The midterm effects of diabetes mellitus on quadriceps and patellar tendons in patients with knee arthrosis: a comparative radiological study

doi:10.1016/j.jdiacomp.2006.07.003

Journal of Diabetes and its Complications

Volume 21, Issue 6, November–December 2007, Pages 392-396

https://doi.org/10.1016/j.jdiacomp.2006.07.003 Get rights and content

Abstract

We sought to evaluate the effects of diabetes on the physical properties of the patellar and quadriceps tendons using radiological techniques. Twenty-seven diabetic and 34 nondiabetic patients with primary osteoarthritis of the right knee were studied. All patients had anteroposterior and lateral knee radiographs. The lengths of the patella and the patellar tendon were measured. The width and thickness of the patellar tendon were determined by ultrasound (US) examination at midpoint. The increase in the thickness of the patellar tendon sheath was graded qualitatively. The length of the quadriceps and patellar tendons, and the thickness and width of tendons in midlength were measured by magnetic resonance imaging (MRI). Buckling of tendons and increase in intensities were also evaluated. The mean age in the diabetic group was 57.6±10.1 years, and the mean age in the control group was 52.6±9.1 years. The mean duration of diabetes was 104.1±67.1 months. X-ray, US, and MRI measurements did not reveal any differences between the two groups. Quadriceps buckling was more prevalent in diabetic patients (P=.025). In both groups, the width of the patellar tendon was greater in men than in women (P=.001). In conclusion, we found no significant structural changes in the patellar and quadriceps tendons in diabetic patients in midterm. On MRI examination, the quadriceps tendons had more buckling in diabetic patients.

Introduction

Diabetes mellitus (DM) is known to cause a wide range of musculoskeletal disorders, including tenosynovitis, joint stiffness, and tendon contracture. Connective tissues are ubiquitous and are involved in long-term complications of DM as a result of alterations in the quantity and quality of the structural macromolecules of the extracellular matrix in a variety of vessels and tissues (Brownlee, 1992).

The shortness and contracture of the quadriceps and patellar tendons make it difficult to rotate the patella laterally during total knee arthroplasty. We observed this difficulty in some diabetic patients during knee operations and decided to investigate the effects of diabetes on the extensor mechanism of the knee using radiological techniques. Abnormalities of interstitial connective tissues involving the skeleton, skin, joints, tendons, and periarticular tissues are well known in DM. Generally, the involvement of connective tissues in diabetes may present as Dupuytren's contracture, carpal tunnel syndrome, flexor tenosynovitis, and adhesive capsulitis (Smith, Burnet, & McNeil, 2003). Tendon involvement has been reported more commonly around the feet and ankles. In their study of the feet of three patients with DM, Ramirez and Raskin (1998) described diabetic foot tendinopathy as the presence of hardened flexor plantar tendons. Such structural changes could contribute to the tightening of the Achilles tendon—a phenomenon consistent with clinical observations of an extreme shortening of the Achilles tendon–gastrocnemius–soleus complex, which is common in advanced diabetic neuropathy (Grant et al., 1997). The involvement of the quadriceps and patellar tendons in diabetes has been reported in the literature only in cases of spontaneous tendon rupture (Brotherton & Ball, 1975, Chautems et al., 2001, Stern & Harwin, 1980).

To our knowledge, there have been no other clinical or radiological studies in the English literature that have evaluated the effects of diabetes on the physical dimension of the patellar and quadriceps tendons.

Section snippets

Study design and population

This was a prospective study. Sixty-one patients (27 diabetic and 34 nondiabetic patients) with osteoarthritis of the knee were included in the study. The inclusive criteria were as follows: age of >40 years, clinical symptoms and signs of osteoarthritis of the knee, X-ray findings suggestive of osteoarthritis, and a history of DM for (for the diabetic group). Physical examination and radiographic findings were used to diagnose osteoarthritis. Measurements were performed on the right knee of

Results

The mean age was 57.6±10.1 (42–80) years in the diabetic group and 52.6±9.1 (40–75) years in the control group (P=.058). Eight of 27 patients in the diabetic group and 9 of 34 patients in the control group were male. The mean duration of diabetes was 104.1±67.1 (2–240) months. Twelve diabetic patients used oral antidiabetics; the rest of the patients used oral antidiabetics and insulin alternately. The duration of insulin use was 36.5±68.0 (0–240) months, and the duration of oral antidiabetics

