Suture anchor repair yields better biomechanical properties than transosseous sutures in ruptured quadriceps tendons

Previous Extensor Mechanism Repair Is Associated With Increased Rates of Surgical Complications Following Total Knee Arthroplasty: A Propensity-matched Analysis

Background

Although extensor mechanism failure following total knee arthroplasty (TKA) is a devastating complication and has been heavily studied in the literature, the impact of extensor mechanism rupture and concomitant repair prior to TKA has not previously been evaluated. The purpose of this investigation was to evaluate how quadriceps and/or patellar tendon repairs prior to TKA would impact medical and surgery-related complications following TKA.

Methods

The PearlDiver database was retrospectively reviewed to identify all primary TKA patients from 2010 to 2019. Patients who underwent quadriceps or patellar tendon repair prior to TKA were matched using a propensity score algorithm to a control cohort. We compared medical and surgical complication rates, emergency room visits, readmissions, and 90-day cost of care between the groups.

Results

A total of 1197 patients underwent extensor mechanism repair prior to TKA and were matched to 11,970 patients who did not undergo repair prior to TKA. Patients who underwent extensor mechanism repair had higher rates of 90-day medical complications, as well as 1-year surgery-related complications including revision TKA (odds ratio [OR] 6.06; P < .001), lysis of adhesions (OR 2.18; P = .026), aseptic loosening (OR 2.21; P = .018), infection (OR 7.58; P < .001), and fracture (OR 8.53; P < .001). Patients with prior extensor mechanism repair were more likely to return to the emergency department (OR 1.66; P < .001) and become readmitted (OR 4.15; P < .001) within 90 days.

Conclusions

Patients with previous extensor mechanism repair exhibited higher medical and surgery-related complications, including lysis of adhesions, following TKA than a control cohort. These findings may suggest that patients may require additional surveillance in the early postoperative period to avoid these disastrous complications following primary TKA.

Similar Outcomes Are Found Between Quadriceps Tendon Repair With Transosseous Tunnels and Suture Anchors: A Systematic Review and Meta-Analysis

Purpose

To evaluate the clinical outcomes and biomechanical performance of transosseous tunnels compared with suture anchors for quadriceps tendon repair.

Methods

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was performed in April 2021 in the following databases: Cochrane Database of Systematic Reviews, PubMed (1980-2021), MEDLINE (1980-2021), Embase (1980-2021), and CINAHL (1980-2021). Level I-IV studies were included if they provided outcome data for surgical repair of the quadriceps tendon using transosseous tunnels or suture anchors with minimum 1-year follow-up. Biomechanical studies comparing transosseous tunnels and suture anchors were separately analyzed.

Results

The systematic search yielded 1,837 citations, 23 of which met inclusion criteria (18 clinical, 5 biomechanical). In total, 13 studies reported results for transosseous repair and 7 studies reported results for repair with suture anchors. There were results for 508 patients from clinical studies. The average postoperative Lysholm score ranged from 88 to 92 for suture anchor repairs and 72.8 to 94 for transosseous repairs with range of motion ranging from 117° to 138° and 116° to 135°, respectively. Synthesis of the biomechanical data revealed the mean difference in load to failure was not significant between constructs (137.21; 95% confidence interval -10.14 to 284.57 N; P = .068).

Conclusions

Transosseous and suture anchor techniques for quadriceps tendon repair result in similar biomechanical and postoperative outcomes. No difference between techniques in regard to ultimate load to failure among comparative biomechanical studies were observed.

Level of Evidence

Level IV, systematic review level III-IV studies.

Editorial Commentary: Quadriceps Tendon Suture Anchor Repair Provides Better Patient-Reported Outcomes Than Transosseous Tunnel Repair: Defining the New Gold Standard

Quadriceps tendon suture anchor repair provides biomechanically greater and more consistent failure loads than transosseous tunnel repair, including less cyclic displacement (gap formation). Although satisfactory clinical outcomes are found with both repair techniques, few studies provide a side-to-side comparison. However, recent research demonstrates better clinical outcomes in using suture anchors, with equal failure rates. Suture anchor repair is minimally invasive requiring smaller incisions, less patellar dissection, and eliminates patellar tunnel drilling that can breach the anterior cortex, create stress risers, result in osteolysis from nonabsorbable intraosseous sutures and longitudinal patellar fractures. Suture anchor quadriceps tendon repair should now be considered the gold standard.

Bilateral Quadriceps Tendon Rupture in a Healthy Individual Following a Motor Vehicle Accident: A Case Report

Bilateral quadriceps tendon rupture (QTR) is a rare injury that typically affects middle-aged men presenting underlying medical conditions, while only a few cases have been reported in healthy individuals. The gold standard treatment of such injuries is prompt surgical repair, followed by postoperative immobilization and physiotherapy. We present the case of a 51-year-old previously healthy man who experienced bilateral, simultaneous, and complete QTR following a high-velocity motor vehicle accident. Physical examination revealed bilateral extensor mechanism disruption and palpable defects at the superior poles of the patellae. MRI confirmed the diagnosis, and the patient underwent surgical repair using three anchor sutures on each side. Postoperative management involved a brief period of immobilization followed by progressive passive motion exercises and protected weight bearing. At a six-month follow-up, the patient had excellent functional outcomes and was satisfied with the treatment.

Use of electrocautery devices for suture passage through the greater tuberosity: a biomechanical study

BACKGROUND

The use of electrocautery to facilitate passage of a suture needle through bone without the aid of a drill or burr is a novel technique that has potential utility in orthopedic procedures, but there is a scarcity of research to support its utility. The specific aims of this cadaveric biomechanical study were to evaluate (1) the axial force reduction during suture passage using electrocautery when applied to rotator cuff repair, (2) the temperature change caused while using electrocautery, and (3) the failure loads and failure modes of this technique.

METHODS

Five matched pairs of fresh frozen humeri were used, classified into 2 groups: with electrocautery on needle (study group) and without electrocautery on needle (control group). Four individual osseous tunnels were made on the greater tuberosity around the insertion of the supraspinatus tendon. Each specimen was sequentially tested in 2 parts: a needle penetration test (part I) to measure the peak axial force and temperature change and a single load-to-failure test (part II) to measure the maximum load to failure as well as the mechanism of failure. A No. 2 FiberWire suture with a straight needle was used.

RESULTS

In part I, the mean peak axial force was lower in the study group compared with the control group for all osseous tunnels but was not statistically significant for individual tunnels. However, there was a significant decrease in peak axial force in the study group of 36% compared with the control group overall (P = .033). There was no significant change in temperature of the tunnel site with the use of electrocautery (mean: 0.2 ± 0.3°C, P = .435). In part II, 100% of the samples from each study group experienced bone tunnel failure. Forty percent of the trials in the study group found lower ultimate failure loads compared with the control group (reduction range: 7%-38%). There was no statistically significant difference in the ultimate failure load between either the loop tested or between the 2 study groups (loop 1: P = .352; loop 2: P = .270).

CONCLUSION

Suture passage using electrocautery does significantly decrease the peak force needed to pass a needle directly through the greater tuberosity. This technique does not appear to burn the bone or weaken the bone tunnels. This technique may be useful during open rotator cuff repair or shoulder arthroplasty, although clinicians should be cautious when using this technique as its utility depends on bone quality and cortical thickness, and in vivo results may differ.

