THEKNE-02075; No of Pages 5 The Knee xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
The Knee
Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repair of chronic quadriceps tendon rupture☆ Haroon Rehman a, Peter Kovacs b,⁎ a b
Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, United Kingdom Dr Gray's Hospital, Elgin, Moray IV30 1SN, United Kingdom
a r t i c l e
i n f o
Article history: Received 21 August 2014 Received in revised form 28 February 2015 Accepted 15 April 2015 Available online xxxx Keywords: Novel chronic quadriceps tendon repair
a b s t r a c t Background: Several techniques have been described for the primary repair of quadriceps tendon ruptures but there is a paucity of literature on operative management of chronic/recurrent quadriceps tendon ruptures. We describe a novel technique for the revision of quadriceps tendon ruptures which uses hamstring, prolene mesh and autologous conditioned plasma augmentation. Methods: Our patient was an independently mobile, active 61 year-old man who sustained staggered, bilateral quadriceps tendon ruptures. He had two failed direct repairs on the left side. The patient was unable to actively extend his knee. On the third attempt, despite maximising quadriceps tendon length using the Codivilla technique the gap remained significant. The left and right semitendinosus and left gracilis tendons were thus harvested and used to augment our repair. A prolene mesh, sized to fit the whole length quadriceps tendon and patella, was then secured to the repair to reinforce it. The repair site was finally injected with autologous conditioned plasma. Results: Satisfactory post-operative outcomes were achieved. The patient was pain-free and able to maintain straight leg raise with a 10 degrees extensor lag at his four months review in clinic. Conclusions: We were able to achieve a stable construct with combination of both well-established and novel tendon lengthening techniques, in addition to mesh and biological augmentation. In our experience this surgical procedure is suitable for the treatment of a large tendon gap defect and will withstand high force transmission. Level of Evidence: Level 5 Evidence © 2015 Elsevier B.V. All rights reserved.
1. Introduction Quadriceps tendon ruptures can result in significant morbidity and disability. Quadriceps tendon ruptures are three times more common than patellar tendon rupture, and more commonly afflict patients over 40 years of age [1]. Males have a greater inherent predisposition [2,3]. Unilateral rupture is 15–20 times more frequent than bilateral injury. Studies have reported that up to 76% of patients may have an underlying medical condition predisposing them to rupture [4]. Although some extensor function may remain from intact medial and lateral retinaculae, the notable extensor lag in full thickness tears warrants treatment. Surgical management can be a challenging endeavour, but the alternative options including lifelong knee bracing and fusion are undesirable.
☆ No sources of financial support were required for the production of this article. ⁎ Corresponding author at: Trauma & Orthopaedics Unit, Dr Gray's Hospital, Elgin, Moray IV30 1SN, United Kingdom. E-mail address: [email protected] (P. Kovacs).
Several techniques have been described for primary repair [5–8] but there is a paucity of literature on operative management of chronic/ recurrent quadriceps tendon ruptures. Revision procedures present additional difficulty due to large tendon defects, retraction of the tendon, muscle atrophy and poor bone stock which can thwart the surgeons' attempt to create a suitable bone tendon join capable of withstanding large forces [9]. Such cases can require lengthening procedures and biologic augmentation. Platelet rich plasma (PRP) is an autologous concentration of human platelets (four to seven times higher than baseline) in a small volume of plasma. It is obtained from the patient's own blood after processing in an automated centrifuge. It contains growth factors and other molecules modulating healing and haemostasis. The increasing use of PRP in orthopaedics potentially presents significant therapeutic opportunities. We describe and provide discussion on a novel technique used for the revision of a chronic quadriceps tendon rupture in a difficult case, using hamstring augmentation, prolene mesh and platelet rich plasma augmentation.
http://dx.doi.org/10.1016/j.knee.2015.04.006 0968-0160/© 2015 Elsevier B.V. All rights reserved.
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
2
H. Rehman, P. Kovacs / The Knee xxx (2015) xxx–xxx
2. Case report
3. Description of technique
Our patient was an independently mobile, active 61 year-old man who sustained staggered, bilateral quadriceps tendon ruptures, requiring a total of five operations over the period of a year. In summary the patient underwent direct primary repair for ruptured left side quadriceps tendon in February 2013; direct primary repair of a ruptured right sided quadriceps tendon in March 2013; direct repair of re-ruptured bilateral quadriceps tendons in April 2013, and finally a biologically (hamstring and PRP) and artificially (prolene mesh) augmented repair for a re-ruptured left side in December 2013. Despite his large chronic rupture we were able to achieve satisfactory surgical outcomes at seven and 15 months for right and left sides, respectively. The patient had little in the way of medical co-morbidities other than hypertension and glaucoma for which he regularly took antihypertensives and topical, long term, steroid drops. The right side healed following the first revision using a transosseous repair. Fibres of rectus femoris tendon were sutured to superior pole of patella through drill holes, as is done for patellar tendon ruptures; Number 5 Ethibond suture was then passed through the quadriceps tendon and then passed through the drill holes in the patella. Satisfactory functional outcomes were achieved by seven months post-operation. Straight leg raise was restored with a five degrees extensor lag. The patient had active range of active movement from 0 to 90°. As the right knee healed with a conventional repair technique, it is excluded from our discussion. The left patellofemoral quadriceps tendon initially ruptured two weeks after a fall onto the left side during natural gait. The patient heard a “crunch” after which he was unable to actively extend his knee. The patient was treated on clinical grounds with intraoperative findings confirming patellofemoral quadriceps tendon rupture. Primary repair of the left side failed at two months. The patient underwent revision direct repair as in the case of the right knee, which despite being protected with a restricted range of movement cast brace, failed again at two months. Physical examination revealed a palpable defect at the superior pole of the patella spanning the extensor mechanism (Fig. 1). The patient had normal range of passive movement. Radiographs excluded fracture and ultrasound confirmed rupture (Fig. 2). The patient opted to delay further surgery for a further six months. Pre-operatively the patient was unable to straight leg raise and unable to walk.
