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

Allogeneic Tendon Transplantation for the Treatment of Pathological Patellar Ligament Defect in Children: Technical Note and 4-Year Follow-Up

OBJECTIVE

The absence of patellar ligament will bring about a severe negative impact on daily life. Many reconstruction techniques have been described in adults. However, there is a lack of technical introduction regarding the reconstruction of the patellar ligament in children. The purpose of this study was to report a surgical technique for reconstructing the patellar ligament in children.

METHOD

A retrospective analysis of the clinical data on a patellar ligament (tendon sheath fibroma) patient with allogeneic tendon reconstruction. An 8-year-old child with postoperative recurrence of left patellar ligament tumor was enrolled in our study. Anterior tibialis tendon allograft was used to reconstruct the patellar ligament after complete resection of the patellar ligament for the tumor. The tunnels were constructed on the deep surface of the tibial tubercle and the root of the quadriceps tendon (to decrease the harmful impact on patella development), respectively. The allogeneic tendon was passed through the tunnels above in the shape of "8," and the two ends of the tendon were attached to the bleeding bone bed at the inferior edge of the patella with suture anchors to achieve better bone-tendon healing. During the follow-up, the knee's range of motion and imaging manifestations were recorded.

RESULT

Postoperative pathology suggests chondromesenchymal hamartoma, a rare benign soft tissue tumor different from the previous operation (tendon sheath fibroma). During the 4-year follow-up, the patient's active range of motion of the knee achieved 0° to 120°; and the patient could walk normally without any external help. Physical examinations (the apprehension sign and J sign) showed no ligamentous instability or patellar ligament tenderness. Imaging analysis showed that the ratio length of the patellar ligament to the patella was almost normal. The integrity, continuity, and shape of the allogeneic ligament showed excellent results in MRI. Combined with clinical and imaging findings, allogeneic tendon patellar ligament reconstruction was deemed successful.

CONCLUSION

Allogeneic ligament reconstruction technique can provide a treatment option by reconstructing the extensor mechanism, minimizing the impact on patellar development, and augmenting biological healing for children with the absence of the patellar ligament.

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.

Intramuscular and intratendinous placenta-derived mesenchymal stromal-like cell treatment of a chronic quadriceps tendon rupture

BACKGROUND

Quadriceps tendon ruptures (QTRs) are rare but debilitating injuries, often associated with chronic metabolic conditions or long-term steroid treatment. While the surgical treatment for acute QTRs is described thoroughly, no common strategy exists for the often frustrating treatment of chronic, reoccurring QTRs. The pro-angiogenic and immunomodulatory properties of placenta-derived adherent mesenchymal stromal-like (PLX-PAD) cells have been described to protect musculoskeletal tissues from inflammation and catabolic cytokine migration, yet little is known about the regenerative potential of PLX-PAD cells in repetitively damaged tendon tissue.

CASE

We report the case of an 80-year-old male patient with a chronic three-time QTR of his right knee. The quadriceps tendon was reconstructed applying a conventional suture anchor repair procedure combined with a synthetic mesh augmentation and additional intramuscular and intratendineous PLX-PAD cell injections as an individualized treatment approach. No adverse events were reported, and excellent radiological and functional outcomes with a passive range of motion of 0/0/120° knee extension-flexion were observed at the 12 month follow-up. Gait analysis confirmed restoration of joint motion, including gait speed, deficit in step length, and knee extensor muscle strength (pre-surgery: 0.98 m/s, 40 cm, 42.4 ± 12.4 N; 9 months post-surgery: 1.07 m/s, 0 cm, 10.4 ± 18.9 N) as well as hyperextension throughout stance and late swing phases (pre-surgery: -11.2 ± 0.9°; 9 months post-surgery: -2.7 ± 1.6°). Postoperative lymphocyte and cytokine analyses from the patient's peripheral blood serum suggested a systemic short-term immunoregulatory reaction with postoperatively increased interleukin (IL)-6 (pre-surgery: 0.79 pg/mL; day 1: 139.97 pg/mL; day 5: 5.58 pg/mL; 9 months: 1.76 pg/mL) and IL-10 (pre-surgery: 0.9 pg/mL; day 1: 1.21 pg/ mL; day 5: 0.3 pg/mL; 9 months: 0.34 pg/mL) levels that decreased again over time.

CONCLUSIONS

Herein, we demonstrate a successfully treated chronic QTR with a synergistic surgical and biological reconstructive treatment approach. This local add-on treatment with PLX-PAD cells may be considered in specific cases of chronic QTRs, not susceptible to traditional suture anchor procedures and which exhibit a high risk of treatment failure. Further scientific engagement is warranted to explore underlying immunomodulatory mechanisms of action behind PLX-PAD cell treatment for tendon injuries.

