Augmented Repair Technique for Patellar Tendon Rupture Using Two Suture Anchors and Three Transosseous Sutures: a retrospective cohort study

Augmented Repair Technique for Patellar Tendon Rupture Using Two Suture Anchors and Three Transosseous Sutures: a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Augmented Repair Technique for Patellar Tendon Rupture Using Two Suture Anchors and Three Transosseous Sutures: a retrospective cohort study Ding Li, Yuchen He, Zhenmu Xu, Yueming Chen, Kai Jiang, Ding Zhou, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4815777/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Aug, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 10 You are reading this latest preprint version Abstract Background Patellar tendon rupture is an uncommon injury that usually requires surgical repair, but no consensus exists regarding the ideal repair technique. Suture anchor repair and the transosseous suture method have be widely used, but the suture anchor technique may cause anchor pull-out, while the transosseous suture method may result in insufficient suture strength. Therefore, we propose and evaluate the efficacy of augmented repair technique with two suture anchors and three transosseous sutures for patellar tendon repairs. Methods We conducted a retrospective cohort study of patients who received surgery for patellar tendon rupture between January 2016 and December 2020. All patients underwent a standardized integrated knee extensor mechanism augmentation repair technique by the same surgeon with 2 suture anchors and 3 transosseous sutures. Radiology, complications, and patient-reported outcomes were recorded. Clinical outcomes were measured using range of motion (ROM), patient satisfaction, Visual Analog Scale (VAS) pain scores, Knee Society Function Score (KSS-F), International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score. Results Totally 40 patients were enrolled with an average age of 33.95 years. Mean follow-up duration was 60 months (range: 36 to 72 months). All cases were diagnosed with patellar tendon rupture at the patellar attachment and received the surgery. The risk of complications was 7.5% (3/40). Mean postoperative ROM improved from 45.65 ± 10.66 to 127.25 ± 3.99 (mean ± SD, p < 0.001). Mean postoperative VAS pain score, KSS-F score, IKDC score, Lysholm score and Tegner score significantly improved (p < 0.001). The median Caton Deschamps Index significantly decreased from 1.71 ± 0.22 to 1.07 ± 0.07 (p < 0.001). Postoperative MRI revealed evident healing between the patellar tendon and the inferior pole of the patella. Conclusions The integrated knee extensor mechanism augmentation repair technique is reliable and effective for patellar tendon rupture. 5-year-follow up results verified its favorable outcomes. patellar tendon rupture augmentation repair suture anchor transosseous suture Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Patellar tendon rupture is a relatively rare injury, with reported incidences approximately 0.68/100,000 person-years in the general population[ 1 ] and notably higher at 6/100,000 person-years within military settings[ 2 ]. This injury typically occurs due to direct and indirect trauma or as a terminal outcome of patellar tendinopathy[ 3 – 6 ]. The proximal insertion of the patellar tendon is the most affected site[ 7 – 9 ]. Patients with patellar tendon rupture caused by patellar tendinopathy may present with concurrent conditions such as systemic lupus erythematosus (SLE), gout, rheumatoid arthritis (RA), obesity, renal insufficiency, Ehlers-Danlos syndrome, and a history of long-term corticosteroid use. [ 10 – 14 ]. Notably, individuals across various demographics, including both the general population and athletes, are susceptible to patellar tendon rupture. The onset age of patellar tendon ruptures typically occurs during adolescence or in middle-aged males between 30 to 40 years old[ 15 , 16 ]. The transosseous repair is widely acknowledged classical gold standard surgical procedure for complete patellar tendon rupture. At present, the suture anchor repair technique has gained popularity due to its superior biomechanical properties. Studies have demonstrated that suture anchor repair exhibits a higher ultimate failure load and less gap formation compared to transosseous repair[ 17 ]. Moreover, in cases of mid-substance rupture, a direct end-to-end repair may be employed. While these methods are commonly utilized by sports medicine clinicians, it's essential to note potential drawbacks. The suture anchor technique carries the risk of anchor pull-out, while the transosseous suture technique may result in inadequate suture tension or even suture breakage, ultimately leading to retearing of the repaired patellar tendon. In efforts to mitigate the risk of retear, numerous augmentation repair methods have been utilized for patellar tendon rupture, such as cerclage wires, Dall–Miles cables, nonabsorbable sutures, suture anchor, cortical button fixation, autologous grafts, allografts or synthetic ligaments enhancement and so on[ 18 – 25 ]. However, despite their intended benefits, these repair techniques often come with inevitable complications, such as re-ruptures, extensor lags, infection, implant breakage, re-operations, skin necrosis, disease transmission and donor-site morbidity[ 21 – 23 , 25 ]. Given the inherent disadvantages of these methods, we proposed the integrated knee extensor mechanism augmentation technique repair for patellar tendon ruptures. In our approach, we combined the use of 2 suture anchors with 3 transosseous sutures to address ruptures at the proximal insertion of the patellar tendon. The aim of our study is to introduce this novel augmentation repair technique and evaluate its efficacy in achieving favorable radiological and functional outcomes over a mean follow-up period of five years. Method Patients Selection A retrospective review was conducted encompassing all patients who underwent repair for patellar tendon rupture between January 2016 and December 2020 at our hospital. Ethics approval (LYF2023028) was obtained from the institutional human research ethics committee of our hospital on 21 February 2023, and informed consent was obtained from all participants prior to their inclusion in the study. All procedures were performed by the same senior surgeon. Patients were evaluated based on medical history, physical examination, and radiological findings. Inclusion criteria comprised patients meeting the following criteria: (1) a documented history of injury with associated knee extension lag; (2) unilateral full-thickness patellar tendon rupture confirmed via magnetic resonance imaging (MRI); (3) surgical intervention performed within 4 weeks post-injury. Exclusion criteria encompassed: (1) bilateral patellar tendon rupture, concurrent ipsilateral extremity fracture or other ligament injuries, or a history of previous surgery; (2) surgical intervention performed beyond 4 weeks post-injury; (3) loss to follow-up; (4) partial-thickness tears, or ruptures not located at the inferior pole of the patella. The CONSORT flow diagram depicting the final patient selection is provided in Figure 1. Demographic data, including age, sex, affected sides, BMI (kg/m 2 ), injury mechanism, days between injury and operation and comorbidities were collected and recorded in Table 1. Preoperative and postoperative radiological findings, clinical functional assessments, and operative protocols were reviewed during the final follow-up. Specifically, assessments included patellar height (Caton–Deschamps index, Fig 2a), tear pattern (partial or complete and the rupture site, Fig 2b). Final radiographic and MRI assessments were conducted to evaluate patellar height and healing between the patellar tendon and patella. No associated intra-articular lesions were identified from preoperative MRI. The postoperative complications were meticulously documented which included re-rupture, infection, implant failure, knee hematoma, arthrofibrosis and venous thrombosis and so on. Table 1. Demographic data of all consecutive cases Demographic Variable Mean or Proportion Age (years) 33.95±10.83(14-55) BMI (kg/ m 2 ) 23.7±4.3(16.8-33.2) Sides N a (%) Left 18 (45%) Right 22 (55%) Gender N a (%) Female 4(10%) Male 36(90%) Injury mechanism N a (%) fall injury 28(70%) sport injury 12(30%) Comorbidities 8(40%) SLE and RA 1 End-stage renal disease 1 Chronic kidney disease 4 1 Gout 2 Diabetes 2 Statin use 1 Preoperative Caton Index 1.71±0.22 Mean Days between injury and operation(days) 3.9±2.3 Data are percentage (%) or mean ± SD (Comorbidities: RA, SLE, Gout, end-stage renal disease, diabetes, statin use). N a refers to the number of individuals. Surgical Techniques The surgical procedure was conducted under both general and regional anesthesia, with the patients positioned supine and a tourniquet applied to the upper thigh. A midline longitudinal incision was made from the superior pole of the patella to the tibial tubercle. Layer-by-layer dissection was performed through the skin, subcutaneous fat, and superficial fascia, exposing the patella, ruptured patellar tendon, and tibial tubercle. Upon exploration, the patellar tendon was found to be completely broken at the inferior pole of the patella with slight retraction and massive hematoma. Additionally, complete