3.1. Position and preparation The patient was placed in the supine position and was operated on under general anaesthetic. Both lower limbs were prepared and draped. 3.2. Approach A longitudinal, anterior, midline, incision was made over the left knee utilising and extending the previous surgical scar. The quadriceps tendon was explored and scar tissue debrided until healthy tissue was observed. 3.3. Procedure A full thickness tear extending through both medial and lateral retinaculae, with a 4.5 cm gap in the tendon substance was observed (Fig. 3). On inspection there were no overt signs of infection. The quadriceps tendon was then mobilised using both blunt and sharp dissection to release adhesions. Direct repair was not achievable. Despite maximising quadriceps tendon length using the Codivilla technique [10] the gap remained significant. The left and right semitendinosus and left gracilis tendons were harvested. The grafts were prepared, sized and pretensioned. Three six millimetres longitudinal, transosseous drill holes were made in the proximal pole of the left patella. Three endobuttons (Arthrex TightRope®, Athrex GmbH, Munich, Germany) were used to fix the doubled hamstring grafts to the patella after appropriate drilling (Fig. 4). Prior to closing the open V of the Codivilla triangle, the proximal ends of the two lateral hamstring grafts were weaved through the most lateral part of quadriceps tendon, starting from the deep surface of the mobilised quadriceps tendon, using the Pulvertaft technique [11] and avoiding the base of the Codivilla triangle. The medial hamstring graft was pulled under the Codivilla triangle's base, into the open V. All three grafts exited on the superficial surface of the quadriceps tendon (Fig. 5). At this stage the open V was closed and the three hamstring grafts' proximal ends were sutured to each other creating a tension free triple sling. Care was taken to avoid patellar malalignment (baja/alta). Once the grafts were secured, the Codivilla triangle was turned down and secured with a polyester suture to cover and reinforce the hamstring grafts (Fig. 6). The retinaculum was repaired and sutured to the Codivilla triangle. A prolene mesh, sized to fit the whole length quadriceps tendon and patella, was then secured to the repair with 2/0 prolene interrupted sutures to further reinforce the repair (Fig. 7). The repair site and patella tunnels were finally injected with five millilitres of platelet rich plasma using a sterile Arthrex Autologous Conditioned Plasma ACP™ Double Syringe System (Athrex GmbH, Munich, Germany). The PRP product was prepared by withdrawing blood from a sterile site and mixing it with an anticoagulant citrate dextrose solution. The sterile syringe was then placed into a bucket for centrifugation at 1500 rpm for five minutes. The cap of the bucket was then opened to allow scrub nurse to take the sterile syringe. The plasma was transferred to a smaller syringe by the scrub nurse. The repair was tested intra-operatively with the tourniquet still inflated; it allowed 40° of knee flexion without excessive tension. A layered closure was performed. 3.4. Post-operative care
Fig. 1. Visible defect in Extensor Mechanism.
Post-operatively the patient was allowed to weight-bear on the affected limb in an above knee cast for six weeks. Early protected range of movement rehabilitation was encouraged thereafter. Thromboprophylaxis was prescribed for six weeks. Out of cast the
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
H. Rehman, P. Kovacs / The Knee xxx (2015) xxx–xxx
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Fig. 2. Pre-operative ultrasound (left) and plain film x-ray (right) findings.
in clinic. Magnetic resonance imaging at six months post-op showed continuity of the quadriceps tendon and satisfactory graft incorporation (Fig. 8). At one year follow-up, following rehabilitative physiotherapy the patient had a 10 degrees extensor lag on straight leg raise and was able to actively flex to 90°. On assessment of passive range of movement, 0 to 100° could be achieved. Importantly the patient was able to weight bear and mobilise on this limb. Although he used a single stick for support, on clinical assessment the patient was able to mobilise short distances unaided and comfortably.
