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Biomechanical evaluation of different surgical techniques for treating patellar

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Article  in  International Orthopaedics · October 2015

DOI: 10.1007/s00264-015-3003-4

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International Orthopaedics (SICOT)
DOI 10.1007/s00264-015-3003-4
ORIGINAL PAPER
Biomechanical evaluation of different surgical techniques
for treating patellar tendon ruptures
Benedikt Schliemann 1 & Niklas Grüneweller 1 & Daiwei Yao 2 & Clemens Kösters 1 &
Simon Lenschow 1 & Steffen B. Roßlenbroich 1 & Michael J. Raschke 1 & Andre Weimann 1
Received: 20 July 2015 / Accepted: 15 September 2015
# SICOT aisbl 2015
Abstract
Purpose The aim of this study was to biomechanically assess
patellar tendon repair techniques with additional cable wire or
polydioxanone suture (PDS) cord augmentation in compari-
son with a suture-anchor repair technique.
Methods Patellar tendon repair was performed in 60 speci-
mens using a porcine bone model. Yield load, maximum load,
stiffness and elongation of patellar tendon reconstructions
with (1) cable wire augmentation, (2) PDS cord augmentation
or (3) suture anchor repair were evaluated using a cyclic load-
ing and load-to-failure test setup.
Results In comparison with suture anchor repair, augmenta-
tion of the reconstruction with either cable wires or PDS cords
provides significantly higher maximum loads (527 and 460 N
vs. 301 N; p<0.01 and p=0,012, respectively) under load-to-
failure testing and less elongation (8.81 mm±1.55 mm and
10.56 mm±3.1 mm vs. 18.38 mm±7.51 mm; p=0.037 and
p=0.033, respectively) under cyclic loading conditions.
Conclusion Augmentation of a patellar tendon repair with
either a cable wire or a PDS cord provides higher primary
stability than suture anchor repair in patellar tendon ruptures.
The study supports the use of additional augmentation of a
Benedikt Schliemann and Niklas Grüneweller contributed equally to this
work.
* Benedikt Schliemann
benedikt.schliemann@ukmuenster.de; http://www.traumacentrum.de
1
Department of Trauma, Hand and Reconstructive Surgery,
University Hospital Münster, Albert-Schweitzer-Campus 1, Building
W1, 48149 Münster, Germany
2
Orthopaedic Clinic of the Hanover Medical School, Annastift
Hospital, Anna-von-Borries Str. 1-7, 30625 Hannover, Germany
tendon repair in the clinical setting in order to prevent loss of
reduction and allow for early post-operative mobilisation.
Keywords Patellar tendon rupture . McLaughlin cerclage .
Suture anchor . Knee-extensor mechanism
Introduction
Tendon ruptures of the lower extremity are rare injuries and
are usually associated with degenerative changes. Lesions of
the extensor apparatus of the knee have serious consequences
for the patient [5, 25]. Ruptures of the patellar tendon account
for approximately 3–6 % of all lesions to the knee extensor
mechanism, corresponding to 1.5–2 % of all tendon ruptures
[10, 20, 22]. Young and active male patients are prone to
patellar tendon ruptures (male:female, 6:1) [9]. Ruptures are
usually localised proximally at the patella–tendon interface,
and bony avulsions are common. Operative treatment is man-
datory in complete ruptures in order to restore the knee exten-
sor mechanism. Different surgical techniques have been de-
scribed. Augmentation of a patellar tendon repair with the use
of cable wires as described by McLaughlin in 1947 has been
widely performed [1, 12, 19, 24]. Cable-wire cerclage should
prevent elevation of the patella and protect the transtendinous
or trans-osseous tendon repair during the healing process.
However, a second operation to remove wires is necessary.
To overcome this problem, resorbable polydioxanone sutures
(PDS) have been used instead of cable wires [12].
In 1999, Marder et al. reported good functional results in a
clinical study on primary tendon repair without augmentation
[18]. However, in a biomechanical study, Ravalin et al. dem-
onstrated a higher stability of augmented repairs with less gap
formation in comparison with repairs without augmentation
[26]. In addition, Ettinger et al., in their biomechanical study,

