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

Low Tensile Strength Suture With Transosseous Tunnels and Suture Anchors 5 mm in Diameter or Greater Are Associated With Higher Failure Rates in Primary Patellar Tendon Repair

Purpose

To determine the rate of and risk factors for clinical failure and return to military duty following primary patellar tendon repair with either transosseous trunnel repair or suture anchor repair.

Methods

The Military Health System Data Repository (MDR) was queried to identify all adult patients undergoing surgical treatment of a patellar tendon rupture in the Military Health System from 2014 to 2018. Patients who underwent either transosseous tunnel repair or suture anchor repair were included. Health records were examined to collect additional data. Univariate analysis and multivariate logistic regression models were used to determine independent risk factors for rerupture.

Results

A total of 450 knees in 437 patients were included. Transosseous tunnel repair was the most frequently used technique (314/450, 77%), followed by suture anchor repair (113/450, 25%). Rerupture occurred in 33 knees (7%). There was no difference in rerupture rate between transosseous tunnel repair and suture anchor repair (P = .15), and this result persisted within the multivariate logistic regression model. Among transosseous tunnel repairs, use of low tensile strength suture was an independent risk factor for repair failure (odds ratio [OR], 3.4; P = .016). Among suture anchor repairs, use of anchors 5.0 mm in diameter or greater (OR, 12.0; P = .027) was an independent risk factor for repair failure.

Conclusions

There is no statistically significant difference in failure rate between transosseous tunnel repair and suture anchor repair in primary patellar tendon ruptures. However, the use of low tensile strength suture with transosseous tunnels and the use of suture anchors 5.0 mm in diameter or greater resulted in significantly higher failure rates. These data suggest that use of high tensile strength suture in transosseous tunnel repair and use of suture anchors less than 5.0 mm in diameter in suture anchor repair result in lower failure rate in primary patellar tendon repair.

Level of Evidence

Level III, retrospective cohort study.

Acute Patellar Tendon Ruptures: An Update on Management

Patellar tendon ruptures can be debilitating injuries. When incomplete, partial tears can be managed nonsurgically with immobilization and progressive rehabilitation. Although complete ruptures remain a relatively uncommon injury, they portend a high level of morbidity. Ruptures typically result from an acute mechanical overload to the extensor mechanism, such as with forced quadriceps contraction and knee flexion. However, chronically degenerated tendons are also predisposed to failure from low-energy injuries. Diagnosis can often be made clinically with recognition of a palpable defect to the tendon, localized patellar tendon tenderness, and inability to actively extend the knee. Diagnosis and surgical planning can be established with radiograph, ultrasonography, or magnetic resonance imaging. Surgical repair is the mainstay of treatment, and there have been many recent advances in repair technique, optimal reconstruction strategies, and supplemental fixation. Time to surgery for complete tears remains the most important prognosticator for success. Direct primary repair can be completed with transosseous tunnels, suture anchor repair, or end-to-end repair. Tendon reconstruction can be achieved with or without mechanical or biologic augments. Rehabilitation programs vary in specifics, but return to sport can be expected by 6 months postoperatively.

Suture Bridge Technique with 5-Ethibond: A Promising Approach for Infrapatellar Pole Fracture Treatment

Purpose

Infrapatellar pole fractures are challenging injuries that require appropriate treatment to ensure optimal functional outcomes. This study aimed to introduce the application of the Suture Bridge technique using the 5-Ethibond for the treatment of infrapatellar patella fracture.

Methods

Five cases of infrapatellar pole fracture that were treated at our institution between February 2020 and September 2021. The patients included one male and four females, with an average age of 66 years (range: 60-77 years). All patients were treated with the Suture Bridge technique using the 5-Ethibond to preserve the infrapatellar pole.

Results

The average operative time was 64 min (range: 50-80 min). The average blood loss during surgery was 51 mL (range: 40-60 mL). All cases demonstrated fracture healing at an average of 10 weeks (range 8-12) after surgery. The patients were followed up for an average period of 14.8 months (8-22). No wound infection or second displacement of fracture fragment was found. Full range of motion was restored in all patients within 12-14 weeks after surgery. None of the patients complained of anterior knee pain.

Conclusions

Based on the findings of the study, it appears that the Suture Bridge technique using 5-Ethibond is a promising and viable option for the treatment of infrapatellar pole fractures.

Suture Anchor Fixation Has Less Gap Formation and No Difference in Complications or Revisions for Patellar Tendon Repair: A Systematic Review

PURPOSE

To evaluate the literature on suture anchor (SA) usage for patellar tendon repair, summarize the overall biomechanical and clinical outcomes, and assess whether the cumulative research supports the adoption of this technique compared with transosseous (TO) repair.

METHODS

A systematic literature review using the Preferred Reporting Items for Systematic and Meta-Analyses guidelines was performed. Multiple electronic databases were searched to identify studies focusing on surgical outcomes of patellar tendon repair with suture anchor usage. Cadaver and animal biomechanical studies, technical studies, and clinical studies were included.

RESULTS

A total of 29 studies met the inclusion criteria: 6 cadaver, 3 animal, 9 technical, and 11 clinical reports. Four of the 6 cadaver studies and 1 of the 2 animal studies found significantly less gap formation from SA than from TO repair. Average gap formation in human studies ranged from 0.9 to 4.1 mm in the SA group compared with 2.9 to 10.3 mm in TO groups. Load to failure was significantly stronger in 1 of 5 cadaver studies and 2 of 3 animal studies, with human studies SA load to failure ranging from 258 to 868 N and TO load to failure ranging from 287 to 763 N. There were 11 clinical studies that included 133 knees repaired using SA. Nine studies showed no difference between complication rate or risk for reoperation, where one study reported a significantly lower re-rupture rate after SA repair compared with TO repair.

CONCLUSIONS

SA repair is a viable option for patellar tendon repair and could have several advantages over TO repair. Multiple studies indicate that SA repair has less gap formation during biomechanical testing compared with TO repair in human cadaver and animal models. No differences in complications or revisions were found in the majority of clinical studies.

CLINICAL RELEVANCE

Both animal and human models suggest SA fixation has potential biomechanical benefits when compared with TO tunnels for patellar tendon repair, whereas clinical studies show no difference in complications and revisions postoperatively.

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.

Re-tensionable Quadriceps Tendon Repair Technique

Quadriceps tendon rupture is a devastating injury that has traditionally been repaired using bone tunnels and knot tying. Recent innovations seeking to address persistent weakness and gap formation of repairs have used suture anchors and knotless technology. Despite these innovations, the clinical outcomes of these repairs continue to be mixed. We describe a technique that leverages a pre-tied knotted high-tension suture construct to allow for a re-tensionable quadriceps repair.

Chronic Quadriceps Tendon Ruptures: Primary Repair of Quadriceps Via Bioaugmentation and Patellar Tendon Lengthening

Quadriceps tendon ruptures are devastating injuries that impair the extensor mechanism of the knee. Complete tears require prompt surgical intervention in order to ensure optimal clinical outcomes. Chronic, neglected ruptures- marked by severe extensor lag, muscular atrophy, and tendon retraction- are difficult to treat. Further, severe patella baja complicates surgical planning. While there is no consensus on optimal treatment for these injuries, many different techniques have been proposed. Unlike many of these approaches, our technique focuses on restoration of patellar height via patellar tendon lengthening. Once patellar height is restored, quadriceps tendon repair can be performed using the native quadriceps tendon. Both the patellar tendon lengthening and the quadriceps tendon repair are augmented with bioinductive implants to ensure optimal healing environments, enabling us to reestablish native extensor mechanism function.