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Abstract

Background:

Reruptures and functional deficits can occur with conventional transosseous quadriceps tendon repair. Previous work has demonstrated the biomechanical superiority of adjustable transosseous metal cortical button fixation over conventional repair. Knotless all-suture anchor (ASA) buttons may provide a similar improvement but have not yet been investigated.

Purpose:

To biomechanically compare adjustable transosseous cortical fixation with knotless ASAs to traditional transosseous repair.

Study Design:

Controlled laboratory study.

Methods:

Eight matched pairs of male cadaveric knees were dissected to isolate and release the quadriceps tendon insertion. Paired knees were randomized to 2.6-mm knotless ASA or control repair, both with Krackow suturing using 1.7-mm suture tape. The ASA technique had two 1.6-mm tunnels through which the knotless ASA loops interlocked with the Krackow sutures. The control technique had three 2.4-mm tunnels through which suture tape tails were passed and tied over bone bridges. Knees were mounted onto a materials testing system and actuated from 5° to 90° of flexion via the quadriceps tendon for 10 native preconditioning cycles and 250 cycles after repair 0.1 Hz, with a peak force of 150 N per cycle. Repairs were loaded to failure at a rate of 50 mm/min. Outcomes included plastic gap formation (mm) during cyclic loading and stiffness (N/mm), yield load (N), and ultimate load (N) during load to failure. Paired t tests were used for statistical analysis (P < .05).

Results:

The ASA had significantly less gap formation at cycle 250 (mean Δ = 6.3 mm; P < .001) and superior stiffness (Δ = 17.7 N/mm; P = .004), yield load (Δ = 40 N; P = .014), and ultimate load (Δ = 127 N; P = .015) compared with the control. The mean transosseous control displacement surpassed the defined critical threshold for gap formation (5.0 mm) in this study by cycle 50, whereas the mean ASA displacement never did.

Conclusion:

Compared with conventional transosseous quadriceps tendon repair, adjustable ASA transosseous repair had 64% less tendon-bone gap formation, 35% greater stiffness, 21% greater yield load, and 27% greater ultimate load.

Clinical Relevance:

Adjustable knotless ASA cortical fixation is a viable alternative for transosseous quadriceps tendon repair that increases repair strength and reduces patellar tunnel drilling.

Keywords

knee patella quadriceps tendon repair transosseous all-suture anchor

Quadriceps tendon ruptures account for approximately 9% of extensor mechanism injuries with an incidence of 0.31 per 100,000 person-years, which has increased annually from 2001 to 2020 by 5.3%.¹² Quadriceps tendon tears are devastating to lower extremity function and require acute repair but, unfortunately, have failure rates ranging broadly in the literature from 0% to 16%.^{2,3,5,10,13,17}

Conventional techniques for quadriceps tendon repair use either transosseous tunnels or suture anchors. Langenhan et al¹⁰ reported a 5% to 8% rerupture rate with transosseous suture repair depending on rehabilitation protocol, with fewer reruptures in a functional rehabilitation group. Elkin et al³ reported a 14% rerupture rate in transosseous suture repairs versus 9% in suture anchor repairs, although Yanke et al¹⁷ found similar failure rates of 15.5%. A recent systematic review and meta-analysis of clinical and biomechanical outcomes after suture anchor repair versus traditional transosseous repair noted similar subjective outcomes reported by patients and similar failure loads in biomechanical testing.²

Adjustable knotless transosseous cortical fixation is an alternative that permits intraoperative tensioning and retensioning to maximize tendon-bone compression and minimize laxity. A previous study examining adjustable fixation with metal cortical button devices demonstrated biomechanical superiority over conventional repair with suture tape and knotless anchors.⁶ A small series of 14 knees in 13 patients demonstrated 0 reruptures in quadriceps tendons repaired with the adjustable transosseous metal cortical button technique.⁵ Additionally, knotless suture anchors were demonstrated to decrease cyclic gap formation and increase failure load compared with traditional suture anchors and transosseous sutures in a cadaveric biomechanical model.⁸ The use of knotless all-suture anchor (ASA) buttons is a variant that may minimize hardware irritation from metal cortical buttons but has not yet been studied biomechanically or clinically. Knowledge of the biomechanical strength of a retensionable ASA transosseous repair will contribute to the development of future clinical studies and the potential reduction of reruptures after quadriceps repair.

The purpose of this study was to biomechanically compare adjustable transosseous cortical fixation with knotless ASAs to traditional transosseous repair. We hypothesized that ASA fixation would reduce gap formation and increase stiffness, yield load, and ultimate load compared with the control.