Transosseous Repair With Nice Knot Augmentation Versus Knotless Suture Anchor Repair With Suture Tape for Quadriceps Tendon Rupture: A Cadaveric Study

Quadriceps tendon rupture is typically repaired using either transosseous tunnels or suture anchors. Recent literature has suggested that suture anchor repair is biomechanically superior to the use of transosseous tunnels. Augmentation of the transosseous technique with Nice knots may result in improved biomechanical properties as compared with a suture anchor construct. To compare biomechanical properties of a novel transosseous quadriceps tendon repair technique with Nice knot augmentation to those of knotless suture anchor repair, an artificial quadriceps tendon rupture was created in 10 matched pairs of cadaveric knees (n=20). Each cadaver was subjected to biomechanical testing to calculate the average ultimate load to failure, repair site gapping after early and late cyclic loading, and stiffness. Transosseous repair augmented with Nice knots as compared with knotless suture anchor repair had greater load to failure (mean±SD, 1489.5±297.6 N vs 717.7±191.4 N, P<.001), decreased gapping after early and late cyclic loading (cycles 1-20: mean±SD, 0.59±0.4 mm vs 2.1±1.2 mm, P=.008; cycles 21-250: mean±SD, 1.2±0.7 mm vs 3.9±1.7 mm, P=.002), and greater construct stiffness (mean±SD, 80.7±15.7 N/mm vs 44.4±13.4 N/mm, P=.001). The transosseous quadriceps tendon repair technique with Nice knot augmentation is biomechanically better than knotless suture anchor repair with regard to ultimate load to failure, gap formation after cyclic loading, and construct stiffness in cadaveric specimens. [Orthopedics. 202x;4x(x):xx-xx.].

Suture Anchor-Based Quadriceps Tendon Repair May Result in Improved Patient-Reported Outcomes but Similar Failure Rates Compared to the Transosseous Tunnel Technique

PURPOSE

The purpose of this study was to compare failure rates and patient-reported outcomes between transosseus (TO) suture and suture anchor (SA) quadriceps tendon repairs.

METHODS

Following institutional review board approval, patients who underwent primary repair for quadriceps tendon rupture with TO or SA techniques between January 2009 and August 2018 were identified from an institutional database and retrospectively reviewed. Patients were contacted for satisfaction (1-10 scale), current function (0-100 scale), failure (retear), and revision surgeries; International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were also collected to achieve a minimum of 2-year follow-up.

RESULTS

Sixty-four patients (34 SA, 30 TO) were available by phone or e-mail at a mean of 4.81 ± 2.60 years postoperatively. There were 10 failures, for an overall failure rate of 15.6%. Failure incidence did not significantly differ between treatment groups (P = .83). Twenty-seven patients (47% of nonfailed patients) had completed patient-reported outcomes. The SA group reported higher subjective function (SA: 90 [85-100] vs TO: 85 [60-93], 95% CI of difference: -19.9 to -2.1 × 10^-5, P = .042), final IKDC (79.6 [50.0-93.6] vs 62.1 [44.3-65.5], 95% CI of difference: -33.0 to -0.48, P = .048), KOOS Pain (97.2 [84.7-97.2] vs 73.6 [50.7-88.2], 95% CI of difference: -36.1 to -3.6 × 10^-5, P = .037), Quality of Life (81.3 [56.3-93.8] vs 50.0 [23.4-56.3], 95% CI of difference: -50.0 to -6.2, P = .026), and Sport (75.0 [52.5-90.0] vs 47.5 [31.3-67.5], 95% CI of the difference: -45.0 to -4.1 × 10^-5, P = .048).

CONCLUSIONS

There is no significant difference in failure rate between transosseus and suture anchor repairs for quadriceps tendon ruptures (P = .83). Most failures occur secondary to a traumatic reinjury within the first year postoperatively. Despite the lack of difference in failure rates, at final follow-up, patients who undergo suture anchor repair may report significantly greater subjective function and final IKDC, KOOS Pain, Quality of Life, and Sport scores.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Primary Quadriceps Tendon Suture Anchor Repair: Case Presentation and Surgical Technique

This case presentation described a technique for repairing an acute quadriceps tendon rupture with suture anchors. The patient was a 51-year-old man who sustained an acute quadriceps tendon rupture after a fall. We used a midline incision over the quadriceps tendon and muscle. The tendon was found to be completely avulsed from the superior border of the patella. Three suture anchors were used to re-approximate the quadriceps tendon to the patella and additional sutures were used to repair the medial and lateral patellar retinacula. The patient had excellent range of motion at his 6-week follow-up appointment after the procedure.

Repair of Bilateral Quadriceps Tendon Rupture Using a Modified Knotless Suture Anchor and Internal Brace Technique: Surgical Technique and Case Report

BACKGROUND

Quadriceps tendon rupture (QTR) is a rare clinical condition often caused by indirect injury in healthy people. In addition, spontaneous and bilateral ruptures can occur in patients with predisposing factors, such as endocrine or rheumatic disease. Currently, several QTR repair techniques have been proposed; however, no consensus exists about the best repair technique.

CASE PRESENTATIONS

A 55-year-old man with renal failure secondary to glomerulonephritis suffered from spontaneous bilateral quadriceps tendon ruptures. Based on a knotless suture anchor and internal brace, a novel double-row suture-bridge configuration surgical approach was used to treat the patient. At 11-month follow-up, the patient maintained excellent function, with a Lysholm score of 91 for both knees.

CONCLUSIONS

This technique may be an effective method for repairing ruptured quadriceps tendons.

Smaller Gap Formation With Suture Anchor Fixation Than Traditional Transpatellar Sutures in Patella and Quadriceps Tendon Rupture: A Systematic Review

PURPOSE

The purpose of this study is to compare the biomechanical properties between traditional transosseous tunnel and suture anchor technique repair for extensor mechanism ruptures and assess for differences in the mechanism of failure of both techniques.

METHODS

A multi-database search (PubMed, EMBASE, and Medline) was performed according to PRISMA guidelines on November 14, 2021. All articles comparing biomechanical properties of transpatellar and suture anchor technique for extensor mechanism ruptures were included. Abstracts, reviews, case reports, studies without biomechanical analysis, conference proceedings, and non-English language studies were excluded. Outcomes pursued included gap formation, load to failure, and mechanism of failure. Relevant data from studies meeting inclusion criteria were extracted and analyzed. Study methodology was assessed using the Methodological Index for Non-Randomized Studies score.

RESULTS

A total of 212 knees were biomechanically assessed, including 98 patella and 114 quadricep tendon ruptures. Five patellar tendon studies were included, and all of them reported significantly smaller gap formation in suture anchor group. Gap formation for suture anchors ranged from .9 mm to 4.1 mm, while that of transpatellar group ranged from 2.9 mm to 10.3 mm. One study reported a significantly higher load to failure in the suture anchor group, while the remaining four studies reported no significant difference. Load to failure for suture anchor ranged from 259 N to 779 N, while that of the transpatellar group ranged from 287 N to 763 N. The most common mechanism of failure was anchor pullout in suture anchor and knot failure in the transpatellar group. Five quadriceps tendon studies were included, and three studies reported statistically significant smaller gap formation in the suture anchor group. Gap formation for suture anchor ranged from 1.5 mm to 5.0 mm, while that of transpatellar group ranged from 3.1 mm to 33.3 mm. Two studies reported a significantly higher load to failure in the suture anchor group, while one study reported a higher load to failure in the transpatellar repair group. Load to failure for suture anchor ranged from 286 N to 740 N, while that of transpatellar group ranged from 251 N to 691 N. The most common mechanism of failure was suture failure in the suture anchor and knot failure in the transpatellar group.

CONCLUSION

Suture anchor fixation displays a better biomechanical profile than traditional transpatellar techniques in terms of smaller gap formations in the repair of both patella and quadriceps tendon injuries. Anchor pullout in suture anchor fixation was present mainly with the use of titanium anchors.

CLINICAL RELEVANCE

These findings above may result in better retention of tendon approximation in patella and quadriceps tendon fixation postoperatively, which may result in earlier recovery. Further randomized controlled clinical trials to compare these techniques are required.

Extensor mechanism ruptures

Native patellar tendon injuries are seen in younger patients compared to quadriceps tendon ruptures.

