Treatment of Patellar Fractures and Injuries to the Extensor Mechanism of the Knee: A Critical Analysis Review

Return to Play and Performance Outcomes After Extensor Mechanism Ruptures in National Football League Athletes

Background

Extensor mechanism ruptures are career-threatening injuries for professional athletes, especially in the National Football League (NFL).

Purpose

To determine the overall return to play (RTP) rate after extensor mechanism ruptures in the NFL, to identify factors influencing injury and return, and to compare postinjury outcomes between patellar tendon (PT) and quadriceps tendon (QT) tears.

Study Design

Case series; Level of evidence, 4.

Methods

A search of all available PT and QT injuries in NFL history was performed using publicly accessible data. Demographic and player performance data were compared to assess factors influencing the occurrence of either injury type and overall RTP. Among players that returned, mean performance data were compared at 1 and 2 full seasons before and after injury.

Results

A total of 74 extensor mechanism injuries were identified, including 45 PT tears and 29 QT tears. The overall RTP rate after extensor mechanism ruptures was 56.8% with a median time to return of 11.3 months. No differences in RTP rates or timing were observed between PT and QT tears. Higher body mass index, lineman positions, and longer preinjury careers were significantly correlated with QT tears. Preseason injuries were associated with significantly lower RTP rates. Overall, athletes who returned played significantly fewer snaps and had lower approximate value in the first full season after return compared with 1 season before injury, with reductions in approximate value persisting into the second season after injury. PT tears were associated with worse deficits in approximate value at 1 season after injury compared with QT tears.

Conclusion

Extensor mechanism ruptures in NFL athletes are associated with a low rate of RTP and an extensive recovery period. Athletes and staff should expect reductions in game play and performance in the first season after return, with worse performance deficits after PT tears compared with QT tears. This study highlights the challenges that professional athletes face in resuming play after extensor mechanism ruptures, emphasizing the need for improved prevention and rehabilitation measures tailored to these career-threatening injuries.

A comparative study on the efficacy of kirschner wire tension band combined with anchor cross-suture internal fixation versus partial patellectomy in the treatment of comminuted inferior pole patellar fractures

OBJECTIVE

The treatment of comminuted inferior pole patellar fractures has long posed a challenge for orthopedic surgeons. This study aims to compare the biomechanical stability and clinical efficacy of Kirschner wire tension band combined with anchor cross-suture fixation versus traditional partial patellectomy in the treatment of comminuted inferior pole patellar fractures.

METHODS

A retrospective analysis was conducted on 14 patients who underwent Kirschner wire tension band combined with anchor cross-suture fixation (Group A) in our department of orthopedics from September 2020 to April 2022. Additionally, we matched 14 patients with similar baseline characteristics who received inferior pole patellectomy combined with patellar tendon repair (Group B). The two groups were compared in terms of operative time, intraoperative blood loss, postoperative complications, and at the final follow-up, knee range of motion (ROM), visual analogue scale (VAS) score, Bostman knee function score, peak knee torque, and Insall-Salvati (IS) ratio.

RESULTS

All patients were followed up for more than 12 months. At the final follow-up, Group A showed significantly better outcomes than Group B in terms of knee range of motion (ROM), Bostman knee function score, knee VAS score, and average peak knee torque, with statistically significant differences (P < 0.05), indicating faster postoperative recovery and better clinical results in Group A. The IS ratio of the injured knee in Group B was 0.71 ± 0.66, less than 0.8, suggesting a decrease in patellar height. There were no significant differences between the two groups in terms of operative time, intraoperative blood loss, or incision length (P > 0.05). In Group A, one patient experienced complications from hardware irritation, while in Group B, one patient had postoperative knee pain, and two patients experienced knee extension weakness after cast removal and rehabilitation.

CONCLUSION

Kirschner wire tension band combined with anchor cross-suture fixation for the treatment of inferior pole patellar fractures yields satisfactory results. This technique provides reliable fixation, restores the original extensor mechanism, promotes early postoperative rehabilitation, and reduces the incidence of complications, making it suitable for clinical application and widespread use.

EVIDENCE LEVEL

Level III (retrospective comparative study).

