This is a chronic neglected quadriceps tendon rupture presenting at 10 weeks post-injury, which represents a complex reconstructive challenge with a worse prognosis than acute repair. The delayed presentation due to misdiagnosis as a 'knee contusion' and patient's social isolation has led to the development of chronic changes that make simple primary repair impossible: (1) Tendon retraction (6cm) with dense scar tissue adherent to femur, (2) Quadriceps muscle contracture with fatty infiltration and atrophy (8cm thigh circumference loss), (3) Fixed flexion contracture of the knee (30° - cannot fully extend passively), (4) Severe patella baja (Insall-Salvati 0.5 indicating massive superior migration), (5) Bone resorption at superior pole from chronic traction. These chronic changes mean that simple suture repair is not possible - even if I could mobilize the retracted tendon down to the patella, the tension would be enormous causing either immediate re-rupture or severe patella infera, and the degenerated atrophic muscle may not generate adequate force even if repaired. I need to counsel him with realistic expectations: (1) This is a salvage procedure, not restoration to normal - at 10 weeks with these chronic changes, the best we can hope for is functional improvement allowing assisted ambulation and transfers, not return to normal or heavy farm work; (2) Even with surgery, he will likely have permanent extensor lag (inability to achieve full active extension), residual weakness (atrophied muscle with fatty infiltration does not fully recover), and need for mobility aids long-term; (3) Surgical options are complex reconstructive procedures with significant risks (infection 10-15%, re-rupture 20-30%, stiffness, need for further procedures); (4) Non-operative management (accepting current disability, using wheelchair and mobility aids, strengthening remaining function) is a valid alternative if he is not medically fit or does not accept surgical risks. However, given his age (60, relatively young), desire to return to farm independence, and current complete loss of function, I would offer him surgical reconstruction with appropriate counseling about realistic outcomes. Surgical options for chronic quadriceps rupture: (1) Codivilla V-Y quadriceps lengthening/plasty: The most commonly used technique for chronic ruptures - involves creating a V-shaped incision in the quadriceps muscle-tendon unit proximally (typically starting 8-10cm above the patella), extending distally to the rupture site; The V incision allows mobilization of the distal tendon stump down to the patella (the two arms of the V separate, lengthening the construct); Once the tendon is advanced and repaired to the patella (using transosseous tunnels or suture anchors as in acute repair), the proximal defect where the V was created is closed in a Y configuration (hence V-Y); This effectively lengthens the extensor mechanism by 4-6cm, allowing repair under acceptable tension; Advantages: Uses patient's own tissue, establishes continuity, well-described technique; Disadvantages: Weakens quadriceps (cutting muscle), limited lengthening (maximum 6cm, may be insufficient for this patient with 6cm retraction plus contracture), residual weakness common (30-40% loss of strength); (2) Scuderi quadriceps turndown flap: Turn down a proximally-based flap of the rectus femoris tendon (typically 2cm wide, 10-12cm long) and fold it distally to bridge the gap; The flap is sutured to the retracted tendon stump and to the patella, providing biologic reinforcement and bridging the defect; Often combined with V-Y lengthening for large gaps; Advantages: Provides additional tissue for reinforcement, biologic augmentation, can bridge 6-8cm gaps when combined with V-Y; Disadvantages: Weakens rectus femoris, complex technically, adds operative time; (3) Achilles tendon allograft: Use fresh-frozen Achilles allograft with attached calcaneus bone block (10-11mm diameter Achilles, 2-3cm calcaneus bone block); Fix the calcaneus bone block to the superior pole of patella with large interference screw (7-9mm), weave the Achilles tendon through the quadriceps muscle proximally and suture to muscle with heavy non-absorbable sutures; Augment with cerclage wire or suture tape from tibial tubercle through quadriceps; Advantages: Can span any gap size, strong thick graft, single-stage procedure, does not further weaken patient's quadriceps muscle; Disadvantages: Allograft risks (disease transmission minimal with modern screening but theoretical, incorporation failure 10-15%, cost, availability), more complex surgery, graft may stretch over time; (4) Whole extensor mechanism allograft: Rarely used, involves quadriceps-patella-patellar tendon-tibial tubercle allograft construct replacing entire mechanism; Reserved for massive loss or multiple failed reconstructions; My recommendation for this patient: I would favor Achilles tendon allograft reconstruction given the 6cm gap, severe muscle atrophy, and need for robust construct. The patient's own quadriceps is already severely atrophied and weak (8cm circumference loss, fatty infiltration on MRI), so further weakening it with V-Y or Scuderi flap is not ideal. The allograft provides strong