found higher failure loads and less elongation for suture an-
chor repairs when compared with trans-osseus sutures [7].
Similar results were found by Bushnell et al., who also found
less gap formation and comparable failure loads for suture
anchor repairs compared with trans-osseous sutures [2].
However, augmentation of those trans-osseus sutures may in-
crease stability and therefore reduce elongation and gap
formation.
Aim of this study was to investigate biomechanical prop-
erties of patellar tendon repair techniques with augmentation
with a suture anchor repair. The hypotheses were that: (1)
suture augmentation with either a cable wire or a PDS cord
would provide higher primary stability than suture anchor
repair, whereas (2) a PDS cerclage provides similar fixation
strength in comparison with a cable wire cerclage.
Materials and methods
This biomechanical study used a porcine knee model. Ethical
approval was not required. Sixty skeletally mature porcine
knees were obtained. The mean age was 6 months (±4 weeks).
Previous studies on anterior cruciate ligament (ACL) recon-
struction demonstrated that bone mineral density (BMD) of
the porcine femur and tibia is comparable with that of young
humans [17]. Directly after harvesting, specimens were stored
at −20 °C and thawed 12 hours prior to testing at room tem-
perature. Saline solution was used to keep specimens moist
during testing. In all specimens, a standardised transvers ten-
don rupture was simulated by a tenotomy ∼3 mm distal of the
distal patella pole. An intra-tendinous repair was performed
using 2–0 Vicryl sutures. After that, all specimens were ran-
domly assigned to three reconstruction groups: additional 5.0-
mm suture anchor fixation (n=20); additional augmentation
with a 1.2-mm cable wire (n=20); additional augmentation
with a 1.3-mm PDS cord (n=20).
Surgical technique
Suture anchor fixation
For anchor repair, we used 5.0-mm titanium suture anchors
(Fa. Karl Storz, Tuttlingen, Germany). Two anchors were
placed in the proximal tibia medially and laterally of the tibial
tuberosity at a 45° angle. The other two anchors were placed
into the distal third of the patella. Sutures were tied in a V-
shaped fashion (Fig. 1).
Cable wire and PDS augmentation
For cable wire augmentation, transverse drill holes with a
diameter of 2 mm were placed at the mid-patellar axis (at least
2 cm from the tip of the patella) and 1.5 cm posterior to the
International Orthopaedics (SICOT)
Fig. 1 Different reconstruction techniques for patellar tendon repair:
trans-tendinous repair with additional suture anchors (left), and
augmentation with either a cable wire or a polydioxanone suture (PDS)
cord (right)
tibial tubercle. A 1.2-mm cable wire was shuttled through the
drill holes and secured with the use of a cable jet tightener
under manual tension. In the PDS group, a 1.3-mm PDS cord
was used instead of a cable wire (Fig. 1).
Biomechanical testing
Biomechanical test setup consisted of a load-to-failure testing
(n = 30) and a cyclic loading protocol (n = 30). After
randomisation to one of the reconstruction groups, specimens
were mounted to the material testing machine (Zwick/
RoellZ005, Zwick, Ulm, Germany) for load-to-failure testing.
The tibia was fixed to the base of the testing frame with the use
of a 5-mm Steinmann pin. A second pin was placed in the
middle third of the patella and mounted to a custom-made
clamp. Load was applied at a rate of 200 mm/minute in line
with the tendon in order to simulate a worst-case scenario. The
load–elongation curve was recorded continuously. Yield load,
maximum load, elongation and stiffness were derived directly
from the load–elongation diagram. The test setup is illustrated
in Fig. 2.
As a second test, a cyclic loading protocol was applied in
order to analyse elongation of the constructs. A pre-load of
5 N was first applied, and all grafts were cyclically pre-
conditioned between 0 and 20 N for ten cycles. The cyclic
loading protocol then consisted of 1200 cycles. Four different
loads were applied (60, 120, 180 and 240 N) for 300 cycles at
0.25 Hz each (Fig. 3). This loading protocol is within the
general range of loads reported in the literature and represents
a relatively modest load level, imitating an accelerated reha-
bilitation protocol, with partial weight bearing and limited
flexion angle post-operatively and increasing flexion angles
and full weight bearing later in the rehabilitation process.
Loading frequency was similar to that of other studies and
appears to be within a physiological range of loading [27].
After cyclic loading, all surviving specimens were loaded
to failure in order to determine residual stability of the
International Orthopaedics (SICOT)

Fig. 2 Biomechanical testing

setup: Cyclic loading and load-to-
failure testing were performed in a
material testing machine (Zwick/
RoellZ005, Zwick). Anterior
(left) and lateral (right) views

reconstructions. The failure mode was macroscopically Results

analysed by digital photo documentation.
Statistical analysis
Statistical analysis was performed with the use of SPSS soft-
ware (IBM SPSS Statistics 21.0, SPSS Chicago, IL, USA). An
analysis of variance (ANOVA) was performed with the
Kruskal–Wallis test for non-parametric data. The Mann–
Whitney-U test was used to detect differences between the
two reconstruction groups. The level of significance was set
at p<0.05.
Load-to-failure testing
Under load-to-failure testing, maximum loads were the
highest in the cable wire augmentation group, with a mean
of 527.2 N (±78.7), in comparison with 460.2 N (±128.3 N)
for the PDS augmentation group and 301.6 N (±80.6) for the
suture anchor fixation group. The difference in maximum load
between cable wire augmentation and suture anchor recon-
struction was statistically significant (p=0.005). Yield loads
were the highest in the cable wire augmentation group

