Suture anchor repair of proximal rectus femoris avulsions in elite ...

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Four professional football players (first-team regulars of European first division football clubs) underwent suture anchor repair of complete proximal rectus ...
Knee Surg Sports Traumatol Arthrosc (2015) 23:2590–2594 DOI 10.1007/s00167-014-3177-0

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Suture anchor repair of proximal rectus femoris avulsions in elite football players Peter Ueblacker · Hans-Wilhelm Müller-Wohlfahrt · Stefan Hinterwimmer · Andreas B. Imhoff · Matthias J. Feucht

Received: 23 May 2014 / Accepted: 8 July 2014 / Published online: 17 July 2014 © Springer-Verlag Berlin Heidelberg 2014

Abstract Purpose To report the results of suture anchor repair of proximal rectus femoris avulsions in elite football players. Methods Four professional football players (first-team regulars of European first division football clubs) underwent suture anchor repair of complete proximal rectus femoris avulsions with significant tendon retraction. The following parameters were analysed: demographic data, mechanism of injury, type of injury, classification according to the Munich consensus statement, time between injury and surgery, time between surgery and full participation in training and availability for match and/or competition selection (return to play/RTP), and time between surgery and the comeback to the first official league match (return to competition/RTC). Radiographic evaluation was performed by magnetic resonance imaging (MRI) obtained pre-operatively and at 6 and 12 weeks post-operatively. All players were followed for at least 24 months after return to play to exclude recurrence. Results Mean age at surgery was 30 ± 2 years. All injuries occurred while kicking a ball, with the dominant leg

affected in all patients. The injury was considered acute in three cases and chronic in one case. According to the Munich classification, all injures were type 4. Mean time to surgery was 60 ± 88 days (range, 8–191), mean time to RTP was 111 ± 15 days (range, 100–134), and mean time to RTC was 140 ± 23 days (range, 114–166). Follow-up MRIs demonstrated anatomically reinserted tendons with decreasing signal intensity over time in all cases. After a mean follow-up of 35 ± 6 months, all players were still competing at the same level as before the injury without re-injury. Conclusion Suture anchor repair of proximal rectus femoris avulsions allows unrestricted return to play in professional elite football players. Return to play can be expected at approximately 16 weeks post-operatively. Level of evidence Case series, IV. Keywords Football · Tendon · Avulsion · Rectus femoris · Professional athletes

Introduction P. Ueblacker (*) · H.-W. Müller-Wohlfahrt MW Center for Orthopedics and Sports Medicine, 80331 Munich, Germany e-mail: [email protected] S. Hinterwimmer · A. B. Imhoff · M. J. Feucht Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany S. Hinterwimmer Sportsclinic Germany, Munich, Germany M. J. Feucht Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Freiburg, Germany

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Quadriceps injuries are frequent in sports that involve repetitive kicking and sprinting such as football in its different forms [1–3]. Within the quadriceps muscle group, the rectus femoris is the most commonly injured muscle [8, 13]. The pattern of rectus femoris injuries ranges from small tears to complete ruptures of its tendinous portion or avulsions at its origin [6, 10, 11, 13, 15]. Proximal avulsions of the rectus femoris are rare injuries [5, 6, 9, 15], and no consensus exists about the most appropriate treatment method. Both conservative and operative treatment have been reported in small case series and case reports with good

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Fig. 1 Suture anchor repair of a proximal rectus femoris avulsion injury. a Intraoperative X-rays of socket drilling and anchor insertion at the anterior inferior iliac spine and superior acetabular ridge; b the mobilised tendon stump is armed with baseball stitches; c completed repair

results [5, 6, 9, 11, 12, 16]. Partial avulsions, e.g. tears of only one of the two tendons, without retraction may heal without surgery, while conservative treatment of complete avulsions with significant retraction of the tendons most likely will not lead to healing at its anatomical origin. The effect of non-anatomical healing on rectus femoris strength and function is currently unknown, but an adverse effect is likely. It is our believe that in case of complete avulsions with significant retraction, surgical refixation of the proximal rectus femoris provides the best initial situation to promote healing at its anatomical origin and thus complete restoration of strength and function. Since suture anchor repair has shown to achieve good functional results in proximal hamstring avulsions [7], we have adopted this treatment modality to proximal rectus femoris avulsions in high-level athletes. The aim of this article was to present our experience with suture anchor repair of complete proximal rectus femoris avulsions in elite football players.

