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

Experimental study on the mechanical properties and thermal damage of laser welding the ruptured flexor digitorum longus tendons

To investigate the influence of laser parameters on the performance of tendon tissue, experiments were conducted and the process of laser-assisted tendon welding was studied. Several conclusions were drawn by analyzing the effects of laser parameters on the tensile strength, microstructure, and collagen content of tendon tissue incisions. The optimal parameters for laser welding tendon tissue were found to be a laser power of 5 W, a scanning speed of 150 mm/s, and a defocus amount of 0 mm, resulting in a laser energy density of 32.164 J/cm2 . At these parameters, the percentage of inactivated cells due to thermal damage was only 23.78%, and the tensile strength of the tendon tissue incisions reached 0.61 MPa. Additionally, the collagen content around the incision was measured to be 33.679%, composed of type I and type III collagens, with the latter accounting for 50.714% of the total collagen content.

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.

Clinical effectiveness of suture anchor repair combined with open reduction and internal fixation in the treatment of deltoid ligament rupture in ankle fracture

Objective

To explore the clinical effectiveness of suture anchor (SA) repair combined with open reduction and internal fixation (ORIF) in the treatment of deltoid ligament rupture (DLR) in ankle fractures.

Methods

This is a retrospective analysis of 210 patients with DLR in ankle fracture who were treated in Beijing Chaoyang Hospital from January 2020 to June 2022. According to the surgical records, 125 patients received SA repair combined with ORIF (Repair group) and 85 patients received ORIF only (Non-repair group). The curative effect, recovery of ankle joint function, pain, and bone metabolism of the two groups were observed.

Results

The clinical effectiveness (overall good) was higher in the Repair group (P<0.05). The American Orthopedic Foot and Ankle Society (AOFAS) score was higher three and six months post-operation in the Repair group, and the Visual Analogue Scale (VAS) score was lower than that of the Non-repair group (P<0.05). The Repair group had higher levels of bone-specific alkaline phosphatase (BALP) and bone gla protein (BGP) than the Non-repair group six months post-operation (P<0.05).

Conclusions

SA combined with ORIF has a good effect in the treatment of DLR in ankle fracture patients, which can promote the recovery of ankle function, relieve postoperative pain and improve bone metabolism.

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.

Repair of Quadriceps and Patellar Tendon Tears

Tears of the quadriceps or patellar tendon usually occur after a sudden eabccentric contraction and are diagnosed by a palpable gap at the injury site combined with an inability to perform a straight leg raise. Bilateral knee radiographs may demonstrate patella alta with patellar tendon tears and patella baja with quadriceps tendon tears compared with the uninjured knee. Ultrasound and magnetic resonance imaging can be helpful when there is uncertainty in the diagnosis. Surgical treatment is indicated for complete tears and some high-grade, partial tears. Nonabsorbable high-strength sutures or suture tape are placed in running locking fashion along the injured tendon and secured to the patella with bone tunnels (i.e., transosseous) or suture anchors. The transosseous technique requires exposure of the length of the patella to drill 3 bone tunnels to shuttle the sutures and tie over either pole of the patella. The suture anchor technique allows for a smaller incision and less soft-tissue dissection and may use a knotted or knotless technique. Biomechanical testing with load to failure is not statistically different between the transosseous and anchor techniques, although anchors have been shown to have less gap formation at the repair site. Repair augmentation with a graft may be beneficial in mid-substance injuries, chronic tears, and in cases of compromised tissue quality. Rehabilitation usually can be initiated immediately with protected weight-bearing in an orthosis, safe-zone knee passive range of motion, and avoidance of active extension. After a period of 6 weeks, rehabilitation can progress with full range of motion and a concentric strengthening program.

Suture Bridge Transosseous Quadriceps Tendon Repair for Spontaneous Quadriceps Tendon Rupture in Patients With End-Stage Renal Disease

End-stage renal disease with spontaneous quadriceps tendon rupture (QTR) is a specific condition that differs from classic QTR. The tissue quality of the quadriceps tendon (QT), the rupture site, the mechanism of injury, and the pathophysiology of the rupture mechanism all have an effect on conventional QT repair procedures, with a higher likelihood of rerupture or failed repair construction. We believe that our technique provides repair-site stability, strong repair construction, increased contact surface healing, and a reduced chance of rerupture after QT repair. Furthermore, in most patients who have end-stage renal disease with QTR, misdiagnosis and/or underestimation occurs, resulting in proximal retraction of the QT and poor results; however, this technique can be performed with alternative procedures such as augmentation or QT lengthening. The suture bridge transosseous QT repair technique relies on biomechanics knowledge for better stability. Suture bridge repair concept can achieve better healing of all layers of the QT until returning to normal activity with no disability and an improved quality of life.

Do Patellar Tendon Repairs Have Better Outcomes than Quadriceps Tendon Repairs? A Prospective Cohort Analysis

Patellar tendon (PT) and quadriceps tendon (QT) ruptures represent significant injuries and warrant surgical intervention in most patients. Outcome data are predominantly retrospective analyses with low sample sizes. There are also minimal data comparing QT and PT repairs and the variables impacting patient outcomes. The level of evidence of the study is level II (prognosis). From the prospective OME cohort, 189 PT or QT repairs were performed between February 2015 and October 2019. Of these, 178 were successfully enrolled (94.2%) with 1-year follow-up on 141 (79.2%). Baseline demographic data included age, sex, race, BMI, years of education, smoking status, and baseline VR-12 MCS score. Surgical and follow-up data included surgeon volume, fixation technique, baseline, and 1-year Knee Injury and Osteoarthritis Outcome Score-Pain (KOOS-Pain), Knee Injury and Osteoarthritis Outcome Score-Physical Function (KOOS-PS), and 1-year Patient Acceptable Symptom State (PASS) scores and complications. Multivariable regression analysis was utilized to identify prognosis and significant risk factors for outcomes-specifically, whether KOOS-Pain or KOOS-PS were different between QT versus PT repairs. There were 59 patients in the PT cohort and 82 patients in QT cohort. Baseline demographic data demonstrated that PT cohort was younger (45.1 vs. 59.5 years, p <0.001), included significantly fewer patients of White race (51.7 vs. 80.0%, p = 0.001), lesser number of years of education (13.9 vs. 15.2 years, p = 0.020), a higher percentage of "high" surgeon volume (72.9% vs. 43.9%, p = 0.001) and 25.4% of PT repairs had supplemental fixation (QT had zero, p <0.001). Multivariable analysis identified gender (female-worse, p = 0.001), years of education (higher-better, p = 0.02), and baseline KOOS-Pain score (higher-better, p <0.001) as the risk factors that significantly predicted KOOS-Pain score. The risk factors that significantly predicted KOOS-PS were gender (female worse, p = 0.033), race (non-White-worse, p <0.001), baseline VR-12 MCS score (higher-better, p <0.001), and baseline KOOS-PS score (higher better, p = 0.029). KOOS-Pain and KOOS-PS scores improved after both QT and PT repairs. Patient reported pain and function at 1 year were similar between PT and QT repairs after adjusting for known risk factors. Multivariable analysis identified female gender and low baseline KOOS scores as predictors for worse outcomes.

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.

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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.

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