Journal Information
Vol. 37. Issue. 3.May - June 2017
Pages 229-356
Vol. 37. Issue. 3.May - June 2017
Pages 229-356
Letter to the Editor
DOI: 10.1016/j.nefroe.2016.10.011
Open Access
Spontaneous tendon ruptures in chronic renal failure
Roturas tendinosas espontáneas en la insuficiencia renal crónica
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José Ruiza,b, Antonio Ríosa,b,c,
Corresponding author
arzrios@um.es

Corresponding author.
, José Manuel Rodrígueza,b,c, Santiago Llorented
a Departamento de Cirugía, Ginecología, Obstetricia y Pediatría, Universidad de Murcia, Murcia, Spain
b Servicio de Cirugía General y de Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
c Instituto Murciano de Investigación Bio-Sanitaria Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, Spain
d Servicio de Nefrología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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Tables (2)
Table 1. Clinical features of spontaneous tendon rupture.
Table 2. Clinical follow up.
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Dear Editor,

Spontaneous rupture of tendons (STR) is not frequent. The pathogenesis is unclear but there are a number risk factors involved: secondary hyperparathyroidism (HPTH), diabetes mellitus, obesity, rheumatoid arthritis, gout, statins, steroids, fluorquinolones and the presence of B and/or C hepatitis virus. In patients with chronic renal failure (CKD) the most frequent cause of tendon rupture is secondary hyperparathyoridims, which is present in most of these patients.1,2

There is no consensus about the treatment. Thus the objective of this study is to analyze the clinical features, risk factors, treatment and clinical evolution of STR in CKD patients.

The study includes end stage renal disease patients on renal replacement therapy that had STR during the years 1994 to 2013. Patients had a complete clinical history and they had a least one-year of follow up. Patient with tendon rupture caused by trauma or those with of the lost follow up were excluded.

There were six patients (0.23%) with STR. Mean age was 46.6±11.8 years, 4 were males (66.7%). Before the episode of STR all patients had been on hemodialysis for an average of 9.1±4.2 years. In 4 cases (66.7%) the STR affected the extremity of one body side and in 2 cases (33.3) they were bilateral.

In six patients there was a rupture of the femoral quadriceps tendon and in 2 cases the patellar tendon was affected. All patients had SHPT and one patient (16.6%) also receive statins to treat hypercholesterolemia (Table 1).

Table 1.

Clinical features of spontaneous tendon rupture.

  Case 1  Case 2  Case 3  Case 4  Case 5  Case 6 
Age  34  57  57  53  30  49 
Gender 
Etiology CKD  Chronic pyelonephritis  Unknown etiology  Polycystic kidneys  Unknown etiology  Chronic pyelonephritis  Glomerulonephritis 
Dialysis  HD  HD  HD  HD  HD  HD 
Dialysis vintage (years)  16  10  10 
Risk factors  SHPT  SHPT  SHPT  SHPT  SHPT  SHPT, statins 
Type of rupture  Partial  Total  Total  Total  Total  Total 
Body side  Unilateral  Unilateral  Unilateral  Unilateral  Bilateral  Bilateral 
Tendons affected  Quadriceps  Quadriceps  Rotuliano  Quadriceps  Quadriceps  Quadriceps (L) and patellar (R) 
PTH (pg/ml)  541  1000  1400  730  1187  950 
Calcium (mg/dl)  11.6  12.4  10.4  12.1  10  10.2 
Phosphate (mg/dl)  6.3  5.9  6.1  5.7  6.4  7.4 
CaxP  73.08  73.16  63.44  68.97  64  75.48 
Alkaline phosphatase (UI/l)  360  679  1000  115  713  243 

R: right; M: male; HD: hemodialysis; SHPT: secondary hyperparathyroidism; L: left; CKD: chronic renal failure; F: female.

All patients underwent urgent (within 5 days) surgical intervention to repair the tendon fracture. In five cases the tendon was detached with respect to the patella and it was reinserted using nonabsorbable suture through transosseous tunnels in the patella. In 3 cases there was a rupture of the tendon and it had to be repaired by end-to-end suture with a material that is not absorbable. Thereafter, the knee had to be immobilized for 8 weeks followed by a rehabilitation period of up to six months after surgery

With respect to the SHPT, all patients had bone pain and one patient (16.6%) complained of pruritus that was refractory to treatment. Mean serum concentration of PTH was 968±308.2pg/ml, the CaxP was 69.6±17.6 and the mean value of alkaline phosphatase was 518.3±334.4UI/l. All patients underwent total parathyroidectomy after a mean period of 3.6±1.7 months.

After 12.5±5 year of follow up there was no further evidence of STR or SHPT and 4 patients (66.7%) underwent renal transplantation (Table 2).

Table 2.

Clinical follow up.

  Case 1  Case 2  Case 3  Case 4  Case 5  Case 6 
Follow up (year)  17  16  16  14 
Renal transplant  No  Yes, same year of STR  Yes, one year after STR  Yes, two years after STR  Yes, two years after STR  No 
Graft rejection  No  Chronic, after 7 years of transplantation. On hemodialysis until end of follow up  No  No  Chronic, after 12 years of transplantation. On hemodialysis until end of follow up  No 
Death at the end of follow up?  No  No  No  Yes  No  Yes 

The feature of a CKD patient with STR is a relatively young patient on hemodialysis for more that 5 years that may be malnourished, with insufficient dose of dialysis, amyloidosis, chronic acidosis and also SHPT which is the most important pathogenic factor for STR.1–5 The pathophysiology is not totally clear; it has been proposed that the increased subperiostial resorption together with elastosis of the connective tissue due to chronic acidosis may debilitate the ostetendinous junction favoring the STR.6–8

STR affecting extensor knee required urgent or immediate surgery, it has to be done within the first few days after rupture, so fibrosis and retraction of tendon and muscle are avoided. Optimal results require immobilization and 4–6 months of rehabilitation.9

In addition to the treatment of STR, it is necessary to control risk factors to prevent new STR. Therefore SHPT should be treated, the use of calcimimetics have markedly reduced the need for parathyroidectomy. In patients with STR and persistent hyperparathyroidism, parathyroidectomy is reccomended.10

In conclusion, STR in CKD patients usually affect the knee extensor tendons; it is more frequent in young males with more than nine years in hemodialysis and the main predisposing factor is SHPT. Quick surgical treatment, rehabilitation and treatment of SHPT allows patient's recovery and prevents long term re-occurrence.

References
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Spontaneous tendon ruptures in patients with end-stage renal disease.
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Spontaneous tendon ruptures in patients on chronic dialysis.
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Orthop Traumatol Surg Res, 99 (2013), pp. S67-S76
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J.V. Torregrosa, J. Bover, J. Cannata Andía, V. Lorenzo, A.L. de Francisco, I. Martínez, et al.
Recomendaciones de la Sociedad Española de Nefrología para el manejo de las alteraciones del metabolismo óseo-mineral en los pacientes con enfermedad renal crónica (S.E.N.-M.M.).

Please cite this article as: Ruiz J, Ríos A, Rodríguez JM, Llorente S. Roturas tendinosas espontáneas en la insuficiencia renal crónica. Nefrologia. 2017;37:341–343.

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