Up to a third of the patients may have local (antecedent tendinopathy and cortisone injections) or systemic risk factors (obesity, diabetes, hyperparathyroidism, chronic renal failure, fluoroquinolone or statin use) of injury, these are more frequent in bilateral disruptions.

Complete extensor mechanism disruptions should be repaired surgically. Although isolated primary repair has been reported to have good outcomes in younger patients with acute tears and good tendon quality, augmentation of the repair with autograft, allograft or synthetic material should be considered in patients with poor tendon quality, chronic tears or tendon defects.

High rates of return to work/sports have been reported in native patellar and quadriceps tendon tears, with re-rupture rates <5%.

Extensor mechanism disruptions in patients with a total knee arthroplasty are challenging due to older age, systemic co-morbidities and poor local conditions, resulting in inferior outcomes compared to native extensor mechanism injuries. Some form of augmentation with autograft, allograft or synthetics is advisable in all cases. Salvage procedures such as whole extensor mechanism allografts provide acceptable outcomes in multiply operated knees with extensive bone and soft tissue deficits.

Transosseous tunnels versus suture anchors for the repair of acute quadriceps and patellar tendon ruptures: A systematic review and meta-analysis of biomechanical studies

BACKGROUND

Multiple techniques have been developed for the repair of acute quadriceps and patellar tendon ruptures with the goal of optimizing clinical outcomes while minimizing complications and costs. The purpose of this study was to evaluate the biomechanical properties of transosseous tunnels and suture anchors for the repair of quadriceps and patellar tendon ruptures.

METHODS

A systematic review of the PubMed and Embase databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using specific search terms and eligibility criteria. Meta-analysis was performed by fixed-effects models for studies of low heterogeneity (I² <25%) and random-effects models for studies of moderate to high heterogeneity (I² ≥25%).

RESULTS

A total of 392 studies were identified from the initial literature search with 7 studies meeting the eligibility criteria for quadriceps tendon repair and 8 studies meeting the eligibility criteria for patellar tendon repair. Based on the random-effects model for total gap formation and load to failure for quadriceps tendon repair, the mean difference was 8.88 mm (95% CI, -8.31 mm to 26.06 mm; p = 0.31) in favor of a larger gap with transosseous tunnels and -117.25N (95%CI, -242.73N to 8.23N; p = 0.07) in favor of a larger load to failure with suture anchors. A similar analysis for patellar tendon repair demonstrated a mean difference of 2.86 mm (95% CI, 1.08 mm to 4.64 mm; p = 0.002) in favor of a larger gap with transosseous tunnels and -56.34N (95% CI, -226.75 to 114.07N; p = 0.52) in favor of a larger load to failure with suture anchor repair.

CONCLUSIONS

Transosseous tunnels are biomechanically similar to suture anchors for quadriceps tendon repair. Patellar tendon repair may benefit from reduced gap formation after cycling with suture anchor repair, but the load to failure for both techniques is biomechanically similar. Additional studies are necessary to evaluate these and alternative repair techniques.

LEVEL OF EVIDENCE

Systematic review and meta-analysis of biomechanical studies, Level V.

A Survey of Treatment Trends for Acute Quadriceps Tendon Ruptures Among North American Surgeons

Background:

To date, little clinical evidence exists to support a specific surgical technique or postoperative rehabilitation protocol for quadriceps tendon ruptures. With a lack of evidence-based superiority, assessment of clinical practices and surgeon preferences is pertinent.

Purpose:

To describe the current surgical technique and rehabilitation preferences among members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine pertaining to acute quadriceps tendon rupture.

Study Design:

Cross-sectional study.

Methods:

Orthopaedic staff members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine were invited to complete an internet-based survey composed of 26 questions assessing current trends in the management and rehabilitation of acute quadriceps tendon rupture. Survey questions were developed after a thorough review of current literature. Survey responses were analyzed and reported using descriptive statistics (absolute values, frequencies, and percentages) where appropriate. Statistical comparisons and contrasts between Canadian and American surgeons were made using chi-square analyses and Student t tests.

Results:

A total of 264 surgeons participated in the survey (136 Canadians; 128 Americans). Canadian surgeons were more likely to obtain a preoperative ultrasound as compared with Americans (43.0% vs 6.7%; P < .00001), while American respondents were more likely to obtain magnetic resonance imaging scans (65.8% vs 10.2%; P < .00001). The transosseous drill hole technique was the most commonly utilized (70.2%); the suture anchor technique was used 20.6% of the time. Canadian respondents trended toward a higher use of transosseous tunnels; however, this was not statistically significant (75.8% vs 64.2%; P = .068). American respondents were more likely to utilize suture anchors (27.5% vs 14.1%; P = .0096). Most respondents advanced range of motion goals stepwise in 2-week intervals of 30° (Canadians, 54.0% vs Americans, 58.5%; P = .3091); timing of range of motion initiation varied.

Conclusion:

Among North American surgeons who responded to this study, the transosseous technique was the most commonly used, and range of motion was generally advanced in a 2-week stepwise fashion. We found several differences in practice between Canadian and American respondents, including the type of preoperative imaging and the frequency of using the suture anchor technique.

Comparison of Biomechanical Failure Loads Between Tape-Type and Conventional Sutures in Internal Knotless Anchor–Based Constructs

Background:

Despite the increasing prevalence of tape-type sutures, whether internal knotless anchors can consistently affix tape-type sutures has not been thoroughly investigated.

Purpose:

To evaluate whether substituting tape-type sutures for conventional sutures influences the suture-holding strength of internal knotless anchors.

Study Design:

Controlled laboratory study. Level of evidence, 5.

Methods:

A total of 3 internal knotless anchors were tested: a spiral core clamping anchor (Footprint Ultra PK), a winged clamping anchor (PopLok), and a spooling anchor (ReelX STT). Four constructs were compared for each type of anchor, with the anchor double or quadruple loaded with tape-type sutures or conventional sutures. The testing protocol comprised preloading suture tension to 10 N; cyclic loading, in which tension increased in increments of 10 N from 10 to 90 N; and a load-to-failure stage set at a speed of 0.5 mm/s. The clinical failure load (CFL) was defined as suture slippage of ≥3 mm. Also, 1-way analysis of variance and power analysis were used to compare the CFLs of the constructs.

Results:

For the quadruple-loaded spiral core clamping anchors, a significant reduction in CFLs was seen with conventional sutures over tape-type sutures (138.10 ± 4.73 vs 80.00 ± 12.25 N, respectively; P < .001). This reduction was not observed under the double-loaded condition (conventional vs tape type: 76.00 ± 5.48 vs 80.00 ± 10.00 N, respectively). Substitution of the suture materials did not significantly reduce the CFLs for the winged clamping anchors (conventional vs tape type: 40.00 ± 10.00 vs 30.00 ± 7.07 N for double loaded, respectively, and 64.00 ± 13.41 vs 50.00 ± 10.00 N for quadruple loaded, respectively) or the spooling anchors (conventional vs tape type: 62.00 ± 19.23 vs 56.32 ± 20.20N for double loaded, respectively, and 72.00 ± 21.68 vs 84.00 ± 13.42 N for quadruple loaded, respectively).

Conclusion:

Substituting tape-type sutures for conventional sutures increased the CFLs of some internal knotless anchors. With specific suture-anchor combinations, quadruple-loaded conventional suture anchors had CFLs higher than those of double-loaded conventional suture anchors.

Clinical Relevance:

When multiple tape-type sutures are used in conjunction with a clamping anchor, clinicians should note a possible reduction in CFLs and resultant early suture slippage.

Delayed diagnosis and treatment of a distal patellar tendon avulsion in an adolescent

Distal patellar tendon avulsions are uncommon. While much is known about proximal patella tendon ruptures, there are very few reports to guide treatment of a patellar tendon disruption near the tibial tuberosity. Moreover, delayed diagnosis and treatment presents additional challenges. We present a distal patellar tendon avulsion in an adolescent whereby diagnosis and treatment were delayed due to a distracting nearby contaminated wound. The tendon was separated from post-traumatic scar then repaired back to its native footprint using suture anchors. This report aims to increase awareness of this rare diagnosis as well as provide details about our chosen treatment and rehabilitation protocol.

