Augmented Repair Technique for Patellar Tendon Rupture Using Two Suture Anchors and Three Transosseous Sutures: a retrospective cohort study

doi:10.21203/rs.3.rs-4815777/v1

Background

Patellar tendon rupture is an uncommon injury that usually requires surgical repair, but no consensus exists regarding the ideal repair technique. Suture anchor repair and the transosseous suture method have be widely used, but the suture anchor technique may cause anchor pull-out, while the transosseous suture method may result in insufficient suture strength. Therefore, we propose and evaluate the efficacy of augmented repair technique with two suture anchors and three transosseous sutures for patellar tendon repairs.

Methods

We conducted a retrospective cohort study of patients who received surgery for patellar tendon rupture between January 2016 and December 2020. All patients underwent a standardized integrated knee extensor mechanism augmentation repair technique by the same surgeon with 2 suture anchors and 3 transosseous sutures. Radiology, complications, and patient-reported outcomes were recorded. Clinical outcomes were measured using range of motion (ROM), patient satisfaction, Visual Analog Scale (VAS) pain scores, Knee Society Function Score (KSS-F), International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score.

Results

Totally 40 patients were enrolled with an average age of 33.95 years. Mean follow-up duration was 60 months (range: 36 to 72 months). All cases were diagnosed with patellar tendon rupture at the patellar attachment and received the surgery. The risk of complications was 7.5% (3/40). Mean postoperative ROM improved from 45.65 ± 10.66 to 127.25 ± 3.99 (mean ± SD, p < 0.001). Mean postoperative VAS pain score, KSS-F score, IKDC score, Lysholm score and Tegner score significantly improved (p < 0.001). The median Caton Deschamps Index significantly decreased from 1.71 ± 0.22 to 1.07 ± 0.07 (p < 0.001). Postoperative MRI revealed evident healing between the patellar tendon and the inferior pole of the patella.

Conclusions

The integrated knee extensor mechanism augmentation repair technique is reliable and effective for patellar tendon rupture. 5-year-follow up results verified its favorable outcomes.

patellar tendon rupture

augmentation repair

suture anchor

transosseous suture

Patellar tendon rupture is a relatively rare injury, with reported incidences approximately 0.68/100,000 person-years in the general population[1] and notably higher at 6/100,000 person-years within military settings[2]. This injury typically occurs due to direct and indirect trauma or as a terminal outcome of patellar tendinopathy[3–6]. The proximal insertion of the patellar tendon is the most affected site[7–9]. Patients with patellar tendon rupture caused by patellar tendinopathy may present with concurrent conditions such as systemic lupus erythematosus (SLE), gout, rheumatoid arthritis (RA), obesity, renal insufficiency, Ehlers-Danlos syndrome, and a history of long-term corticosteroid use. [10–14]. Notably, individuals across various demographics, including both the general population and athletes, are susceptible to patellar tendon rupture. The onset age of patellar tendon ruptures typically occurs during adolescence or in middle-aged males between 30 to 40 years old[15, 16].

The transosseous repair is widely acknowledged classical gold standard surgical procedure for complete patellar tendon rupture. At present, the suture anchor repair technique has gained popularity due to its superior biomechanical properties. Studies have demonstrated that suture anchor repair exhibits a higher ultimate failure load and less gap formation compared to transosseous repair[17]. Moreover, in cases of mid-substance rupture, a direct end-to-end repair may be employed. While these methods are commonly utilized by sports medicine clinicians, it's essential to note potential drawbacks. The suture anchor technique carries the risk of anchor pull-out, while the transosseous suture technique may result in inadequate suture tension or even suture breakage, ultimately leading to retearing of the repaired patellar tendon.

In efforts to mitigate the risk of retear, numerous augmentation repair methods have been utilized for patellar tendon rupture, such as cerclage wires, Dall–Miles cables, nonabsorbable sutures, suture anchor, cortical button fixation, autologous grafts, allografts or synthetic ligaments enhancement and so on[18–25]. However, despite their intended benefits, these repair techniques often come with inevitable complications, such as re-ruptures, extensor lags, infection, implant breakage, re-operations, skin necrosis, disease transmission and donor-site morbidity[21–23, 25].

Given the inherent disadvantages of these methods, we proposed the integrated knee extensor mechanism augmentation technique repair for patellar tendon ruptures. In our approach, we combined the use of 2 suture anchors with 3 transosseous sutures to address ruptures at the proximal insertion of the patellar tendon. The aim of our study is to introduce this novel augmentation repair technique and evaluate its efficacy in achieving favorable radiological and functional outcomes over a mean follow-up period of five years.