Methods

Specimen Preparation

Eight matched pairs of fresh-frozen male cadaveric knees (mean, 46.9 years; range, 41-56 years) without evidence of bony deformity or previous injury were acquired from registered tissue banks. Institutional review board approval is not required for cadaveric research by our institution. Specimens remained frozen at −20°C and were thawed at room temperature for 24 hours once for preparation and testing. Knees remained refrigerated at 4°C for intermittent periods and were acclimatized to room temperature before testing.

Knees were dissected of all soft tissue proximal to the femoral epicondyles, excluding the quadriceps tendon. The peripheral quadriceps structures (vastus medialis, vastus lateralis, and retinaculum) were dissected to isolate the quadriceps tendon on the patella. A nylon strap was secured 4 cm proximal to the quadriceps tendon insertion with a whipstitch for later testing purposes. A hole was drilled in the tibia 14 cm distal to the tibial plateau to hang weights that compensated for the weight of the remainder of the missing lower extremity. The bone quality of each patella was quantitatively measured at the anterosuperior aspect using a microindentation hardness tester (OsteoProbe; Active Life Scientific) per the manufacturer's instructions to ensure consistent bone quality between matched-pair cadavers.

Transosseous Repair Techniques

Transosseous techniques were randomized within each matched pair. Before beginning each repair, quadriceps tendons were cut at their insertions, leaving 2 mm of tendon temporarily intact on the medial and lateral sides for anatomic reduction of the tendon, keeping the tendon stabilized to facilitate the repair in the skeletonized model. Countertension (10 N) was applied through the nylon strap throughout the repair.

For the ASA repair technique, 2 equidistant transosseous bone tunnels (approximately 5 mm from the center, medially and laterally) were drilled using 1.6-mm Steinmann pins and a drill guide (Arthrex). Tunnels were drilled in a slightly posterior-to-anterior direction, starting at the superior pole of the patella and exiting the inferior pole of the patella. Shuttling sutures were used to pull the preconverted repair loops and suture limbs of 2 ASAs (2.6-mm Knee FiberTak Double Knotless; Arthrex) through the superior pole of the patella while the anchor body was set against the inferior pole of the patella (Figure 1A).

Figure 1.

Final repair constructs for the (A) all-suture anchor and (B) control groups with bone tunnels indicated. The 2.6-mm all-suture anchor (Knee FiberTak Double Knotless; Arthrex) is shown in panel A with visualization of repair loop reduction and tensioning. Krackow stitching was performed in a “U” configuration for the all-suture anchor group, beginning and ending proximally. In contrast, the control group was stitched in an inverted “U” configuration, beginning and ending distally.

Next, the quadriceps tendon was Krackow stitched in the distal 3 cm of the tendon on the medial and lateral sides with 1.7-mm suture tapes (SutureTape; Arthrex), starting and ending proximally with 4 throws in each direction before final knot tying with a surgeon's knot and 5 alternating half-hitches. Between the most distal passes, the suture tape was fed through the preconverted ASA repair loops. Thereafter, the remaining insertion was released, and the tendon was reduced to the patella in full extension by tensioning the ASA suture limbs, thus shortening the ASA loops. The free suture limbs were passed through the midsubstance of the tendon, and the knee was manually cycled from 0° to 90° for 10 cycles before final retensioning and knot tying with a surgeon's knot and 5 alternating half-hitches.

For the control repair technique, the quadriceps tendon was similarly Krackow stitched, but instead, starting and ending distally (Figure 1B). Three equidistant, transosseous bone tunnels were drilled into the superior pole of the patella using 2.4-mm pins and a drill guide (Arthrex). The suture tape strands were fed through the tunnels via passing sutures, and the remaining tendon insertion was released. The limbs were then tensioned at full extension to reduce the tendon and knotted with a surgeon's knot and 5 alternating half-hitches over the bone bridges.

Cyclic Testing

Biomechanical testing was performed using a modification of previously described methods of extensor mechanism repair.^6,9,11 Femurs were individually mounted onto a custom fixture at the base of a servohydraulic materials testing system (Model 8871; Instron) such that the transepicondylar axis was parallel to the base and the tibia was unconstrained in neutral positioning. The proximal quadriceps tendon was oriented along its anatomic axis and attached to a 5-kN load cell by fixing a hook to the nylon strap and using a metal cable and pulley system (Figure 2A). Weights (range, 1.5-3.5 kg) were added to the distal end of the tibia to simulate the weight of the lower extremity, such that a mean force of 150 ± 10 N was generated on extension to 5° of flexion. This force level was chosen as it reflects the quadriceps tendon force required to actuate the full leg into extension.¹¹ Full extension was not used to prevent potential hyperextension of the knee.⁹

Figure 2.