tears of the lateral and medial retinaculum were commonly observed. The hematoma was evacuated, and the area thoroughly irrigated. Subsequently, meticulous debridement of the inferior pole of the patella was performed, followed by preparation of the bone bed while protecting the remnant of the patellar tendon. (Fig 3a and Fig 4a). Two 2.9mm absorbable suture anchors (Smith & Nephew, MA, USA) were placed in the inferior pole of the patella. A 2.0 Kirschner wire was used to drill three bone tunnels from bottom-up across the middle-part patella. Three patellar tunnels were segregated by 2 suture anchors from lateral to medial (Fig 3 b and Fig 4b). it is crucial to ensure that the orientation of the guide wire is not excessively downward to prevent damage to the articular cartilage. If necessary, intraoperative fluoroscopy may be employed to assist in guiding the wire placement accurately. Three 2# nonabsorbable ultrabraid sutures (Smith & Nephew, MA, USA) were stitched to the distal patellar tendon stump using a whip stitch technique, aligning them with the orientation of the patellar tunnels. Three ultrabraid sutures were sequentially passed through the patellar tunnels with the aid of an eyelet guide needle (refer to Fig 3c and Fig 4c). All six ends of the sutures were left at the superior pole of the patella to be secured later. Following this, the sutures attached to the anchors were stitched the proximal tendon stump at the inferior pole of the patella using Krakow technique. It is imperative to ensure that the proximal stump is adequately sewn to the main body of the patellar tendon, while also meticulously repairing the torn lateral and medial retinaculum with these sutures. Then the knee joint was flexed and extended 10-20 times to ensure no gap formation at the interface between the patellar tendon and patella. All six ends of the sutures were tied each other at 45° of knee flexion. One MB-66 suture was passed around the patella to reduce the overall tension (Fig 3d and Fig 4d). At completion of the procedure, the surgeon performed a thorough assessment of the ROM and ensured appropriate tension of the repaired patellar tendon at maximum knee flexion. Finally, the operated extremity was immobilized in a mobile brace set in full extension. Postoperative Rehabilitation Following the surgical procedure, patients were promptly permitted to start isometric quadriceps exercises and full weight bearing as tolerated while wearing a knee brace locked in full extension. Controlled physiotherapy was initiated, allowing for passive ROM exercises from 0° to 90°. 6 weeks later, patients were encouraged to do full ROM and active knee extension. Quadriceps-strengthening exercises commenced after three months, with resistance gradually increased over time. Gradual reintroduction to running activities was initiated after six months. Statistical Analysis All patients underwent clinical evaluation at 1, 3-, 6-, 12-, and 24-months post-surgery. Preoperative and postoperative ROM, patient satisfaction, VAS pain, the KSS-F, IKCD score, Lysholm score, Tegner score were recorded. Demographic data were summarized using mean ± standard deviation (SD) for continuous variables and number (%) for categorical variables. Statistical analysis was performed using the Wilcoxon signed-rank test to compare KSS-F scores, VAS scores, IKDC score, Lysholm Score, and Tegner score before and after surgery. A p-value < 0.05 was considered statistically significant. Data were analyzed using GraphPad 9.0. Results Totally, 40 patients were included in this study. The demographic characteristics of the patients were summarized in Table 1 . Most patients were males (90%, 36/40) with an average age of 33.95 ± 10.83 years (ranging from 14 to 55 years). The mean BMI were 23.27 ± 3.49kg/m 2 (16.8 to 33.2 kg/m 2 ). Twenty-eight patients sustained injuries from falls, while twelve were injured during sports activities. The mean duration between injury and surgery was 3.9 ± 2.3 days. Eight patients had medical comorbidities, including a 54-year-old female with SLE and RA, a 35-year-old male with a history of kidney transplantation 8 years prior and one patient in chronic kidney disease (CKD) Stage IV. Two patients had gout. Two patients had Diabetes and one had been on statin therapy for 5 years. At the final follow-up, patellar height was found to be normal in all patients, and the median Caton Deschamps Index were significantly decreased from 1.71 ± 0.22 (1.32–2.11) to 1.07 ± 0.07 (0.92–1.26) ( p < 0.001). Postoperative MRI at the 2-year follow-up revealed definite healing between the patellar tendon and the patella, as evidenced by the disappearance of the gap at the interface (refer to Fig. 5 a, b, c). The mean operative time was 82.15 minutes (range: 66–118 minutes). And the average followed-up period was 60 months (range: 36–72 months). All patients were satisfied with the outcomes at the last follow-up. All patients had active full knee ROM. Notably, there were no instances of re-rupture, infection, or cutaneous complications observed in any of the patients. The rate of complications was 7.5% (3/40). One patient undergoing renal dialysis that required arthroscopic debridement due to knee hematoma, while another patient received standard anticoagulant treatment for deep venous thrombosis. One patient underwent reoperation for arthroscopic debridement due to arthrofibrosis. All patients had returned to normal daily-life and preinjury sports at the final follow-up. Significant improvement in knee function were observed among all patients (Table 2 ). Specifically, the mean postoperative ROM improved from 45.65 ± 10.66 to 127.25 ± 3.99 ( p < 0.001). The mean postoperative VAS pain score reduced from 6.20 ± 1.11 to 1.25 ± 0.79 ( p < 0.001). The mean Knee Society function Score was significantly improved from 24.50 ± 13.37 to 91.75 ± 5.45 ( p < 0.001). The mean Lysholm score improved from 35.40 ± 3.21 to 89.05 ± 3.95 ( p < 0.001). The mean Tegner score improved from 0.8 ± 0.62 to 4.85 ± 0.93 ( p < 0.001). The mean IKDC score improved from 29.75 ± 4.34 to 72.65 ± 2.85 ( p < 0.001). Table 2 Comparison of preoperative and postoperative knee function scores in all consecutive patients Evaluation item Preoperative Postoperative p - value ROM 45.65 ± 10.66 127.25 ± 3.99 < 0.001 Pain, VAS (0–10) 6.20 ± 1.11 1.25 ± 0.79 < 0.001 KSS Function 24.50 ± 13.37 91.75 ± 5.45 < 0.001 Lysholm score 35.40 ± 3.21 89.05 ± 3.95 < 0.001 Tegner score 0.8 ± 0.62 4.85 ± 0.93 < 0.001 IKDC score 29.75 ± 4.34 72.65 ± 2.85 < 0.001 Data are mean ± SD. VAS: visual analog scale. Discussion Our study demonstrated the reliability and efficacy of the integrated knee extensor mechanism augmentation repair technique for addressing patellar tendon rupture. Short-term outcomes validate the effectiveness of this repair method in yielding favorable radiological and functional results. The reported incidence of patellar tendon rupture is approximately 0.68/100,000 person-years in general population 1–2 . Patella fracture, quadriceps tendon rupture and patellar tendon rupture are the three most common injury sites of knee extensor structures[ 3 ]. The classification of patellar tendon rupture is often based on the injury site, which typically includes the inferior pole of the patella, mid-substance, and the tibial tuberosity. The most common site of patellar tendon rupture is the inferior pole of the patella[ 7 – 9 ]. Patellar tendon ruptures are categorized based on the period between injury and surgery into acute and chronic ruptures[ 26 ]. Acute injuries typically occur within a timeframe of up to 4 weeks post-injury and necessitate immediate intervention. Conversely, chronic injuries often arise due to factors such as conservative treatment, missed diagnosis, or chronic patellar tendinopathy[ 27 ]. It is well known that surgical treatment is the optimal treatment for full-thickness patellar tendon ruptures to reestablish knee function. Patellar tendon fixation methods vary depending on factors such as the location of tendon disruption, surgeon preference, and the availability of implant materials. While transosseous suture repair has historically been advocated as the gold standard surgical approach for complete patellar tendon ruptures, it is associated with certain complications, including re-ruptures and extensor lags, often stemming from gap formation at the repair site[ 1 ]. Recent biomechanical studies have shed light on the advantages of suture anchor repairs, demonstrating significantly less gap formation and higher ultimate failure loads compared to traditional transosseous repairs[ 7 , 8 , 17 ]. Bushnell et al[ 8 ] has shown that suture anchors repair has a higher ultimate load to failure and less gap formation than that of transosseous repairs. In a multicenter study, James O'Dowd et al[ 9 ] reported that the transosseous group experienced 24 retears (7.5%), whereas the anchor group exhibited no re-ruptures. This finding underscores a significantly higher re-rupture rate in the transosseous repair group compared to the anchor group. Several case reports on suture anchor repairs have confirmed satisfactory outcomes, with no major complications or need for reoperations.