Reconstruction of Chronic Quadriceps Tendon Rupture: The Quadriceps Advancement and Imbrication Technique

BACKGROUND

Chronic extensor mechanism disruption after total knee arthroplasty (TKA) is a rare but challenging condition. There are several surgical approaches for quadriceps tendon repairs. In this report, we present a modified surgical technique for quadriceps tendon repair in chronic extensor mechanism disruption without the use of allografts or mesh augmentation.

METHODS

We retrospectively reviewed 12 consecutive cases of chronic extensor mechanism with complete quadriceps tendon ruptures after TKA that underwent the advancement and imbrication technique. Patient outcomes were evaluated using the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, the range of motion and extensor lag measurements, and standardized lateral radiographs were reviewed for Insall-Salvati-Ratio preoperatively and at their most recent follow-up visit.

RESULTS

There were 12 knees from patients who had a mean age of 72 years (range, 62 to 81) and were evaluated with a mean follow-up of 15.9 months (range, 11.4 to 50.9). The extensor lag significantly improved from 40.8 ± 31.9° (range, 10 to 90°) to 2.9 ± 6.9° (P = .014), the Insall-Salvati-Ratio significantly changed from 0.87 to 1.07 (P = .010), and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement showed a significant difference: a raw score of 13.0 ± 5.8 versus 8.7 ± 5.6 (P = .002) and an interval score of 54.1 ± 14.0 versus 66.2 ± 15.6 (P = .001).

CONCLUSIONS

Reconstruction of extensor mechanism in chronic quadriceps tendon ruptures after TKA with the advancement and imbrication technique showed excellent functional outcomes with no extensor lag and excellent restoration of motion. This technique can be combined with TKA revision surgery or used on its own. To ensure successful outcomes, the authors favor rigid immobilization for 12 weeks before starting mobilization.

Study on the therapeutic effect of Kirschner wire tension band combined with anchor cross-stitch technique in the treatment of comminuted patellar inferopolar fractures

PURPOSES

Fractures of the inferior patellar pole, unlike other patellar fractures, present challenges for traditional surgical fixation methods. This article introduces the clinical technique and outcomes of using Kirschner wire tension band combined with anchor screw cross-stitch fixation for comminuted inferior patellar pole fractures.

METHODS

This retrospective case series study included 14 patients with comminuted inferior patellar pole fractures treated at our institution from September 1, 2020, to April 30, 2022. All patients underwent surgery using the Kirschner wire tension band with anchor screw cross-stitch technique. Follow-up assessments involved postoperative X-rays to evaluate fracture healing, as well as clinical parameters such as healing time, Visual Analog Scale (VAS) scores, range of motion (ROM), and Bostman scores.

RESULTS

All patients were followed for an average of over 12 months, with no cases of internal fixation failure. Knee joint stability and function were excellent. X-rays revealed an average healing time of approximately 10.79 ± 1.53 weeks, hospitalization lasted 5.64 ± 1.15 days, surgery took approximately 37.86 ± 5.32 minutes, and intraoperative blood loss was 33.29 ± 8.15 ml. One patient experienced irritation from the internal fixation material. At the final follow-up, the Bostman score averaged 28.29 ± 0.83, knee joint flexion reached 131.07° ± 4.88°, all patients achieved full knee extension, and the VAS score was 0.36 ± 0.63.

CONCLUSION

Kirschner wire tension band with anchor screw cross-stitch fixation for comminuted inferior patellar pole fractures delivered satisfactory clinical outcomes. This surgical method, characterized by its simplicity and reliability, is a valuable addition to clinical practice.

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.

Mid-vastus total knee arthroplasty for medial osteoarthritis recovers gait balance control better than lateral parapatellar approach three months post-surgery