(A) Knees underwent 5° to 90° of cyclic flexion by actuating the quadriceps tendon using a pulley on a servohydraulic materials testing system. Weights were applied to compensate for the remainder of the missing lower extremity. (B) Tendon-bone gap formation was determined via optical tracking with fiducial markers placed on the quadriceps and patella. The final gap formation was defined as the mean displacement of the quadriceps markers with respect to the mean displacement of the patellar markers (ie, rigid body motion compensation) after 250 cycles. F, force.

Native knees were preconditioned (ie, before performing repairs) from 5° to 90° of flexion for 10 cycles at 0.1 Hz in position control. During this phase, actuator displacement values corresponding to 5° and 90° of flexion were recorded for each knee and used for repair state testing. After repair, passive fiducial makers were applied to the quadriceps tendon and patella for optical tracking (ARAMIS 3D 12M; ZEISS), and each knee underwent 250 loading cycles from 5° to 90° of flexion at 0.1 Hz in position control. Tendon-bone gap formation (mm), defined as the mean displacement of the quadriceps tendon markers with respect to the mean location of the patellar markers, was measured at 90° of flexion at cycles 1, 10, 50, 100, 150, 200, and 250 (Figure 2B). A critical gap threshold of 5.0 mm was defined in this study as a level that may impair healing, consistent with previous literature.^9,15

Load-to-Failure Testing

After cyclic loading, the patella and quadriceps tendon were harvested from each knee as a single construct and placed on a separate materials testing system (Model E3000; Instron) for load-to-failure testing, with failure occurring when loads dropped to ±5 N or if the actuator's stroke length of 60 mm was reached. The patella was secured at the base with anatomically contoured clamps, and the tendon was gripped in line with the patella at the load cell with tissue clamps (Figure 3). The gauge length, defined in this study as the distance between the superior pole of the patella and the grip point on the quadriceps tendon, was 4 cm. Constructs were held at 20 N of tension for 30 seconds before pulling to failure at 50 mm/min.¹⁶ The stiffness (N/mm) in the linear elastic region, yield load (0.2% offset; N), and ultimate load (N) were determined by analysis of the load-displacement data in MATLAB software (MathWorks). The failure mode was recorded.

Figure 3.

Patella-quadriceps constructs were placed on an electromechanical materials testing system and secured using custom tissue clamps with a gauge length of 4 cm.

Statistical Analysis

All statistics were performed with an α of .05 and β of .20 in SigmaPlot Version 14.0 (Systat Software). An a priori power analysis of data from Kindya et al⁸ revealed a minimum of 7 samples to detect a difference of 2.7 mm between quadriceps tendon repairs with 80% power. Paired t tests were used for comparisons of bone quality, gap formation, stiffness, yield load, and ultimate load.

Results

The bone quality scores of matched-pair patellas were not significantly different (P = .075), and thus all matched-pair samples were included in the paired statistical analyses.

Gap Formation

The ASA exhibited a significant reduction (P < .001) in repair gapping when compared with the control at all measured cycles (Figure 4, Table 1). The overall mean gap formation for the control exceeded the critical gap threshold of 5.0 mm by cycle 50, whereas the overall mean gap formation for ASA did not surpass this limit through 250 cycles. The mean gap formation at cycle 250 was 3.6 ± 1.5 mm for ASA and 9.9 ± 2.0 mm for the control (Δ = 6.3 mm; 95% CI, 4.9-7.8 mm).

Figure 4.

Gap formation analyzed at discrete intervals throughout cyclic loading for transosseous quadriceps tendon repair using an all-suture anchor (ASA) or control technique. A clinically important gap threshold of 5.0 mm, which may indicate impaired healing, is provided for reference.^9,15 Values are shown as mean ± SD.

Table 1

Gap Formation With Cyclic Loading Measured at 90° of Flexion for Transosseous Quadriceps Tendon Repair Using the ASA or Control Technique ^a

Group	Cycle Count
Group	1	10	50	100	150	200	250
ASA	0.9 ± 0.5	1.8 ± 0.9	2.6 ± 1.1	3.0 ± 1.2	3.2 ± 1.3	3.4 ± 1.4	3.6 ± 1.5
Control	2.3 ± 0.7	4.5 ± 1.1	6.9 ± 1.4	8.1 ± 1.6	8.9 ± 1.7	9.5 ± 1.9	9.9 ± 2.0

Values are given in millimeters as mean ± SD. ASA, all-suture anchor.