[ 19 , 20 ]. To decrease the risk of retear, many surgeons attempt to repair the severely ruptured patellar tendon with different enhancement techniques to obtain more stable extensor construct[ 23 ]. Various enhancement repair methods have been applied to patellar tendon rupture[ 20 – 25 ]. The advantages of augmentation repair were favored by cadaveric studies[ 28 – 30 ]. The augmentation of patellar tendon repairs can decrease gap formation at the ruptured site and allow early mobilization[ 23 , 31 ]. Another cadaveric research confirmed that augmentation repair by semitendinosus tendon can decrease the gap formation than that of no augmentation repair[ 31 ]. Several clinical studies have prompted various methods of augmenting repairs of patellar tendon ruptures[ 23 , 25 ]. Ihab I et al[ 30 ] reported successfully repaired patellar tendon augmented by semitendinosus tendon with no major complications. Core et al[ 25 ] reported that patellar tendon enhanced with synthetic ligament achieved satisfactory clinical scores. However, some patients reported experiencing a distinct foreign body sensation, which contributed to increased hospitalization costs. Additionally, it is worth noting that this technique may not be available in all institutions. In clinical practice, most non-traumatic ruptures of the patellar tendon are caused by chronic patellar tendinopathy or concomitant diseases, such as SLE, local steroid injection, renal failure and metabolic diseases[ 3 , 4 , 6 ]. These patients usually have poor tendon quality, impaired tendon blood supply and concurrent osteoporosis which are challenges for surgeons. As mentioned earlier, both the suture anchor and transosseous suture techniques have their limitations. The suture anchor technique has the risk of anchor pull-out, particularly in osteoporotic patellae, and transosseous suture technique potentially leads to inadequate suture strength, breakage, or bony bridge cutting, ultimately resulting in repaired patellar tendon failure. Here in this study, we combined 2 suture anchors with 3 transosseous sutures method to address the patellar tendon rupture at the proximal insertion. All patients in our study were satisfied with functional scores significantly improved. Compared to previous studies, our integrated knee extensor mechanism augmentation repair method has demonstrated several advantages. Firstly, our augmentation technique effectively prevents anchor pullout, a complication typically associated with the suture anchor technique. Moreover, insufficient repair or suture breakage were not found. By placing two suture anchors at the inferior pole of the patella, we were able to suture a major part of the patellar tendon to both the patella and its remnant. Additionally, three transosseous sutures were passed through the patella, allowing them to be tied together at the superior pole and reconnecting the ruptured patellar tendon with both the patella and the quadriceps tendon. Secondly, our technique restores a wider footprint contact area, resulting in a more stable and robust extensor construct that enables early functional rehabilitation. Thirdly, the operation time for our technique (83 minutes) did not significantly increase compared with previous reports[ 32 ], suggesting that it can be easily mastered by senior surgeons. Lastly, the total surgical costs will not experience a dramatic increase, especially with the national centralized purchase of high-price consumable materials in our country[ 24 , 25 , 33 ]. All patients expressed high satisfaction with the good or excellent knee function observed during the average 5-year follow-up period. Particularly noteworthy is the absence of any retears in our consecutive cases, a notable outcome directly attributable to the advantages offered by our augmentation repair technique. In contrast, Bushnell et al.[ 32 ] presented a 21% failure rate in their clinical results of suture anchor repairs among 14 patients. Furthermore, the occurrence of postoperative complications in our study is also associated with concurrent diseases. For instance, one patient undergoing renal dialysis and having undergone renal transplantation twice, along with severe anemia, was recovered after arthroscopic debridement because of knee hematoma. Similarly, another patient with a high body mass index was successfully treated with standard anticoagulant therapy for deep venous thrombosis. Additionally, 1 case underwent reoperation of arthroscopic debridement because of arthrofibrosis. Despite these challenges, all the patients were able to return to their normal daily activities and preinjury sports. With meticulous surgical technique and standard rehabilitation protocols, there is a relatively low rate of complications in our case series[ 28 , 34 ]. There are also some limitations in our study. Firstly, the retrospective nature of the study imposes inherent limitations, including potential biases in data collection and analysis. Secondly, the sample size is relatively small, and the follow-up duration is relatively short, which may limit the generalizability of the findings and the ability to assess long-term outcomes accurately. Thirdly, the absence of a randomized control group treated with alternative methods precludes direct comparison and limits the ability to establish causal relationships between the augmentation technique and outcomes. Finally, our study did not include gait analysis and muscle strength detection, which are important measures for assessing functional outcomes and may provide additional insights into postoperative recovery. Long-term studies should be carried out to ensure maintenance of both stability and functionality, restored after surgery. We also inspire other surgeons to further evaluate the validity of this augmentation technique and to perform continued evaluation for long-term outcomes. Conclusion This retrospective study provides evidence supporting the effectiveness and reliability of the integrated knee extensor mechanism augmentation repair technique for patellar tendon rupture. The short-term results verified good radiological and functional outcomes. It is also recommended for patients with patellar tendon ruptures who present with chronic patellar tendinopathy. Abbreviations The following abbreviations are used in this manuscript: ROM Range of Motion VAS Visual Analog Scale KSS-F Knee Society Function Score IKDC International Knee Documentation Committee SD Standard Deviation MRI Magnetic Resonance Imaging SLE Systemic Lupus Erythematosus RA Rheumatoid Arthritis BMI Body Mass Index ACLR Anterior Cruciate Ligament Reconstruction CKD Chronic Kidney Disease Declarations Ethics statement and consent to participate This study was approved by the Second Xiangya Hospital committee for clinical research (LYF2023028). Informed consent was obtained from all individual participants included in the study. Availability of data and materials The datasets analyzed during the current study are available from the corresponding author upon reasonable request. Competing Interests The authors declare no competing interests. Funding This work was partially supported by grants from the Natural Science Foundation of Hunan Province, Health Research Project of Hunan Provincial Health Commission and the Scientific Research Launch Project for new employees of the Second Xiangya Hospital of Central South University (2023JJ40823, W20243122, QH2023024 to YH). Author Contributions All authors contributed to the study conception and design. Design of the surgical planning, data collection and analysis were performed by DL, QL and WZ. The first draft of the manuscript was written by DL, YH and ZX. KJ, YC and DZ reviewed and edited the manuscript. And all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements None References Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury. 2008;39:1338-44. Fredericks DR, Slaven SE, McCarthy CF, Dingle ME, Brooks DI, Steelman TJ, et al. 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Knee. 2012;19:508-12. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Aug, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 18 Jun, 2025 Reviews received at journal 17 Jun, 2025 Reviews received at journal 15 Jun, 2025 Reviewers agreed at journal 14 Jun, 2025 Reviewers agreed at journal 11 Jun, 2025 Reviewers invited by journal 04 Sep, 2024 Editor invited by journal 08 Aug, 2024 Editor assigned by journal 08 Aug, 2024 Submission checks completed at journal 08 Aug, 2024 First submitted to journal 28 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4815777","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":347905108,"identity":"25f72a1d-7f5d-40de-b9db-d44cf1c1d294","order_by":0,"name":"Ding Li","email":"","orcid":"","institution":"Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Ding","middleName":"","lastName":"Li","suffix":""},{"id":347905109,"identity":"61cc4222-a2de-4e27-af41-0a3aed0057dd","order_by":1,"name":"Yuchen He","email":"","orcid":"","institution":"Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Yuchen","middleName":"","lastName":"He","suffix":""},{"id":347905110,"identity":"bc51e297-b9d7-4a64-829c-93a615b19309","order_by":2,"name":"Zhenmu Xu","email":"","orcid":"","institution":"Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Zhenmu","middleName":"","lastName":"Xu","suffix":""},{"id":347905111,"identity":"06b38096-7f98-43d9-982b-8c022413bdc3","order_by":3,"name":"Yueming Chen","email":"","orcid":"","institution":"Central