Patients Selection

A retrospective review was conducted encompassing all patients who underwent repair for patellar tendon rupture between January 2016 and December 2020 at our hospital.

Ethics approval (LYF2023028) was obtained from the institutional human research ethics committee of our hospital on 21 February 2023, and informed consent was obtained from all participants prior to their inclusion in the study. All procedures were performed by the same senior surgeon. Patients were evaluated based on medical history, physical examination, and radiological findings. Inclusion criteria comprised patients meeting the following criteria: (1) a documented history of injury with associated knee extension lag; (2) unilateral full-thickness patellar tendon rupture confirmed via magnetic resonance imaging (MRI); (3) surgical intervention performed within 4 weeks post-injury. Exclusion criteria encompassed: (1) bilateral patellar tendon rupture, concurrent ipsilateral extremity fracture or other ligament injuries, or a history of previous surgery; (2) surgical intervention performed beyond 4 weeks post-injury; (3) loss to follow-up; (4) partial-thickness tears, or ruptures not located at the inferior pole of the patella. The CONSORT flow diagram depicting the final patient selection is provided in Figure 1.

Demographic data, including age, sex, affected sides, BMI (kg/m²), injury mechanism, days between injury and operation and comorbidities were collected and recorded in Table 1. Preoperative and postoperative radiological findings, clinical functional assessments, and operative protocols were reviewed during the final follow-up. Specifically, assessments included patellar height (Caton–Deschamps index, Fig 2a), tear pattern (partial or complete and the rupture site, Fig 2b). Final radiographic and MRI assessments were conducted to evaluate patellar height and healing between the patellar tendon and patella. No associated intra-articular lesions were identified from preoperative MRI. The postoperative complications were meticulously documented which included re-rupture, infection, implant failure, knee hematoma, arthrofibrosis and venous thrombosis and so on.

Table 1. Demographic data of all consecutive cases

Demographic Variable	Mean or Proportion
Age (years)	33.95±10.83(14-55)
BMI (kg/ m²)	23.7±4.3(16.8-33.2)
Sides	N^a(%)
Left	18 (45%)
Right	22 (55%)
Gender	N^a(%)
Female	4(10%)
Male	36(90%)
Injury mechanism	N^a (%)
fall injury	28(70%)
sport injury	12(30%)
Comorbidities	8(40%)
SLE and RA	1
End-stage renal disease	1
Chronic kidney disease 4	1
Gout	2
Diabetes	2
Statin use	1
Preoperative Caton Index	1.71±0.22
Mean Days between injury and operation(days)	3.9±2.3

Data are percentage (%) or mean ± SD (Comorbidities: RA, SLE, Gout, end-stage renal disease, diabetes, statin use).

N^a refers to the number of individuals.

Surgical Techniques

The surgical procedure was conducted under both general and regional anesthesia, with the patients positioned supine and a tourniquet applied to the upper thigh. A midline longitudinal incision was made from the superior pole of the patella to the tibial tubercle. Layer-by-layer dissection was performed through the skin, subcutaneous fat, and superficial fascia, exposing the patella, ruptured patellar tendon, and tibial tubercle. Upon exploration, the patellar tendon was found to be completely broken at the inferior pole of the patella with slight retraction and massive hematoma. Additionally, complete tears of the lateral and medial retinaculum were commonly observed. The hematoma was evacuated, and the area thoroughly irrigated. Subsequently, meticulous debridement of the inferior pole of the patella was performed, followed by preparation of the bone bed while protecting the remnant of the patellar tendon. (Fig 3a and Fig 4a).

Two 2.9mm absorbable suture anchors (Smith & Nephew, MA, USA) were placed in the inferior pole of the patella. A 2.0 Kirschner wire was used to drill three bone tunnels from bottom-up across the middle-part patella. Three patellar tunnels were segregated by 2 suture anchors from lateral to medial (Fig 3 b and Fig 4b). it is crucial to ensure that the orientation of the guide wire is not excessively downward to prevent damage to the articular cartilage. If necessary, intraoperative fluoroscopy may be employed to assist in guiding the wire placement accurately. Three 2# nonabsorbable ultrabraid sutures (Smith & Nephew, MA, USA) were stitched to the distal patellar tendon stump using a whip stitch technique, aligning them with the orientation of the patellar tunnels. Three ultrabraid sutures were sequentially passed through the patellar tunnels with the aid of an eyelet guide needle (refer to Fig 3c and Fig 4c). All six ends of the sutures were left at the superior pole of the patella to be secured later. Following this, the sutures attached to the anchors were stitched the proximal tendon stump at the inferior pole of the patella using Krakow technique. It is imperative to ensure that the proximal stump is adequately sewn to the main body of the patellar tendon, while also meticulously repairing the torn lateral and medial retinaculum with these sutures. Then the knee joint was flexed and extended 10-20 times to ensure no gap formation at the interface between the patellar tendon and patella. All six ends of the sutures were tied each other at 45° of knee flexion. One MB-66 suture was passed around the patella to reduce the overall tension (Fig 3d and Fig 4d). At completion of the procedure, the surgeon performed a thorough assessment of the ROM and ensured appropriate tension of the repaired patellar tendon at maximum knee flexion. Finally, the operated extremity was immobilized in a mobile brace set in full extension.