Load to Failure

The ASA group had significantly greater stiffness (Δ = 17.7 N/mm; P = .004), yield load (Δ = 40 N; P = .014), and ultimate load (Δ = 127 N; P = .015) compared with the control (Figures 5 -7) (Table 2). One matched pair was excluded from statistical analysis due to an observed patellar slip within the fixtures that led to an inaccurate assessment of the tensile behavior.

Figure 5.

Load-displacement curves for the (A) control specimen and (B) all-suture anchor (ASA) specimen for the same matched pair. A line of best fit (blue) was approximated in the linear elastic region to determine the stiffness, and a 0.2% offset line (orange) was created to find the yield load at its intersection with the curve. Maximum (Max) load is also denoted on the graphs.

Figure 6.

Transosseous quadriceps tendon repair stiffness for control and all-suture anchor (ASA) techniques.

Figure 7.

Transosseous quadriceps tendon repair yield (0.2% offset) and ultimate load for control and all-suture anchor (ASA) techniques.

Table 2

Load-to-Failure Analysis for Transosseous Quadriceps Tendon Repair Using the ASA or Control Technique ^a

Outcome	ASA	Control	Δ 95% CI	P Value
Stiffness, N/mm	71.9 ± 10.6	54.1 ± 8.7	6.5-28.9	.004
Yield load (0.2%), N	246 ± 31	206 ± 20	6-74	.014
Ultimate load, N	712 ± 113	584 ± 159	17-238	.015

Values are given as mean ± SD. Bold P values indicate statistical significance. ASA, all-suture anchor.

Failure modes were visually observed and agreed on by 2 authors (B.L.S. and M.D.T.) and included tunnel migration (3/7) and tendon suture rupture (4/7) for the ASA and tunnel migration (3/7) and knot loosening (4/7) for the control.

Discussion

The present study investigated the biomechanical properties of a novel transosseous quadriceps tendon repair method, which combines the advantages and surgeon familiarity of a transosseous approach with the advantages of adjustable knotless fixation. Compared with a traditional transosseous repair, the adjustable transosseous knotless ASA technique had significantly less gap formation and significantly greater stiffness, yield load, and ultimate load at time zero. The results demonstrate the biomechanical superiority of the knotless ASA technique.

Several previous biomechanical studies have evaluated various quadriceps tendon repair techniques, most commonly comparing traditional transosseous techniques with near-cortex suture anchor techniques.¹⁴ As is typical in biomechanical studies of tendon or ligament repairs, the first key biomechanical outcome is gapping or elongation during cyclic testing. In the present study, at all cycle counts, the ASA transosseous technique had decreased gap formation compared with the traditional transosseous repair technique, with a maximum mean gap formation of 3.6 mm in the ASA group compared with 9.9 mm in the traditional transosseous group. The findings have clinical significance given that previous literature has established a displacement or gap threshold of 5.0 mm for a successful extensor mechanism repair.^9,15 The control group exceeded a mean gap formation of 5.0 mm by cycle 50, while the mean gap formation for the ASA group never exceeded this threshold.

A recent systematic review of biomechanical quadriceps repair studies assessed the cyclic displacement of transosseous repairs, separating the results into initial displacement (10-100 cycles) and final displacement (130-1000 cycles).¹ For the traditional transosseous repair, initial displacements ranged from 1.9 to 12.2 mm, with a mean of 6.3 mm. Final displacement ranged from 3.1 to 33.3 mm, with a mean of 12.1 mm. These findings are consistent with the control transosseous repair group in the present analysis. Interestingly, the ASA group in the present study had nearly identical final cyclic displacement (3.6 mm) compared with the mean of the suture anchor group (2.9 mm) in the same systematic review.¹ Not included in this systematic review was a recent biomechanical study that compared a suture anchor group (control) with a transosseous, adjustable cortical fixation technique similar to what is described in the present study but with far cortical metal buttons.⁶ The mean maximum gap at 200 cycles in the suture anchor group was 7.7 mm compared with 4.0 mm in the adjustable cortical group. The data from the present study add to this investigation by supporting the efficacy of transosseous, adjustable cortical fixation, with potential biomechanical advantages over even suture anchor repair techniques.