Hospital of Shaoyang","correspondingAuthor":false,"prefix":"","firstName":"Yueming","middleName":"","lastName":"Chen","suffix":""},{"id":347905112,"identity":"62930a6d-b4de-4aa4-b7ff-bb082350af23","order_by":4,"name":"Kai Jiang","email":"","orcid":"","institution":"The First Hospital of Hunan University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Jiang","suffix":""},{"id":347905113,"identity":"df48c358-041e-4d5b-8739-c6360381ed38","order_by":5,"name":"Ding Zhou","email":"","orcid":"","institution":"Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Ding","middleName":"","lastName":"Zhou","suffix":""},{"id":347905114,"identity":"fa536674-c0a8-49d8-a258-8e958242febb","order_by":6,"name":"Qian Liu","email":"","orcid":"","institution":"Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Qian","middleName":"","lastName":"Liu","suffix":""},{"id":347905115,"identity":"c5fdc92d-d22d-45ce-842e-ccd51c00cabb","order_by":7,"name":"Weihong Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYDACCRBhcABIMB+AiBwgXgtbAilawMp4DIjTIj+7x0ziQ8EdOXP+NR8//mxjkOO7kcD4uQCPFsY5Z8wkZxg8M7ac8XazNG8bg7HkjQRm6Rl4tDBL5Jjd5jE4nLjhxtltzIxtDEBGAhszDx4tbCAtf8BazjxjBDqsnqAWHpAWBpCW8z1sDECHJRgQ0iIhkVb+s8fgsLHBDTZjaZ5zEoYzzzxslsanRX5G8maDH38OyxmcP/zw448yG3m+48kHP+PTgmRfApgEYsYGojQwMPAfIFLhKBgFo2AUjDgAABmfTjnFPmmSAAAAAElFTkSuQmCC","orcid":"","institution":"Second Xiangya Hospital of Central South University","correspondingAuthor":true,"prefix":"","firstName":"Weihong","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2024-07-28 08:24:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4815777/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4815777/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-025-09018-8","type":"published","date":"2025-08-13T15:57:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64604634,"identity":"1a587b6d-02e7-4d30-8128-8d20483d8de4","added_by":"auto","created_at":"2024-09-16 12:45:48","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":562068,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flow diagram showed the final patients selection\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4815777/v1/68b67b3a39d88caf69a23ee1.jpg"},{"id":64604546,"identity":"9a82290e-2861-40ea-ab1b-5e13e6b98a82","added_by":"auto","created_at":"2024-09-16 12:45:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55556,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative imaging results (a) Preoperative true lateral radiograph of the affected knee showed patella alta, the Caton–Deschamps index is 2.11. (b) Preoperative MRI showed complete patellar tendon rupture at the inferior pole of patella\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4815777/v1/9c7bb9678004f127f0da0565.jpg"},{"id":64604545,"identity":"d547ab19-6d3d-4f7c-adb1-ba8b4e21a4a3","added_by":"auto","created_at":"2024-09-16 12:45:46","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":446243,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative pictures showed (a) The blue arrows and yellow trianglesindicated the completed rupture of the patellar tendon, (b) The blue arrows showed three 2# nonabsorbable ultrabraid sutures that were used to suture the distal patellar tendon, and the yellow trianglesshowed 2 suture anchors placed in the patellar lower pole, (c) The blue arrows showed sutures passed through the patellar tunnels, (d) The yellow triangles showed the sutures of the end of the patellar tendon with suture anchors, and the white pentagrams showed the MB-66 reduction suture of the peripatellar soft tissue, integrated knee extensor mechanism augmentation repair completed\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4815777/v1/9c1c70246c354ef3127f2975.jpg"},{"id":64604635,"identity":"fadd77b3-d9cc-4c5b-bde6-8cf81eb54da5","added_by":"auto","created_at":"2024-09-16 12:45:49","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":173197,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic drawing of integrated knee extensor mechanism augmentation repair (a) the patellar tendon was completed rupture, (b) suture anchors was placed, (c) sutures were passed through the patellar tunnels, (d) integrated knee extensor mechanism augmentation repaired completely\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4815777/v1/73c97eea3957b081dc24932e.jpg"},{"id":64604590,"identity":"9c17b03e-0af0-4ecf-8b16-749b52ea6867","added_by":"auto","created_at":"2024-09-16 12:45:47","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":27408,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative MRI results (a) the red arrows showed continuity and integrity of the patellar tendon. The yellow arrow showed the patella tunnel. (b) and (c) The yellow triangle showed the patella tunnels and the blue pentagram showed 2 suture anchors\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4815777/v1/3f77d42c8748dbdf3455559a.jpg"},{"id":89310639,"identity":"462bb498-0f48-4fe2-b16b-935632afb1e8","added_by":"auto","created_at":"2025-08-18 16:09:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1843982,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4815777/v1/b4f363ac-6776-4ee8-9a8d-2157a729604e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Augmented Repair Technique for Patellar Tendon Rupture Using Two Suture Anchors and Three Transosseous Sutures: a retrospective cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003ePatellar tendon rupture is a relatively rare injury, with reported incidences approximately 0.68/100,000 person-years in the general population[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and notably higher at 6/100,000 person-years within military settings[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This injury typically occurs due to direct and indirect trauma or as a terminal outcome of patellar tendinopathy[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The proximal insertion of the patellar tendon is the most affected site[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Patients with patellar tendon rupture caused by patellar tendinopathy may present with concurrent conditions such as systemic lupus erythematosus (SLE), gout, rheumatoid arthritis (RA), obesity, renal insufficiency, Ehlers-Danlos syndrome, and a history of long-term corticosteroid use. [\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Notably, individuals across various demographics, including both the general population and athletes, are susceptible to patellar tendon rupture. The onset age of patellar tendon ruptures typically occurs during adolescence or in middle-aged males between 30 to 40 years old[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe transosseous repair is widely acknowledged classical gold standard surgical procedure for complete patellar tendon rupture. At present, the suture anchor repair technique has gained popularity due to its superior biomechanical properties. Studies have demonstrated that suture anchor repair exhibits a higher ultimate failure load and less gap formation compared to transosseous repair[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Moreover, in cases of mid-substance rupture, a direct end-to-end repair may be employed. While these methods are commonly utilized by sports medicine clinicians, it's essential to note potential drawbacks. The suture anchor technique carries the risk of anchor pull-out, while the transosseous suture technique may result in inadequate suture tension or even suture breakage, ultimately leading to retearing of the repaired patellar tendon.\u003c/p\u003e\u003cp\u003eIn efforts to mitigate the risk of retear, numerous augmentation repair methods have been utilized for patellar tendon rupture, such as cerclage wires, Dall\u0026ndash;Miles cables, nonabsorbable sutures, suture anchor, cortical button fixation, autologous grafts, allografts or synthetic ligaments enhancement and so on[\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, despite their intended benefits, these repair techniques often come with inevitable complications, such as re-ruptures, extensor lags, infection, implant breakage, re-operations, skin necrosis, disease transmission and donor-site morbidity[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGiven the inherent disadvantages of these methods, we proposed the integrated knee extensor mechanism augmentation technique repair for patellar tendon ruptures. In our approach, we combined the use of 2 suture anchors with 3 transosseous sutures to address ruptures at the proximal insertion of the patellar tendon. The aim of our study is to introduce this novel augmentation repair technique and evaluate its efficacy in achieving favorable radiological and functional outcomes over a mean follow-up period of five years.