Midterm outcome and strength assessment after quadriceps tendon refixation with suture anchors

PURPOSE

Quadriceps tendon ruptures (QTR) occur predominantly in middle-aged patients through violent eccentric contraction that occurs either when trying to regain balance or during a fall on the hyperflexed knee. The aim of this study was to quantify midterm postoperative results, including strength potential measured via standardized strength tests following acute (< six weeks) quadriceps tendon refixation using suture anchors.

METHODS

All consecutive patients with QTR who underwent surgical suture anchor refixation between 2012 and 2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Tegner Activity Scale (TAS), Lysholm score, International Knee Documentation Committee subjective knee form (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, return to work rates, and Visual Analog Scale (VAS) for pain. Additionally, a standardized clinical examination and an isometric strength assessment of knee extension and flexion were performed.

RESULTS

A total of 17 patients (median age 61.0 [25-75% IQR 50.5-72.5]) were available for final assessment at a mean follow-up of 47.1 ± SD 25.4 months. The majority of patients were male (82.4%) and most injuries occurred due to a fall on the hyperflexed knee (76.5%). The average time interval between trauma and surgery was 12.7 ± 7.5 days. Patients achieved a moderate level of activity postoperatively with a median TAS of 4 (3-5.5) and reported good to excellent outcome scores (Lysholm score: 97 (86.5-100); IKDC: 80.7 ± 13.5; KOOS subscales: pain 97.2 (93.1-100), symptoms 92.9 (82.5-100), activities of daily living 97.1 (93.4-100), sport and recreation function 80 (40-97.5) and knee-related quality of life 87.5 (62.5-100). All patients were able to fully return to work and reported little pain [VAS: 0 (0-0)]. No postoperative complications were reported. Strength measurements revealed a significant deficit of knee extension strength in comparison to the contralateral side (p = 0.011).

CONCLUSION

Suture anchor refixation of acute QTR leads to good functional results and high patient satisfaction without major complications. Isometric knee extension strength, however, may not be fully restored compared to the unaffected side.

Acute Quadriceps Tendon Rupture: Presentation, Diagnosis, and Management

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The incidence of quadriceps tendon rupture is estimated to be 1.37 cases per 100,000 people/year, with a predilection for these injuries in patients who are ≥40 years of age.

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Quadriceps tendon ruptures are more likely to occur in the presence of preexisting comorbidities such as rheumatoid arthritis, systemic lupus erythematosus, gout, chronic kidney disease, secondary hyperparathyroidism, diabetes mellitus, and peripheral vascular disease. The most common mechanism of injury is a simple fall.

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Magnetic resonance imaging is the gold-standard test for diagnosing quadriceps tendon ruptures, with a reported sensitivity, specificity, and positive predictive value of 1.0.

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Complete tears require prompt surgical intervention; the most common technique is transosseous sutures passed through longitudinal patellar drill holes. Suture anchors have been proposed as an alternative method; they have shown superior biomechanical results in cadaveric models.

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Early functional mobilization with full weight-bearing and progressive range-of-motion exercises is recommended for rehabilitation following injury.

Quadriceps tendon repair using double row suture anchor fixation: Case reports and review of the literature

Introduction

Traumatic rupture of the quadricipital tendon is rare and disabling. The traditional repair technique involving transpatellar tunnels is still relevant, but this technique seems to be superseded for the technique using anchors. This study aimed to present the place of the anchors in quadriceps tendon tears, and assess the functional results after a means follow-up of 18.66 months.

Case reports

We report 03 cases of acute rupture of the quadricipital tendon collected in the Trauma Surgery and Orthopaedics Department. The average age was 53.66 years, all patients were male, the rupture occurred after a sporting accident in one case, and in 2 cases concerning minimal trauma from a fall in 2 patients followed for renal failure. The average consultation time was 48 h. The right knee was affected in 2. The clinical presentation was identical in all patients with the deficit of active extension of the leg. All patients were treated surgically with the use of double row anchors. The technique used consisted of insertion of two 5.0 mm anchors at the base of the patella, and the proximal part of the quadricipital tendon was sutured with heavy absorbable sutures using Krakow suture.

Results

At a mean follow-up of 18.66 months, no infectious complications were noted, no active extension deficit and the active flexion average was 123.33°.

Conclusion

The rupture of the quadricipital tendon is a rare injury. Surgical treatment by double row anchors gives excellent results with a satisfactory medium-term functional recovery and allow early rehabilitation.

•

Quadriceps tendon ruptures are rare and compromise the knee's extension mechanism.

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The surgical traditional technique consisted of reinsertion of the quadricipital tendon by transosseous stitches.

•

Surgical repair with suture anchors has been shown to have decreased gap formation and increased ultimate loads to failure.

Isokinetic Evaluation of Knee Strength and Endurance in Hemodialysis Patients Treated with the Transpatellar Tunnel Technique for Bilateral Spontaneous Quadriceps Tendon Ruptures

There are numerous surgical techniques described for treating acute quadriceps tendon rupture. We aim to evaluate the strength of the quadriceps tendon using isokinetic tests in hemodialysis patients treated with the transpatellar tunnel technique for bilateral spontaneous quadriceps tendon ruptures. Additionally, functional and clinical results were investigated and compared with hemodialysis patients without a history of quadriceps tendon rupture. We retrospectively reviewed hemodialysis patients diagnosed with quadriceps tendon rupture who were operated between 2005 and 2015 at our institution. Eight patients with simultaneous bilateral quadriceps tendon rupture treated with the transpatellar tunnel technique (group 1; the operated group) and 10 patients with chronic renal failure without a history of quadriceps tendon rupture who underwent hemodialysis (group 2; the control group) were included in this study. The active range of motion (ROM), Lysholm and Tegner scores, knee flexor and extensor muscle strengths, and endurances were measured using an isokinetic dynamometer for each group and compared between the groups. The mean age was 44.6 and 40.2 years in groups 1 and 2, respectively. The mean follow-up was 58.6 (range, 24-140) months in group 1. The active ROM was 113.7 ± 9.7 degrees in group 1 and 130 ± 4.8 degrees in group 2 (p < 0.001). The mean Tegner score was not significantly different between the groups (1.87 ± 1.1 in group 1 vs. 2.6 ± 0.9 in group 2; p = 0.212). However, the Lysholm score was significantly higher in group 2 (93.2 ± 7.3 vs. 76.7 ± 13.8; p = 0.009). The mean extensor strength and endurance were significantly higher in group 2 than in group 1. The mean flexor strength and endurance were higher in group 1 than in group 2, but no significant difference was found. Although using the transpatellar tunnel technique for bilateral spontaneous quadriceps tendon ruptures in hemodialysis patients can provide acceptable functional results, the ROM and strength particularly in extensor muscle might be significantly lower than control group. Level of evidence is Level III therapeutic case-control study.

Early, Bilateral Re-Rupture of Quadriceps Tendon After Previous Bone-Anchor Repair for Simultaneous, Low-Energy, Bilateral Quadriceps Rupture: A Case Report and Literature Review

Patient: Male, 42-year-old

Final Diagnosis: Bilateral quadriceps tendon re-rupture

Symptoms: Disability • pain

Medication: —

Clinical Procedure: —

Specialty: Orthopedics and Traumatology

Biomechanical Testing of Suture Anchor Versus Transosseous Tunnel Technique for Quadriceps Tendon Repair Yields Similar Outcomes: A Systematic Review

Purpose

To systematically review the literature to evaluate the biomechanical properties of the suture anchor (SA) versus transosseous tunnel (TO) techniques for quadriceps tendon (QT) repair.