TREATMENT OF QUADRICEPS TENDON RUPTURE IN HEMODIALYSIS PATIENTS: A 2020 UPDATE

ABSTRACT Quadriceps tendon tears are uncommon injuries often associated with chronic diseases, including end-stage renal disease (ESRD). The role of secondary hyperparathyroidism as a predisposing factor for tendon tears in this group of patients is well documented, and the weakening of the tendon-bone junction is part of this context. The treatment of choice for quadriceps tendon ruptures in patients with ESRD is surgery, which should be performed as soon as possible. There are several surgical techniques to be used, but the lack of comparative studies does not allow us to conclude which one is the best option. More recent publications have preferred the association of techniques, with emphasis on the use of autologous tendon grafts as a reinforcement tool, which is the author’s procedure of choice. Recent studies reported the use of biological agents to stimulate healing and allografts, but the information seems preliminary to be routinely recommended. Level of evidence II; Obsevation of therapeutic studies.

Single-stage quadriceps tendon reconstruction with gastrocnemius fascia and knee soft tissue defect reconstruction with medial gastrocnemius flap-A case report

INTRODUCTION

Quadriceps tendon rupture, although uncommon, is associated with knee joint instability and requires surgical repair. A variety of methods including allografts, synthetic grafts and autologous tendons are used for tendon reconstruction. This work is reported in line with the SCARE criteria (Agha et al., 2018) for case report publication.

PRESENTATION OF CASE

A new method of simultaneous quadriceps tendon reconstruction and soft tissue knee reconstruction in a 38-year-old male patient following trauma to his knee and subsequent multiple surgeries and wound infections. In a single-stage procedure, gastrocnemius muscle fascia was used for quadriceps tendon reconstruction and medial head of the gastrocnemius muscle flap with split-thickness skin graft was used to cover the soft tissue defect on the anterior aspect of the knee following previous post-operative soft tissue infections and subsequent skin necrosis.

DISCUSSION

The only way to maintain the vitality of the patella was to reconstruct the defect with well-vascularized tissue so we decided to use the medial gastrocnemius muscle flap. To obtain good quality tissue for the quadriceps tendon reconstruction, we decided to use the gastrocnemius muscle fascia to minimise the morbidity of the donor region and to reduce the duration of surgery.

CONCLUSION

Postoperatively, the patient had an excellent cosmetic outcome with full active extension and limited flexion of the knee joint caused by the preoperative condition. To our knowledge, quadriceps tendon reconstruction using the gastrocnemius muscle fascia has never been reported in English literature and is as valuable as already known reconstruction methods using other tendons or fascia.

Reconstruction of knee extensor with patellar tendon autograft following intraoperative radiotherapy

BACKGROUND

Patellar tendon autograft after intraoperative extracorporeal radiotherapy has been used for reconstruction of the extensor mechanism following limb-sparing wide tumor resection around the knee. The purpose of this study was to determine the clinical outcome of this reconstruction technique.

METHODS

We retrospectively reviewed six consecutive patients with peripatellar tendon and proximal tibial sarcoma who underwent reconstruction of the knee extensor mechanism. The resection area was planned to be contained with the patellar tendon in order to obtain a wide margin. First, the patella was osteotomized at the midline, and the inferior half of patella, patellar tendon, and tibial tuberosity were excised en bloc. The resected segments were devitalized with intraoperative extracorporeal radiotherapy and reimplanted into the original site. A follow-up evaluation included an assessment of the range of motion, extensor lag, the International Society of Limb Salvage score, and complications.

RESULTS

Six patients were followed up for 121-270 months. One patient underwent an additional reconstruction with total knee arthroplasty due to a collapse of the tibial subchondral bone. A supracondylar fracture of the femur occurred in two patients, and a delayed union of the osteosynthesis site of the tibial shaft was observed in one patient. At the latest follow up, extensor lag had a median of five degrees, and International Society of Limb Salvage scores had a median of 83%. No local recurrence or rupture of the patellar tendon was observed.

CONCLUSIONS

Reconstruction of the knee extensor mechanism using a patellar tendon treated with intraoperative radiotherapy is a reliable and successful method.