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003ePatients Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective review was conducted encompassing all patients who underwent repair for patellar tendon rupture between January 2016 and December 2020 at our hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval (LYF2023028) was obtained from the institutional human research ethics committee of our hospital on 21 February 2023, and informed consent was obtained from all participants prior to their inclusion in the study. All procedures were performed by the same senior surgeon. Patients were evaluated based on medical history, physical examination, and radiological findings. Inclusion criteria comprised patients meeting the following criteria: (1) a documented history of injury with associated knee extension lag; (2) unilateral full-thickness patellar tendon rupture confirmed via magnetic resonance imaging (MRI); (3) surgical intervention performed within 4 weeks post-injury. Exclusion criteria encompassed: (1) bilateral patellar tendon rupture, concurrent ipsilateral extremity fracture or other ligament injuries, or a history of previous surgery; (2) surgical intervention performed beyond 4 weeks post-injury; (3) loss to follow-up; (4) partial-thickness tears, or ruptures not located at the inferior pole of the patella. The CONSORT flow diagram depicting the final patient selection is provided\u0026nbsp;in Figure 1.\u003c/p\u003e\n\u003cp\u003eDemographic data, including age, sex, affected sides, BMI (kg/m\u003csup\u003e2\u003c/sup\u003e), injury mechanism, days between injury and operation and comorbidities were collected and recorded in Table 1. Preoperative and postoperative radiological findings, clinical functional assessments, and operative protocols were reviewed during the final follow-up. Specifically, assessments included patellar height (Caton\u0026ndash;Deschamps index, Fig 2a), tear pattern (partial or complete and the rupture site, Fig 2b). Final radiographic and MRI assessments were conducted to evaluate patellar height and healing between the patellar tendon and patella. No associated intra-articular lesions were identified from preoperative MRI. The postoperative complications were meticulously documented which included re-rupture, infection, implant failure, knee hematoma, arthrofibrosis and venous thrombosis and so on.\u003c/p\u003e\n\u003cp\u003eTable 1. Demographic data of all consecutive cases\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eDemographic Variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003eMean or Proportion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e33.95\u0026plusmn;10.83(14-55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eBMI (kg/ m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e23.7\u0026plusmn;4.3(16.8-33.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eSides\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003eN\u003csup\u003ea\u0026nbsp;\u003c/sup\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e18 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e22 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003eN\u003csup\u003ea\u0026nbsp;\u003c/sup\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e4(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e36(90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eInjury mechanism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003eN\u003csup\u003ea\u003c/sup\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003efall injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e28(70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003esport injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e12(30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e8(40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eSLE and RA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eEnd-stage renal disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eChronic kidney disease 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eGout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eStatin use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative Caton Index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e1.71\u0026plusmn;0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003eMean Days between injury and operation(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003e3.9\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are percentage (%) or\u0026nbsp;mean \u0026plusmn; SD\u0026nbsp;(Comorbidities: RA, SLE, Gout, end-stage renal disease, diabetes, statin use).\u003c/p\u003e\n\u003cp\u003eN\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e refers to the number of individuals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surgical procedure was conducted under both general and regional anesthesia, with the patients positioned supine and a tourniquet applied to the upper thigh. A midline longitudinal incision was made from the superior pole of the patella to the tibial tubercle. Layer-by-layer dissection was performed through the skin, subcutaneous fat, and superficial fascia, exposing the patella, ruptured patellar tendon, and tibial tubercle. Upon exploration, the patellar tendon was found to be completely broken at the inferior pole of the patella with slight retraction and massive hematoma. Additionally, complete tears of the lateral and medial retinaculum were commonly observed. The hematoma was evacuated, and the area thoroughly irrigated. Subsequently, meticulous debridement of the inferior pole of the patella was performed, followed by preparation of the bone bed while protecting the remnant of the patellar tendon. (Fig 3a and Fig 4a).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo 2.9mm absorbable suture anchors (Smith \u0026amp; Nephew, MA, USA) were placed in the inferior pole of the patella. A 2.0 Kirschner wire was used to drill three bone tunnels from bottom-up across the middle-part patella. Three patellar tunnels were segregated by 2 suture anchors from lateral to medial (Fig 3 b and Fig 4b). it is crucial to ensure that the orientation of the guide wire is not excessively downward to prevent damage to the articular cartilage. If necessary, intraoperative fluoroscopy may be employed to assist in guiding the wire placement accurately. Three 2# nonabsorbable ultrabraid sutures (Smith \u0026amp; Nephew, MA, USA) were stitched to the distal patellar tendon stump using a whip stitch technique, aligning them with the orientation of the patellar tunnels. Three ultrabraid sutures were sequentially passed through the patellar tunnels with the aid of an eyelet guide needle (refer to Fig 3c and Fig 4c). All six ends of the sutures were left at the superior pole of the patella to be secured later. Following this, the sutures attached to the anchors were stitched the proximal tendon stump at the inferior pole of the patella using Krakow technique. It is imperative to ensure that the proximal stump is adequately sewn to the main body of the patellar tendon, while also meticulously repairing the torn lateral and medial retinaculum with these sutures. Then the knee joint was flexed and extended 10-20 times to ensure no gap formation at the interface between the patellar tendon and patella. All six ends of the sutures were tied each other at 45\u0026deg; of knee flexion. One MB-66 suture was passed around the patella to reduce the overall tension (Fig 3d and Fig 4d). At completion of the procedure, the surgeon performed a thorough assessment of the ROM and ensured appropriate tension of the repaired patellar tendon at maximum knee flexion. Finally, the operated extremity was immobilized in a mobile brace set in full extension. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Rehabilitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the surgical procedure, patients were promptly permitted to start isometric quadriceps exercises and full weight bearing as tolerated while wearing a knee brace locked in full extension. Controlled physiotherapy was initiated, allowing for passive ROM exercises from 0\u0026deg; to 90\u0026deg;. 6 weeks later, patients were encouraged to do full ROM and active knee extension. Quadriceps-strengthening exercises commenced after three months, with resistance gradually increased over time. Gradual reintroduction to running activities was initiated after six months. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent clinical evaluation at 1, 3-, 6-, 12-, and 24-months post-surgery. Preoperative and postoperative ROM, patient satisfaction, VAS pain, the KSS-F, IKCD score, Lysholm score, Tegner score were recorded.\u003c/p\u003e\n\u003cp\u003eDemographic data were summarized using mean \u0026plusmn; standard deviation (SD) for continuous variables and number (%) for categorical variables. Statistical analysis was performed using the Wilcoxon signed-rank test to compare KSS-F scores, VAS scores, IKDC score, Lysholm Score, and Tegner score before and after surgery. A p-value \u0026lt; 0.05 was considered statistically significant. Data were analyzed using GraphPad 9.0.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTotally, 40 patients were included in this study. The demographic characteristics of the patients were summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most patients were males (90%, 36/40) with an average age of 33.95\u0026thinsp;\u0026plusmn;\u0026thinsp;10.83 years (ranging from 14 to 55 years). The mean BMI were 23.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49kg/m\u003csup\u003e2\u003c/sup\u003e (16.8 to 33.2 kg/m\u003csup\u003e2\u003c/sup\u003e). Twenty-eight patients sustained injuries from falls, while twelve were injured during sports activities. The mean duration between injury and surgery was 3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 days. Eight patients had medical comorbidities, including a 54-year-old female with SLE and RA, a 35-year-old male with a history of kidney transplantation 8 years prior and one patient in chronic kidney disease (CKD) Stage IV. Two patients had gout. Two patients had Diabetes and one had been on statin therapy for 5 years. At the final follow-up, patellar height was found to be normal in all patients, and the median Caton Deschamps Index were significantly decreased from 1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22 (1.32\u0026ndash;2.11) to 1.