Methods

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase using PRISMA guidelines to identify studies that evaluated the biomechanical properties of SA and TO techniques for repair of a ruptured QT. The search phrase used was “quadriceps tendon repair biomechanics”. Evaluated properties included ultimate load to failure (N), displacement (mm), stiffness (N/mm), and mode of failure.

Results

Five studies met inclusion criteria, including a total of 72 specimens undergoing QT repair via the SA technique and 42 via the TO technique. Three of 4 studies found QTs repaired with SA to have significantly less elongation upon initial cyclic loading when compared to QTs repaired with the TO technique (P < .05). Three of 5 studies found QTs repaired with SA to have significantly less elongation upon final cyclic loading when compared to QTs repaired with the TO technique (P < .05). The pooled analysis from 4 studies reporting on initial displacement showed a statistically significant difference in favor of the SA group compared to the TO group (P = .03). The pooled analysis from studies reporting on secondary displacement and ultimate load to failure showed no significant difference between the SA and TO groups (P > .05). The most common mode of failure in both groups was suture slippage.

Conclusion

On the basis of the included cadaveric studies, QTs repaired via the SA technique have less initial displacement upon cyclic testing when compared to QTs repaired via the TO technique. However, final displacement and ultimate load to failure outcomes did not reveal differences between the two fixation strategies. Knot slippage remains a common failure method for both strategies.

Quadriceps reconstruction with suture anchor and Achilles allograft combination in quadriceps tendon re-rupture after primary surgical repair: A novel technique

Quadriceps ruptures are one of the pathological conditions of the knee extensor mechanism, accounting for 3% of all tendon injuries. These injuries cause substantial disability of the extensor mechanism. Primary repair is the treatment of choice in acute presentation. In the setting of chronic conditions, the treatment becomes more challenging. Available surgical options include lengthening procedures, and reconstruction with auto graft or allografts. The traditional Scuderi and Codivilla techniques are challenging to perform in degenerative or traumatic retracted ruptures. There is no standard effective treatment in these patients, which yields the best clinical and biomechanical outcomes. An 18-year-old male patient with quadriceps re-rupture after a primary repair was managed with allograft reconstruction using suture anchors. At six years of follow-up, the patient gained a full range of motion with excellent clinical outcomes. He returned to his previous work. In conclusion, quadriceps reconstruction using suture anchor and Achilles allograft combination is a feasible technique in neglected cases who present with quadriceps tendon re-rupture after primary surgical repair.

A Simultaneous Rupture of the Patellar Tendon and the Con-tralateral Quadriceps Tendon in a Patient with Chronic Renal Failure Undergoing Long Term Hemodialysis

Background:

Quadriceps or patellar tendon rupture incidence is relatively low, especially simultaneous bilateral rupture, which usually reported as a complication of chronic systemic disorders such as renal failure.

Objective:

Herein, we report a case of bilateral knee extensor mechanism ruptured in a patient with chronic renal failure on long standing hemodialysis.

Case presentation:

A 38-year-old white male, a known case of chronic renal failure on long term hemodialysis, presented to our clinic with clinical signs of bilateral simultaneous knee extensor tendons rupture. After proper workup simultaneous quadriceps and contralateral patellar tendons rupture diagnosis was made. The patient was managed with surgical repair of the tendons and within few days after the surgery he started physiotherapy and rehabilitation program, using walking crutches partial weight bearing mobilization was allowed, and a gradual increase of knee flexion within brace was applied. He used the knee braces and the walking crutches for two months, to ensure complete healing of the repaired tendon with a sufficient strength to allow full weight bearing. At four-year follow-up, complete bilateral knee extensor tendons healing and both knees functional outcome was satisfactory.

Conclusion:

A simultaneous rupture of quadriceps and contralateral patellar tendons is a rare event in patients with chronic renal failure undergoing long term hemodialysis. With early surgical intervention and good physiotherapy, the patient usually has good recovery of both knees function.

Quadriceps Tendon Repair Using Double-Row Suture Anchor Fixation

Quadriceps tendon ruptures compromise the knee extensor mechanism and cause an inability to ambulate and significant functional limitations. Therefore, the vast majority of quadriceps tendon ruptures are indicated for operative intervention to restore patient mobility and function. Although these injuries were traditionally repaired using a transosseous repair technique, recent literature has shown that suture anchor repair may offer biomechanical advantages. Additionally, research in other areas of orthopaedics has found that a double-row suture anchor construct can offer additional biomechanical strength to tendinous repair. This technical note describes a safe and effective quadriceps tendon repair using a double-row suture anchor construct.

Suture Anchor Versus Transosseous Tunnel Repair for Inferior Pole Patellar Fractures Treated With Partial Patellectomy and Tendon Advancement: A Biomechanical Study

Background:

Comminuted inferior pole patellar fractures can be treated in numerous ways. To date, there have been no studies comparing the biomechanical properties of transosseous tunnels versus suture anchor fixation for partial patellectomy and tendon advancement of inferior pole patellar fractures.

Hypothesis:

Suture anchor repair will result in less gapping at the repair site. We also hypothesize no difference in load to failure between the groups.

Study Design:

Controlled laboratory study.

Methods:

Ten cadaveric knee extensor mechanisms (5 matched pairs; patella and patellar tendon) were used to simulate a fracture of the extra-articular distal pole of the patella. The distal simulated fracture fragment was excised, and the patellar tendon was advanced and repaired with either transosseous bone tunnels through the patella or 2 single-loaded suture anchors preloaded with 1 suture per anchor. Load to failure and elongation from cycles 1 to 250 between 20 and 100 N of force were measured, and modes of failure were recorded. Statistical analysis was performed using a paired 2-tailed Student t test.

Results:

The suture anchor group had less gapping during cyclic loading as compared with the transosseous tunnel group (mean ± SD, 6.83 ± 2.23 vs 13.30 ± 5.74 mm; P = .047). There was no statistical difference in the load to failure between the groups. The most common mode of failure was at the suture-anchor interface in the suture anchor group (4 of 5) and at the knot proximally on the patella in the transosseous tunnel group (4 of 5).

Conclusion:

Suture anchors yielded similar strength profiles and less tendon gapping with cyclic loading when compared with transosseous tunnels in the treatment of comminuted distal pole of the patellar fractures managed with partial patellectomy and patellar tendon advancement.

Clinical Relevance:

Suture anchors may offer robust repair and earlier range of motion in the treatment of fractures of the distal pole of the patella. Clinical randomized controlled trials would help clinicians better understand the difference in repair techniques and confirm the translational efficacy in clinical practice.

Suture repair of patellar inferior pole fracture: Transosseous tunnel suture compared with anchor suture

Patellar inferior pole fracture is difficult to treat due to the inherent weakness of small comminuted distal fragments. However, suture fixation was recently introduced and reported. The aim of the present study was to evaluate and compare the clinical outcomes of two suture techniques, transosseous tunnel suture (TTS) and anchor suture (AS), for the fixation of patellar inferior pole fracture. A total of 35 patients with patellar inferior pole fracture treated at the Second Affiliated Hospital of Nanchang University (Nanchang, China) between June 2014 and April 2018 were retrospectively reviewed. Of these, 14 were treated with the TTS technique and 21 using AS fixation. The operation time, incision length and total cost were determined and compared. Functional outcomes were analyzed with the visual analog scale (VAS), Bostman and Lysholm scores and knee joint ranges of motion (ROMs). Postoperative complications were also observed and recorded. The mean follow-up was 22.6±9.7 and 18.7±5.9 months for TTS and AS, respectively. The groups were similar regarding age, sex, operative side and time to surgery. A smaller incision length and shorter operation time but higher hospital costs were observed in the AS group (P<0.01). For functional evaluation, there was no significant difference in VAS, Bostman and Lysholm scores or ROM between the 2 groups (P>0.05). No postoperative complications were observed in the TTS group. Only one patient in the AS group experienced a superficial minor wound infection. The TTS and AS techniques provided similarly satisfactory clinical outcomes for treating patellar inferior pole fracture. TTS had the advantage of cost-effectiveness due to saving anchors, while AS had a shorter operation time and a smaller incision length.