5. Discussion
Satisfactory post-operative outcomes were achieved. The patient was pain-free and able to maintain straight leg raise with a 10 degrees extensor lag at his four months review
Chronic quadriceps tendon ruptures are difficult to repair. Rerupture following primary repair can be particularly challenging. Failure to restore the extensor mechanism after injury can have debilitating consequences for patients. Surgical treatment has remained largely unchanged for several decades. We present a revision solution for complex cases of tendon re-rupture. Our procedure restored the patient's extensor mechanism, allowing him to walk and ultimately preventing his knee from being fused. The use of hamstring autografts in revision quadriceps tendon repair has previously been described by McCormick et al. [9] and the use of synthetic mesh for the reconstruction of the patellar tendon by Browne and Hanssen [12]. Both studies demonstrated reasonable results. To our knowledge the combination and technical application of biological augmentation using hamstring grafts and platelet rich plasma, and artificial augmentation using prolene mesh for the repair of patellofemoral quadriceps tendon have not previously been described in the literature. Although there are no specific studies assessing the biomechanics of hamstring grafts in biological augmentation of the patellofemoral quadriceps tendon repair, the grafts have been scientifically tested in other
Fig. 4. Surgeon threads patella tunnels with Endobutton suture ends.
Fig. 5. Hamstring grafts exiting Codivilla triangle.
Fig. 3. Defect in patellofemoral quadriceps tendon under direct vision.
patient was allowed to mobilise with crutches, but non-weight bearing for six weeks. 4. Results
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
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H. Rehman, P. Kovacs / The Knee xxx (2015) xxx–xxx
Fig. 6. Codivilla triangle turned down and secured to cover grafts distally.
areas of soft tissue, lower limb surgery. The viability of hamstring grafts in anterior cruciate ligament reconstruction demonstrating both biomechanical stability [13] and graft incorporation [14,15] provides an indirect evidence base for their use as biological implant in our case. Several techniques for autogenous biological augmentation of the patellar tendon have been described with good results [16–18]. We feel that the use of autologous material in tendon reconstruction eliminates the potential for disease transmission and reduces the potential for graft rejection. Although hamstring augmentation alone may be sufficient for repair of massive gaps, our patient had extremely poor tissue quality. We would recommend caution in the weaving technique as weaving through the base of the Codivilla triangle can further substantially weaken the patellofemoral quadriceps tendon and make reattachment difficult. Furthermore, in the presence of a massive gap the Codivilla triangle is too short to cover the patella in the way that it was originally described. The use of a woven monofilament mesh in our procedure provides two functions. The primary purpose was to provide scaffolding for the ingrowth of fibrous host tissue much in the same way as it is used, to great effect, by General surgeons for hernia repair [19]. All meshes cause a foreign body reaction involving inflammation, fibrosis, calcification, thrombosis and formation of granulomas [20]. The pores in mesh are infiltrated macrophages, fibroblasts, blood vessels and collagen. An intense fibrotic reaction ensures strong adherence to the surrounding tissue (i.e. abdominal wall in general surgery) [21]. Animal models
Fig. 7. Prolene mesh fixed to repair.
Fig. 8. MRI at 6 months demonstrating graft incorporation.
have demonstrated that mature fibrous tissue can fully infiltrate a mesh framework by 12 weeks [22]. Although there is not a robust evidence base for the use of mesh in human tendon repair, positive results have been reported using mesh to secondarily repair the Achilles tendons of rabbits [23]. Additionally, the mesh was implanted to confer additional tensile strength to the repair beyond the mechanical properties of the soft tissues alone in the early post-operative period. The synthetic mesh maintains tensile strength over a longer period of time as compared to biological materials [24]. Although eventually the combination of graft incorporation and fibrous scar tissue provided mechanical stability to the repair, we believe that the mesh was important in allowing early range of movement physiotherapy. Autologous conditioned plasma, a PRP product was injected into our construct to enhance the healing process at cellular level. The authors feel that the PRP product enhanced graft incorporation in this case. Platelet rich plasma was developed in the 1970s but recent technologic advances have increased its availability and applicability in contemporary Medicine. The healing properties of PRP are thought to be attributed to the high concentrations of autologous growth factors and secretory proteins which consequentially enhance recruitment, proliferation, and differentiation of cells involved in tissue regeneration [25]. The tissue repair response in musculoskeletal tissue injury progresses from blood clot to fibroblastic scar formation through an elaborate sequence of events including: platelet degranulation with release of growth factors and cytokines, chemotaxis of inflammatory cells and activation and proliferation of local platelet-derived growth factor progenitor cells. In the case of callus formation, new bone formation also forms part of the process. Growth factors found in the microenvironment of a blood clot include: transforming growth factor beta (TGFb); insulin-like growth factor (IGF); vascular endothelial growth factors (VEGFs); epidermal growth factor (EGF) and fibroblast growth factor-2 (FGF-2). TGF-b is known to increase matrix synthesis (e.g. type 1 collagen) and VEGF and FGF-2 increase angiogenesis. The use of PRP aims to enhance this reparative environment. The use of autologous PRP