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07 (0.92\u0026ndash;1.26) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Postoperative MRI at the 2-year follow-up revealed definite healing between the patellar tendon and the patella, as evidenced by the disappearance of the gap at the interface (refer to Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003ea, b, c).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mean operative time was 82.15 minutes (range: 66\u0026ndash;118 minutes). And the average followed-up period was 60 months (range: 36\u0026ndash;72 months). All patients were satisfied with the outcomes at the last follow-up. All patients had active full knee ROM. Notably, there were no instances of re-rupture, infection, or cutaneous complications observed in any of the patients. The rate of complications was 7.5% (3/40). One patient undergoing renal dialysis that required arthroscopic debridement due to knee hematoma, while another patient received standard anticoagulant treatment for deep venous thrombosis. One patient underwent reoperation for arthroscopic debridement due to arthrofibrosis. All patients had returned to normal daily-life and preinjury sports at the final follow-up.\u003c/p\u003e\u003cp\u003eSignificant improvement in knee function were observed among all patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Specifically, the mean postoperative ROM improved from 45.65\u0026thinsp;\u0026plusmn;\u0026thinsp;10.66 to 127.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean postoperative VAS pain score reduced from 6.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11 to 1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean Knee Society function Score was significantly improved from 24.50\u0026thinsp;\u0026plusmn;\u0026thinsp;13.37 to 91.75\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean Lysholm score improved from 35.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21 to 89.05\u0026thinsp;\u0026plusmn;\u0026thinsp;3.95 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean Tegner score improved from 0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62 to 4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean IKDC score improved from 29.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.34 to 72.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.85 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of preoperative and postoperative knee function scores in all consecutive patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEvaluation item\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreoperative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePostoperative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e- value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eROM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e45.65\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;10.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e127.25\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain, VAS (0\u0026ndash;10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e6.20\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.25\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKSS Function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e24.50\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;13.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e91.75\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;5.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLysholm score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e35.40\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e89.05\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTegner score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.8\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.85\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIKDC score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e29.75\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;4.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e72.65\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. VAS: visual analog scale.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study demonstrated the reliability and efficacy of the integrated knee extensor mechanism augmentation repair technique for addressing patellar tendon rupture. Short-term outcomes validate the effectiveness of this repair method in yielding favorable radiological and functional results.\u003c/p\u003e\u003cp\u003eThe reported incidence of patellar tendon rupture is approximately 0.68/100,000 person-years in general population\u003csup\u003e1\u0026ndash;2\u003c/sup\u003e. Patella fracture, quadriceps tendon rupture and patellar tendon rupture are the three most common injury sites of knee extensor structures[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The classification of patellar tendon rupture is often based on the injury site, which typically includes the inferior pole of the patella, mid-substance, and the tibial tuberosity. The most common site of patellar tendon rupture is the inferior pole of the patella[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Patellar tendon ruptures are categorized based on the period between injury and surgery into acute and chronic ruptures[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Acute injuries typically occur within a timeframe of up to 4 weeks post-injury and necessitate immediate intervention. Conversely, chronic injuries often arise due to factors such as conservative treatment, missed diagnosis, or chronic patellar tendinopathy[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt is well known that surgical treatment is the optimal treatment for full-thickness patellar tendon ruptures to reestablish knee function. Patellar tendon fixation methods vary depending on factors such as the location of tendon disruption, surgeon preference, and the availability of implant materials. While transosseous suture repair has historically been advocated as the gold standard surgical approach for complete patellar tendon ruptures, it is associated with certain complications, including re-ruptures and extensor lags, often stemming from gap formation at the repair site[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecent biomechanical studies have shed light on the advantages of suture anchor repairs, demonstrating significantly less gap formation and higher ultimate failure loads compared to traditional transosseous repairs[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Bushnell et al[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] has shown that suture anchors repair has a higher ultimate load to failure and less gap formation than that of transosseous repairs. In a multicenter study, James O'Dowd et al[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reported that the transosseous group experienced 24 retears (7.5%), whereas the anchor group exhibited no re-ruptures. This finding underscores a significantly higher re-rupture rate in the transosseous repair group compared to the anchor group. Several case reports on suture anchor repairs have confirmed satisfactory outcomes, with no major complications or need for reoperations.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo decrease the risk of retear, many surgeons attempt to repair the severely ruptured patellar tendon with different enhancement techniques to obtain more stable extensor construct[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Various enhancement repair methods have been applied to patellar tendon rupture[\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The advantages of augmentation repair were favored by cadaveric studies[\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The augmentation of patellar tendon repairs can decrease gap formation at the ruptured site and allow early mobilization[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Another cadaveric research confirmed that augmentation repair by semitendinosus tendon can decrease the gap formation than that of no augmentation repair[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Several clinical studies have prompted various methods of augmenting repairs of patellar tendon ruptures[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Ihab I et al[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] reported successfully repaired patellar tendon augmented by semitendinosus tendon with no major complications. Core et al[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] reported that patellar tendon enhanced with synthetic ligament achieved satisfactory clinical scores. However, some patients reported experiencing a distinct foreign body sensation, which contributed to increased hospitalization costs. Additionally, it is worth noting that this technique may not be available in all institutions.