Chronic Quadricep Tendon Rupture Reconstruction with Poly-Tape and Achilles' Tendon Allograft: A Case Report and Review of the Literature

Introduction

Chronic rupture of the quadriceps tendon is an uncommon but debilitating injury, seen only in 1.37/100,000 patients per annum. The problems associated with this injury are the inability to walk due to disruption of the extensor mechanism and pain. There is limited literature on the reconstruction methods for this injury. This study aims to provide a case report and review of similar cases, using artificial tape and allograft.

Case Report

A 60-year-old male patient was operated on for chronic quadriceps tendon rupture after falling on his knee with forced flexion. The surgical management in our case consisted of mobilization of the proximal quadriceps tendon and muscle belly with a V-Y tendon plasty, advancement of the tendon, and repair using the Krakow technique through intraosseous patellar tunnels, augmented with Poly-Tape (Neoligaments©) and an Achilles' tendon allograft. This was used due to poor patient tissue quality and the extent of the defect. We also searched the literature for chronic quadriceps tendon ruptures reconstruction using poly tape or Achilles' tendon allograft.

Conclusion

Chronic quadriceps tendon rupture repairs have relatively poor outcomes, and no surgical procedure has been proven to be the gold standard treatment. We believe the novel combination of Poly-Tape supplemented with Achilles' tendon allograft produces a structurally competent reconstruction in patients with poor tissue quality and large defects and produced good results in our case report.

Chronic Lateral Ankle Instability Treated With Tendon Allografting: A Preliminary Comparison of Arthroscopic and Open Anatomic Ligament Reconstruction

Background:

Roughly 30% of patients with chronic lateral ankle instability (CLAI) have long-lasting painful instability requiring surgical intervention. Ligament reconstruction with the traditional open method and using tendon allografts can provide sufficient mechanical stability for severe CLAI. Arthroscopic ligament reconstruction with tendon allograft has recently been introduced to treat CLAI.

Purpose:

In this study, we describe an arthroscopic ligament reconstruction procedure involving the use of the tendon allograft for patients with CLAI, and we compare the efficacy of this procedure with open ligament reconstruction with tendon allograft.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We enrolled 10 patients (4 men and 6 women) with CLAI (mean age, 37.3 years; range, 16-57 years) who underwent arthroscopic ligament reconstruction with tendon allografting between November 2017 and June 2019. The control group consisted of 10 patients who received open tendon allograft reconstruction. Preoperative and 2-year postoperative functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale (AOFAS), Karlsson Ankle Functional Score (KAFS), pain visual analog scale (VAS), 12-Item Short Form Health Survey (SF-12), and Tegner activity score (TAS).

Results:

The mean operative time was 118 and 110 minutes in the arthroscopic and open groups, respectively. At 2-year follow-up, scores on the AOFAS improved significantly compared with preoperatively, from 71.3 to 96.4 (P = .006) in the arthroscopic group, and from 68.6 to 96.7 (P = .005) in the open group. The postoperative AOFAS, VAS, KAFS, and SF-12 scores did not differ significantly between the 2 groups; however, the TAS score was significantly higher in the arthroscopic reconstruction group compared with in the open group (7 vs 6.1, respectively; P = .01).

Conclusion:

Arthroscopic ligament reconstruction with tendon allografting resulted in sufficient ankle stability and no donor-site morbidity. This procedure can yield similar functional outcomes to open reconstruction technique and may be an option for the management of CLAI.

Posterior Tibial Tendon Allograft Reconstruction for Stage II Adult Acquired Flatfoot: A Case Series