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
H. Rehman, P. Kovacs / The Knee xxx (2015) xxx–xxx
provides the patient with all the benefits of receiving highly concentrated, biologically active growth factors and reduces the risk of adverse immune reactions. Current research suggests that PRP can play a significant role in enhancing soft tissue healing [26] though its role in bone repair is yet unclear [27,28]. The clinical use of PRP has been described in a variety of surgical fields including periodontal, craniofacial and spinal surgery. Unfortunately much of the literature exists in the form of commentary and case reports, many of which are anecdotal with few including controls to definitively define the role of PRP [29]. With specific reference to tendon surgery, it has been shown in laboratory studies that in human tenocyte cultures, PRP stimulates cell proliferation and total collagen production [30]. Mishra and Pavelko showed significant improvement in their series of 15 patients suffering from lateral epicondilitis following localised injection of PRP [31]. Sanchez et al. used PRP in conjunction with open repair of teno-Achilles ruptures in athletes (n = 6) finding faster recovery of range of movement, no wound complications and less time to resumption of training in the test arm [32]. Randelli et al. reported significant reduction in pain and increase in functional scoring for patients who receive PRP injections following rotator cuff repair [33]. Although the use of PRP is not indicated for every tendon repair, we would encourage the use of PRP as a readily available, costeffective and easily harvested source of growth factors to improve the likelihood of healing and graft incorporation for complex cases. Hamstring augmentation, prolene augmentation or platelet rich plasma injection as individual technical aspects of our procedure would have been insufficient to treat our patient and resulted in further operation failure and soft tissue compromise. In combination the techniques worked very well with excellent outcomes for the patient, given the circumstances. The authors of this report are confident that the technique can be reproduced by general Trauma and Orthopaedic surgeons and does not necessarily require subspecialist input. The authors emphasise that it should not be used as a first line procedure in place of traditional techniques. 6. Conclusion We were able to achieve a stable construct for a re-revision of a quadriceps tendon rupture repair by combining a well-established tendon lengthening technique with artificial and biological augmentation. Our technique is not recommended as a first line revision option, but has a better functional outcome than a knee fusion in massive irreparable tears. In our experience this operation is suitable as a salvage procedure where a large tendon gap defect exists in chronic cases and it will withstand high force transmission. Conflict of interest We have no conflict of interests to declare. References [1] Rockwood CA, Green DP, Bucholz RW, Heckman JD. Rockwood and Green's fractures in adults. Lippincott Williams & Wilkins; 2006. [2] Puranik GS, Faraj A. Outcome of quadriceps tendon repair. Acta Orthop Belg 2006; 72(2):176. [3] Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 2008;39(12):1338–44. [4] Shah MK. Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. South Med J 2002;95(8):860–6. [5] Konrath GA, Chen D, Lock T, Goitz HT, Watson J, Moed B, et al. Outcomes following repair of quadriceps tendon ruptures. J Orthop Trauma 1998;12(4):273–9.
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[6] Scuderi C. Ruptures of the quadriceps tendon: study of twenty tendon ruptures. Am J Surg 1958;95(4):626–35. [7] Rasul T, Fischer DA. Primary repair of quadriceps tendon ruptures: results of treatment Abraham. Clin Orthop 1993;289:205–7. [8] O'shea K, Kenny P, Donovan J, Condon F, McElwain J. Outcomes following quadriceps tendon ruptures. Injury 2002;33(3):257–60. [9] McCormick F, Nwachukwu BU, Kim J, Martin SD. Autologous hamstring tendon used for revision of quadriceps tendon tears. Orthopedics 2013;36(4):e529–32. [10] Canale ST, Beaty JH. Repair of acute rupture of the tendon of the quadriceps femoris muscle. Campbell's Operative Orthopaedics: Expert Consult Premium Edition—Enhanced Online Features. Elsevier Health Sciences; 2012 2345. [11] Canale ST, Beaty JH. Fish-mouth end-to-end suture (Pulvertaft). Campbell's Operative Orthopaedics: Expert Consult Premium Edition—Enhanced Online Features. Elsevier Health Sciences; 2012 3256–7. [12] Browne JA, Hanssen AD. Reconstruction of patellar tendon disruption after total knee arthroplasty results of a new technique utilizing synthetic mesh. J Bone Joint Surg 2011;93(12):1137–43. [13] Hamner DL, BROWN CH, Steiner ME, Hecker AT, Hayes WC. Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg 1999;81(4): 549–57. [14] Prodromos C, Joyce B, Shi K. A meta-analysis of stability of autografts compared to allografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2007;15(7):851–6. [15] Pinczewski LA, Clingeleffer AJ, Otto DD, Bonar SF, Corry IS. Integration of hamstring tendon graft with bone in reconstruction of the anterior cruciate ligament. Arthroscopy 1997;13(5):641–3. [16] RAND JA, MORREY BF, BRYAN RS. Patellar tendon rupture after total knee arthroplasty. Clin Orthop 1989;244:233–8. [17] Cadambi A, Engh G. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. J Bone Joint Surg Am 1992;74: 974–9. [18] Rhomberg M, Schwabegger AH, Ninkovic M, Bauer T, Ninkovic M. Gastrocnemius myotendinous flap for patellar or quadriceps tendon repair, or both. Clin Orthop 2000;377:152–60. [19] EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: metaanalysis of randomized controlled trials. Ann Surg 2002 Mar;235(3):322–32. [20] Klosterhalfen B, Hermanns B, Rosch R, Junge K. Biological response to mesh. Eur Surg 2003;35(1):16–20. [21] Brown C, Finch J. Which mesh for hernia repair? Ann R Coll Surg Engl 2010;92(4): 272–8. [22] Winston LA, Terry AF, Jardine JH, Parrish FF. The result of replacement of partial or total collateral ligaments with Marlex (R) mesh in the knees of dogs. Clin Orthop 1978;137:287–90. [23] Hosey G, Kowalchick E, Tesoro D, Balazsy J, Klocek J, Pederson B, et al. Comparison of the mechanical and histologic properties of Achilles tendons in New Zealand white rabbits secondarily repaired with Marlex mesh. J Foot Surg 1991 May-Jun;30(3): 214–33. [24] Dora CD, Dimarco DS, Zobitz ME, Elliott DS. Time dependent variations in biomechanical properties of cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh and autologous fascia in the rabbit model: implications for sling surgery. J Urol 2004;171(5):1970–3. [25] Foster T, Puskas B, Mandelbaum B, Gerhardt M, Rodeo S. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med 2009;37(11):2259–72. [26] Murray MM, Spindler KP, Ballard P, Welch TP, Zurakowski D, Nanney LB. Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagen–platelet-rich plasma scaffold. J Orthop Res 2007;25(8):1007–17. [27] Kark LR, Karp JM, Davies JE. Platelet releasate increases the proliferation and migration of bone marrow-derived cells cultured under osteogenic conditions. Clin Oral Implants Res 2006;17(3):321–7. [28] Gruber R, Kandler B, Fischer MB, Watzek G. Osteogenic differentiation induced by bone morphogenetic proteins can be suppressed by platelet-released supernatant in vitro. Clin Oral Implants Res 2006;17(2):188–93. [29] Alsousou J, Thompson M, Hulley P, Noble A, Willett K. The biology of platelet-rich plasma and its application in trauma and orthopaedic surgery: a review of the literature. J Bone Joint Surg (Br) 2009 Aug;91(8):987–96. [30] de Mos M, van der Windt AE, Jahr H, van Schie HT, Weinans H, Verhaar JA, et al. Can platelet-rich plasma enhance tendon repair? A cell culture study. Am J Sports Med 2008 Jun;36(6):1171–8. [31] Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered plateletrich plasma. Am J Sports Med 2006 Nov;34(11):1774–8. [32] Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Mujika I. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med 2007 Feb;35(2):245–51. [33] Randelli PS, Arrigoni P, Cabitza P, Volpi P, Maffulli N. Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study. Disabil Rehabil 2008;30(20–22): 1584–9.
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
Contents lists available at ScienceDirect
The Knee
Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repair of chronic quadriceps tendon rupture☆ Haroon Rehman a, Peter Kovacs b,⁎ a b
Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, United Kingdom Dr Gray's Hospital, Elgin, Moray IV30 1SN, United Kingdom
a r t i c l e
i n f o
Article history: Received 21 August 2014 Received in revised form 28 February 2015 Accepted 15 April 2015 Available online xxxx Keywords: Novel chronic quadriceps tendon repair
a b s t r a c t Background: Several techniques have been described for the primary repair of quadriceps tendon ruptures but there is a paucity of literature on operative management of chronic/recurrent quadriceps tendon ruptures. We describe a novel technique for the revision of quadriceps tendon ruptures which uses hamstring, prolene mesh and autologous conditioned plasma augmentation. Methods: Our patient was an independently mobile, active 61 year-old man who sustained staggered, bilateral quadriceps tendon ruptures. He had two failed direct repairs on the left side. The patient was unable to actively extend his knee. On the third attempt, despite maximising quadriceps tendon length using the Codivilla technique the gap remained significant. The left and right semitendinosus and left gracilis tendons were thus harvested and used to augment our repair. A prolene mesh, sized to fit the whole length quadriceps tendon and patella, was then secured to the repair to reinforce it. The repair site was finally injected with autologous conditioned plasma. Results: Satisfactory post-operative outcomes were achieved. The patient was pain-free and able to maintain straight leg raise with a 10 degrees extensor lag at his four months review in clinic. Conclusions: We were able to achieve a stable construct with combination of both well-established and novel tendon lengthening techniques, in addition to mesh and biological augmentation. In our experience this surgical procedure is suitable for the treatment of a large tendon gap defect and will withstand high force transmission. Level of Evidence: Level 5 Evidence © 2015 Elsevier B.V. All rights reserved.
1. Introduction Quadriceps tendon ruptures can result in significant morbidity and disability. Quadriceps tendon ruptures are three times more common than patellar tendon rupture, and more commonly afflict patients over 40 years of age [1]. Males have a greater inherent predisposition [2,3]. Unilateral rupture is 15–20 times more frequent than bilateral injury. Studies have reported that up to 76% of patients may have an underlying medical condition predisposing them to rupture [4]. Although some extensor function may remain from intact medial and lateral retinaculae, the notable extensor lag in full thickness tears warrants treatment. Surgical management can be a challenging endeavour, but the alternative options including lifelong knee bracing and fusion are undesirable.