Extensor Mechanism Allograft in Osteosarcoma of the Patella: A Case Report

CASE

A 24-year-old female diagnosed with fibroblastic osteosarcoma of the patella underwent a total patellectomy and surgical reconstruction with a large bone-tendon allograft of the extensor mechanism and adjuvant chemotherapy. At 5 years' postoperative, the patient has adequate disease control and excellent joint function.

CONCLUSIONS

Reconstruction with an extensor mechanism allograft is an appropriate alternative for patients with malignant patella tumors without tumor contamination of the joint, allowing for satisfactory knee function and disease control.

Atraumatic acute bilateral quadriceps tendon rupture in a patient with bilateral patella spurs. A case report and review of literature

BACKGROUND AND AIM OF THE WORK

the spontaneous and simultaneous rupture of both quadriceps tendons is uncommon and has rarely been reported in medical literature. The current case involves a 62-years old man with bilateral atraumatic complete quadriceps tendon rupture. Aim of this study is to provide a systematic review of this case and a literature review of similar cases. Methods: we reviewed and analyzed this patient's records. Initial x rays of both knees showed a bilateral patellar spur. Real time ultrasonography scan of both knees showed a complete tear of quadriceps. The repair has consisted on end to end Krackow sutures associated with bone suture to the proximal pole of the patella using patellar drill holes. We also researched the literature for bilateral simultaneous rupture of the quadriceps tendon. Results: The patient suffered only from seasonal asthma (receiving only inhaled corticosteroids) and he was overweight (BMI: 33,5), he did not do any type of sport, he was a biker. The patient was able to walk after 3 weeks with both knee cast. The patients had a 120° pain free range of motion in both knees 4 months after surgery. Conclusion: Simultaneous bilateral quadriceps tendon rupture is really very rare and these are generally reported as case presentation in the literature. This injury usually presents in middle aged people with a history of chronic illness. The general recommendation is to perform surgical intervention within 48-72 hours after injury.

Atraumatic acute bilateral quadriceps tendon rupture in a patient with bilateral patella spurs. A case report and review of literature

BACKGROUND AND AIM OF THE WORK

the spontaneous and simultaneous rupture of both quadriceps tendons is uncommon and has rarely been reported in medical literature. The current case involves a 62-years old man with bilateral atraumatic complete quadriceps tendon rupture. Aim of this study is to provide a systematic review of this case and a literature review of similar cases. Methods: we reviewed and analyzed this patient's records. Initial x rays of both knees showed a bilateral patellar spur. Real time ultrasonography scan of both knees showed a complete tear of quadriceps. The repair has consisted on end to end Krackow sutures associated with bone suture to the proximal pole of the patella using patellar drill holes. We also researched the literature for bilateral simultaneous rupture of the quadriceps tendon. Results: The patient suffered only from seasonal asthma (receiving only inhaled corticosteroids) and he was overweight (BMI: 33,5), he did not do any type of sport, he was a biker. The patient was able to walk after 3 weeks with both knee cast. The patients had a 120° pain free range of motion in both knees 4 months after surgery. Conclusion: Simultaneous bilateral quadriceps tendon rupture is really very rare and these are generally reported as case presentation in the literature. This injury usually presents in middle aged people with a history of chronic illness. The general recommendation is to perform surgical intervention within 48-72 hours after injury.

Allograft Reconstruction of the Extensor Mechanism after Resection of Soft Tissue Sarcoma

INTRODUCTION

Soft tissue tumors around the knee joint still pose problems for the excision and subsequent reconstruction.

METHODS

In the 6 included patients the soft tissue sarcoma has its base on the anterior surface of the extensor mechanism and expands towards the skin. The entire extensor apparatus (quadriceps tendon, patella, and patellar tendon) was resected and replaced by a fresh-frozen allograft.

RESULTS

The mean follow-up was 6.7 years (range: 2-12.4 years). In two patients a local recurrence occurred, resulting in a 5-year local recurrence-free rate of 66.7% (95% CI: 19.5%-90.4%). Distant metastases were found in 4 patients resulting in a 5-year metastasis-free rate of 33.3% (95% CI: 4.6%-67.5%). Two patients underwent at least one revision surgery, including one patient in whom the allograft had to be removed. According to the ISOLS function score 24.7 points (range: 19-28 points) were achieved at the last follow-up. The mean active flexion of the knee joint was 82.5° (range: 25-120°) and a mean extension lag of 10° (range: 0-30°) was observed.

CONCLUSIONS

The replacement of the extensor mechanism by an allograft is a reasonable option, allowing wide margins and restoration of active extension in most patients.

TRIAL REGISTRATION

The presented study is listed on the ISRCTN registry with trial number ISRCTN63060594.