Revision quadriceps tendon repair: A case series and technique guide to a novel repair.

Introduction: Revision quadriceps tendon repair is a challenging problem. In this four-case series, novel quadriceps tendon revision resulted in improved range of motion and durable repair for patients with recurrent rupture. Methods: Our technique includes a combination of a running locked #5 FiberWire or 2 mm SutureTape suture placed through parallel medial, lateral, and central drill holes in the patella with running Krackow-type quadriceps tendon repair medially and laterally resulting in four strands, delivering the vastus medialis and medial quadriceps tendon to an anatomic repair at the superior pole of the patella, with 2 sutures passed centrally and 1 each passed medially and laterally and then tied. Reinforcement is performed using a tibialis anterior tendon allograft with placement at the inferior pole of the patella starting superolaterally coursing lateral to medial through infrapatellar tendon. It is then threaded medially into the centrally repaired portion of the quadriceps tendon, and then back down to the lateral suprapatellar and lateral patellar retinaculum, giving three crossing strands. This is repaired with multiple interrupted 0 Vicryl mattress sutures. Immobilization postoperatively was dictated by patient's body habitus. Results: Patient 1 was a 79-year-old obese man treated after two prior revision periprosthetic quadriceps repair procedures. He was immobilized in a knee immobilizer for 8 weeks postoperatively. He was revised for TKA instability at 6 months postoperatively, and one month later returned to the operating room for persistent hematoma; repair was noted to be intact. Patient 2 was a 39-year-old morbidly obese man who was revised after failure of one revision quadriceps repair. He was protected with an external fixator for 6 weeks. Patient 3 was a 49-year-old obese man who was treated with four revision quadriceps repair procedures over the course of 15 years. Postoperatively he was treated with a knee immobilizer. Patient 4 was a 71-year-old obese man who was treated after failure of one prior revision quadriceps repair procedure. He was casted postoperatively for one month. On final follow up, all patients were able to maintain straight leg raise, with functional range of motion and ambulation. Conclusion: Revision quadriceps tendon repair using an anterior tibialis tendon allograft is a viable solution for obese patients with recurrent quadriceps tendon ruptures.