Materials and methods Four professional elite football players underwent suture anchor repair of complete proximal rectus femoris avulsions at a single institution. All players were first-team regulars of European first division football clubs, and all of them participated in international competitions (UEFA Champions League or UEFA Europa League). Three players were members of the corresponding national football team.

Reinsertion of the tendon was performed with two suture anchors (5.5 mm titanium Corkscrew FT, Arthrex, Naples, FL, USA), which were placed at the anterior inferior iliac spine and at the superior acetabular ridge (Fig. 1). Post-operatively, no cast or brace was used. Weight bearing was restricted to 20 kg during the first 2 weeks and was gradually increased during the third and fourth postoperative week. Range of motion was limited to 0° of hip extension and 60° of knee flexion for the first 2 weeks. Afterwards, hip extension was increased by 10° and knee flexion by 30° in 2-week intervals. Combined knee flexion and hip extension was strictly avoided during the first 6 weeks. Full range of motion was allowed at 6 weeks after the operation. An individual training plan with recommendations for training with increasing intensity was given to every player. Cycling was allowed 6 weeks post-operatively; running with increased intensity was initiated not before 8 weeks after surgery. Progressive exercising was performed to retrain the muscle in complex movement patterns. The players were only allowed to advance to the next stage when they were free of pain. Regular clinical followups were performed to evaluate the healing progress. Ultrasound and magnetic resonance imaging (MRI) were performed 6 and 12 weeks after surgery. Demographic data of the players, mechanism of injury, type of injury (chronic vs. acute), classification according to the Munich consensus statement [14], complications during surgery and post-operative follow-up, and the time interval between injury and surgery (time to surgery) were evaluated. After suture anchor repair, all players were followed prospectively and the time interval between surgery

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and full participation in training and availability for match and/or competition selection (return to play/RTP), and time between surgery and the comeback to the first official league match (return to competition/RTC) were analysed. RTP was the main outcome criteria since RTC takes usually longer than RTP, especially in football, where players are back to full training before they are planned by the coach for matches. After RTP, all players were followed for at least 24 months in order to exclude recurrence or inability to play. The team physicians were interviewed periodically for subjective complaints of the players. Data are presented as mean ± standard deviation and range.

Results Basic data and injury mechanism All players were male, and the mean age at the time of surgery was 30 ± 2 (28–32) years. In all cases, the dominant leg was injured; the left leg was involved in three cases, and the right leg in one case. All injuries occurred while kicking a ball without involvement of an opposing player. The mean time to surgery was 60 ± 88 days with a wide range of 8–191 days. The injury was considered acute in three cases and chronic in one case. Imaging and intraoperative findings Pre-operative MRI revealed avulsion of both the direct and reflected head with tendon retraction of >2 cm in all players (Fig. 2a, b), which was considered an indication for surgical repair. According to the Munich classification [14], all injuries were graded as type 4. No intra- or post-operative complications were observed. Follow-up MRI at 6 and 12 weeks post-operatively revealed reinserted tendons in all players without evidence of retraction (Fig. 2c–f). There was no dislocation of suture anchors. In all cases, the repaired tendons were thicker compared to the contralateral side with signs of fibrosis in the intramuscular tendon of the rectus femoris muscle (Fig. 2c, e). Altered signal intensity of the repaired tendons (post-operative oedema) decreased from 6 to 12 weeks post-operatively (Fig. 2c, e). Follow-up evaluation Mean time to RTP was 111 ± mean time to RTC was 140 ± player with the chronic injury RTP and RTC. RTC at the same

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15 (100–134) days, and 23 (114–166) days. The had the longest time to level as before the injury

was achieved by all players. After a mean follow-up of 35 ± 6 months, all players were still competing at the same level as before the injury and no recurrent injury was observed. Interviews with the team physicians revealed no subjective complaints, no restrictions in the ability to play, and no feeling of muscle weakness or pain.