Safety and Performance of Titanium Suture Anchors Used in Knee Ligament Repair Procedures

Injuries to the knee ligaments can be particularly disabling in young patients, given the risk of long-term disability if adequate fixation is not achieved during initial repair. The TWINFIX™ titanium (Ti) suture anchor with ULTRABRAID™ Suture (Smith and Nephew, London, UK) was designed to secure tendon and ligament reconstructions with increased boney ingrowth at the anchor site with minimal invasive technique. This retrospective analysis looked at 33 patients (41 implants) operated with this device between 2015 and 2019 at a single institution. The average age of patients was 33.18 years (standard deviation [SD], 15.26), with an average body mass index of 24.88 (SD, 3.49). The indications were lateral extra-articular tenodesis during anterior cruciate ligament reconstruction, medial patellofemoral ligament reconstruction, quadriceps or patellar tendon repair and medial collateral ligament repair. After an average follow up of 24.3 + 6.53 months, there was no reports of clinical failure or radiographic evidence of implant failure or loosening. One patient experienced a complication unrelated to the study device, requiring manipulation under anesthesia with resolution of symptoms. This case series supports the safety and performance of this implants for the knee procedures in which its use is indicated. Additional follow-up will be required to determine whether these effects are sustained at medium- and long-term durations.

Outcomes following quadriceps tendon repair using transosseous tunnels versus suture anchors: A systematic review

INTRODUCTION

Two major techniques are used to repair complete quadriceps tendon ruptures, transosseous tunnel (TT) and the suture anchor (SA). There are multiple studies comparing the biomechanical outcomes of repairs performed with TT or SA. Our purpose was to compare the clinical outcomes following quadriceps tendon repair using SA and TT fixation techniques.

METHODS

Three major search engines were used with predetermined keyword searches to perform a systematic review of literature. These studies were independently scanned by two reviewers using PRISMA criterion. All included studies had to include at least one of the following outcome measures: range of motion (ROM), Lysholm score, complications, and/or re-ruptures.

RESULTS

Using three major search engines, 1039 articles were identified. After removing duplicates and screening for inclusion, 49 articles were reviewed. Two independent reviewers searched the studies to meet the inclusion criteria, and eight studies were selected. These eight studies included 156 knees in the TT group and 54 knees in the SA group. The TT group had a significantly better ROM after QT repair (132.5° versus 127.0°, p = 0.02). There was no significant difference in Lysholm scores between the TT group (92.6) and SA group (91.0, p = 0.11). There were significantly more complications in SA groups (9.3% versus 1.3%, p = 0.013), but not a significant difference in re-rupture rate between those undergoing SA vs. TT repair (3.7% versus 0%, p = 0.065). The SA group had a significantly higher age at time of surgery (63.62 vs. 54.32) CONCLUSION: The current study suggests that, following quadriceps tendon rupture, there are no significant differences in functional outcome between TT and SA techniques. Those undergoing TT repair attained a statistically significantly greater final ROM but this difference may not be clinically relevant. There was a statistically significantly higher rate of post-operative complications using SA technique.

Adjustable Cortical Fixation Device for Quadriceps Tendon Repair: A Cadaveric Biomechanical Study

BACKGROUND

Adjustable cortical fixation devices have demonstrated utility in orthopaedic applications, such as ankle syndesmosis repair.

PURPOSE

To assess the cyclic gap formation of a quadriceps tendon repair technique using an adjustable cortical fixation device compared with repair with knotless suture anchors and suture tape, a modification of conventional suture anchor repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen matched pairs of cadaveric knees were used. Specimens in each pair were randomized to undergo either modified suture anchor repair (control) or adjustable cortical fixation repair. The control repair was performed as previously described. The experimental repair was performed using 2 No. 2 FiberWire sutures placed into the quadriceps tendon in a running locked Krackow configuration and 2 adjustable loop devices passed through transosseous tunnels. The lagging strands of the devices were tensioned to seat the cortical fixation buttons at the inferior patellar pole and then tied to the free Krackow strands at the superior pole to complete the repair. The mean plastic gap (permanent tendon displacement that did not recover with cyclic extension) and mean maximum gap (peak displacement that occurred with cyclic knee flexion and partially recovered with extension) were evaluated during cyclic loading for 500 cycles of full knee extension to 90° of flexion.

RESULTS

At all testing intervals, the mean plastic gap was significantly smaller for the cortical fixation group versus the suture anchor group (P < .02). Similarly, the mean maximum gap was significantly smaller for the cortical fixation specimens at all testing intervals (P < .01). After cyclic loading, the mean maximum gap was significantly smaller in the cortical fixation group (4.80 ± 1.56 mm) versus the suture anchor group (8.47 ± 1.47 mm; P = < .001). The mean plastic gap was also significantly smaller in the cortical fixation versus the suture anchor group (3.25 ± 1.10 mm vs 6.57 ± 1.62 mm, respectively; P = < .001).

CONCLUSION

Quadriceps tendon repair using an adjustable cortical fixation device demonstrated superior biomechanical properties in cyclic displacement testing compared with repair using the suture anchor technique.

CLINICAL RELEVANCE

These results suggest that an adjustable cortical fixation device is a biomechanically viable alternative for quadriceps tendon repair.

Clinical and Biomechanical Outcomes following Knee Extensor Mechanism Reconstruction

Purpose

To evaluate clinical and biomechanical outcomes after knee extensor mechanism reconstruction (KEMR).

Methods

Patients who underwent KEMR at our institution from 2011 to 2018 were identified. Patient-reported outcomes (Kujala, Lysholm, Tegner Activity Scale) were compiled at clinical follow-up. Isokinetic testing was conducted using the BioDex system 4 pro dynamometer at slow (60°/s), intermediate (180°/s), and fast (300°/s) speeds in a 9-patient subset.

Results

From 2011 to 2018, 12 patients (12 knees, 10 male, 5 right, mean age: 54.3 ± standard deviation: 15.2 years) with KEM injuries requiring tendon reconstruction with a 1-year minimum follow up were identified. Postoperative follow-up was 42.6 months (range: 12.0-93.0 months). Procedures included patellar (7) and quadriceps tendon reconstruction (5). Postoperative versus preoperative Tegner Activity Scale scores demonstrated significant improvement (3.5 ± 2.5 vs 1.5 ± 1.2, n = 8, P = .05). Postoperative versus preoperative Kujala scores significantly improved (70.3 ± 11.7 vs 43.6 ± 15.7, n = 8, P = .010). There was significant improvement in preoperative to postoperative KEMR extension lag (29.4 ± 22.2° vs 0.83 ± 1.9°, P = .002). Clinically, there was no difference in passive range of motion between the operative and contralateral knee. BioDex testing demonstrated decreased maximum work generated from the operative versus contralateral knee at slow (70.4 ± 30.4 Joules vs 101.9 ± 40.6 J; P = .028), intermediate (52.0 ± 45.4 J vs 69.8 ± 63.7 J; P = .038), and fast (43.8 ± 41.7 J vs 57.5 ± 53.8 J; P = .050) speeds. Range of motion was less in the operative versus contralateral knee at all speeds: P = .011, .038, and .024. The average peak torque generated per body weight was smaller in the operative versus contralateral knee at slow speed (P = .038).

Conclusions

Patients undergoing KEMR in this study have significantly improved clinical outcomes despite having strength deficits that persist postoperatively.

Level of Evidence

Therapeutic Case Series, Level IV.