Postoperative Rehabilitation

Following the surgical procedure, patients were promptly permitted to start isometric quadriceps exercises and full weight bearing as tolerated while wearing a knee brace locked in full extension. Controlled physiotherapy was initiated, allowing for passive ROM exercises from 0° to 90°. 6 weeks later, patients were encouraged to do full ROM and active knee extension. Quadriceps-strengthening exercises commenced after three months, with resistance gradually increased over time. Gradual reintroduction to running activities was initiated after six months.

Statistical Analysis

All patients underwent clinical evaluation at 1, 3-, 6-, 12-, and 24-months post-surgery. Preoperative and postoperative ROM, patient satisfaction, VAS pain, the KSS-F, IKCD score, Lysholm score, Tegner score were recorded.

Demographic data were summarized using mean ± standard deviation (SD) for continuous variables and number (%) for categorical variables. Statistical analysis was performed using the Wilcoxon signed-rank test to compare KSS-F scores, VAS scores, IKDC score, Lysholm Score, and Tegner score before and after surgery. A p-value < 0.05 was considered statistically significant. Data were analyzed using GraphPad 9.0.

Totally, 40 patients were included in this study. The demographic characteristics of the patients were summarized in Table 1. Most patients were males (90%, 36/40) with an average age of 33.95 ± 10.83 years (ranging from 14 to 55 years). The mean BMI were 23.27 ± 3.49kg/m² (16.8 to 33.2 kg/m²). Twenty-eight patients sustained injuries from falls, while twelve were injured during sports activities. The mean duration between injury and surgery was 3.9 ± 2.3 days. Eight patients had medical comorbidities, including a 54-year-old female with SLE and RA, a 35-year-old male with a history of kidney transplantation 8 years prior and one patient in chronic kidney disease (CKD) Stage IV. Two patients had gout. Two patients had Diabetes and one had been on statin therapy for 5 years. At the final follow-up, patellar height was found to be normal in all patients, and the median Caton Deschamps Index were significantly decreased from 1.71 ± 0.22 (1.32–2.11) to 1.07 ± 0.07 (0.92–1.26) (p < 0.001). Postoperative MRI at the 2-year follow-up revealed definite healing between the patellar tendon and the patella, as evidenced by the disappearance of the gap at the interface (refer to Fig. 5a, b, c).

The mean operative time was 82.15 minutes (range: 66–118 minutes). And the average followed-up period was 60 months (range: 36–72 months). All patients were satisfied with the outcomes at the last follow-up. All patients had active full knee ROM. Notably, there were no instances of re-rupture, infection, or cutaneous complications observed in any of the patients. The rate of complications was 7.5% (3/40). One patient undergoing renal dialysis that required arthroscopic debridement due to knee hematoma, while another patient received standard anticoagulant treatment for deep venous thrombosis. One patient underwent reoperation for arthroscopic debridement due to arthrofibrosis. All patients had returned to normal daily-life and preinjury sports at the final follow-up.

Significant improvement in knee function were observed among all patients (Table 2). Specifically, the mean postoperative ROM improved from 45.65 ± 10.66 to 127.25 ± 3.99 (p < 0.001). The mean postoperative VAS pain score reduced from 6.20 ± 1.11 to 1.25 ± 0.79 (p < 0.001). The mean Knee Society function Score was significantly improved from 24.50 ± 13.37 to 91.75 ± 5.45 (p < 0.001). The mean Lysholm score improved from 35.40 ± 3.21 to 89.05 ± 3.95 (p < 0.001). The mean Tegner score improved from 0.8 ± 0.62 to 4.85 ± 0.93 (p < 0.001). The mean IKDC score improved from 29.75 ± 4.34 to 72.65 ± 2.85 (p < 0.001).

