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      Clinical outcomes after treatment of quadriceps tendon ruptures show equal results independent of suture anchor or transosseus repair technique used – A pilot study

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          Abstract

          Biomechanical studies have shown the use of suture anchors (SA) to be superior to the traditional transosseous sutures (TS) in the repair of quadriceps tendon rupture (QTR). This study aimed to analyze and compare the functional outcomes of patients treated for quadriceps tendon ruptures using suture anchors or transosseous sutures. Patients having undergone suture anchor repair or transosseous suture repair for quadriceps tendon rupture between 2010 and 2015 at one of the two participating hospitals were included. Patients from site A underwent TS repair (TS group) while patients from site B underwent SA repair (SA group). Exclusion criteria included previous or concomitant injuries of the involved knee, penetrating injuries and pre-existing neurological conditions. Clinical outcome was assessed by subjective scores (Lysholm and Tegner Scores, International Knee Documentation Committee (IKDC) Score, Visual Analog Scale (VAS) for pain), quadriceps isokinetic strength testing, Insall-Salvati Index (ISI), and physical examination. Non-parametrical statistical analysis was conducted using the Mann-Whitney U test. Twenty-seven patients were included in the study of which 17 patients (63%) were available for follow-up (SA group: 9, TS group: 8). All patients were male with a mean age of 62.7 (SD: 8.8) and 57.9 (SD: 12.7) years for the SA group and TS group, respectively. The groups did not differ in terms of demographic characteristics. No clinically significant differences were identified between the two groups. There were no re-ruptures in either group. Treatment of quadriceps tendon rupture using suture anchors provides a clinically valid alternative treatment to the gold-standard transosseous suture repair.

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          Clinical outcomes after repair of quadriceps tendon rupture: a systematic review.

          The existing evidence regarding the management of quadriceps tendon rupture remains obscure. The aim of the current review is to investigate the characteristics, the different techniques employed and to analyse the clinical outcomes following surgical repair of quadriceps tendon rupture. An Internet based search of the English literature of the last 25 years was carried out. Case reports and non-clinical studies were excluded. The methodological quality of the included studies was assessed using the Coleman Methodology Score. All data regarding mechanism and site of rupture, type of treatment, time elapsed between diagnosis and repair, patients' satisfaction, clinical outcome, return to pre-injury activities, complications and recurrence rates were extracted and analysed. Out of 474 studies identified, 12 met the inclusion criteria. The average of Coleman Methodology Score was 50.46/100. In total 319 patients were analysed with a mean age of 57 years (16-85). The mean time of follow-up was 47.5 months (3 months to 24 years). The most common mechanism of injury was simple fall (61.5%). Spontaneous ruptures were reported in 3.2% of cases. The most common sites of tear were noted between 1cm and 2 cm of the superior pole of the patella and, in the older people, at the osseotendinous junction. The most frequently used repair technique was patella drill holes (50% of patients). Simple sutures were used in mid-substance ruptures. Several reinforcement techniques were employed in case of poor quality or retraction of the torn ends of tendon. The affected limb was immobilised in a cast for a period of 3-10 weeks. Quadriceps muscular atrophy and muscle strength deficit were present in most of the cases. Worst results were noted in delayed repairs. Reported complications included heterotopic ossifications in 6.9% of patients, deep venous thrombosis or pulmonary embolism in 2.5%, superficial infection in 1.2% and deep infection in 1.1%. It appears that the type of surgical repair does not influence the clinical results. The majority of the studies reported good or excellent ROM and return to the pre-injury activities. The overall rate of re-rupture was 2%.
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            Early motion after quadriceps and patellar tendon repairs: outcomes with single-suture augmentation.

            Complications of immobilization after quadriceps and patellar tendon repairs include decreased patellar mobility, limited flexion, persistent pain, muscle weakness, and patella baja. In contrast, early motion limits muscle atrophy, accelerates tendon healing, and prevents joint stiffness. Quadriceps and patellar tendon repairs protected with a "relaxing suture" are strong enough to safely permit early motion, full weightbearing, and brace-free ambulation. Case series; Level of evidence, 4. Twenty quadriceps and 30 patellar tendon ruptures were treated with a primary repair augmented with a single No. 5 Ethibond suture, a postoperative regimen of controlled motion and full weightbearing at 7 to 10 days, and brace-free ambulation at 6 weeks after surgery. At a minimum follow-up of 12 months, results of surgery were assessed with the Lysholm knee rating system. Six weeks after surgery, 120 degrees of flexion and brace-free ambulation were the goals and were achieved at a mean of 7.2 and 7.7 weeks, respectively. By 6 months, all patients reached their preinjury levels of activity (eg, basketball, softball, Rocky Mountain tour guide), 40 had full active extension, and 10 lacked 3 degrees to 10 degrees of active extension. There were no postoperative complications. At a mean follow-up of 4 years (range, 1-12 years), the Lysholm scores averaged 92 points (range, 84-100 points), and there were 35 excellent, 15 good, and no fair or poor results. Quadriceps and patellar tendon repairs protected by a relaxing suture were strong enough to safely permit early motion, weightbearing, and brace-free ambulation while producing good and excellent results.
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              Analysis of subjective knee complaints using visual analog scales.

              A questionnaire using a system of visual analog scales was developed for analyzing subjective knee complaints. This system was tested on 117 consecutive patients who had undergone knee surgery and 65 patients at their initial office evaluation of a knee disorder. The validity of and patient affinity for this type of questionnaire was compared with that of three other established subjective evaluation methods. The visual analog scale system was shown to be valid and comparable to other methods while offering several advantages. It brought greater sensitivity and greater statistical power to data collection and analysis by allowing a broader range of responses than did traditional categorical responses. It removed bias that was introduced by examiner questioning, and it allowed graphic temporal comparisons. Most importantly, patient affinity was higher for this type of subjective evaluation than for other methods.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Writing – original draft
                Role: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Investigation
                Role: Data curationRole: Formal analysisRole: Investigation
                Role: Data curationRole: Investigation
                Role: ConceptualizationRole: Project administration
                Role: ConceptualizationRole: ResourcesRole: Supervision
                Role: ResourcesRole: Supervision
                Role: ConceptualizationRole: InvestigationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                19 March 2018
                2018
                : 13
                : 3
                : e0194376
                Affiliations
                [1 ] Department of Trauma Surgery, Medical University of Vienna, Vienna, Austria
                [2 ] Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
                [3 ] Department of Trauma Surgery and Sports Traumatology, Danube Hospital, Vienna, Austria
                Mayo Clinic Minnesota, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-17-44342
                10.1371/journal.pone.0194376
                5858832
                29554109
                580b8412-0558-4b74-a3cc-8998b63071b7
                © 2018 Plesser et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 20 December 2017
                : 1 March 2018
                Page count
                Figures: 4, Tables: 4, Pages: 11
                Funding
                The authors received no specific funding for this work.
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                Biology and Life Sciences
                Anatomy
                Biological Tissue
                Connective Tissue
                Tendons
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                Surgical and Invasive Medical Procedures
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