0363-5465/102/3030-0469$02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 30, No.

4 2002 American Orthopaedic Society for Sports Medicine

Biomechanical Comparison of Patellar Tendon Repairs in a Cadaver Model

An Evaluation of Gap Formation at the Repair Site with Cyclic Loading
Richard V. Ravalin,* MD, Augustus D. Mazzocca, MD, John C. Grady-Benson, MD, Carl W. Nissen, MD, and Doug J. Adams, PhD From The University of Connecticut, Department of Orthopaedic Surgery, Farmington, Connecticut

Background: Ruptures of the patellar tendon are rare injuries. Surgical treatment for this injury is mandatory. Hypothesis: Gap formation does not differ between the three patellar tendon repair techniques. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaveric knees were used to compare three techniques of patellar tendon repairs. The standard suture repair used two Krackow sutures placed in the avulsed patellar tendon, passed through transpatellar drill holes, and secured with the knee in 30 of flexion. In the second group, suture repair was augmented with a No. 5 Ethibond suture. In the third group, suture repair was augmented with a 2.0 Dall-Miles cable. Testing was performed with the specimens mounted to a custom knee jig with the tibia free, simulating the knee moment of a 70-kg person. Each knee was then cycled 250 times at 0.25 Hz. Results: Gap formation across the standard suture repair averaged 7.3 mm; across the suture augmentation and cable augmentation groups it averaged 4.9 mm and 3.5 mm, respectively. Conclusions: Augmentation of patellar tendon avulsions can decrease gap formation at the repair site, allowing early mobilization. Clinical Relevance: Gap formation seen in repair without augmentation could lead to clinical failure with resultant patella alta and extensor mechanism lag. 2002 American Orthopaedic Society for Sports Medicine

Ruptures of the patellar tendon are rare injuries that generally occur in patients younger than 40 years of age. The majority of these ruptures occur at the distal pole of the patella, but they can also occur in the midsubstance of the tendon or at the insertion on the tibial tubercle. Surgical treatment for this injury is mandatory. For distal pole avulsions, sutures are used to attach the tendon to a bony trough at the distal pole of the patella through longitudinal transpatellar holes. The sutures are then tied over the superior pole of the patella with the knee at approximately 30 of flexion. Historically, the procedure

* Address correspondence and reprint requests to Richard V. Ravalin, MD, 512 Chestnut Street, Pacific Grove, CA 93950. Funding was received from companies related to products mentioned in this study. See Acknowledgment for funding information.

has been to immobilize the knee joint in extension for 6 weeks to minimize strain at the repair site during tendon healing. However, monomeric collagen production, fibril reorientation, and cross-linking all depend on the presence of applied stresses in the tendon.8, 24 In the absence of stress, collagen production decreases and remodeling does not occur.8, 24 Other disadvantages of the traditional procedure include poor articular cartilage nutrition, formation of adhesions, atrophy of muscles, and weakness in the ligament tissue.4, 6, 14, 21, 25 Small retrospective studies of patellar tendon repairs are numerous.3, 5, 9 12, 1519, 23 Each describes a standard repair with or without augmentation and no standardized evaluation. To the best of our knowledge, no biomechanical studies have been performed to evaluate current methods of surgical fixation of the patellar tendon with and without augmentation. The purpose of this study was to
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evaluate the mechanical integrity of different patellar tendon repair techniques under cyclic loading.

MATERIALS AND METHODS

Twelve fresh-frozen cadaveric knees (midthigh to midtibia) were used to compare three techniques of patellar tendon repair. The average donor age was 66 years (range, 55 to 91). None of the specimens had any evidence of significant pathologic conditions of the joint. The skin and the subcutaneous tissue of each knee were removed, while the retinaculum and joint capsule were kept intact. The quadriceps tendon was freed and sutured from 30 to 70 mm proximal to the superior pole of the patella with nylon webbing. A minimum of eight interrupted No. 5 Ethibond (Ethicon Inc., Somerville, New Jersey) mattress sutures were used to suture the tendon to the webbing. The nylon webbing was then looped proximally for a total length of 30 cm and connected in series to a servohydraulic mechanical testing machine (Model 858, MTS Corp., Eden Prairie, Minnesota) via a connecting cable around a pulley. By cutting the tendon transversely from the distal pole of the patella, a defect was created in the patellar tendon. A 3-mm cuff of patellar tendon was left attached to the distal pole of the patella for placement of a miniature displacement transducer (DVRT, Microstrain Inc., Burlington, Vermont). After the repair was secured, a small piece of rigid polyurethane was applied to the anterior surface of the patellar tendon with cyanoacrylate glue to correct the offset between the residual cuff and the repaired tendon. This application allowed the DVRT attachment points across the repair site to be aligned properly throughout the 90 arc of motion of the knee. Three different patellar tendon repair techniques were used (Fig. 1), and all repairs were performed by the same surgeon (RVR). Anatomic repair was confirmed by visual inspection. Standard Repair: Two separate Krackow sutures13 (No. 5 Ethibond) were placed in the patellar tendon and passed through three transpatellar drill holes (two sutures through the central hole and one suture through the medial and lateral holes) and secured superiorly with the knee at 30 of flexion. Suture Augmentation: Suture repair was performed as previously described and augmented with a No. 5 Ethibond suture placed through transverse drill holes in the midpatellar axis and 1 cm posterior to the tibial tubercle in the proximal tibia. The suture was then secured with the knee at 90 of flexion, allowing a flexion arc of 0 to 90 for biomechanical testing. Cable Augmentation: Suture repair was performed as previously described and augmented with a 2.0 Dall-Miles cable and sleeve set (Howmedica Inc., Rutherford, New Jersey) placed through transverse drill holes in the midpatellar axis and 1 cm posterior to the tibial tubercle in the proximal tibia and then secured with the knee at 90 of flexion. Manual tension of the cable was applied with the cable jet tightener. The sleeve was then crimped once a 90 arc of motion was ensured for biomechanical testing.