Suture Tape Reduces Quadriceps Tendon Repair Gap Formation Compared With High-Strength Suture: A Cadaveric Biomechanical Analysis

PURPOSE

To compare the biomechanical differences between quadriceps tendon (QT) repair with high-strength suture (HSS) versus suture tape (ST) with varying number of suture passes.

METHODS

In total, 28 fresh-frozen QTs were randomized into 2 groups: (1) HSS; or (2) ST; specimens were then further randomized into subgroups of either 4 or 6 suture passes. Specimens were secured within a materials testing system and a 150-N preload was applied for 10 seconds followed by a cyclic loading protocol between 50 N and 250 N for 1000 cycles. Video was used to follow tracking markers used to calculate the magnitude of tendon displacement. Two-way univariate analysis of variance was used to determine the effect of suture type and passes on the displacement after preloading and mixed repeated-measures analysis of variance was used to determine the effect of suture type and passes on displacement following cyclic loading.

RESULTS

There were large increases in displacement following the preload across all conditions (7.82 ± 3.64 mm), with no statistically significant differences between groups. There was a significant difference in the mean (± standard deviation) displacement between the ST (5.24 ± 2.82 mm) and HSS (7.93 ± 2.91 mm) starting at 200 cycles, which became more pronounced with successive testing out to 1000 cycles (P = .021). There were no significant difference with respect to the number of suture or tape passes.

CONCLUSIONS

Following preloading at 150 N, significant displacement occurred in both QT repair groups. ST demonstrated significantly less displacement than HSS under cyclic loading and had greater ultimate failure loads.

CLINICAL RELEVANCE

When performing QT repair, emphasis should be placed on appropriate pretensioning of sutures to at least 150 N before knot-tying. In addition, where available, ST should be used over HSS to reduce further cyclic elongation and improve ultimate failure loads.

Bilateral Avulsion Fracture of the Fibula Head of the Knee Associated with Avulsion Fracture of the Iliotibial Band: A Rare Case of Fracture Segond Associated with Arcuate Fracture

Fibular head avulsion fractures are rare and are so-called the arcuate signal. Avulsion fracture of the iliotibial band and anterolateral ligament is known as a Segond fracture, and it is another rare entity. We describe the case of a 27-year-old woman who was hit by a car and suffered polytrauma, mainly suffering injuries to both knees. Radiographs of the knees showed a Segond fracture associated with the arched signal bilaterally. The aim of this study is to present a rare case report and literature review of a bilateral fibular head avulsion fracture associated with an anterolateral tibial avulsion fracture.

The utility of electrocautery for suture passage through bone: A biomechanical study

Electrosurgical devices are routinely employed during surgery. The use of a Bovie Electrosurgical Unit (ESU) to facilitate the passage of a suture needle through bone has not been studied in the literature. This study aimed to identify force reduction with the application of Bovie ESU to the suture needle through the bone. Peak and the average axial force required for a suture needle to penetrate cadaveric proximal humeri were measured using a custom setup. Twenty-four trials were conducted without electricity, and 72 trials were conducted with a Bovie ESU applying current. Needle size and Bovie ESU power settings were varied. t Tests and analysis of variance were used with p ≤ 0.05 denoting statistical significance. The application of electricity reduced the peak and average axial force needed for a needle to pierce bone, regardless of the Bovie ESU power setting (p < 0.001). The average peak force with the Bovie ESU was 65.7 N, compared with 126.0 N without (p < 0.001), a 47.9% reduction. The average axial force with the Bovie ESU was 38.2 N compared with 81.8 N without (p < 0.001), a 53.3% reduction. There was no significant difference in peak or average axial forces between power settings. At 30 and 90 W of power, larger needle size was associated with significantly lower peak (p = 0.001 and p < 0.001, respectively) and axial (p = 0.002 and p = 0.004, respectively) force. The Bovie ESU reduces the axial force required to pass a suture needle through bone. The use of this technique may allow for the avoidance of drilling for soft tissue repair. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:954-960, 2020.

Clinical outcomes after treatment of quadriceps tendon ruptures show equal results independent of suture anchor or transosseus repair technique used - A pilot study

Biomechanical studies have shown the use of suture anchors (SA) to be superior to the traditional transosseous sutures (TS) in the repair of quadriceps tendon rupture (QTR). This study aimed to analyze and compare the functional outcomes of patients treated for quadriceps tendon ruptures using suture anchors or transosseous sutures. Patients having undergone suture anchor repair or transosseous suture repair for quadriceps tendon rupture between 2010 and 2015 at one of the two participating hospitals were included. Patients from site A underwent TS repair (TS group) while patients from site B underwent SA repair (SA group). Exclusion criteria included previous or concomitant injuries of the involved knee, penetrating injuries and pre-existing neurological conditions. Clinical outcome was assessed by subjective scores (Lysholm and Tegner Scores, International Knee Documentation Committee (IKDC) Score, Visual Analog Scale (VAS) for pain), quadriceps isokinetic strength testing, Insall-Salvati Index (ISI), and physical examination. Non-parametrical statistical analysis was conducted using the Mann-Whitney U test. Twenty-seven patients were included in the study of which 17 patients (63%) were available for follow-up (SA group: 9, TS group: 8). All patients were male with a mean age of 62.7 (SD: 8.8) and 57.9 (SD: 12.7) years for the SA group and TS group, respectively. The groups did not differ in terms of demographic characteristics. No clinically significant differences were identified between the two groups. There were no re-ruptures in either group. Treatment of quadriceps tendon rupture using suture anchors provides a clinically valid alternative treatment to the gold-standard transosseous suture repair.

Open Repair of Quadriceps Tendon With Suture Anchors and Semitendinosus Tendon Allograft Augmentation

Quadriceps tendinopathy in an increasingly recognized diagnosis can lead to quadriceps tendon rupture, especially in the older population. It can be caused by repeated micro trauma or also predisposed by systemic diseases such as diabetes mellitus and connective tissue disorders that can in turn lead to extensor mechanism deficits. Although a trial of conservative treatment is advocated, operative treatment should be performed in cases of persistent pain, extension deficit, or complete rupture of the tendon. The purpose of this Technical Note is to describe in detail a procedure for open repair of a quadriceps tendon, with significant degeneration due to quadriceps tendinopathy, using suture anchors and semitendinosus tendon allograft augmentation.

Acute quadriceps tendon rupture repaired by suture anchors: Outcomes at 7 years' follow-up in 25 cases

INTRODUCTION

Acute quadriceps tendon rupture is rare. The gold-standard repair technique is transosseous patellar suture. Biomechanical studies have validated the use of anchors as an alternative. The present study sought to report long-term clinical and radiological results in a series of acute quadriceps tendon rupture repaired with anchors. The study hypothesis was that results are comparable to those of the gold-standard technique.

METHODS

A retrospective continuous study included 25 knees with acute quadriceps tendon rupture, operated on by a single surgeon between 2007 and 2013: 22 patients; 17 males, 5 females; mean age, 64 years (range: 52-87 years). Modified Bunnell suture was performed, using either 2 anchors (19 knees) or 3 anchors (6 knees). Anchors were positioned under 20° flexion. The factors studied were: active range of motion, muscle strength, patient satisfaction, Lysholm score, return to work, and the radiological behavior of the anchors.

RESULTS

At a mean follow-up of 7 years (range: 3-9 years), all but 1 patient had 0° active extension. Mean active flexion was 128° (range: 110-150°), and mean muscle strength was 4.9/5. Mean Lysholm score was 92. Subjective results proved satisfactory or very satisfactory in 23 cases. Working patients returned to work at a mean 4.2 months. There were no cases of anchor migration or of re-rupture. One poorly tolerated anchor was ablated at 2 years, without functional impact.

