Suture Anchor Repair of Quadriceps Tendon Rupture

Knee extensor mechanism rupture is an uncommon, but significant, injury. The inability to actively extend the knee precludes normal gait. Quadriceps tendon injuries usually result from a simple fall in middle-aged men.1 Although low-energy fall mechanism of injury is most common, spontaneous rupture tends to occur in a subset of medical conditions (Table).2,3 Patients with quadriceps tendon ruptures are typically older (>40 years) than those who sustain patellar tendon injuries (<40 years).4 Optimal treatment mandates early evaluation, diagnosis, and surgical treatment,5 as operative treatment of chronic ruptures and nonsurgical treatment have inferior outcomes.2,6 Operative management of quadriceps tendon rupture has traditionally used either longitudinal (superior to inferior) trans-patellar drill holes (for tendinous avulsions) or simple suture repair with or without reinforcement (for intratendinous midsubstance ruptures).2 The complication and re-rupture rates after surgical repair have been approximately 14% and 2%, respectively.2 However, recent literature has demonstrated a previously unreported complication of displaced patellar stress fracture in patients undergoing extensor mechanism reconstruction using trans-patellar drill holes.7 In addition, normal anatomic studies of the quadriceps-patella tendo-osseous junction illustrate a more superficial junction (anterior 50%) with a footprint on the superior and anterior surface.8 Recently, surgeons have used a novel “pulley technique” with suture anchors to anatomically re-create the anatomic footprint for other tendinous avulsion repairs, including proximal hamstrings.9,10 Therefore, given the drill hole stress-riser effect and reproduction of normal anatomy, the authors recommend a suture anchor-based pulley technique repair that best replicates the normal anatomic footprint and may potentially avoid the risk of patellar fracture.