Discussion

The effects of long-term diabetes on tendon structure have been studied in diabetic dogs by Lancaster, Haut, and DeCamp (1994). The length of diabetic tendon preparations was found to be 13% less than that of controls. The average cross-sectional area and the volume of diabetic canine patellar tendons did not differ from those of controls (Lancaster et al., 1994). In our study, we did not detect any changes in patellar tendon length, width, and thickness. This may be due to the shortness of the

References (15)

W.P. Grant et al.
Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon
Journal of Foot and Ankle Surgery
(1997)
R.L. Lancaster et al.
Changes in the mechanical properties of patellar tendon preparations of spontaneously diabetic dogs under long-term insulin therapy
Journal of Biomechanics
(1994)
Ph. Neyret et al.
Patellar tendon length—The factor in patellar instability?
The Knee
(2002)
L.C. Ramirez et al.
Diabetic foot tendinopathy: Abnormalities in the flexor plantar tendons in patients with diabetes mellitus
Journal of Diabetic Complications
(1998)
B.J. Brotherton et al.
Bilateral simultaneous rupture of the quadriceps tendons
British Journal of Surgery
(1975)
M. Brownlee
Glycation products and the pathogenesis of diabetic complications
Diabetes Care
(1992)
R. Chautems et al.
Bifocal avulsion of patellar tendon in a adult
Revue de Chirurgie Orthopedique et Reparatrice de L’Appareil Moteur
(2001)

There are more references available in the full text version of this article.

Cited by (18)