Surgical treatment for a stage II adult acquired flatfoot has consisted of reconstruction of the diseased posterior tibial tendon with flexor digitorum longus tendon transfer, combined with osteotomies to address the underlying deformity. This case series presents an alternative to tendon transfer using allograft tendon for posterior tibial tendon reconstruction. Four patients who underwent stage II flatfoot reconstruction with posterior tibial tendon allograft transplantation were included. All patients had preoperative radiographs demonstrating flatfoot deformity and magnetic resonance imaging showing advanced tendinopathy of the posterior tibial tendon. Allograft tendon transplant was considered in patients demonstrating adequate posterior tibial tendon excursion during intraoperative assessment. Additional procedures were performed as necessary depending on patient pathology. Postoperatively, all patients remained non-weightbearing in a short leg cast for 6 weeks. Radiographs performed during the postoperative course demonstrated well-maintained and improved alignment. No complications were encountered. Each patient demonstrated grade 5 muscle strength and were able to perform a single-limb heel rise at the time of final follow-up. The average follow-up duration was 19.0 months. Flexor digitorum longus transfer has been studied extensively for stage II adult acquired flatfoot. However, the flexor digitorum longus has been shown to be much weaker relative to the posterior tibial tendon, and concern remains regarding its ability to recreate the force of the posterior tibial tendon. Our results demonstrate that posterior tibial tendon allograft reconstruction combined with flatfoot reconstruction is a reasonable option. This alternative has the advantage of preserving the stronger muscle without disturbing regional anatomy.

Pitfalls during biomechanical testing - Evaluation of different fixation methods for measuring tendons endurance properties

The goal of the study was to find a proper technique to fix tendon grafts into an INSTRON loading machine. From 8 human cadavers, 40 grafts were collected. We removed the bone-patella tendon-bone grafts, the semitendinosus and gracilis tendons, the quadriceps tendon-bone grafts, the Achilles tendons, and the peroneus longus tendons from each lower extremity. We tested the tendon grafts with five different types of fixation devices: surgical thread (Premicron 3), general mounting clamp, wire mesh, cement fixation, and a modified clamp for an INSTRON loading machine. The mean failure load in case of surgical thread fixation was (381N ± 26N). The results with the general clamp were (527N ± 45N). The wire meshes were more promising (750N ± 21N), but did not reach the outcomes we desired. Easy slippages of the ends of the tendons from the cement encasements were observed (253N ± 18N). We then began to use Shi's clamp that could produce 977N ± 416N peak force. We combined Shi's clamp with freezing of the graft and the rupture of the tendon itself demonstrated an average force of 2198 N ± 773N. We determined that our modified frozen clamp fixed the specimens against high tensile forces.

Minimally invasive reconstruction of the lateral ankle ligaments using semitendinosus autograft or tendon allograft

BACKGROUND

The purpose of the study was to retrospectively compare the therapeutic effect between semitendinosus autograft and tendon allograft for lateral ankle ligaments reconstruction.

METHODS

From September 2006 to June 2011, 68 patients (41 males, 27 females) with chronic ankle instability underwent anatomical reconstruction of the lateral ligaments using semitendinosus autograft (autograft group, 32 patients) or tendon allograft (allograft group, 36 patients) via a minimally invasive approach. All patients were followed up for at least 12 months. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and stress tests were used to evaluate the clinical outcomes. Operation time, time to heal and complications were also recorded.

RESULTS

Compared with allograft group, the average operation time was significantly increased (85.5 ± 11.5 minutes vs 58.1 ± 10.2 minutes, P < .0001), but the mean time to heal was significantly shorter (11.2 ± 4.1 months vs 13.5 ± 5.2 months, P = .0458) in the autograft group. Although the mean AOFAS score was significantly increased at the final follow-up in the autograft group (95.1 ± 7.5 vs 62.3 ± 8.2, P = .0001) and allograft group (94.8 ± 5.5 vs 60.2 ± 8.4, P < .0001), no significant difference in AOFAS was found between these 2 groups. Similarly, there was no significant difference in talar tilt or shift between autograft and allograft groups. In addition, no patients complained of weakness or disability at the donor site in the autograft group, while incisional swelling was observed in 4 patients in the allograft group, which was resolved via dressing change, oral use of indomethacin or dexamethasone.

CONCLUSION

Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach was safe and effective for ankle instability with a relatively short time for healing and minimal donor site problems.

LEVEL OF EVIDENCE

Level III, comparative case series.

Use of controlled low dose gamma irradiation to sterilize allograft tendons for ACL reconstruction: biomechanical and clinical perspective

As reviewed here, numerous biomechanical and clinical studies support the use of controlled, low temperature irradiation of allograft tendons, to provide both excellent clinical results and medical-device grade sterile allografts with minimal risk of disease transmission.