Figure 1. Patellar tendon repairs with or without an augmentation loop. The suture repair consisted of two sets of Krackow sutures placed in the avulsed patellar tendon and passed through longitudinal drill holes in the patella. The repair was then secured over the proximal pole of the patella with the knee at 30 of flexion. The suture or cable augmentation loop was secured with the knee at 90 of flexion. Threaded steel rods were cemented into the intramedullary canals of the distal femur and proximal tibia using Simplex P polymethyl methacrylate (Howmedica Inc.). The femur was secured to a metal block on a customized knee-testing jig that allowed the knee to rest at 90 with the tibia free. The quadriceps tendon cable was then connected to the hydraulic actuator through a pulley. To simulate the weight of an intact foot and lower leg, a 5-pound weight was attached to the tibial rod 33 cm distal to the medial epicondyle (the axis of rotation). Previous studies have demonstrated that this construct provides a moment at the knee similar to that occurring in an average 70-kg person.2 Each knee was extended to 0 against this moment via the quadriceps tendon for 250 cycles at 0.25 Hz, with quadriceps tension and cyclic displacement recorded across the repair site. Initially, 1000 cycles was chosen as the number that would simulate weekly knee cycles performed during an accelerated ACL rehabilitation program.1, 22 However, a pilot study at our institution showed no difference in displacement after 250 cycles; therefore the number of cycles was reduced. Gap formation at the repair site of more than 5 mm was arbitrarily chosen as the measure of a failed tendon repair. After the augmentation groups completed 250 cycles, the suture or cable was removed, and the knee was cycled another 25 times to evaluate the protective effect of the augmentation device and to check the integrity of the standard repair. Additional displacement was recorded.

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Analysis of Data A repeated measures analysis of variance with Fishers post hoc analysis was used to analyze the data for each repair technique. The P value was set at 0.05.

RESULTS
Suture Repair The gap across the suture repair site averaged 7.3 0.5 mm after 250 cycles. While the parameters for displacement were set on the MTS machine during the first two cycles, the repair site gapped an average of 4 mm grossly. The gap formation after 10 cycles averaged 3.4 0.2 mm. Between 10 and 100 cycles, the average gap was 2.7 0.5 mm. Additional gapping averaged 1.2 0.1 mm from 100 to 250 cycles. Therefore, the total displacement across the repair site averaged 11.3 0.5 mm. The suture repair was thus considered a failure. Suture Augmentation The gap across the repair augmented with a suture loop averaged 4.9 0.5 mm after 250 cycles (P 0.0003 compared with suture repair). There was no evidence of gap formation at the repair site after the MTS setup. After 10 cycles, the average gap was 2.5 0.4 mm. Between 10 and 100 cycles, the increase in gap formation averaged 2.0 0.2 mm. An additional 0.4 0.2 mm was seen between 100 and 250 cycles. Because the average gap formation recorded was less than 5 mm, the suture augmentation was considered a successful repair. After the suture augmentation loop was removed, the average gap formation with an additional 25 cycles was 3.0 mm. Cable Augmentation The gap across the repair augmented with a cable loop averaged 3.5 0.8 mm after 250 cycles (P 0.0001 and 0.0114 compared with the suture repair and suture augmentation groups, respectively). There was no evidence of gap formation at the repair site after the MTS setup. Gapping after 10 cycles averaged 2.1 0.7 mm. Between 10 and 100 cycles, the increase in gap formation averaged 0.9 0.2 mm. Additional gapping averaged 0.4 0.1 mm from 100 to 250 cycles. By definition, the cable augmentation repair group was considered a success. After the cable was removed, the average gap formation with the additional 25 cycles was 4.2 mm. Only two of four specimens could be averaged for this result because of complications resulting in disruption of the underlying standard repair. Total gap formation for the three methods is shown in Figure 2. All loads recorded by the MTS through the quadriceps tendon were less than 250 N. Complications Technical complications occurred in four of four knee specimens with the suture loop augmentation and two of four

Figure 2. Total gap formation in the three types of repairs.

knee specimens with the cable loop augmentation. All of the suture loop augmentation complications consisted of diminished knee extension by 3 to 5 caused by failure of the suture loop in full extension with MTS displacement. Therefore, the suture loop augmentation group was cycled through a limited 85 to 88 arc of motion. The cable loop augmentation group complications occurred at the completion of the 250 cycles. After the cable was removed, the knees were cycled an additional 25 times to evaluate the protective effect of the wire. Two knees demonstrated gross disruption at the repair site with the first cycle after the cable was cut. In each specimen, all three of the transpatellar sutures (suture repair) failed, thus disrupting the DVRT.

