Title : Silent breakdown: Spontaneous tendon ruptures in hemodialysis patients
Abstract:
Spontaneous tendon ruptures are rare but severe complications in patients undergoing long-term hemodialysis for End-Stage Kidney Disease (ESKD). The underlying mechanisms are multifactorial, involving chronic uremia, secondary hyperparathyroidism, vascular calcifications, and collagen degradation. These patients are prone to tendon weakening, leading to rupture even with minimal exertion. Prompt recognition, surgical repair, and structured rehabilitation are crucial to restoring function and preventing long-term disability.
Case Presentations: We report three cases of spontaneous tendon ruptures in hemodialysis patients, each highlighting different presentations and surgical management approaches.
Case 1: A 61-year-old male, on hemodialysis for five years due to diabetic nephropathy, presented with bilateral patellar tendon ruptures after experiencing sudden knee instability. MRI confirmed complete ruptures, and surgical repair with suture anchors and transosseous fixation was performed.
Case 2: A 44-year-old male, on hemodialysis for ten years due to IgA nephropathy, sustained bilateral triceps tendon ruptures with minimal exertion. Loss of active elbow extension led to surgical repair using suture anchor fixation, followed by an intensive rehabilitation program.
Case 3: A 26-year-old female with lupus nephritis on five years of hemodialysis experienced bilateral patellar tendon ruptures without preceding trauma. Surgical repair with augmentation techniques was performed to reinforce the weakened tendons. Rehabilitation led to satisfactory recovery.
Discussion: Tendon ruptures in hemodialysis patients often present bilaterally and without significant trauma. Chronic metabolic derangements, particularly hyperparathyroidism and uremic toxicity, contribute to tendon degeneration. Diagnosis can be delayed due to the subtle onset of symptoms, necessitating imaging with MRI or ultrasound for confirmation. Surgical repair is challenging due to poor tendon quality, requiring strong fixation techniques such as transosseous tunnels or suture anchors.
Postoperative management must balance early mobilization with the risk of repair failure. Rehabilitation protocols should be tailored to optimize tendon healing while preventing joint stiffness and muscle atrophy. Given the high recurrence risk, strategies to improve tendon integrity in ESKD patients, including better control of mineral bone disorders, warrant further investigation.
Conclusion: Spontaneous tendon ruptures are an underrecognized but disabling complication in hemodialysis patients. Awareness, early diagnosis, and appropriate surgical intervention are crucial for functional recovery. A multidisciplinary approach, including nephrologists, orthopedic surgeons, and physiotherapists, is essential for optimal management. Future research should focus on preventive strategies to reduce the incidence of these debilitating injuries.