☆ No sources of financial support were required for the production of this article. ⁎ Corresponding author at: Trauma & Orthopaedics Unit, Dr Gray's Hospital, Elgin, Moray IV30 1SN, United Kingdom. E-mail address: [email protected] (P. Kovacs).
Several techniques have been described for primary repair [5–8] but there is a paucity of literature on operative management of chronic/ recurrent quadriceps tendon ruptures. Revision procedures present additional difficulty due to large tendon defects, retraction of the tendon, muscle atrophy and poor bone stock which can thwart the surgeons' attempt to create a suitable bone tendon join capable of withstanding large forces [9]. Such cases can require lengthening procedures and biologic augmentation. Platelet rich plasma (PRP) is an autologous concentration of human platelets (four to seven times higher than baseline) in a small volume of plasma. It is obtained from the patient's own blood after processing in an automated centrifuge. It contains growth factors and other molecules modulating healing and haemostasis. The increasing use of PRP in orthopaedics potentially presents significant therapeutic opportunities. We describe and provide discussion on a novel technique used for the revision of a chronic quadriceps tendon rupture in a difficult case, using hamstring augmentation, prolene mesh and platelet rich plasma augmentation.
http://dx.doi.org/10.1016/j.knee.2015.04.006 0968-0160/© 2015 Elsevier B.V. All rights reserved.
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
2
H. Rehman, P. Kovacs / The Knee xxx (2015) xxx–xxx
2. Case report
3. Description of technique
Our patient was an independently mobile, active 61 year-old man who sustained staggered, bilateral quadriceps tendon ruptures, requiring a total of five operations over the period of a year. In summary the patient underwent direct primary repair for ruptured left side quadriceps tendon in February 2013; direct primary repair of a ruptured right sided quadriceps tendon in March 2013; direct repair of re-ruptured bilateral quadriceps tendons in April 2013, and finally a biologically (hamstring and PRP) and artificially (prolene mesh) augmented repair for a re-ruptured left side in December 2013. Despite his large chronic rupture we were able to achieve satisfactory surgical outcomes at seven and 15 months for right and left sides, respectively. The patient had little in the way of medical co-morbidities other than hypertension and glaucoma for which he regularly took antihypertensives and topical, long term, steroid drops. The right side healed following the first revision using a transosseous repair. Fibres of rectus femoris tendon were sutured to superior pole of patella through drill holes, as is done for patellar tendon ruptures; Number 5 Ethibond suture was then passed through the quadriceps tendon and then passed through the drill holes in the patella. Satisfactory functional outcomes were achieved by seven months post-operation. Straight leg raise was restored with a five degrees extensor lag. The patient had active range of active movement from 0 to 90°. As the right knee healed with a conventional repair technique, it is excluded from our discussion. The left patellofemoral quadriceps tendon initially ruptured two weeks after a fall onto the left side during natural gait. The patient heard a “crunch” after which he was unable to actively extend his knee. The patient was treated on clinical grounds with intraoperative findings confirming patellofemoral quadriceps tendon rupture. Primary repair of the left side failed at two months. The patient underwent revision direct repair as in the case of the right knee, which despite being protected with a restricted range of movement cast brace, failed again at two months. Physical examination revealed a palpable defect at the superior pole of the patella spanning the extensor mechanism (Fig. 1). The patient had normal range of passive movement. Radiographs excluded fracture and ultrasound confirmed rupture (Fig. 2). The patient opted to delay further surgery for a further six months. Pre-operatively the patient was unable to straight leg raise and unable to walk.
3.1. Position and preparation The patient was placed in the supine position and was operated on under general anaesthetic. Both lower limbs were prepared and draped. 3.2. Approach A longitudinal, anterior, midline, incision was made over the left knee utilising and extending the previous surgical scar. The quadriceps tendon was explored and scar tissue debrided until healthy tissue was observed. 3.3. Procedure A full thickness tear extending through both medial and lateral retinaculae, with a 4.5 cm gap in the tendon substance was observed (Fig. 3). On inspection there were no overt signs of infection. The quadriceps tendon was then mobilised using both blunt and sharp dissection to release adhesions. Direct repair was not achievable. Despite maximising quadriceps tendon length using the Codivilla technique [10] the gap remained significant. The left and right semitendinosus and left gracilis tendons were harvested. The grafts were prepared, sized and pretensioned. Three six millimetres longitudinal, transosseous drill holes were made in the proximal pole of the left patella. Three endobuttons (Arthrex TightRope®, Athrex GmbH, Munich, Germany) were used to fix the doubled hamstring grafts to the patella after appropriate drilling (Fig. 4). Prior to closing the open V of the Codivilla triangle, the proximal ends of the two lateral hamstring grafts were weaved through the most lateral part of quadriceps tendon, starting from the deep surface of the mobilised quadriceps tendon, using the Pulvertaft technique [11] and avoiding the base of the Codivilla triangle. The medial hamstring graft was pulled under the Codivilla triangle's base, into the open V. All three grafts exited on the superficial surface of the quadriceps tendon (Fig. 5). At this stage the open V was closed and the three hamstring grafts' proximal ends were sutured to each other creating a tension free triple sling. Care was taken to avoid patellar malalignment (baja/alta). Once the grafts were secured, the Codivilla triangle was turned down and secured with a polyester suture to cover and reinforce the hamstring grafts (Fig. 6). The retinaculum was repaired and sutured to the Codivilla triangle. A prolene mesh, sized to fit the whole length quadriceps tendon and patella, was then secured to the repair with 2/0 prolene interrupted sutures to further reinforce the repair (Fig. 7). The repair site and patella tunnels were finally injected with five millilitres of platelet rich plasma using a sterile Arthrex Autologous Conditioned Plasma ACP™ Double Syringe System (Athrex GmbH, Munich, Germany). The PRP product was prepared by withdrawing blood from a sterile site and mixing it with an anticoagulant citrate dextrose solution. The sterile syringe was then placed into a bucket for centrifugation at 1500 rpm for five minutes. The cap of the bucket was then opened to allow scrub nurse to take the sterile syringe. The plasma was transferred to a smaller syringe by the scrub nurse. The repair was tested intra-operatively with the tourniquet still inflated; it allowed 40° of knee flexion without excessive tension. A layered closure was performed. 3.4. Post-operative care
Fig. 1. Visible defect in Extensor Mechanism.