Table 2
Comparison of preoperative and postoperative knee function scores in all consecutive patients
Evaluation item	Preoperative	Postoperative	p- value
ROM	45.65 ± 10.66	127.25 ± 3.99	< 0.001
Pain, VAS (0–10)	6.20 ± 1.11	1.25 ± 0.79	< 0.001
KSS Function	24.50 ± 13.37	91.75 ± 5.45	< 0.001
Lysholm score	35.40 ± 3.21	89.05 ± 3.95	< 0.001
Tegner score	0.8 ± 0.62	4.85 ± 0.93	< 0.001
IKDC score	29.75 ± 4.34	72.65 ± 2.85	< 0.001

Data are mean ± SD. VAS: visual analog scale.

Our study demonstrated the reliability and efficacy of the integrated knee extensor mechanism augmentation repair technique for addressing patellar tendon rupture. Short-term outcomes validate the effectiveness of this repair method in yielding favorable radiological and functional results.

The reported incidence of patellar tendon rupture is approximately 0.68/100,000 person-years in general population^1–2. Patella fracture, quadriceps tendon rupture and patellar tendon rupture are the three most common injury sites of knee extensor structures[3]. The classification of patellar tendon rupture is often based on the injury site, which typically includes the inferior pole of the patella, mid-substance, and the tibial tuberosity. The most common site of patellar tendon rupture is the inferior pole of the patella[7–9]. Patellar tendon ruptures are categorized based on the period between injury and surgery into acute and chronic ruptures[26]. Acute injuries typically occur within a timeframe of up to 4 weeks post-injury and necessitate immediate intervention. Conversely, chronic injuries often arise due to factors such as conservative treatment, missed diagnosis, or chronic patellar tendinopathy[27].

It is well known that surgical treatment is the optimal treatment for full-thickness patellar tendon ruptures to reestablish knee function. Patellar tendon fixation methods vary depending on factors such as the location of tendon disruption, surgeon preference, and the availability of implant materials. While transosseous suture repair has historically been advocated as the gold standard surgical approach for complete patellar tendon ruptures, it is associated with certain complications, including re-ruptures and extensor lags, often stemming from gap formation at the repair site[1].

Recent biomechanical studies have shed light on the advantages of suture anchor repairs, demonstrating significantly less gap formation and higher ultimate failure loads compared to traditional transosseous repairs[7, 8, 17]. Bushnell et al[8] has shown that suture anchors repair has a higher ultimate load to failure and less gap formation than that of transosseous repairs. In a multicenter study, James O'Dowd et al[9] reported that the transosseous group experienced 24 retears (7.5%), whereas the anchor group exhibited no re-ruptures. This finding underscores a significantly higher re-rupture rate in the transosseous repair group compared to the anchor group. Several case reports on suture anchor repairs have confirmed satisfactory outcomes, with no major complications or need for reoperations.[19, 20].

To decrease the risk of retear, many surgeons attempt to repair the severely ruptured patellar tendon with different enhancement techniques to obtain more stable extensor construct[23]. Various enhancement repair methods have been applied to patellar tendon rupture[20–25]. The advantages of augmentation repair were favored by cadaveric studies[28–30]. The augmentation of patellar tendon repairs can decrease gap formation at the ruptured site and allow early mobilization[23, 31]. Another cadaveric research confirmed that augmentation repair by semitendinosus tendon can decrease the gap formation than that of no augmentation repair[31]. Several clinical studies have prompted various methods of augmenting repairs of patellar tendon ruptures[23, 25]. Ihab I et al[30] reported successfully repaired patellar tendon augmented by semitendinosus tendon with no major complications. Core et al[25] reported that patellar tendon enhanced with synthetic ligament achieved satisfactory clinical scores. However, some patients reported experiencing a distinct foreign body sensation, which contributed to increased hospitalization costs. Additionally, it is worth noting that this technique may not be available in all institutions.

In clinical practice, most non-traumatic ruptures of the patellar tendon are caused by chronic patellar tendinopathy or concomitant diseases, such as SLE, local steroid injection, renal failure and metabolic diseases[3, 4, 6]. These patients usually have poor tendon quality, impaired tendon blood supply and concurrent osteoporosis which are challenges for surgeons. As mentioned earlier, both the suture anchor and transosseous suture techniques have their limitations. The suture anchor technique has the risk of anchor pull-out, particularly in osteoporotic patellae, and transosseous suture technique potentially leads to inadequate suture strength, breakage, or bony bridge cutting, ultimately resulting in repaired patellar tendon failure. Here in this study, we combined 2 suture anchors with 3 transosseous sutures method to address the patellar tendon rupture at the proximal insertion. All patients in our study were satisfied with functional scores significantly improved.