Patellar tendon buckling in post-operative total knee arthroplasty patients is more prominent than in healthy controls
2019, Medical Engineering and Physics
Citation Excerpt :
Until recently, buckling of the patellar tendon during knee extension was suggested to be indicative of knee pathology [17–19]. Yet recent work has shown that patellar tendon buckling is largely present in healthy subjects [20], and is affected by age [21]. The clinical relevance of buckling has yet to be fully elucidated, but one hypothesis is that it may serve as a mechanical buffer protecting the tendon from sudden contractions, similar to the function of microstructural tendon crimp [22] and likely plays a role in the function of the extensor mechanism of the knee.
Recent evidence suggests the patellar tendon undergoes buckling during normal knee flexion, which likely contributes to the functioning of the extensor mechanism. Thus, evaluating buckling in patients following total knee arthroplasty (TKA), where extensor mechanism dysfunction remains a common complication, may be relevant. The study goals were to identify whether post-TKA patients exhibit differences in patellar tendon buckling from healthy, similarly-aged adults and whether such buckling correlates with knee and patellar tendon health. Patellar tendon buckling was assessed during passive knee flexion using ultrasound in post-TKA patients (n = 20; 12M, 68 ± 8 years) and compared with previously reported data from healthy adults (n = 12; 12M; 70 ± 8 years). Patients exhibited significantly larger (p < 0.01) buckling magnitude and angles than healthy adults, and reduced distal buckling was linked with better Knee Society Scores (p = 0.04, R² = 0.24). The greater patellar tendon buckling observed in post-TKA patients could arise due to factors related to the surgery itself (e.g. infrapatellar fat pad resection) or it may be that post-TKA patients had greater patellar tendon buckling before their procedure. Alterations in patellar tendon buckling may predispose individuals to post-surgical complications including instability, anterior knee pain, and extensor mechanism dysfunction, with further work necessary to elucidate potential links.
Ultrasonographic Evaluation of Lower Extremity Entheseal Sites in Diabetic Patients Using Glasgow Ultrasound Enthesitis Scoring System Score
2017, Journal of Medical Ultrasound
Citation Excerpt :
Several studies have shown increased thickness and stiffness of the plantar fascia and Achilles tendon in Type 2 DM patients [9,16]. Furthermore, a small number of radiological studies assessed quadriceps and patellar tendons, and showed the influence of diabetic status [21–23]. A few case presentations indicating spontaneous quadriceps tendon rupture were reported for DM patients [24,25].
The prevalence of musculoskeletal complications in diabetes mellitus (DM) increases with the duration of disease and with poor glycemic control. Our aim was to evaluate lower extremity musculoskeletal complications in patients with DM using the Glasgow Ultrasound Enthesitis Scoring System, and to reveal the relationship between clinical and sonographic findings.
A total of 67 patients (25 men, 42 women) with DM were included in the study. All the diabetic patients were selected if they did not have any symptom of musculoskeletal system in the lower extremities. They were divided into four groups. Ultrasonographic assessment was performed according to the Glasgow Ultrasound Enthesitis Scoring System with an Esaote MyLab 5 device equipped with a 5–13 MHz linear transducer. Correlation between diabetes duration and lower extremity enthesopathy scores were evaluated.
There was a significant correlation between duration of DM and total Glasgow Ultrasound Enthesitis Scoring System scores (p < 0.001). In addition, duration of DM was significantly correlated with enthesophyte scores and erosion scores (both p < 0.001). There was a significant difference among Groups 1–4 for the mean enthesophyte score and mean erosion score (both, p < 0.001).
Musculoskeletal ultrasonography is an effective, inexpensive, and useful tool without radiation for evaluating diabetic patients for the early diagnosis of musculoskeletal complications.
Evidence of patellar tendon buckling during passive knee extension
2016, Knee
Citation Excerpt :
Patellar tendon buckling was observed in all subjects, though some subjects exhibited buckling only in the distal portion of the tendon. These results contrast with early reports that found buckling to only occur in a subset of asymptomatic patients [15,23] and instead suggest that buckling may be a normal mechanism of healthy tendon function. Although tendon buckling at such a macro-scale has not been well-described previously, tendon crimp is a well-known phenomenon that has been observed to arise at the levels of the fibril (diameter: 50 to 500 nm [24,25]) and fiber (diameter: 50 to 300 μm [24,26,27]).
The purpose of this study was to investigate and describe buckling of the patellar tendon.
Healthy young adults (28 ± 4 years, 10F/10M) underwent passive knee flexion/extension during the simultaneous measurement of knee angle and collection of cine ultrasound from the patellar tendon. Patellar tendon buckling was observed visually in ultrasound images, and the corresponding knee angle at which evidence of buckling disappeared was identified.
All subjects showed evidence of distal buckling which occurred on average at 23 ± 8° flexion. Proximal buckling was only observed in fourteen subjects (10F/4M) at an average of 15 ± 8°. Buckling patterns varied between subjects, but with high within-subject consistency. Buckling magnitude increased with age (p = 0.03) and decreased with more weekly exercise (p = 0.02).
The patellar tendon exhibited significant buckling in knee extension suggesting that buckling is a component of healthy knee function. Like tendon crimp, buckling may serve as a protective mechanism, allowing the tissue to unwrinkle prior to undergoing pure strain. The links between increased buckling magnitude and both age and reduced activity suggest that excessive buckling may be maladaptive, though future work is necessary to elucidate this relationship. Buckling is relevant to consider when estimating tendon length, as buckling can lead to significant underestimation of resting length and thus overestimation of strain.