Post-operatively the patient was allowed to weight-bear on the affected limb in an above knee cast for six weeks. Early protected range of movement rehabilitation was encouraged thereafter. Thromboprophylaxis was prescribed for six weeks. Out of cast the
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
H. Rehman, P. Kovacs / The Knee xxx (2015) xxx–xxx
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Fig. 2. Pre-operative ultrasound (left) and plain film x-ray (right) findings.
in clinic. Magnetic resonance imaging at six months post-op showed continuity of the quadriceps tendon and satisfactory graft incorporation (Fig. 8). At one year follow-up, following rehabilitative physiotherapy the patient had a 10 degrees extensor lag on straight leg raise and was able to actively flex to 90°. On assessment of passive range of movement, 0 to 100° could be achieved. Importantly the patient was able to weight bear and mobilise on this limb. Although he used a single stick for support, on clinical assessment the patient was able to mobilise short distances unaided and comfortably.
5. Discussion
Satisfactory post-operative outcomes were achieved. The patient was pain-free and able to maintain straight leg raise with a 10 degrees extensor lag at his four months review
Chronic quadriceps tendon ruptures are difficult to repair. Rerupture following primary repair can be particularly challenging. Failure to restore the extensor mechanism after injury can have debilitating consequences for patients. Surgical treatment has remained largely unchanged for several decades. We present a revision solution for complex cases of tendon re-rupture. Our procedure restored the patient's extensor mechanism, allowing him to walk and ultimately preventing his knee from being fused. The use of hamstring autografts in revision quadriceps tendon repair has previously been described by McCormick et al. [9] and the use of synthetic mesh for the reconstruction of the patellar tendon by Browne and Hanssen [12]. Both studies demonstrated reasonable results. To our knowledge the combination and technical application of biological augmentation using hamstring grafts and platelet rich plasma, and artificial augmentation using prolene mesh for the repair of patellofemoral quadriceps tendon have not previously been described in the literature. Although there are no specific studies assessing the biomechanics of hamstring grafts in biological augmentation of the patellofemoral quadriceps tendon repair, the grafts have been scientifically tested in other
Fig. 4. Surgeon threads patella tunnels with Endobutton suture ends.
Fig. 5. Hamstring grafts exiting Codivilla triangle.
Fig. 3. Defect in patellofemoral quadriceps tendon under direct vision.
patient was allowed to mobilise with crutches, but non-weight bearing for six weeks. 4. Results
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
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H. Rehman, P. Kovacs / The Knee xxx (2015) xxx–xxx
Fig. 6. Codivilla triangle turned down and secured to cover grafts distally.
areas of soft tissue, lower limb surgery. The viability of hamstring grafts in anterior cruciate ligament reconstruction demonstrating both biomechanical stability [13] and graft incorporation [14,15] provides an indirect evidence base for their use as biological implant in our case. Several techniques for autogenous biological augmentation of the patellar tendon have been described with good results [16–18]. We feel that the use of autologous material in tendon reconstruction eliminates the potential for disease transmission and reduces the potential for graft rejection. Although hamstring augmentation alone may be sufficient for repair of massive gaps, our patient had extremely poor tissue quality. We would recommend caution in the weaving technique as weaving through the base of the Codivilla triangle can further substantially weaken the patellofemoral quadriceps tendon and make reattachment difficult. Furthermore, in the presence of a massive gap the Codivilla triangle is too short to cover the patella in the way that it was originally described. The use of a woven monofilament mesh in our procedure provides two functions. The primary purpose was to provide scaffolding for the ingrowth of fibrous host tissue much in the same way as it is used, to great effect, by General surgeons for hernia repair [19]. All meshes cause a foreign body reaction involving inflammation, fibrosis, calcification, thrombosis and formation of granulomas [20]. The pores in mesh are infiltrated macrophages, fibroblasts, blood vessels and collagen. An intense fibrotic reaction ensures strong adherence to the surrounding tissue (i.e. abdominal wall in general surgery) [21]. Animal models
Fig. 7. Prolene mesh fixed to repair.