Compared to previous studies, our integrated knee extensor mechanism augmentation repair method has demonstrated several advantages. Firstly, our augmentation technique effectively prevents anchor pullout, a complication typically associated with the suture anchor technique. Moreover, insufficient repair or suture breakage were not found. By placing two suture anchors at the inferior pole of the patella, we were able to suture a major part of the patellar tendon to both the patella and its remnant. Additionally, three transosseous sutures were passed through the patella, allowing them to be tied together at the superior pole and reconnecting the ruptured patellar tendon with both the patella and the quadriceps tendon. Secondly, our technique restores a wider footprint contact area, resulting in a more stable and robust extensor construct that enables early functional rehabilitation. Thirdly, the operation time for our technique (83 minutes) did not significantly increase compared with previous reports[32], suggesting that it can be easily mastered by senior surgeons. Lastly, the total surgical costs will not experience a dramatic increase, especially with the national centralized purchase of high-price consumable materials in our country[24, 25, 33].

All patients expressed high satisfaction with the good or excellent knee function observed during the average 5-year follow-up period. Particularly noteworthy is the absence of any retears in our consecutive cases, a notable outcome directly attributable to the advantages offered by our augmentation repair technique. In contrast, Bushnell et al.[32] presented a 21% failure rate in their clinical results of suture anchor repairs among 14 patients. Furthermore, the occurrence of postoperative complications in our study is also associated with concurrent diseases. For instance, one patient undergoing renal dialysis and having undergone renal transplantation twice, along with severe anemia, was recovered after arthroscopic debridement because of knee hematoma. Similarly, another patient with a high body mass index was successfully treated with standard anticoagulant therapy for deep venous thrombosis. Additionally, 1 case underwent reoperation of arthroscopic debridement because of arthrofibrosis. Despite these challenges, all the patients were able to return to their normal daily activities and preinjury sports. With meticulous surgical technique and standard rehabilitation protocols, there is a relatively low rate of complications in our case series[28, 34].

There are also some limitations in our study. Firstly, the retrospective nature of the study imposes inherent limitations, including potential biases in data collection and analysis. Secondly, the sample size is relatively small, and the follow-up duration is relatively short, which may limit the generalizability of the findings and the ability to assess long-term outcomes accurately. Thirdly, the absence of a randomized control group treated with alternative methods precludes direct comparison and limits the ability to establish causal relationships between the augmentation technique and outcomes. Finally, our study did not include gait analysis and muscle strength detection, which are important measures for assessing functional outcomes and may provide additional insights into postoperative recovery. Long-term studies should be carried out to ensure maintenance of both stability and functionality, restored after surgery. We also inspire other surgeons to further evaluate the validity of this augmentation technique and to perform continued evaluation for long-term outcomes.

This retrospective study provides evidence supporting the effectiveness and reliability of the integrated knee extensor mechanism augmentation repair technique for patellar tendon rupture. The short-term results verified good radiological and functional outcomes. It is also recommended for patients with patellar tendon ruptures who present with chronic patellar tendinopathy.

The following abbreviations are used in this manuscript:

ROM	Range of Motion
VAS	Visual Analog Scale
KSS-F	Knee Society Function Score
IKDC	International Knee Documentation Committee
SD	Standard Deviation
MRI	Magnetic Resonance Imaging
SLE	Systemic Lupus Erythematosus
RA	Rheumatoid Arthritis
BMI	Body Mass Index
ACLR	Anterior Cruciate Ligament Reconstruction
CKD	Chronic Kidney Disease

Ethics statement and consent to participate

This study was approved by the Second Xiangya Hospital committee for clinical research (LYF2023028). Informed consent was obtained from all individual participants included in the study.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author upon reasonable request.

Competing Interests

The authors declare no competing interests.

Funding

This work was partially supported by grants from the Natural Science Foundation of Hunan Province, Health Research Project of Hunan Provincial Health Commission and the Scientific Research Launch Project for new employees of the Second Xiangya Hospital of Central South University (2023JJ40823, W20243122, QH2023024 to YH).

Author Contributions

All authors contributed to the study conception and design. Design of the surgical planning, data collection and analysis were performed by DL, QL and WZ. The first draft of the manuscript was written by DL, YH and ZX. KJ, YC and DZ reviewed and edited the manuscript. And all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

None

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No competing interests reported.

Augmented Repair Technique for Patellar Tendon Rupture Using Two Suture Anchors and Three Transosseous Sutures: a retrospective cohort study

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Abstract

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Methods

Results

Conclusions

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Background

Method

Results

Discussion

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Abbreviations

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