Biocomposite Augmentation in Revision Quadriceps Tendon Repair

Quadriceps tendon ruptures are uncommon, typically affecting middle-aged men, often due to trauma or systemic comorbidities. Primary repairs yield excellent outcomes; however, revision surgery poses challenges due to poor tissue quality and vascularity.

Revision repair is indicated after failed primary surgery with recurrent extensor mechanism deficit-patella baja, extensor lag, palpable defect. Magnetic resonance imaging can confirm the diagnosis and approximate reducibility. Biologic augmentation is indicated in the presence of an especially poor healing environment, poor postoperative compliance, or a high fall risk. This technique requires a reducible tendon.

Positioning is supine with a lateral thigh post and foot positioner. The midline incision is recreated. Two No. 2 FiberWire sutures are placed in the quadriceps tendon in a modified Krackow fashion. Beath pins create 3 parallel transpatellar tunnels and shuttle the sutures through them. A No. 5 FiberWire circumferential cerclage and biocomposite shoelace are placed around the patella. With the knee in hyperextension, the transosseous sutures and suture cerclage are tied, the retinaculum repaired, and the shoelace tensioned and secured with sutures. A platelet-rich plasma-soaked biocomposite patch is secured over the repair construct before a layered closure and application of a hinged brace locked in extension.Rehabilitation begins with weightbearing as tolerated with the knee brace locked in extension for 1 week. Thereafter, the brace can be unlocked to the degree of stress-free flexion achieved intraoperatively at rest. From weeks 6 to 12, range of motion (ROM) gradually progresses to achieve full motion by 3 months. Strengthening, especially eccentric quadriceps exercises, begins after 3 months, with activity progression as tolerated.

While the literature on revision outcomes is limited, especially for this novel technique, primary repairs show rerupture rates of 2% to 8%. Optimal outcomes-regarding ROM, strength, patient satisfaction-are associated with intervention <3 weeks. Index suture anchor fixation also carries a slightly higher risk of complications and retear compared with transosseous tunnels. These technical and chronicity considerations can serve as risk factors for patients presenting for revision repair and support prompt revision surgery when indicated.

This technique combines the structural and cellular support of biocomposite augmentation with the mechanical stability of transosseous fixation and suture cerclage, offering a comprehensive, reproducible solution for complex revision cases.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.