Fig. 8. MRI at 6 months demonstrating graft incorporation.
have demonstrated that mature fibrous tissue can fully infiltrate a mesh framework by 12 weeks [22]. Although there is not a robust evidence base for the use of mesh in human tendon repair, positive results have been reported using mesh to secondarily repair the Achilles tendons of rabbits [23]. Additionally, the mesh was implanted to confer additional tensile strength to the repair beyond the mechanical properties of the soft tissues alone in the early post-operative period. The synthetic mesh maintains tensile strength over a longer period of time as compared to biological materials [24]. Although eventually the combination of graft incorporation and fibrous scar tissue provided mechanical stability to the repair, we believe that the mesh was important in allowing early range of movement physiotherapy. Autologous conditioned plasma, a PRP product was injected into our construct to enhance the healing process at cellular level. The authors feel that the PRP product enhanced graft incorporation in this case. Platelet rich plasma was developed in the 1970s but recent technologic advances have increased its availability and applicability in contemporary Medicine. The healing properties of PRP are thought to be attributed to the high concentrations of autologous growth factors and secretory proteins which consequentially enhance recruitment, proliferation, and differentiation of cells involved in tissue regeneration [25]. The tissue repair response in musculoskeletal tissue injury progresses from blood clot to fibroblastic scar formation through an elaborate sequence of events including: platelet degranulation with release of growth factors and cytokines, chemotaxis of inflammatory cells and activation and proliferation of local platelet-derived growth factor progenitor cells. In the case of callus formation, new bone formation also forms part of the process. Growth factors found in the microenvironment of a blood clot include: transforming growth factor beta (TGFb); insulin-like growth factor (IGF); vascular endothelial growth factors (VEGFs); epidermal growth factor (EGF) and fibroblast growth factor-2 (FGF-2). TGF-b is known to increase matrix synthesis (e.g. type 1 collagen) and VEGF and FGF-2 increase angiogenesis. The use of PRP aims to enhance this reparative environment. The use of autologous PRP
Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
H. Rehman, P. Kovacs / The Knee xxx (2015) xxx–xxx
provides the patient with all the benefits of receiving highly concentrated, biologically active growth factors and reduces the risk of adverse immune reactions. Current research suggests that PRP can play a significant role in enhancing soft tissue healing [26] though its role in bone repair is yet unclear [27,28]. The clinical use of PRP has been described in a variety of surgical fields including periodontal, craniofacial and spinal surgery. Unfortunately much of the literature exists in the form of commentary and case reports, many of which are anecdotal with few including controls to definitively define the role of PRP [29]. With specific reference to tendon surgery, it has been shown in laboratory studies that in human tenocyte cultures, PRP stimulates cell proliferation and total collagen production [30]. Mishra and Pavelko showed significant improvement in their series of 15 patients suffering from lateral epicondilitis following localised injection of PRP [31]. Sanchez et al. used PRP in conjunction with open repair of teno-Achilles ruptures in athletes (n = 6) finding faster recovery of range of movement, no wound complications and less time to resumption of training in the test arm [32]. Randelli et al. reported significant reduction in pain and increase in functional scoring for patients who receive PRP injections following rotator cuff repair [33]. Although the use of PRP is not indicated for every tendon repair, we would encourage the use of PRP as a readily available, costeffective and easily harvested source of growth factors to improve the likelihood of healing and graft incorporation for complex cases. Hamstring augmentation, prolene augmentation or platelet rich plasma injection as individual technical aspects of our procedure would have been insufficient to treat our patient and resulted in further operation failure and soft tissue compromise. In combination the techniques worked very well with excellent outcomes for the patient, given the circumstances. The authors of this report are confident that the technique can be reproduced by general Trauma and Orthopaedic surgeons and does not necessarily require subspecialist input. The authors emphasise that it should not be used as a first line procedure in place of traditional techniques. 6. Conclusion We were able to achieve a stable construct for a re-revision of a quadriceps tendon rupture repair by combining a well-established tendon lengthening technique with artificial and biological augmentation. Our technique is not recommended as a first line revision option, but has a better functional outcome than a knee fusion in massive irreparable tears. In our experience this operation is suitable as a salvage procedure where a large tendon gap defect exists in chronic cases and it will withstand high force transmission. Conflict of interest We have no conflict of interests to declare. References [1] Rockwood CA, Green DP, Bucholz RW, Heckman JD. Rockwood and Green's fractures in adults. Lippincott Williams & Wilkins; 2006. [2] Puranik GS, Faraj A. Outcome of quadriceps tendon repair. Acta Orthop Belg 2006; 72(2):176. [3] Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 2008;39(12):1338–44. [4] Shah MK. Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. South Med J 2002;95(8):860–6. [5] Konrath GA, Chen D, Lock T, Goitz HT, Watson J, Moed B, et al. Outcomes following repair of quadriceps tendon ruptures. J Orthop Trauma 1998;12(4):273–9.
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Please cite this article as: Rehman H, Kovacs P, Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repai..., Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.04.006
