Purpose
The purpose of this study is to compare the biomechanical properties between traditional
transosseous tunnel and suture anchor technique repair for extensor mechanism ruptures
and assess for differences in the mechanism of failure of both techniques.
Methods
A multi-database search (PubMed, EMBASE, and Medline) was performed according to PRISMA
guidelines on November 14, 2021. All articles comparing biomechanical properties of
transpatellar and suture anchor technique for extensor mechanism ruptures were included.
Abstracts, reviews, case reports, studies without biomechanical analysis, conference
proceedings, and non-English language studies were excluded. Outcomes pursued included
gap formation, load to failure, and mechanism of failure. Relevant data from studies
meeting inclusion criteria were extracted and analyzed. Study methodology was assessed
using the Methodological Index for Non-Randomized Studies score.
Results
A total of 212 knees were biomechanically assessed, including 98 patella and 114 quadricep
tendon ruptures. Five patellar tendon studies were included, and all of them reported
significantly smaller gap formation in suture anchor group. Gap formation for suture
anchors ranged from .9 mm to 4.1 mm, while that of transpatellar group ranged from
2.9 mm to 10.3 mm. One study reported a significantly higher load to failure in the
suture anchor group, while the remaining four studies reported no significant difference.
Load to failure for suture anchor ranged from 259 N to 779 N, while that of the transpatellar
group ranged from 287 N to 763 N. The most common mechanism of failure was anchor
pullout in suture anchor and knot failure in the transpatellar group. Five quadriceps
tendon studies were included, and three studies reported statistically significant
smaller gap formation in the suture anchor group. Gap formation for suture anchor
ranged from 1.5 mm to 5.0 mm, while that of transpatellar group ranged from 3.1 mm
to 33.3 mm. Two studies reported a significantly higher load to failure in the suture
anchor group, while one study reported a higher load to failure in the transpatellar
repair group. Load to failure for suture anchor ranged from 286 N to 740 N, while
that of transpatellar group ranged from 251 N to 691 N. The most common mechanism
of failure was suture failure in the suture anchor and knot failure in the transpatellar
group.
Conclusion
Suture anchor fixation displays a better biomechanical profile than traditional transpatellar
techniques in terms of smaller gap formations in the repair of both patella and quadriceps
tendon injuries. Anchor pullout in suture anchor fixation was present mainly with
the use of titanium anchors.
Clinical Relevance
These findings above may result in better retention of tendon approximation in patella
and quadriceps tendon fixation postoperatively, which may result in earlier recovery.
Further randomized controlled clinical trials to compare these techniques are required.
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References
- Acute quadriceps tendon ruptures: A series of 50 knees with an average follow-up of more than 6 years.Orthop Traumatol Surg Res. 2014; 100: 213-216
- Light microscopic histology of quadriceps tendon ruptures.Int Orthop. 2012; 36: 2367-2371
- Histologic analysis of ruptured quadriceps tendons.Knee Surg Sports Traumatol Arthrosc. 2010; 18: 85-88
- Biomechanical comparison of patellar tendon repairs in a cadaver model: An evaluation of gap formation at the repair site with cyclic loading.Am J Sports Med. 2002; 30: 469-473
- Ligament-tendon fixation: Analysis of a new stitch and comparison with standard techniques.Orthopedics. 1988; 11: 909-917
- Patellar stress fracture after transosseous extensor mechanism repair: report of 3 cases.Am J Sports Med. 2012; 40: 1668-1672
- The evolution of suture anchors in arthroscopic rotator cuff repair.Arthroscopy. 2013; 29: 1589-1595
- Patellar tendon repair with suture anchors using a combined suture technique of a Krackow-Bunnell weave.J Orthop Trauma. 2009; 23: 68-71
- Repair of quadriceps tendon ruptures using suture anchors.Arthroscopy. 2002; 18: 556-559
- Repair of patellar tendon rupture using suture anchors.J Knee Surg. 2008; 21: 122-129
- Repair of patellar tendon rupture with suture anchors.Arthroscopy. 2007; 23: 906.e1-906.e4
- Prospective multicentre study of the clinical and functional outcomes following quadriceps tendon repair with suture anchors.Eur J Orthop Surg Traumatol. 2016; 26: 85-92
- Operative treatment of acute patellar tendon ruptures.Am J Sports Med. 2020; 48: 2686-2691
- Outcomes following quadriceps tendon repair using transosseous tunnels versus suture anchors: A systematic review.Injury. 2021; 52: 339-344
- The use of suture anchors in repair of the ruptured patellar tendon: a biomechanical study.Am J Sports Med. 2006; 34: 1492-1499
- Biomechanical properties of suture anchor repair compared with transosseous sutures in patellar tendon ruptures: a cadaveric study.Am J Sports Med. 2013; 41: 2540-2544
