Abstract
Background:
The quadriceps tendon is crucial in allowing knee extension, attaching distally to the patella. While ruptures of the tendon are rare, retear can lead to muscle atrophy and complex tendon deficits with retraction which may make revision repairs difficult to perform. To avoid re-rupture, the repair is commonly augmented with an allograft or autograft, theoretically strengthening the repair.
Indications:
Patients are indicated for surgery when presenting with a chronic, symptomatic quadriceps rupture verified on provocative testing and advanced imaging.
Technique Description:
Adhesions and fibrotic tissues around the vastus muscles and tendon are released. Sutures and anchor materials from the previous reconstruction are removed. Fibrotic tissues at the distal end of the retracted quad tendon are removed. The tendon is then loosened from the proximal aspect with the applied traction through the suspension suture placed distal to the tendon. The gap is measured and a V-Y quadricepsplasty was performed at twice the length of the measured gap. In the proximal aspect of the tendon, the limbs of the V-plasty are left incomplete. Next, traction is applied to allow for a tightening exertion to the patella. The proximal Y limb is sutured together in a side-to-side fashion to allow for tendon distalization while retaining the distal traction of the patellar tendon. The medial and lateral limbs were then closed with a suture, completing the tendon advancement. Fibrotic tissues around the superior pole of the patella are removed to prepare for tendon reattachment. Two anchors on the medial and lateral sides are placed, and the suture threads from both anchors are tied in a Krackow configuration. The medial and lateral-sided suture knots are then tied together over the tendon and covered again with the Achilles allograft, completing the repair.
Results:
Outcomes of revision quadriceps repair have been promising, with good to excellent functional outcomes, successful return to activities, and objective outcomes.
Discussion/Conclusion:
Although initial studies report favorable outcomes following current repair techniques, there is a lack of quality literature on outcomes following primary or revision quadriceps repair. Future studies are necessary to determine the reliability, efficacy, and clinical outcomes following this procedure.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
Here we present a case presentation for a re-revision quad tendon repair with vastus advancement.
Our author’s conflicts of interests can be seen here.
The quadriceps tendon is an integral part of the knee extensor mechanism, attaching distally to the patella. Ruptures of the tendon are rare, with a prevalence rate of around 1 per 100,000 people per year, are significantly more common in males, and are particularly seen as a complication following total knee arthroplasty. 2 Retear can lead to muscle atrophy, a decrease in bone stock, and complex tendon deficits with retraction which may make revision repairs difficult to perform. 3 To avoid re-rupture, the repair is commonly augmented with an allograft or autograft, theoretically strengthening the repair.
Our patient is a 71-year-old man who presented with a previous quad tendon repair 5 months prior and revision 3 months prior using an Achilles tendon allograft. The patient was referred to our practice demonstrating significant range of motion deficits, difficulty ambulating, and weakness over their right knee. They currently ambulate with a walker and hinged knee brace.
Physical examination demonstrated a normal range of motion with intact strength on flexion and extension. They were tender over the posterior fossa and have a positive anterior drawer and unstable Lachman and pivot shift.
X-rays were obtained demonstrating an overall preserved joint space with no fracture. However, particularly in the lateral view, a decrease in patellar height was seen. Magnetic resonance imaging sequences show proximately retractive quadriceps tendon and avulsed Achilles tendon allograft. Given the patient’s imaging and physical examination, a re-revision quad tendon repair with vastus advancement was indicated and performed.
After the local infiltrative analgesia, a longitudinal midline incision was performed. Subcutaneous tissues were passed. The tendon and re-ruptured region were identified. Adhesions and fibrotic tissues around the vastus muscles and tendon are released.
Sutures and anchor materials from the previous reconstruction are removed. Fibrotic tissues at the distal end of the retracted quad tendon are removed. The tendon is then loosened from the proximal aspect with the applied traction through the suspension suture placed distal to the tendon. The gap is measured and a V-Y quadricepsplasty was then performed.
The V-plasty is performed at twice the length of the measured gap, or to the length of tendon available if less than this amount. The broad base of the V is advanced into the defect. In the proximal aspect of the tendon, the limbs of the V-plasty are left incomplete. The adhesions around the V-plasty-applied segment are then removed.
Next, traction is applied to allow for a tightening exertion to the patella.
This is confirmed to ensure an adequate amount of traction is applied.
Once acceptable exertion is obtained, the proximal Y limb is sutured together in a side-to-side fashion to allow for distalization of the tendon while the assistant retains the distal traction of the patellar tendon. This allows the V to be converted into a Y. After this was completed, the medial and lateral limbs were then closed with a number 2 ethibond suture, completing the advancement of the tendon.
Here you can see the closing of the medial and lateral limbs of the V-Y-plasty, respectively.
After the V-Y quadricepsplasty, fibrotic tissues around the superior pole of the patella are removed for the preparation of the tendon reattachment. Two anchors are used for the reattachment, and these are placed on the medial and lateral sides of the superior pole of the patella. A 3.5-mm drill with a guide is then used to place 2 drill holes and then tapped, allowing for the placement of the 5.5 bio-composite anchors.
The suture threads from both anchors are then used in a Krackow suture configuration in the distal quadricep tendon.
The medial and lateral-sided suture knots are then tied together and, if deemed necessary, the repair can be strengthened with additional knots.
The tendon was sutured and covered again with the Achilles allograft, attached to the distal aspect of a tibial tubercle, left over from the previous reconstruction. Final view and stability are checked in a limited range of motion examination and the skin and subcutaneous tissues are closed in the same fashion.
Postoperatively, the patient was provided ice immediately with weight-bearing as tolerated. The brace is placed in full extension until their first postoperative visit. After 1 day, the patient should begin physical therapy exercises and should reach full extension and 90° of flexion within 6 to 8 weeks.
Initial case reports of revision quadriceps repair demonstrate good to excellent functional outcomes with a successful, painless return to sports. 4 A recent systematic review of clinical studies reporting on the outcomes of quad tendon repairs showed a low revision rate in addition to improved objective outcomes and successful return to daily activities. 1 However, the review reports a low overall quality of studies reviewed, highlighting the lack of quality literature on outcomes following primary or revision quadriceps repair, particularly those chronic in nature. Future studies are necessary to determine the reliability, efficacy, and clinical outcomes following this procedure.
Thank you for watching our case presentation for our re-revision quadriceps tendon repair and vastus advancement.
Footnotes
Submitted December 31, 2022; accepted May 1, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: J.C. is a paid consultant, receives research support/grants, and receives royalties from Arthrex, Inc, CONMED Linvatec, Ossur, and Smith and Nephew; and is a board or committee member for AOSSM, Arthroscopy Association of North America, and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine. 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.