Fig. 3 Cyclic loading-ramp

protocol with different loads
applied for 300 cycles each in
order to simulate an accelerated
post-operative rehabilitation
protocol
 International Orthopaedics (SICOT)

(450.93 N ± 73.00 N vs. 407.67 ± 93.97 N and 166.20 ± Similarly, stiffness of the reconstruction techniques varied be-
62.93 N). Again, cable wire and PDS cord augmentation tween groups. Stiffness was significantly higher for the cable
showed significantly higher yield loads than the suture anchor wire and PDS augmentation groups when compared with the
reconstruction group (p=0.001 and p=0.038, respectively). suture anchor reconstruction group (32.75 N/mm±9.08 mm

Fig. 4 Maximum load, stiffness

and yield load of the three
reconstruction groups after load-
to-failure testing
International Orthopaedics (SICOT)

Fig. 5 Elongation of the three

reconstruction groups under
cyclic loading using the ramp
protocol

and 26.76 N/mm±10.87 N/mm vs. 17.09 N/mm±11.13 N/ Mode of failure

mm; p=0.043 and p=0.045, respectively). No significant dif-
ferences were found between cable wire and PDS augmenta-
tion techniques for any variable tested. Results of the load-to-
failure protocol are illustrated in Fig. 4.
Cyclic loading protocol
All specimens survived the cyclic loading protocol. In all
four steps of the ramp protocol, reconstructions with either
a cable wire or a PDS cord showed less elongation com-
pared with the suture anchor reconstruction group (Fig. 5).
After 1200 cycles, elongation was the lowest in the cable
wire augmentation group (mean 8.81 mm ± 1.55 mm) in
comparison with 10.56 mm ± 3.1 mm for the PDS cord
augmentation group and 18.38 mm±7.51 mm for the su-
ture anchor reconstruction group. Cable wire and PDS cord
augmentation showed significantly less elongation compared
with the suture anchor reconstruction group (p=0.037 and
0.033, respectively). Again, no significant differences were
found between cable wire and PDS augmentation techniques
under cyclic loading.
Results of load-to-failure testing following the cyclic load-
ing protocol are listed in Table 1.
During load-to-failure analysis, the mode of failure varied
between reconstruction groups. As expected, both cable wire
and PDS cord augmentation groups failed due to migration of
the cerclage through the patella, with subsequent perforation
of the inferior cortex and cerclage slippage. This occurred in
all cases of the cable wire group and in six cases of the PDS
cord augmentation group. The remaining four cases in the
latter group failed due to rupture of the cord itself. In the suture
anchor group, bony pullout of anchors at either the patella (n=
4) or tibial (n=4) fixation site was the most frequent mode of
failure. The remaining two specimens failed due to suture
rupture at the anchor eyelet.
Discussion
With the presented data, both hypotheses (suture augmenta-
tion provides higher stability than anchor repair; PDS cerclage
provides similar biomechanical properties when compared
with cable wire augmentation) were confirmed. Significant
differences were detected for maximum load, yield load, stiff-
ness and elongation between augmentation groups (cable wire
and PDS) and the suture anchor repair group under cyclic

Table 1 Results of load-to-

failure testing following the cyclic Variable Mean±SD P value (Kruskal–Wallis)
loading protocol. Kruskal–Wallis
test showed significant Cable wire PDS cord Suture anchor
differences between
reconstruction groups, favoring Maximum load (N) 538.31±54.91 445.46±53.85 344.40±144.39 0.012
the cable wire and polydioxanone Yield load (N) 457.09±30.81 399.01±44.21 296.80±102.63 0.002
suture (PDS) cord reconstruction Stiffness (N/mm) 39.17±4.35 30.92±9.60 20.16±13.33 0.004
groups
Elongation (mm) 13.85±1.63 15.40±4.49 20.09±8.39 n.s.