DISCUSSION
Most patellar tendon ruptures are caused by an eccentric contraction of the quadriceps muscles at knee flexion angles greater than 45. These ruptures are easily diagnosed with an accurate history and physical examination. The radiographic findings of patella alta and abnormal InsallSalvati or Blackburne-Peel measurements are obvious. Surgical intervention is the rule for treatment of these ruptures and should be performed as soon as possible. The operative technique for repairing disruptions of the patellar tendon from the inferior pole of the patella includes the use of multiple locking sutures (Krackow13) placed through longitudinal transpatellar drill holes. The tendon is then appropriately tensioned and secured over the proximal pole of the patella (standard repair) with the knee at 30 of flexion. This repair can be augmented with suture, surgical tape, wires, cables, autograft tissue (semitendinosus tendon), or allograft tissue if the surgeon desires. Ideally, the repair allows intraoperative knee flexion to 90 and the repaired tendon is lax (1 cm) in full extension. The clinical significance of this study was twofold. The results showed how much gapping occurred across the suture repair with cyclic loading and whether augmentation decreased gap formation at the repair site. The type of augmentation needed to prevent excessive gap formation was also indicated. These results should influence the choice of activity allowed during postoperative rehabilitation, depending on the technique used.

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Accelerated rehabilitation after patellar tendon repair includes weightbearing as tolerated with the knee in full extension, isometric quadriceps/hamstring muscle strengthening, and early range of motion with a knee flexion arc from 0 to 90 for 6 weeks. We prefer to use active-assisted and active range of motion exercises three times a day. To allow this motion we prefer to augment all patellar tendon repairs with either a suture or cable loop between the patella and the proximal tibia. This fixed loop is placed through transverse drill holes in the midpatellar axis and 1 cm posterior to the tibial tubercle and then secured (after the suture repair), allowing 90 of flexion. Before our current study, no biomechanical comparison of patellar tendon repair techniques had been performed. We were specifically interested in evaluating the amount of gap formation seen across the repair site with cyclic loading. Our knee extension model simulated a moment at the knee of a 70-kg person. The MTS machine was controlled by displacement, extending the knee from 90 of flexion to full extension and then controlling flexion back to 90. The loads applied to the quadriceps tendon were always less than 250 N per cycle, simulating an accelerated rehabilitation protocol. Augmentation of patellar tendon avulsion with a fixed loop between the patella and the tibia should reduce strain across the repair site if early motion is allowed. Theoretically, this fixed loop can cause patella baja and result in patellofemoral overload. Because the fixed loop is tensioned (after the suture repair is secured at 30) to allow 90 of flexion, any passive extension creates laxity in the loop as the knee approaches full extension. This laxity is diminished when an active load is applied to the quadriceps tendon. The goal of the fixed loop is to resist strain at the repair site while serving as a temporary link for the extensor mechanism when the quadriceps tendon is actively loaded. Because problems associated with flexor tendons of the hand are different from those of large tendons such as the Achilles and patellar tendons, the results of the former cannot be applied to the latter.7 In the hand, repair displacement of 1 to 2 mm can cause a problem with functional motion. Healed gap formations greater than 3 mm have been shown to have significant differences in biomechanical properties compared with those less than 3 mm.20 Large-tendon gap formation of more than 1 cm has been reported in the Achilles tendon postoperatively and correlates with a decrease in plantar flexion strength clinically.7 In the literature, no specific amount of displacement has been defined that correlates with failure of large-tendon repairs. For our study, displacement of more than 5 mm was arbitrarily defined as a failure. A controlled gap formation ( 5 mm) should stimulate the repair process and improve the strength of the tendon callus. This organized repair tissue should theoretically heal without a residual extensor lag or quadriceps muscle weakness. Larger gaps of more than 5 mm would likely heal with weaker disorganized scar tissue. The results of our study support the need for augmentation of patellar tendon repairs if early active range of motion is desired. Because the suture repair group failed

within an average of 12 cycles, we do not recommend accelerated rehabilitation when using only this repair. This recommendation applies for at least 4 to 6 weeks postoperatively because the healing tissues are generally at their weakest at 3 weeks, and excessive force seen during the early remodeling phase may be detrimental. Although gap formation was seen in each augmented group, both groups maintained a successful repair with cyclic loading. Cable loop augmentation provided the best protective effect but required a second operation for hardware removal.

ACKNOWLEDGMENT
The authors acknowledge Howmedica, Inc. (Rutherford, New Jersey) for funding and donation of cadaveric knees and products.

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