- Knotless suture anchor with suture tape quadriceps tendon repair is biomechanically superior to transosseous and traditional suture anchor-based repairs in a cadaveric model.Arthroscopy. 2017; 33: 190-198
- Comparison of the suture anchor and transosseous techniques for patellar tendon repair: A biomechanical study.Am J Sports Med. 2016; 44: 2076-2080
- Biomechanical analysis of patellar tendon repair with knotless suture anchor tape versus transosseous suture.Orthop J Sports Med. 2020; 8 (2325967120954808)
- Suture anchor repair yields better biomechanical properties than transosseous sutures in ruptured quadriceps tendons.Knee Surg Sports Traumatol Arthrosc. 2015; 23: 1039-1045
- Biomechanical evaluation of suture anchor versus transosseous tunnel quadriceps tendon repair techniques.Arthroscopy. 2016; 32: 1117-1124
- Biomechanical evaluation of suture anchor versus transosseous tunnel patellar tendon repair techniques.J Knee Surg. 2019; 32: 825-832
- Preferred reporting items for systematic reviews and meta-analyses: PRISMA statement.PLoS Med. 2009; 6e1000097
- Methodological index for non-randomized studies (minors): and validation of a new instrument.ANZ J Surg. 2003; 73: 712-716
- Quadriceps tendon rupture: biomechanical comparison of transosseous equivalent double-row suture anchor versus transosseous tunnel repair.J Knee Surg. 2012; 25: 335-339
- Suture anchor versus suture through tunnel fixation for quadriceps tendon rupture: a biomechanical study.Orthopedics. 2008; 31: 441
- Experimental determination of forces transmitted through the patello-femoral joint.J Biomech. 1988; 21: 17-23
- Achilles tendon rupture: avoiding tendon lengthening during surgical repair and rehabilitation.Yale J Biol Med. 2011; 84: 289-300
- Failure with continuity in rotator cuff repair "healing".Am J Sports Med. 2013; 41: 134-141
- Outcomes following repair of quadriceps tendon ruptures.J Orthop Trauma. 1998; 12: 273-279
- Outcomes following quadriceps tendon ruptures.Injury. 2002; 33: 257-260
- Clinical outcomes after repair of quadriceps tendon rupture: A systematic review.Injury. 2012; 43: 1931-1938
- Extensor mechanism ruptures of the knee: Differences in demographic data and long-term outcome after surgical treatment.Injury. 2015; 46: 1957-1963
- The effects of chronic unloading and gap formation on tendon-to-bone healing in a rat model of massive rotator cuff tears.J Orthop Res. 2014; 32: 439-447
- The effect of muscle loading on flexor tendon-to-bone healing in a canine model.J Orthop Res. 2008; 26: 1611-1617
- Morphology and matrix composition during early tendon to bone healing.Clin Orthop Relat Res. 1997; : 253-260
- Tendon-healing to cortical bone compared with healing to a cancellous trough. A biomechanical and histological evaluation in goats.J Bone Joint Surg Am. 1995; 77: 1858-1866
- Biomechanical evaluation of different surgical techniques for treating patellar tendon ruptures.Int Orthop. 2016; 40: 1717-1723
- Traumatic patellar tendon ruptures: A follow-up study of primary repair and a neutralization wire.J Trauma. 1994; 36: 658-660
- Rupture of the patellar tendon: A review of 68 cases and a retrospective study of 29 ruptures comparing two methods of augmentation.Arch Orthop Trauma Surg. 2001; 121: 578-582
- Augmentation of patellar tendon repair with poly-p-dioxannone cord.Injury. 2002; 33: 263-264
- Early motion after quadriceps and patellar tendon repairs: Outcomes with single-suture augmentation.Am J Sports Med. 2008; 36: 316-323
- Patellar tendon repair augmentation with a knotless suture anchor internal brace: A biomechanical cadaveric study.Am J Sports Med. 2018; 46: 1199-1204
- Proximal patellar tendon repair: Internal brace technique with unicortical buttons and suture tape.Arthrosc Tech. 2017; 6: e491-e497
- Suture anchor fixation strength in osteopenic versus non-osteopenic bone for rotator cuff repair.Arch Orthop Trauma Surg. 2009; 129: 373-379
- Pullout strength of suture anchors used in rotator cuff repair.J Bone Joint Surg Am. 2003; 85: 2190-2198
- Anchor design and bone mineral density affect the pull-out strength of suture anchors in rotator cuff repair: Which anchors are best to use in patients with low bone quality?.Am J Sports Med. 2004; 32: 1466-1473
- Effect of structural design on the pullout strength of suture anchors for rotator cuff repair.J Orthop Res. 2018; 36: 3318-3327
- The epidemiology of musculoskeletal tendinous and ligamentous injuries.Injury. 2008; 39: 1338-1344
- Acute quadriceps tendon rupture repaired by suture anchors: Outcomes at 7 years' follow-up in 25 cases.Orthop Traumatol Surg Res. 2017; 103: 597-601
- Influence of suture material on the biomechanical behavior of suture-tendon specimens: A controlled study in bovine rotator cuff.Am J Sports Med. 2008; 36: 907-912
Article info
Publication history
Published online: January 20, 2022
Accepted:
January 3,
2022
Received:
August 9,
2021
Footnotes
The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Identification
Copyright
© 2022 by the Arthroscopy Association of North America