tissue that can span the gap without further compromising his muscle. Surgical plan: (1) Pre-operative: Medical optimization (check comorbidities, anesthetic risk - 60yo farmer likely has cardiac disease, diabetes), physiotherapy to improve passive ROM and reduce flexion contracture (intensive stretching for 2-4 weeks pre-op, aim to get extension to at least 10-15° short of full - currently 30° contracture makes surgery very difficult), plan for prolonged surgery (3-4 hours) and recovery; (2) Surgical technique: Position supine with tourniquet, midline incision (15-20cm) centered on superior pole of patella extending proximally, identify and mobilize retracted quadriceps tendon stump (will be densely adherent to femur with scar - sharp dissection required, may need to release vastus lateralis/medialis from femoral shaft to gain any length), prepare superior pole of patella (debride soft tissue, decorticate to healthy bleeding bone - may have significant bone loss requiring grafting or remodeling), prepare Achilles allograft (thaw per protocol, trim calcaneus bone block to appropriate size for patella, prepare tendon end); Fix calcaneus bone block to superior pole of patella: Create trough in superior pole with rongeur and burr to accept bone block (2-3cm deep), position block and compress, fix with large interference screw (7-9mm bioabsorbable or metal) directed anteroinferiorly - screw should achieve rigid fixation (bone-to-bone healing most reliable part of construct); Weave Achilles tendon through quadriceps muscle: Pass sutures through Achilles in Krackow pattern, create tunnels/windows through quadriceps muscle and tendon stump proximally (about 8-10cm above patella), pull Achilles through and suture to quadriceps with heavy non-absorbable sutures under appropriate tension; Tension: Flex knee to 60-90° (as much as flexion contracture allows), apply moderate tension to restore patella height toward normal (target Insall-Salvati 0.8-0.9, up from 0.5 - full correction may not be possible), use intraoperative C-arm to check position; CRITICAL: Must accept some residual patella baja - trying to fully correct to 1.0-1.1 will create excessive tension and fail; Augmentation: MANDATORY - cerclage wire (18-gauge) or suture tape from tibial tubercle through graft and quadriceps acts as safety belt, shares load, protects graft during healing and early rehabilitation; Repair retinaculum if any salvageable tissue; Closure: May need Z-plasty or V-Y closure of skin if significant shortening makes primary closure tight; (3) Post-operative protocol (very conservative given chronic changes and reconstruction): Brace locked in extension 6-8 weeks minimum (longer than acute repair - graft needs time to incorporate), non-weight-bearing or touch-toe weight-bearing for 6 weeks (protect bone-bone healing of calcaneus block), ROM extremely gradual: 0° only first 4-6 weeks, then 0-30° weeks 6-10, 0-60° weeks 10-14, 0-90° weeks 14-20 (may never achieve beyond 90° given pre-existing contracture and muscle damage), passive ROM first with therapist, active-assisted once muscle reactivates, full active quad strengthening delayed 12-16 weeks (must allow graft incorporation before loading); DVT prophylaxis critical (prolonged immobilization, surgery time, age 60); Serial X-rays to monitor patella position and bone block healing (bone block should heal by 8-12 weeks, graft incorporation takes 6-9 months); Expected timeline: 12-18 months to maximal recovery; (4) Realistic prognosis and counseling: Outcomes for chronic quadriceps reconstruction worse than acute repair: Only 50-60% achieve functional extensor mechanism (defined as ability to perform straight leg raise and ambulate without brace), 40-50% have permanent extensor lag (typically 10-30° - cannot achieve last 10-30° of active extension, compensate by hyperextending hip), quadriceps strength recovery limited (at best 50-70% of normal - muscle has undergone atrophy and fatty infiltration which is irreversible), return to farm work very unlikely (may achieve light duties, but heavy labor, climbing, kneeling not realistic), complications high: Re-rupture 20-30% (vs 5-8% acute), infection 10-15% (long surgery, dead space, allograft), stiffness 40-50% (pre-existing contracture, prolonged immobilization, adhesions), graft failure or stretching 15-20% (persistent lag despite intact graft), need for revision surgery 20-25%, permanent disability 30-40% (persistent severe lag or failure requiring brace or mobility aids); Success definition: Goal is functional independence for basic ADLs (transfers, walking with walker or cane, light household tasks) NOT return to normal or farm work; If he can achieve SLR and walk with assistive device, that is successful outcome given baseline of wheelchair-dependent; Must counsel that surgery is salvage attempt, not cure, and even with surgery he may need long-term mobility aids; Alternative: Non-operative management with bracing (locked knee brace or KAFO), wheelchair, home modifications - may be appropriate if medically unfit or unwilling to accept surgical risks and prolonged recovery. This is a difficult decision requiring extensive counseling and shared decision-making with patient and family.