Primary Repair of Chronic Quadriceps Tendon Rupture With Dermal Allograft Augmentation: Surgical Technique and Case Review

Video Transcript

In this case-based presentation, we discuss a surgical technique for primary repair of chronic quadriceps tendon rupture with dermal allograft augmentation. The authors have no financial conflict of interest pertinent to his topic.

This presentation will include a background on quadriceps tendon rupture, some commonly used surgical techniques, our case presentation, and a brief overview of the literature.

Background

Quadriceps tendon ruptures occur in approximately 1 patient per 100,000 per year more commonly in men older than 40 years from an eccentric load to a flexed knee, direct blow, or traumatic laceration.^3,5 Patients present with tenderness, palpable gap at rupture site, patella hypermobility, and extensor lag or inability to actively extend the knee. Workup includes orthogonal radiographs as well as magnetic resonance imaging to differentiate between partial and complete tears.

Acute complete tears are primarily repaired with suture anchors or patella bone tunnels.^1,6,7 Chronic complete tears can be treated in a variety of ways depending on chronicity and amount of tendon retraction. When possible, primary repair can be used. Lengthening or augmentation procedures have been described to augment end-to-end repair, and in cases of poor tissue quality or significant tendon retraction, autograft and allograft reconstruction can be used.^2,12 In cases with incomplete tears with intact extensor mechanism, nonoperative management with knee immobilization can be considered. ⁴

The literature recommends prompt surgical management, when possible, but the optimal timing is still controversial, with historical trends allowing for more time between injury and repair. Scuderi ¹⁵ recommends repair within 48 to 72 hours while Rougraff et al ¹⁴ and Elatti et al ⁵ suggest that optimal results can be achieved if repair occurs within 1 and 2 to 3 weeks, respectively. The method of repair is also under debate. Petri et al ¹¹ reported less gap formation during cyclic loading and higher failure loads with suture anchor repair compared to transosseous suture tunnels. However, Yanke et al ¹⁷ reported similar in vivo failure rates between the 2 techniques.

Oliva et al ⁹ performed a systematic review of chronic quadriceps ruptures that included 25 articles and 97 patients. Overall outcomes were poor with 10% rerupture rates, 22% extensor lag of more than 5°, and half with decreased active flexion range of motion.^13,16

Allograft augmentation can be used to help increase the strength of the repair and improve healing rates. The dermal allograft provides a scaffolding for cellular migration and collagen formation to help solidify the bone-tendon interface. Mirzayan et al ⁸ found that tendon repair, when augmented with dermal allograft, increased suture pullout strength and maximum load to failure in biomechanical studies involving pectoralis major repair. This has also been found in distal biceps, rotator cuff, and peroneus longus repair. Pasqualini et al ¹⁰ found that healing rates of rotator cuff repairs improved from 40% to 85% when allograft augmentation was used. Tensor fascia lata autograft and Achilles allograft can also be considered. It is our preference to allograft rather than autograph to avoid donor site morbidity. We use a dermal allograft in the case, but Achilles allograft is a viable option.

Indications

Elattar et al ⁴ published a review of quadriceps tendon repair and reconstruction in the Journal of Bone and Joint Surgery. The authors suggested that primary repair should be used whenever tension-free end-to-end tendon repair can be achieved. They report graft reconstruction can result in good outcomes but should be considered a salvage procedure. Oliva et al ⁹ performed a systematic review comparing various reconstructive techniques and showed that autografts may result in better functional outcomes and lower complication rates compared to allografts. However, given the lack of evidence-based recommendations, they concluded surgeons’ experience seems to be the key factor in the choice of the most appropriate procedure.

In our case, a 30-year-old man presents with a left knee injury after falling downstairs 2 months ago at work. He was initially scheduled for surgery through the workers’ compensation clinic, but his claim was ultimately denied. This delayed his presentation to our clinic. He reported daily marijuana use and 3 alcoholic drinks per day. Otherwise, medical history was noncontributory. On examination, he had a 30° extensor lag with a palpable suprapatellar gap. He also had a hard mass over the medial quad tendon. The knee was ligamentously stable, and extremity was neurovascularly intact. Clinic radiographs obtained 2 months postinjury showed a possible superior pole patella avulsion fracture and heterotopic ossification at the avulsion site. Magnetic resonance imaging confirmed a complete tear of the quadriceps tendon. The patient was diagnosed with a chronic quadriceps tendon tear with heterotopic ossification. He was scheduled for primary repair of the quadriceps tendon with dermal allograft augmentation.