Total knee arthroplasty (TKA) approaches affect recovery outcomes, with different levels of residual loss of muscle strength and functional deficits. The current study compared the gait balance control in older individuals 3 months after TKA via the lateral parapatellar approach (LPPA) and mid-vastus approach (MVA) in terms of the inclination angle (IA) of the center of pressure (COP) to the body's center of mass (COM) vector, and the rate of change of IA (RCIA). In a gait laboratory, 12 patients with severe medial knee osteoarthritis who had undergone bilateral TKA via LPPA and 12 via MVA were evaluated and compared against 12 healthy controls for their balance control during gait 3 months after surgery. The participants' kinematic data and ground reaction forces were measured synchronously using an 8-camera motion capture system and three forceplates, respectively, from which the COM, COP, IA and RCIA were calculated using a 13-body-segment model. The LPPA group showed significantly greater sagittal IA during DLS (p < 0.01) but less sagittal and frontal RCIA throughout the gait cycle (p < 0.04) compared to controls. The MVA showed better recovery in the balance control with most IA and RCIA variables similar to those of the healthy controls throughout the gait cycle. The patients with LPPA walked with a compromised balance control throughout the gait cycle while the MVA group showed close-to-normal balance control with a slight decrease in sagittal RCIA during SLS. The current between-approach findings were likely related to the differences in the muscles involved during surgery, suggesting that MVA may be a better choice than LPPA when taking short-term gait balance control into consideration.

Adjunct neutralization plating in patella fracture fixation: a technical trick

Patella fracture outcomes are positive overall; however, in some cases, traditional fixation methods result in complications, including loss of fixation and irritable hardware requiring removal. We present a technique of plate fixation that we believe has the potential to improve stability and is less offensive in more comminuted fracture patterns. Improved stability should allow unfettered advancement of rehabilitation without concern for loss of fixation. Lower profile fixation offers a potential for diminishing the presence of irritating hardware requiring removal. We present our technique for using plate fixation to augment more complex patella fracture patterns.

The Injury Mechanism of Knee Extensor Mechanism Rupture in Professional Athletes: A Video Analysis Study

Background

In Professional Athletes, quadriceps and patellar tendon ruptures are devastating injuries, often resulting in the loss of a season or a decreased return to the pre-injury level of sport. This study aimed to perform a comprehensive Video Analysis on extensor mechanism rupture (EMR) to describe the body postures and related mechanism in Professional Athletes.

Methods

Using publicly available data on quadriceps tendon and patellar tendon ruptures from between 2000 and 2020, 52 elite athletes were identified. Of these, twenty-eight injuries with adequate video data were analyzed for Injury Mechanism, body posture, as well as player and sports characteristics.

Results

Of the 27 athletes included in the study, with an average age of 28.18 ± 4.96 years, there were injuries in 28 extremities (1 case bilateral). The patellar tendon was ruptured in 20 cases (71.4%), and the quadriceps tendon in 8 cases (28.6%). There was total tendon rupture in 13 cases, and partial rupture in 6 cases (data for 1 case was not available). In 20 cases (70.4%), there was no contact resulting in the injury. Four of the contact injuries occurred in American football (3 direct, one indirect), 3 in basketball (1 direct, two indirect), and 1 in baseball (direct).

Conclusion

The results of this research indicate that EMR occurs most commonly when the knee is in flexion and the ankle is in plantar flexion. There is the tendency for the knee to be in valgus at the time of injury. This information can guide physical therapy techniques, including neuromuscular training, proprioception, and balance training in the prevention of EMR in elite athletes.

Patellar Fracture Fixation With Cannulated Compression Screws and FiberTape Cerclage

Transverse patella fractures with loss of knee extensor mechanism function are a common orthopaedic injury requiring operative fixation. Current accepted surgical options for noncomminuted transverse fractures include open reduction with tension band wiring. Although these procedures result in good clinical outcomes and fracture healing, symptomatic hardware from the historically used metal implants is very common. The purpose of this Technical Note is to describe a technique for treatment of transverse patellar fractures using cannulated compression screws with tensioned high-resistance suture tape functioning as the tension band. This technique provides effective, reproducible fracture fixation while minimizing symptomatic hardware, failure, and reoperation.

Twisting Steel Wires with a Drill: A New Surgical Technique

Stainless steel wires are often used to fix specific types of fractures in orthopaedic surgery using pliers. This article aims to introduce a new technique to twist steel wires by using an electric drill. The steps before twisting the wire are the same as usual. Our technique is as follows. First, tighten the two ends of wire by using pliers, then insert both the ends of wires into the drill and hold in place. Second, set the drill to reverse mode. Third, start turning the drill, then the two wires begin to intertwine and tighten. It is important to stop turning before the wire (the twisted part) begins to bend. Finally, cut the twisted part of wire in place, and bend the wire stump. This technique can achieve a better appearance while saving the strength of surgeons. It has the same clinical effect as the traditional method. This technique provides a new method for surgery and wide clinical application.