to establish normal tissue planes proximal to the extensor mechanism. It is also useful to take additional time to define the borders of the rectus femoris tendon and the vastus lateralis and medialis insertions into the patella. The medial parapatellar capsular incision begins at the proximal extent of the rectus tendon and ends distally one centimeter medial to the tibial tubercle. After a medial arthrotomy, release of any adhesions in the suprapatellar pouch and the medial and lateral gutters should be performed. Careful release or excision of scarred or contracted tissue leads to increased flexion and easier eversion of the patella and provides adequate exposure in many patients. Access to the lateral gutter is more difficult after a standard medial arthrotomy. A medial capsular release from the tibia is typically extended past the mid-coronal plane, usually to the posteromedial corner of the knee just anterior to the semimembranosus insertion. External rotation of the tibia after medial release and clearing of the gutters and the suprapatellar pouch usually increases knee flexion to some degree. The next maneuver that improves exposure is the application of traction on the patella as the knee …

Surgical Treatment of Knee Dysfunction in Cerebral Palsy

The prerequisites for normal gait are: (1) stability in the stance phase of gait, (2) clearance of the foot in the swing phase, (3) proper foot preposition in swing, and (4) an adequate step length. In the stance phase, the knee provides shock absorption and energy conservation; in the swing phase, it allows foot clearance. To accomplish these functions, the knee must extend fully in stance and flex approximately 60 degrees in swing. Consequently, balanced muscle action at the hip, knee, and ankle joints, combined with adequate acceleration from the hip flexor and triceps surae muscles, is essential. In the crouch gait of spastic cerebral palsy, hamstring lengthening alone often converts the flexed-knee gait to an extended-knee, stiff-legged gait with inadequate swing-phase knee flexion. This unwanted conversion is due to cospasticity of the quadriceps and hamstring muscles. Restoration of normal knee function in patients with spastic paralysis is more successful when fractional hamstring lengthening is combined with a transfer of the distal rectus femoris tendon to either the iliotibial band or the distal tendon of the semitendinosus.

Surgical Management of Congenital and Habitual Dislocation of the Patella

Twelve patients with congenital dislocation of the patella (CDP) and 23 patients with habitual dislocation of the patella (HDP) were followed for 2-15 years after surgical stabilization of the patella. The underlying pathology in both conditions was contracture of the quadriceps mechanism, which was more severe in CDP. Surgical stabilization in most cases included an extensive lateral release, medial plication, and transfer of the lateral half of the patella tendon. Lengthening of the rectus femoris tendon was required in many cases. With appropriate operative procedures, satisfactory results were achieved in 36 of the 41 knees (87.8%).

Influence of component orientation on peg failure of patellar surface replacements

To determine the relative influence of anteroinferior iliac spine (AIIS) or subspine decompression on proximal rectus femoris integrity and iliopsoas excursion throughout a physiological range of motion.Nineteen cadaveric hips from 10 specimens were dissected to retain the origin of the rectus femoris direct and indirect heads. The anatomic footprints of the origins were measured with calipers. Serial 5-mm resections of the AIIS were made to determine the extent of proximal tendon disruption that corresponded to each resection. Iliopsoas tendon tracking was also assessed after sequential AIIS decompression by measuring the excursion of the medial border of the iliopsoas tendon as it traveled from its native resting position to the point where it first encountered bony impingement at the AIIS.The mean proximal-distal footprint of the rectus femoris direct head was 17.95 ± 2.99 mm. The mean medial-lateral distance was 11.84 ± 2.34 mm. There was a consistent bare area along the inferior aspect of the AIIS that averaged 4.84 ± 1.42 mm. The average percentage of remaining footprint after each 5-mm resection (5 to 25 mm) was 96%, 65%, 35%, 14%, and 11%, respectively, with statistical significance noted after resections larger than 5 mm (P < .001). The native excursion distance of the iliopsoas tendon was 14.05 mm. With each 5-mm resection, the percentage of excursion before impingement on the AIIS increased by 18%, 45%, 72%, 95%, and 100%, respectively, which was statistically significance after all resections (P < .001).Our study maps the anatomic footprint of the direct head of the rectus femoris tendon and confirms a previously identified bare area along the inferior aspect of the AIIS. Female cadaveric hips had a significantly smaller rectus footprint than male cadavers in our study (P < .001). Subspine decompression greater than 10 mm significantly compromises the rectus femoris origin and should be avoided when performing arthroscopic AIIS decompression. In addition, subspine decompression significantly improves tracking of the iliopsoas tendon throughout a physiological range of motion and may be considered a surgical adjunct when treating symptomatic iliopsoas snapping.Arthroscopic subspine decompression serves as an important treatment modality for AIIS impingement. With a more thorough understanding of AIIS anatomy, subspine decompression can be used to relieve impingement symptoms and possibly improve iliopsoas tracking while safely maintaining rectus femoris footprint integrity.

Experimental Mechanical and Histologic Evaluation of the Kennedy Ligament Augmentation Device

Reconstruction of the knee with a chronic injury to the anterior cruciate ligament is an unsolved problem. Biologic graft substitutes have failed to maintain knee stability in the longer postreconstruction intervals. In an attempt to overcome the limitations in graft performance, synthetic materials have been proposed to augment the biologic tissue. In this study, a 6-mm polypropylene braid Ligament Augmentation Device (LAD) possessing a tensile strength of 1500 N and excellent fatigue and creep properties was investigated as an adjunct to the MacIntosh/Marshall Over-the-Top repair. A two-year animal study of 54 adult goats was conducted in which experimental ACL defects were created and reconstructed with a transplant consisting of a portion of the rectus femoris tendon, prepatellar tissue, and the central one-third of the patellar tendon. The goats were equally divided between nonaugmented and LAD-augmented groups and sacrificed at three, six, 12, and 24 months after surgery. Mechanically, the augmented transplants were substantially stronger at the time of initial implantation (364N versus 26N) and again at two years (841N versus 528N). Intermediate times did not demonstrate a difference in strength. Histologically, the augmented transplants consisted of a loosely organized fibrous capsule surrounding the LAD. At 24 months, "insertion fibers" were noted to provide continuity between the fibrous tissue and bone on both the tibia and femur.

QUADRICEPSPLASTY

1. Thirty cases of stiff knee treated by the operation of quadricepsplasty are reviewed. 2. The causes and morbid anatomy are analysed. The operative technique is based on an appreciation of the latter. 3. The after-care must be meticulous and prolonged. Manipulation under anaesthesia was used after operation in over half the cases. 4. The results were most gratifying. There were two technical failures but in the remaining twenty-eight cases the average gain of fiexion was 68 degrees. In twenty-one of these active extension was full and it was only 5 degrees short in another three. Permanent loss of active extension occurred when the rectus femoris tendon had to be divided or lengthened.

A NEW AMPUTATION IN THE LOWER THIRD OF THE THIGH

This description of an amputation through the distal extremity of the femur records a sufficient number of novel features to justify its report as a new operation. The essential details of the operation in summary are as follows: The anterior flap includes the soft tissues of the upper part of the leg as far as the level of the tibial tuberosity, while the posterior flap is a little longer and extends well down on the gastrocnemius muscle. The popliteal vessels and nerves are ligated through an amuscular and avascular cleavage plane on the medial aspect of the low thigh. All the hamstring muscles are severed at their tendinous insertions on the tibia, and the femur is sectioned in the condylar flare, just proximal to the adductor tubercle. The patella is dissected from the anterior flap from the joint side, leaving the rectus femoris tendon in the floor of the patellar