Surgical Treatment of Chronic Rupture of the Quadriceps Using a Modified Pulvertaft Weave Technique

Abstract

The extensor mechanism provides active knee joint extension and stability of the patellofemoral joint. Rupture of the quadriceps tendon, although uncommon, is therefore associated with impairment in knee joint stability and, thus, requires surgical repair. Although various techniques provide excellent clinical outcomes for acute rupture, treatment of chronic rupture remains clinically challenging. We describe our modified technique for quadriceps tendon repair using a semitendinosus tendon autograft, with suturing of the quadriceps tendon stump to the patella via transosseous sutures, wherein the use of allograft and anchors is avoided. Our modified Pulvertaft weave technique is simple and reproducible.

Fig 1

(A) A transverse tunnel is created in the patella using a 5-mm cannulated drill. (B) Three parallel longitudinal tunnels are created for threading. (C) The repair wires are maintained on the carrying handle at the proximal end of each longitudinal tunnel created in the patella to facilitate the transport of the wires.

Fig 2

(A) Krackow sutures, using 2 threads of polyester suture (No. 2 Ethibond), are placed in the middle portion of the quadriceps tendon, with 4 wires maintained in situ at the distal end of the quadriceps tendon. The prepared semitendinosus tendon is shown by the arrow. (B) Punctiform holes are created in the medial border of the quadriceps tendon. (C) Punctiform holes are created in the lateral border of the quadriceps tendon. Of note, at least 3 holes should be created in the medial and lateral borders of the quadriceps tendon.

Fig 3

(A) The semitendinosus tendon is passed through the transverse tunnel, leaving 2 symmetrical ends of the graft, shown by the arrow. (B) The 2 ends of the graft are weaved through the medial and lateral holes placed in the borders of the quadriceps tendon, using the Pulvertaft technique, ensuring that, ultimately, the tip of the graft points anteriorly (arrow). (C) The ends of the graft are placed under traction and sutured over the quadriceps tendon to reduce the anterior gap to the extent possible, with only a central gap remaining (arrow).

Fig 4

The distal ends of the semitendinosus tendon are placed under traction, crossed over, and sutured over the quadriceps tendon (in a locking X formation) to reduce the anterior gap in the tendon by pulling on the 4 polyester suture strands (from the previous Krackow sutures), forming a transosseous suture in the distal pole of the patella.

Fig 5

(A) Preoperative radiograph, showing patella baja and calcification of the distal end of the quadriceps tendon (arrow). (B) Immediate postoperative radiograph, showing the distal portion of the quadriceps tendon anchored into the patella.

Fig 6

Physical examination showing full active knee extension achieved at 3 months postoperatively (post-op).