Technique Description

The patient is examined preoperatively and found to have approximately 30° of extension lag on the affected knee. The patient is positioned in the supine position with a small bump under the hip on the operative side. A nonsterile tourniquet is placed on the operative thigh, and the patient's leg is prepped and draped in the usual fashion. The patella is identified and marked out. The quad tendon stump is palpated. A 10-cm midline incision is marked from the quad tendon extending just distal to the proximal pole of the patella. An incision is made through the skin down to the quadriceps tendon fascia. Full-thickness skin flaps are developed medially and laterally. The scar bridging the tendon gap is released off of the patella and debrided in sections, taking care not to excise healthy quad tendon. Heterotopic ossification in the gap and deep to the quad tendon is thoroughly debrided using sharp dissection and rongeurs. Fluoroscopy is used to help determine whether all of the heterotopic ossification has been removed. Attention is placed onto the proximal pole of the patella. Scar tissue and heterotopic ossification overlying the proximal pole of the patella is debrided with rongeurs and curettes until healthy-appearing bone is exposed. The quad tendon excursion is noted to be adequate for primary repair. Two sets of fiber tapes are used to secure the quad tendon using Krackow stitches. The 4 tails of suture tape can be seen. The center of the patella is identified. Medial and lateral holes are drilled along the dorsal aspect of the patella for the suture anchors. The drill holes are then tapped. The joint is irrigated and examined for any excess debris prior to quad tendon fixation. The paired tails of the medial and lateral suture tapes are loaded onto 2 suture anchors. The suture anchors are simultaneously inserted, taking care to tension both sides equally. The medial and lateral extensor retinaculum are repaired using additional suture tapes. The suture tapes are cut, but the anchor suture and loops are left alone. These will be used to secure the dermal allograft. The extensor retinaculum is now approximated over the quad tendon stump. An ArthroFLEX (Arthrex) decellularized dermal allograft that is 1 mm × 4 cm × 7 cm is measured and prepared with the epidermal layer facing anterior. The medial and lateral anchor sutures and loops are fed through the medial and lateral aspects of the dermal allograft, respectively, using a free needle. To secure the dermal allograft, we prefer to use the stay suture from the medial anchor and pass it through the knotless mechanism of the lateral anchor and vice versa. This allows for a broad area of direct compression of the allograft against the site of repair at the tendon-bone interface between the 2 anchors. The allograft is trimmed so it fits just over the tendon surface. The edges of the allograft are secured using a combination of suture tape and 0 Vicryl (Ethicon). The skin is closed in layered fashion and the wound is covered in a soft dressing. The knee is then placed in a hinged knee brace and locked in extension.

Postoperatively, we protected the patient's weightbearing with crutches for 6 weeks and allowed full weightbearing starting at 6 weeks once his gait normalized. Extension bracing was placed for 6 weeks and weaned. Patient began progressive range of motion and isometric strengthening at 3 weeks. We will allow him to jog at 16 weeks and graduate him to running and agility exercises at 20 weeks.

Results and Discussion

At the 6-month postoperative visit, the patient had no pain over the quadriceps tendon and had active range of motion of 0° to 115° at the knee without an extensor lag. He had returned to work and activities.

Quadricep tendon tears are relatively rare orthopaedic injuries that often require operative intervention. Primary repair leads to good results and is an option in chronic ruptures. Graft reconstruction are viable options in salvage situations. Literature regarding optimal technique is limited, and mode of repair or reconstruction is largely dependent on surgeon preference at this time. Our preference is to perform a primary repair if possible. In cases where tissue degeneration may have occurred secondary to a subacute chronic nature, allograft augmentation is our preference to help facilitate incorporation of the tendon tissue to bone.