\u003c/p\u003e\u003cp\u003eIn clinical practice, most non-traumatic ruptures of the patellar tendon are caused by chronic patellar tendinopathy or concomitant diseases, such as SLE, local steroid injection, renal failure and metabolic diseases[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These patients usually have poor tendon quality, impaired tendon blood supply and concurrent osteoporosis which are challenges for surgeons. As mentioned earlier, both the suture anchor and transosseous suture techniques have their limitations. The suture anchor technique has the risk of anchor pull-out, particularly in osteoporotic patellae, and transosseous suture technique potentially leads to inadequate suture strength, breakage, or bony bridge cutting, ultimately resulting in repaired patellar tendon failure. Here in this study, we combined 2 suture anchors with 3 transosseous sutures method to address the patellar tendon rupture at the proximal insertion. All patients in our study were satisfied with functional scores significantly improved.\u003c/p\u003e\u003cp\u003eCompared to previous studies, our integrated knee extensor mechanism augmentation repair method has demonstrated several advantages. Firstly, our augmentation technique effectively prevents anchor pullout, a complication typically associated with the suture anchor technique. Moreover, insufficient repair or suture breakage were not found. By placing two suture anchors at the inferior pole of the patella, we were able to suture a major part of the patellar tendon to both the patella and its remnant. Additionally, three transosseous sutures were passed through the patella, allowing them to be tied together at the superior pole and reconnecting the ruptured patellar tendon with both the patella and the quadriceps tendon. Secondly, our technique restores a wider footprint contact area, resulting in a more stable and robust extensor construct that enables early functional rehabilitation. Thirdly, the operation time for our technique (83 minutes) did not significantly increase compared with previous reports[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], suggesting that it can be easily mastered by senior surgeons. Lastly, the total surgical costs will not experience a dramatic increase, especially with the national centralized purchase of high-price consumable materials in our country[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAll patients expressed high satisfaction with the good or excellent knee function observed during the average 5-year follow-up period. Particularly noteworthy is the absence of any retears in our consecutive cases, a notable outcome directly attributable to the advantages offered by our augmentation repair technique. In contrast, Bushnell et al.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] presented a 21% failure rate in their clinical results of suture anchor repairs among 14 patients. Furthermore, the occurrence of postoperative complications in our study is also associated with concurrent diseases. For instance, one patient undergoing renal dialysis and having undergone renal transplantation twice, along with severe anemia, was recovered after arthroscopic debridement because of knee hematoma. Similarly, another patient with a high body mass index was successfully treated with standard anticoagulant therapy for deep venous thrombosis. Additionally, 1 case underwent reoperation of arthroscopic debridement because of arthrofibrosis. Despite these challenges, all the patients were able to return to their normal daily activities and preinjury sports. With meticulous surgical technique and standard rehabilitation protocols, there is a relatively low rate of complications in our case series[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere are also some limitations in our study. Firstly, the retrospective nature of the study imposes inherent limitations, including potential biases in data collection and analysis. Secondly, the sample size is relatively small, and the follow-up duration is relatively short, which may limit the generalizability of the findings and the ability to assess long-term outcomes accurately. Thirdly, the absence of a randomized control group treated with alternative methods precludes direct comparison and limits the ability to establish causal relationships between the augmentation technique and outcomes. Finally, our study did not include gait analysis and muscle strength detection, which are important measures for assessing functional outcomes and may provide additional insights into postoperative recovery. Long-term studies should be carried out to ensure maintenance of both stability and functionality, restored after surgery. We also inspire other surgeons to further evaluate the validity of this augmentation technique and to perform continued evaluation for long-term outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis retrospective study provides evidence supporting the effectiveness and reliability of the integrated knee extensor mechanism augmentation repair technique for patellar tendon rupture. The short-term results verified good radiological and functional outcomes. It is also recommended for patients with patellar tendon ruptures who present with chronic patellar tendinopathy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eThe following abbreviations are used in this manuscript:\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eROM\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eRange of Motion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eVisual Analog Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eKSS-F\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eKnee Society Function Score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eIKDC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eInternational Knee Documentation Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eSLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eSystemic Lupus Erythematosus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eRheumatoid Arthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eBody Mass Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eACLR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior Cruciate Ligament Reconstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.20216606498195%\" valign=\"top\"\u003e\n \u003cp\u003eCKD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.79783393501805%\" valign=\"top\"\u003e\n \u003cp\u003eChronic Kidney Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics statement and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Second Xiangya Hospital committee for clinical research (LYF2023028). Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was partially supported by grants from the Natural Science Foundation of Hunan Province, Health Research Project of Hunan Provincial Health Commission and the Scientific Research Launch Project for new employees of the Second Xiangya Hospital of Central South University (2023JJ40823, W20243122, QH2023024 to YH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Design of the surgical planning, data collection and analysis were performed by DL, QL and WZ. The first draft of the manuscript was written by DL, YH and ZX. KJ, YC and DZ reviewed and edited the manuscript. And all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eClayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury. 2008;39:1338-44.\u003c/li\u003e\n\u003cli\u003eFredericks DR, Slaven SE, McCarthy CF, Dingle ME, Brooks DI, Steelman TJ, et al. Incidence and Risk Factors of Acute Patellar Tendon Rupture, Repair Failure, and Return to Activity in the Active-Duty Military Population. Am J Sports Med. 2021;49:2916-23.\u003c/li\u003e\n\u003cli\u003evan der Worp H, van Ark M, Roerink S, Pepping GJ, van den Akker-Scheek I, Zwerver J. Risk factors for patellar tendinopathy: a systematic review of the literature. British Journal of Sports Medicine. 2011;45:446-52.\u003c/li\u003e\n\u003cli\u003eFigueroa D, Figueroa F, Calvo R. Patellar Tendinopathy: Diagnosis and Treatment. The Journal of the American Academy of Orthopaedic Surgeons. 2016;24:e184-e92.\u003c/li\u003e\n\u003cli\u003eMatava MJ. Patellar Tendon Ruptures. The Journal of the American Academy of Orthopaedic Surgeons. 1996;4:287-96.\u003c/li\u003e\n\u003cli\u003eSchwartz A, Watson JN, Hutchinson MR. Patellar Tendinopathy. Sports Health. 2015;7:415-20.\u003c/li\u003e\n\u003cli\u003eBlack JC, Ricci WM, Gardner MJ, McAndrew CM, Agarwalla A, Wojahn RD, et al. Novel Augmentation Technique for Patellar Tendon Repair Improves Strength and Decreases Gap Formation: A Cadaveric Study. Clin Orthop Relat Res. 2016;474:2611-8.\u003c/li\u003e\n\u003cli\u003eBushnell BD, Byram IR, Weinhold PS, Creighton RA. The use of suture anchors in repair of the ruptured patellar tendon: a biomechanical study. Am J Sports Med. 2006;34:1492-9.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Dowd JA, Lehoang DM, Butler RR, Dewitt DO, Mirzayan R. Operative Treatment of Acute Patellar Tendon Ruptures. Am J Sports Med. 2020;48:2686-91.\u003c/li\u003e\n\u003cli\u003eGarner MR, Gausden E, Berkes MB, Nguyen JT, Lorich DG. Extensor Mechanism Injuries of the Knee: Demographic Characteristics and Comorbidities from a Review of 726 Patient Records. J Bone Joint Surg Am. 2015;97:1592-6.