SD standard deviation

loading and load-to-failure testing. In contrast, no significant
differences were found between cable wire and PDS cord
augmentation, although cable wire augmentation tends to sus-
tain higher maximum loads and less elongation after cyclic
loading.
These results are consistent with those of Ravalin et al.,
who found a decreased gap formation at the patellar tendon
repair site when a standard suture repair using Krackow
stitches was augmented with either a cable wire or a no. 5
Ethibond suture [13, 26]. Those authors concluded that
suturing alone leads to clinical failure, with subsequent lag
of knee-extensor mechanism. Other biomechanical studies
showed that suture anchor repair provides higher stability in
comparison with trans-osseous sutures and is therefore prefer-
able in clinical practice. Two cadaver studies by Ettinger et al.
and Bushnell et al. demonstrated significantly higher maxi-
mum loads and smaller gap formations in patellar tendon re-
pairs with suture anchors when compared with trans-osseous
sutures [2, 7]. However, in these studies, trans-osseus sutures
were not augmented by cable wires or PDS cords. We dem-
onstrated in the study reported here that failure loads after
patellar tendon repairs with additional augmentation
outperform those of suture anchor repairs (527.2 N and
460.2 N for augmented repairs vs. 301.6 N for suture anchor
group).
In the clinical setting, good results have been reported for
the classic cable wire augmentation originally described by
McLaughlin in 1947 [19]. More recently, Ramseier et al. pre-
sented clinical results of 17 patients treated with cable wire
augmented sutures for a patellar tendon rupture [24]. No dif-
ferences in range of motion (ROM) and muscle strength were
found in comparison with the uninjured leg >24 months after
surgery.
Suture anchors, also used in treating distal patellar pole
fractures, are an alternative option for a patellar tendon repair
[11]. Capiola and Re and Bushnell et al. reported on clinical
results of suture anchor repair without augmentation [3, 4].
The latter group followed 14 patients for an average of
29 months. Although 11 patients had excellent ROM and
strength and returned to their pre-operative level of function,
three re-ruptures occurred. In that small series, these results
represent a recurrence rate of 21 %, implying that every fifth
patient sustains a re-rupture [3]. In contrast, in a study by
Kasten et al., no re-rupture occurred after patellar tendon re-
pair with either an additional cable wire or PDS cord augmen-
tation [12].
With regard to clinical results mentioned above, biome-
chanical results of our study support the use of additional
augmentation with either a cable wire or a PDS cord.
Significantly higher maximum loads can be achieved, and
elongation under cyclic loading can be decreased. From a
clinical point of view, the additional augmentation protects
the tendon repair and therefore supports tendon healing, with
International Orthopaedics (SICOT)
subsequently lower risk of a re-rupture. In addition, higher
primary stability of the augmented reconstruction would allow
for accelerated rehabilitation with early weight-bearing and
free ROM of the affected knee. For quadriceps and Achilles
tendon repair, better functional results with accelerated post-
operative rehabilitation are reported [6, 14, 23].
Some limitations apply to this study. A porcine bone-
tendon-bone model was used, which diminishes comparabili-
ty with cadaver studies such as that of Ravalin et al. [26]. The
scarcity of human donors makes it difficult to test young hu-
man knees in sufficient numbers to draw statistically signifi-
cant conclusions. However, using porcine bones and tendons
guarantees comparability because there is only a minimal dif-
ference in age and consistency of porcine bones and tendons
once they are harvested. In cadaver studies, donor age varies
considerably, and furthermore, donors are usually older than
patients affected by patellar tendon ruptures. For example,
Bushnell et al. found variations in failure mode within the
suture anchor repair group [2]. The authors assumed that this
was due to inconsistent bone quality of the cadaveric speci-
mens, since a correlation exists between anchor pullout
strength and BMD. In addition, in cadaver studies, little is
known about donor medical conditions, which may compro-
mise the validity of results, since patellar tendon ruptures usu-
ally occur due to degenerative changes caused by comorbid-
ities such as diabetes mellitus, impaired renal function or long-
term steroid therapy [10]. In a porcine bone model, such fac-
tors can be excluded. Similarly, procine bone models are also
widely used in biomechanical studies on other ligament recon-
structions in the knee, i.e. ACL repair [15, 16]. However,
Nurmi et al. demonstrated that failure loads after inference
screw fixation of tendon grafts in ACL reconstruction may
be overestimated when porcine bones are used [21]. These
factors must be taken into account when interpreting the re-
sults of our study. Moreover, the testing setup does not
completely reflect the in vivo condition, as augmentation
loops were tensioned in extension and biomechanical tests
were performed in full extension in order to simulate a
worst-case scenario. In humans, knee flexion results in ten-
sioning of the patellar tendon, and patellar tendon ruptures
usually occur due to indirect trauma to the flexed knee.
Furthermore, augmentation loops are secured in 60–90° of
flexion during surgery in order to allow postoperative ROM
exercise. However, with loads applied in extension, the integ-
rity of augmentation loops and anchor repairs is tested ade-
quately. A similar test setup has been used previously [8].
Conclusion
In this porcine bone model, patellar tendon reconstruction
with additional augmentation by either cable wires or PDS
cords provided higher maximum loads and less elongation
International Orthopaedics (SICOT)
under cyclic loading and load-to-failure testing in comparison
with suture anchor fixation. With regards to clinical results
reported in the literature, our data support the use of additional
augmentation to allow for early weight bearing and an accel-
erated rehabilitation protocol.
Compliance with ethical standards
Conflict of interest All authors declare that they have no conflict of
interest.
Ethical approval All applicable international, national, and/or institu-
tional guidelines for the care and use of animals were followed.
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