Reconstruction of a quadriceps tendon tear using Polyvinylidene fluoride sutures and patellar screw fixation: A biomechanical study

Comparing clinical outcomes between transosseous patellar suture fixation versus suture anchor repair in the treatment of quadriceps tendon rupture

Background

The standard surgical treatment of quadriceps tendon ruptures remains transosseous suture (TS) repair through the patella. Literature on suture anchor (SA) repair techniques is limited to biomechanical studies and small case series. SA offers superior biomechanical properties while maintaining a less-invasive approach to the patella and surrounding soft tissue. The objective of this study was to compare outcomes and complications of quadriceps tendon ruptures repaired with TS versus SA.

Methods

A retrospective review of patients undergoing surgical repair of quadriceps tendon injuries between 2007 and 2018 was performed. Patients treated with TS repair or SA repair were identified. Clinical outcomes and complications were identified in the electronic medical record. Chi-squared, Fisher's exact, and independent sample t-tests were used to compare SA and TS groups.

Results

This study included 154 quadriceps tendon ruptures in 143 patients: 128 males and 15 females with a mean age of 58.4 years. There were 41 injuries treated with SA repair and 113 injuries treated with TS repair. The average follow-up for the SA and TS groups was 8.0 and 7.9 months, respectively. Extension lag (3.3° vs 1.7°, p = 0.17) and terminal flexion (121° vs 116°, p = 0.29) were not statistically different between the SA and TS groups. Graded strength testing between SA and TS groups (4.4 vs 4.6, p = 0.03) was functionally comparable. There were no differences in complication rates.

Conclusion

SA repair of quadriceps tendon ruptures provided similar clinical results compared to the gold standard TS repair. Range of motion and strength in this short-term follow-up study were comparable between groups with no difference in complication rates.

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.

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.

[Improved technique for perforation of patella combined with suture anchor and non-tourniquet for repairing acute rupture of the bone tendon junction of quadriceps tendon]

Objective

To investigate effectiveness of a improved technique for perforation of patella combined with suture anchor and non-tourniquet for repairing acute rupture of the bone tendon junction of quadriceps tendon.

Methods

Between June 2010 and June 2016, 15 patients with acute rupture of the bone tendon junction of quadriceps tendon were treated with the improved technique for perforation of patella combined with suture anchor and non-tourniquet. Of them, 14 were male and 1 was female, aged from 19 to 74 years (mean, 44 years). Seven cases were sports injuries, 5 cases were caused by slipping, and 3 cases were caused by violent trauma. The duration of quadriceps tendon rupture ranged from 3 hours to 3 days (median, 2 days). The right side was involved in 9 cases, and the left side in 6 cases. All of the cases were closed injuries. The patients had no sequelae of limb dysfunction and no limb joint surgery in the past. All the patients received anteroposterior and lateral X-ray films of the knee joint and patella axial films during follow-up. Knee function of the patients after operation was evaluated by Lysholm scoring system and Kujala scoring system.

Results

The operation time was 50-60 minutes (mean, 55 minutes). The intraoperative blood loss was 50-150 mL, with an average of 87 mL. Primary healing of incision was obtained in all patients without complications. All patients were followed up 12-24 months (mean, 18 months). At 1 year after operation, the knee joint function of all patients recovered well; the knee Lysholm score was 92-96, with an average of 94 and the patellofemoral joint Kujala score was 90-95, with an average of 93. There was no re-rupture of quadriceps tendon or loosening of internal fixation during follow-up. According to the lateral and axial X-ray films at 1 year after operation, the patella depth index, femur trochlea depth, sulcus angle, and Insall-Salvati index were 3.62-4.09 (mean, 3.84), 4.45-6.50 (mean, 5.56), 137-145° (mean, 142°), and 0.90-1.18 (mean, 1.06). The lateral patellofemoral angle increased, and the patellar tilt angle and the patella lateral shift distance reduced, all showing significant differences when compared with preoperative ones ( P<0.05).

Conclusion

The improved technique for perforation of patella combined with suture anchor and non-tourniquet for repairing acute rupture of the bone tendon junction of quadriceps tendon can reconstruct a stable patellofemoral joint, increase the strength of fixing, disperse stress effectively and evenly, and increase the area for tendon-bone healing.

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.