\u003c/li\u003e\n\u003cli\u003eBoublik M, Schlegel T, Koonce R, Genuario J, Lind C, Hamming D. Patellar tendon ruptures in National Football League players. Am J Sports Med. 2011;39:2436-40.\u003c/li\u003e\n\u003cli\u003eMacchi M, Spezia M, Elli S, Schiaffini G, Chisari E. Obesity Increases the Risk of Tendinopathy, Tendon Tear and Rupture, and Postoperative Complications: A Systematic Review of Clinical Studies. Clin Orthop Relat Res. 2020;478:1839-47.\u003c/li\u003e\n\u003cli\u003eSeng C, Lim YJ, Pang HN. Spontaneous disruption of the bilateral knee extensor mechanism: a report of two cases. Journal of orthopaedic surgery (Hong Kong). 2015;23:262-6.\u003c/li\u003e\n\u003cli\u003eTakata Y, Nakase J, Numata H, Oshima T, Tsuchiya H. Repair and augmentation of a spontaneous patellar tendon rupture in a patient with Ehlers-Danlos syndrome: a case report. Archives of orthopaedic and trauma surgery. 2015;135:639-44.\u003c/li\u003e\n\u003cli\u003eHo HM, Lee WK. Traumatic bilateral concurrent patellar tendon rupture: an alterative fixation method. Knee Surg Sports Traumatol Arthrosc. 2003;11:105-11.\u003c/li\u003e\n\u003cli\u003eTao Z, Liu W, Ma W, Luo P, Zhi S, Zhou R. A simultaneous bilateral quadriceps and patellar tendons rupture in patients with chronic kidney disease undergoing long-term hemodialysis: a case report. BMC Musculoskel Disord. 2020;21:179.\u003c/li\u003e\n\u003cli\u003eEttinger M, Dratzidis A, Hurschler C, Brand S, Calliess T, Krettek C, et al. Biomechanical properties of suture anchor repair compared with transosseous sutures in patellar tendon ruptures: a cadaveric study. Am J Sports Med. 2013;41:2540-4.\u003c/li\u003e\n\u003cli\u003eRavalin RV, Mazzocca AD, Grady-Benson JC, Nissen CW, Adams DJ. Biomechanical comparison of patellar tendon repairs in a cadaver model: an evaluation of gap formation at the repair site with cyclic loading. Am J Sports Med. 2002;30:469-73.\u003c/li\u003e\n\u003cli\u003eCapiola D, Re L. Repair of patellar tendon rupture with suture anchors. Arthroscopy. 2007;23:906 e1-4.\u003c/li\u003e\n\u003cli\u003eGaines RJ, Grabill SE, DeMaio M, Carr D. Patellar tendon repair with suture anchors using a combined suture technique of a Krackow-Bunnell weave. Journal of orthopaedic trauma. 2009;23:68-71.\u003c/li\u003e\n\u003cli\u003eLee D, Stinner D, Mir H. Quadriceps and patellar tendon ruptures. J Knee Surg. 2013;26:301-8.\u003c/li\u003e\n\u003cli\u003eOde GE, Piasecki DP, Habet NA, Peindl RD. Cortical Button Fixation: A Better Patellar Tendon Repair? Am J Sports Med. 2016;44:2622-8.\u003c/li\u003e\n\u003cli\u003eOtsubo H, Kamiya T, Suzuki T, Kuroda M, Ikeda Y, Matsumura T, et al. Repair of Acute Patellar Tendon Rupture Augmented with Strong Sutures. J Knee Surg. 2017;30:336-40.\u003c/li\u003e\n\u003cli\u003eSchutte V, Schmidt-Hebbel A, Imhoff AB, Achtnich A. [Patellar tendon ruptures : Internal bracing and augmentation technique]. Oper Orthop Traumatol. 2019;31:45-55.\u003c/li\u003e\n\u003cli\u003eCore M, Anract P, Raffin J, Biau DJ. Traumatic Patellar Tendon Rupture Repair Using Synthetic Ligament Augmentation. J Knee Surg. 2020;33:804-9.\u003c/li\u003e\n\u003cli\u003eMaffulli N, Del Buono A, Loppini M, Denaro V. Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures: average 5.8-year follow-up. J Bone Joint Surg Am. 2013;95:e1231-6.\u003c/li\u003e\n\u003cli\u003eTsarouhas A, Iosifidis M, Kotzamitelos D, Traios S. Combined rupture of the patellar tendon, anterior cruciate ligament and lateral. Hippokratia. 2011;15:178-80.\u003c/li\u003e\n\u003cli\u003eBelhaj K, El Hyaoui H, Tahir A, Meftah S, Mahir L, Rafaoui A, et al. Long-term functional outcomes after primary surgical repair of acute and chronic patellar tendon rupture: Series of 25 patients. Ann Phys Rehabil Med. 2017;60:244-8.\u003c/li\u003e\n\u003cli\u003eBeranger JS, Kajetanek C, Bayoud W, Pascal-Mousselard H, Khiami F. Return to sport after early surgical repair of acute patellar tendon ruptures. Orthop Traumatol Surg Res. 2020;106:503-7.\u003c/li\u003e\n\u003cli\u003eEl D, II, Mohamed MM, Al Assassi M. Primary repair of ruptured patellar tendon augmented by semitendinosus. J Knee Surg. 2014;27:207-13.\u003c/li\u003e\n\u003cli\u003eKrushinski EM, Parks BG, Hinton RY. Gap formation in transpatellar patellar tendon repair: pretensioning Krackow sutures versus standard repair in a cadaver model. Am J Sports Med. 2010;38:171-5.\u003c/li\u003e\n\u003cli\u003eBushnell BD, Tennant JN, Rubright JH, Creighton RA. Repair of patellar tendon rupture using suture anchors. J Knee Surg. 2008;21:122-9.\u003c/li\u003e\n\u003cli\u003eMassey PA, Myers M, McClary K, Brown J, Barton RS, Solitro GF. Biomechanical Analysis of Patellar Tendon Repair With Knotless Suture Anchor Tape Versus Transosseous Suture. Orthop J Sports Med. 2020;8:2325967120954808.\u003c/li\u003e\n\u003cli\u003eChen B, Li R, Zhang S. Reconstruction and restoration of neglected ruptured patellar tendon using semitendinosus and gracilis tendons with preserved distal insertions: two case reports. Knee. 2012;19:508-12.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"patellar tendon rupture, augmentation repair, suture anchor, transosseous suture","lastPublishedDoi":"10.21203/rs.3.rs-4815777/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4815777/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePatellar tendon rupture is an uncommon injury that usually requires surgical repair, but no consensus exists regarding the ideal repair technique. Suture anchor repair and the transosseous suture method have be widely used, but the suture anchor technique may cause anchor pull-out, while the transosseous suture method may result in insufficient suture strength. Therefore, we propose and evaluate the efficacy of augmented repair technique with two suture anchors and three transosseous sutures for patellar tendon repairs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort study of patients who received surgery for patellar tendon rupture between January 2016 and December 2020. All patients underwent a standardized integrated knee extensor mechanism augmentation repair technique by the same surgeon with 2 suture anchors and 3 transosseous sutures. Radiology, complications, and patient-reported outcomes were recorded. Clinical outcomes were measured using range of motion (ROM), patient satisfaction, Visual Analog Scale (VAS) pain scores, Knee Society Function Score (KSS-F), International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTotally 40 patients were enrolled with an average age of 33.95 years. Mean follow-up duration was 60 months (range: 36 to 72 months). All cases were diagnosed with patellar tendon rupture at the patellar attachment and received the surgery. The risk of complications was 7.5% (3/40). Mean postoperative ROM improved from 45.65\u0026thinsp;\u0026plusmn;\u0026thinsp;10.66 to 127.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99 (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Mean postoperative VAS pain score, KSS-F score, IKDC score, Lysholm score and Tegner score significantly improved (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The median Caton Deschamps Index significantly decreased from 1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22 to 1.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Postoperative MRI revealed evident healing between the patellar tendon and the inferior pole of the patella.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe integrated knee extensor mechanism augmentation repair technique is reliable and effective for patellar tendon rupture. 5-year-follow up results verified its favorable outcomes.\u003c/p\u003e","manuscriptTitle":"Augmented Repair Technique for Patellar Tendon Rupture Using Two Suture Anchors and Three Transosseous Sutures: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-16 12:45:33","doi":"10.21203/rs.3.rs-4815777/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-18T07:36:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-17T16:19:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-15T12:52:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173970542819942757570646227685483888147","date":"2025-06-14T11:23:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166323689888979185939343816739532220254","date":"2025-06-11T20:09:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-04T11:20:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-08T07:14:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-08T05:56:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-08T05:56:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-07-28T08:23:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d241f5e-023a-45af-9e2c-11ab647090c6","owner":[],"postedDate":"September 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T16:04:18+00:00","versionOfRecord":{"articleIdentity":"rs-4815777","link":"https://doi.org/10.1186/s12891-025-09018-8","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-08-13 15:57:14","publishedOnDateReadable":"August 13th, 2025"},"versionCreatedAt":"2024-09-16 12:45:33","video":"","vorDoi":"10.1186/s12891-025-09018-8","vorDoiUrl":"https://doi.org/10.1186/s12891-025-09018-8","workflowStages":[]},"version":"v1","identity":"rs-4815777","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4815777","identity":"rs-4815777","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}