The second key biomechanical outcome in studies of tendon or ligament repairs is failure load. In the present study, the mean ultimate load of 712 N in the ASA group was significantly greater than that of 584 N in the control group, with substantially less variability that may in part be attributed to inconsistent knot strength for knotted primary fixation.⁷ Belk et al¹ also reported ultimate load in their recent systematic review comparing transosseous and suture anchor techniques. The mean ultimate load across the transosseous groups was 386 N compared with 511 N in the suture anchor group, which was not significantly different in pooled analyses. One potential explanation for the higher failure loads observed in our data is the use of suture tape, which has been previously demonstrated to reduce gap formation and increase the ultimate load in quadriceps tendon repair.¹⁶

Regarding the modes of failure, the ASA and control groups primarily experienced tendon suture rupture and knot loosening, respectively, which are common failure modes reported in similar studies.¹ The amount of knot loosening is a consequence of knot security, which is known to vary substantially within and between surgeons.⁷ Tunnel migration was the secondary mode of failure for both groups, likely underscoring the importance of bone quality when evaluating fixation techniques, particularly in patients with osteoporosis. This effect may be mitigated by utilizing drill trajectories that maximize cortical bone at the inferior tunnel exit. Additionally, reducing peak contact pressure on the inferior pole of the patella may contribute to reducing the risk of tunnel migration. The deformable body of the ASA broadens at the inferior pole, theoretically distributing force more effectively than the suture bridge, which concentrates force across a smaller area due to its geometry. Clinical data are warranted to identify the failure modes in patients and whether a reduction in complications exists with the ASA technique.

Although this is a time-zero biomechanical study, there are potential clinical advantages to the described technique. While traditional transosseous and suture anchor techniques have reasonable clinical outcomes and low failure rates,^2,17 most cannot be retensioned intraoperatively. Recent technological advances have allowed for knotless fixation with the ability to retension in the shoulder and hip for labral repair and in the knee for ACL reconstruction, making many surgeons familiar with such options for extensor mechanism repair. Gould et al⁶ published both biomechanical and early clinical studies⁵ of a technique allowing retensioning, but with the caveat of metal buttons at the distal pole of the patella, which could lead to hardware irritation. Both techniques reduce the number of required patellar tunnels from 3 to 2, which better maintains the integrity of the patella and minimizes fracture risk. The current technique provides robust biomechanical data to further support its use and potentially avoid hardware irritation with an ASA device.

There are several limitations of the present study. First, this time-zero biomechanical study does not necessarily represent an in vivo scenario in which the patient is immobilized during early postoperative rehabilitation and healing can occur, stabilizing the repair. Donor age ranged from 41 to 56 years, in male cadavers only, to reflect the demographic most associated with quadriceps tendon rupture.⁴ Consequently, the results may not reflect performance across age and sex. Furthermore, there were likely limitations in the tendon quality compared with what is encountered in vivo, which often has some degree of degeneration or compromised biomechanical qualities. This study compared 2 transosseous techniques. While there would be obvious interest in comparing these to a third group with suture anchor repairs, this would not be feasible with the matched-pair study design. The matched-pair design was selected to help eliminate confounding variables and increase statistical power over independent samples. Finally, we did not provide a cost analysis comparison of the 2 groups, as this would require clinical data and rerupture rates to fully evaluate all cost considerations.

Conclusion

Footnotes

Acknowledgements

The authors thank Brittany Glaeser, MS, for assistance with cadaveric dissection and preparation.

Final revision submitted March 14, 2025; accepted March 31, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: The study was funded by Arthrex grant No. AIRR-0209. J.R.W. has received speaking fees from Arthrex and Vericel and consulting fees from Arthrex and Geistlich and has stock or stock options in Viewfi. M.D.T. is an employee of Arthrex. B.L.S. is an employee of Arthrex. B.C.W. has received speaking fees from Arthrex, consulting fees from Arthrex and LifeNet, and research support from Arthrex. R.M.F. has received speaking fees from AlloSource, Arthrex, JRF, and Ossur; consulting fees from AlloSource, Arthrex, and JRF; research support from Arthrex and Smith & Nephew; and publishing royalties and financial or material support from Elsevier. O.L.H. is an employee of Arthrex. C.A.W. is an employee of Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval was not sought for the present study.

ORCID iD

Coen A. Wijdicks

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Transosseous Quadriceps Tendon Repair With Knotless All-Suture Anchors Is Biomechanically Superior to Traditional Transosseous Fixation

Abstract

Background:

Purpose:

Study Design:

Methods:

Results:

Conclusion:

Clinical Relevance:

Keywords

Methods

Specimen Preparation

Transosseous Repair Techniques

Cyclic Testing

Load-to-Failure Testing

Statistical Analysis

Results

Gap Formation

Load to Failure

Discussion

Conclusion

Footnotes

Acknowledgements

ORCID iD

References