CONCLUSION

Outcomes with anchors were comparable to those of the gold-standard technique. Anchors allow immediate rehabilitation, without risk of anchor migration. The technique provided satisfactory functional recovery.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Arthroscopic suture repair of acute quadriceps tendon ruptures

Acute quadriceps tendon ruptures disrupt the continuity of the extensor mechanism and must be treated surgically. Tendon reattachment with suture anchors has recently been shown to be biomechanically superior to reattachment through transosseous tunnels. In this context, arthroscopy is an interesting alternative. It can limit postoperative wound healing and infectious complications, while ensuring functional outcomes that are equivalent to standard techniques. The goal of this technical note is to describe an original, reproducible method for arthroscopic reattachment of the quadriceps tendon with suture anchors. Four patients were operated using this technique in a pilot study. No wound healing, infectious complications or re-tears were observed. At 6 months' postoperative, the mean subjective IKDC score was 85.8/100.

Knotless Suture Anchor With Suture Tape Quadriceps Tendon Repair Is Biomechanically Superior to Transosseous and Traditional Suture Anchor-Based Repairs in a Cadaveric Model

PURPOSE

To compare the biomechanical properties of a knotless suture anchor with suture tape quadriceps tendon repair technique with transosseous and suture anchor repair techniques.

METHODS

Twenty matched pairs of cadaveric knees underwent a quadriceps tendon avulsion followed by repair via the use of transosseous tunnels with #2 high-strength sutures, 5.5-mm biocomposite fully threaded suture anchors with #2 high-strength sutures, or 4.75-mm biocomposite knotless suture anchors with suture tape. Ten knees were repaired via transosseous repair and 10 via fully threaded suture anchor repair, and their matched specimens were repaired with suture tape and knotless anchors. Biomechanical analysis included displacement during cyclic loading over 250 cycles, construct stiffness, ultimate load to failure, and failure mode analysis.

RESULTS

Compared with transosseous repairs, quadriceps tendons repaired with knotless suture tape demonstrated significantly less displacement during cyclic loading (cycles 1-20 3.6 ± 1.3 vs 6.3 ± 1.9 mm, P = .003; cycles 20-250 2.0 ± 0.4 vs 3.1 ± 0.9 mm, P = .011), improved construct stiffness (67 ± 25 vs 26 ± 12 N/mm, P = .001), and greater ultimate load to failure (616 ± 149 vs 413 ± 107 N, P = .004). Our repair technique also demonstrated improved biomechanical parameters compared with fully threaded suture anchor repair in initial displacement during cyclic loading (cycles 1-20 3.0 ± 0.8 vs 5.1 ± 0.9 mm, P < .001), construct stiffness (62 ± 20 vs 28 ± 10 N/mm, P = .001) and ultimate load to failure (579 ± 129 vs 399 ± 87 N, P = .006).

CONCLUSIONS

Repair of quadriceps tendon ruptures with this knotless suture anchor with suture tape repair technique is biomechanically superior in cyclic displacement, construct stiffness, and ultimate load to failure compared with transosseous and fully threaded suture anchor techniques in cadaveric specimens.

CLINICAL RELEVANCE

The demonstration that our repair technique is biomechanically superior to previously described techniques in a cadaveric setting suggests that consideration should be given to this technique.

Biomechanical comparison of fixation techniques for medial collateral ligament anatomical augmented repair

PURPOSE

Although the majority of medial collateral ligament (MCL) ruptures can be treated conservatively with good results, some injuries require operative treatment. Besides MCL reconstruction, anatomical augmented repair may be considered. This study was to assess biomechanical properties of different fixation techniques regarding elongation and ultimate load to failure.

METHODS

MCL anatomical augmented repair was simulated by fixation of porcine superficial digital flexor tendon grafts at porcine tibiae. Ten different fixation techniques were assessed. Fixation of the tendon graft was performed using 4.0-mm cancellous screws and either (1) 13.5-mm spiked polyether ketone (PEEK) washers; (2) 14-mm spiked washers; (3) 14-mm suture washers; (4) 14-mm customized washers; (5-8) combination of washers and No. 2 polyester sutures (FiberWire©); or using (9) single or (10) double 5.5-mm titanium suture anchors with No. 2 polyethylene sutures (Ultrabraid^®). Biomechanical analysis included pretensioning of the constructs at 20 N for 30 s following cyclic loading of 250 cycles between 20 and 100 N at 1 Hz for measurement of elongation. Additionally, ultimate failure load and failure mode analysis were performed.

RESULTS

Spiked PEEK washers secured with polyester sutures (5) yielded best biomechanical properties at time zero for both, elongation during cyclic loading (2.9 ± 0.7 mm) and ultimate failure load (469.8 ± 64.3 N).

CONCLUSIONS

These results suggest that spiked PEEK washers secured with polyester sutures are the most appropriate fixation technique for MCL anatomical augmented repair, thus providing best requirements to allow early knee mobilization and prevent secondary knee laxity.

Biomechanical Evaluation of Suture Anchor Versus Transosseous Tunnel Quadriceps Tendon Repair Techniques

PURPOSE

To evaluate the biomechanical fixation strength of suture anchor and transosseous tunnel repair of the quadriceps tendon in a standardized cadaveric repair model.

METHODS

Twelve "patella-only" specimens were used. Dual-energy X-ray absorptiometry measurement was performed to ensure equal bone quality amongst groups. Specimens were randomly assigned to either a suture anchor repair of quadriceps tendon group (n = 6) or a transosseous tunnel repair group (n = 6). Suture type and repair configuration were equivalent. After the respective procedures were performed, each patella was mounted into a gripping jig. Tensile load was applied at a rate of 0.1 mm/s up to 100 N after which cyclic loading was applied at a rate of 1 Hz between magnitudes of 50 to 150 N, 50 to 200 N, 50 to 250 N, and tensile load at a rate of 0.1 mm/s until failure. Outcome measures included load to failure, displacement at 1st 100 N load, and displacement after each 10th cycle of loading.

RESULTS

The measured cyclic displacement to the first 100 N, 50 to 150 N, 50 to 200 N, and 50 to 250 N was significantly less for suture anchors than transosseous tunnels. There was no statistically significant difference in ultimate load to failure between the 2 groups (P = .40). Failure mode for all suture anchors except one was through the soft tissue. Failure mode for all transosseous specimens but one was pulling the repair through the transosseous tunnel.

CONCLUSIONS

Suture anchor quadriceps tendon repairs had significantly decreased gapping during cyclic loading, but no statistically significant difference in ultimate load to failure when compared with transosseous tunnel repairs. Although suture anchor quadriceps tendon repair appears to be a biomechanically superior construct, a clinical study is needed to confirm this technique as a viable alternative to gold standard transosseous techniques.

CLINICAL RELEVANCE

Although in vivo studies are needed, these results support the suture anchor technique as a viable alternative to transosseous repair of the quadriceps tendon.

Biomechanical comparison of three methods for distal Achilles tendon reconstruction

PURPOSE

To compare the load at failure and stiffness associated with three surgical techniques for distal Achilles tendon reconstruction (AT).

METHODS

Nine matched pairs of fresh-frozen human cadaveric ATs were divided into three groups. Distal AT reconstruction was performed using suture anchors or one of two lengths of tendon overlap (10 or 5 mm). Each tendon was loaded to failure. The load at failure (N), stiffness (N/mm), and mode of failure were recorded. Differences in load at failure and stiffness were analysed.

RESULTS

Mean load at failure was significantly higher in the 10-mm group than in the 5-mm group (p < 0.05) or the suture-anchor group (p < 0.05). Load at failure did not differ significantly between the suture-anchor and 5-mm group, and stiffness did not differ significantly between any two groups. In the 10- and 5-mm groups, failure was caused by the grafts pulling out through the substance of the AT. Modes of failure varied in the suture-anchor group.

CONCLUSIONS

The load at failure was higher in the 10-mm group than in the 5-mm and suture-anchor groups. Although all three surgical techniques provide sufficient primary load-bearing ability, the 10-mm tendon-overlap technique may be more conducive to early post-operative rehabilitation.