This study demonstrates the complexity of tendon behavior even in healthy adults undergoing passive motion, suggesting that buckling may be relevant to an improved understanding of tendon health and pathology.
Reconstruction of a deficient patella in revision total knee arthroplasty: Results of a new surgical technique using transcortical wiring
2015, Journal of Arthroplasty
This study aimed to report the results of a novel surgical technique for the reconstruction of a deficient patella during revision total knee arthroplasty (TKA). Twenty-eight patients (30 knees) with a deficient patella were treated with an onlay-type prosthesis and bone-augmenting procedure, using acrylic bone cement and transcortical wiring. The technique was indicated when the thickness of remnant patella was less than 8 mm with variable amounts of the peripheral rim. Mean follow-up period was 36.6 months (range, 24 to 55 months).The respective mean Knee Society scores for knee and function improved from 34.2 and 23 points, preoperatively to 73.5 and 61 points, at final follow-up. One patient experienced patellar fracture 1 week after surgery. There were no complications associated with implanted hardware.
Bilateral tendon tears of the extensor mechanism of the knee: A series of cases
2012, Rehabilitacion
Las roturas bilaterales del aparato extensor de la rodilla son infrecuentes y se asocian clásicamente a enfermedades sistémicas. Estas lesiones pueden ser óseas, de patela o tuberosidad tibial anterior, musculares o tendinosas. Las más comunes de todas son las fracturas de rótula, seguidas de roturas del tendón cuadricipital o rotuliano.
Las roturas bilaterales tanto del tendón rotuliano como cuadricipital, al ser infrecuentes, pueden ser infradiagnosticadas retrasando el tratamiento quirúrgico y la posterior rehabilitación; suelen ser traumáticas. En la literatura existen publicaciones sobre algunos casos de roturas tendinosas bilateral del aparato extensor de la rodilla asociadas a enfermedades sistémicas como isuficiencia renal, diabetes mellitus o artritis reumatoide o al uso prolongado de quinolonas o corticoides.
En este trabajo describimos 4 casos clínicos de roturas tendinosas bilaterales del aparato extensor, sin y con enfermedades sistémicas asociadas.
Bilateral injuries of the knee extensor mechanism are uncommon and are generally related to systemic diseases. Such injuries may be muscle tears, bone fractures (patella and tibial tubercle) and tendinous disruptures. Patella fractures are described as being the most common of these, followed by injuries of the quadriceps and patellar tendons.
As bilateral disruption of either patellar and/or quadricipital tendons is uncommon, it may be underdiagnosed, thus delaying the surgical treatment and subsequent rehabilitation. They are generally traumatic. There are publications in the literature on some cases of bilateral tendinous disruptions of the knee extensor complex associated to systemic diseases such as renal failure, diabetes mellitus or rheumatoid arthritis or the continued use of steroids or fluoroquinolones.
We report four cases of bilateral knee tendon disruption in patients with and without systemic disease.
Diabetes mellitus impairs tendon-bone healing after rotator cuff repair
2010, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
In support of these findings, diabetes has been strongly associated with reduced bone mass and delayed fracture healing in humans.21,40 Tendon structure and healing after injury is affected by diabetes as well.1,4,8,29,37,38,44,52,53 Ramirez and Raskin described diabetic foot tendinopathy as a syndrome of hardened, stiff plantar tendons in diabetic patients.52
Studies have demonstrated a significant decrease in skeletal mass, bone mineral density, and impaired fracture healing in the diabetic population. However, the effect of sustained hyperglycemia on tendon-to-bone healing is unknown.
Forty-eight male, Lewis rats underwent unilateral detachment of the supraspinatus tendon followed by immediate anatomic repair with transosseous fixation. In the experimental group (n = 24), diabetes was induced preoperatively via intraperitoneal injection of streptozotocin (STZ, 65 mg/kg) and confirmed with both pre- and post-STZ injection intraperitoneal glucose tolerance tests (IPGTT). Animals were sacrificed at 1 and 2 weeks postoperatively for biomechanical, histomorphometric, and immunohistochemical analysis. Serum hemoglobin A1c (HbA1c) levels were measured at 2 weeks postoperatively. Statistical comparisons were performed using Student t tests with significance set at P < .05.
IPGTT analysis demonstrated a significant impairment of glycemic control in the diabetic compared to control animals (P < .05). Mean HbA1c level at 2 weeks postoperatively was 10.6 ± 2.7% and 6.0 ± 1.0% for the diabetic and control groups, respectively (P < .05). Diabetic animals demonstrated significantly less fibrocartilage and organized collagen, and increased AGE deposition at the tendon-bone interface (P < .05). The healing enthesis of diabetic animals demonstrated a significantly reduced ultimate load-to-failure (4.79 ± 1.33N vs 1.60 ± 1.67N and 13.63 ± 2.33N vs 6.0 ± 3.24N for control versus diabetic animals at 1 and 2 weeks, respectively) and stiffness compared to control animals (P < .05).
Sustained hyperglycemia impairs tendon-bone healing after rotator cuff repair in this rodent model. These findings have significant clinical implications for the expected outcomes of soft tissue repair or reconstructive procedures in diabetic patients with poor glycemic control.

View all citing articles on Scopus

View full text

Original articleThe midterm effects of diabetes mellitus on quadriceps and patellar tendons in patients with knee arthrosis: a comparative radiological study

Abstract

Introduction

Section snippets

Study design and population

Results

Discussion

Journal of Foot and Ankle Surgery

Journal of Biomechanics

The Knee

Journal of Diabetic Complications

Bilateral simultaneous rupture of the quadriceps tendons

British Journal of Surgery

Glycation products and the pathogenesis of diabetic complications

Diabetes Care

Bifocal avulsion of patellar tendon in a adult

Revue de Chirurgie Orthopedique et Reparatrice de L’Appareil Moteur

Original article
The midterm effects of diabetes mellitus on quadriceps and patellar tendons in patients with knee arthrosis: a comparative radiological study