Discussion The most important finding of the present study was that suture anchor repair of complete proximal rectus femoris avulsions with retracted tendons allowed unrestricted return to play in professional elite football players. After a mean follow-up of 35 months, all players were still competing at the same level without recurrence. Proximal avulsions of the rectus femoris are rare, and the appropriate treatment of this injury is controversial [5, 15]. Gamradt et al. [5] reported the course of nonoperative treatment in 11 professional American football players with avulsion of the proximal rectus femoris. The mean return to play time was 69.2 days, with a wide range of 21–208 days. This study indicates that return to play is possible after nonoperative treatment; however, the authors do not mention whether retraction of the avulsed tendon was present. In our clinical practice, we recommend nonoperative treatment for avulsions without significant retraction. Most likely, these are partial injuries, e.g. avulsions of only the direct or the reflected head. In our patient cohort, retraction of the avulsed tendon >2 cm was present in all patients. Conservative treatment in these cases most likely does not restore normal anatomy. Non-anatomical healing may result in lowered strength and diminished function [11]. Straw et al. [16] performed strength testing before and after direct suture repair in a semiprofessional football player with a chronic rupture of the rectus femoris muscle at the proximal musculotendinous junction. This patient remained unable to sprint or kick a ball despite physiotherapy and rehabilitation for 12 months. Before the operation, the affected quadriceps had only 66 % of concentric power compared to the normal side. Six months after surgical repair, quadriceps strength was restored to nearly normal [16]. Within the quadriceps muscle group, the rectus femoris is the only biarticular muscle. Because of its function as a hip flexor and knee extender, this muscle is of special importance during sports that involve kicking a ball or sprinting, such as football [4, 9]. In high-level athletes, return to the pre-injury activity level after avulsion of the proximal rectus femoris is therefore dependent on regaining normal function and strength. All athletes of this study returned to the same level as before the injury and interviews with the team physicians revealed full function and

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Fig. 2 Axial and coronal MRI sequences pre-operatively (a, b) and at 6 weeks (c, d) and 12 weeks (e, f) post-operatively. Pre-operative images show tendinous avulsion of both heads with significant retraction. The bone-tendon gap is clearly visible; the wavy course of the tendon is caused by retraction (b). Follow-up MRI demonstrates anatomically reinserted tendons without retraction. Suture anchors are in situ causing slight artefacts in the images. Note the decreasing signal intensity of the repaired tendons over time (c vs. e) due to tendon remodelling

no subjective feelings of muscle weakness. Suture anchor repair of rectus femoris avulsions is therefore believed to restore muscle function and strength to (nearly) normal levels. In our clinical practice, primary repair is favoured especially in professional athletes. This approach has also been favoured by other authors [6, 11, 12]. Langer and Selesnick [12] reported on the treatment of a proximal rectus femoris avulsion in an Olympic-level 100-m sprinter with surgical

repair 11 days after the injury. Irmola et al. [11] reported on five cases with total avulsion of the direct head of the rectus femoris. Four of the patients were professional football players and one a national-level 110-m hurdler. The delay from the injury to surgery ranged 18–102 days (median 53 days). Surgical refixation was performed using 2–4 suture anchors. All of the patients were able to return to their pre-injury activity level 5–10 months post-operatively

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(median 9 months). The currently largest case study was performed by Garcia et al. [6]. These authors assessed the results of surgical treatment of ruptures of the proximal rectus femoris in ten professional football players. Four patients had a complete avulsion, three patients had a rupture within 3 cm proximal to the tendon insertion, and three patients had a rupture >4 cm proximal to the tendon insertion. In six cases, the tendon was repaired by direct suture with non-absorbable sutures and in four cases bone anchoring sutures were used. Nine patients were additionally treated with plasma rich in growth factors. The mean time to return to play was 3.8 months. After a mean follow-up of 34.8 months, all patients returned to play at the prior level, none of the patients had recurrence of the injury or pain. These data are consistent with the results of our study. Limitations of the present study are the small number of patients and the lack of objective data such as muscle strength measurements. Nevertheless, our patients represent a unique cohort of elite football players competing at the highest international level. All of them suffered from the same type of injury and the same operative procedure was performed by a single surgeon. These strict criteria distinguish our study from previous reports [6, 11], which included different types of injuries (partial and complete, retracted and non-retracted), heterogeneous patients (professional and recreational athletes), and various repair techniques. Since complete rectus femoris avulsions are rare injuries, we believe that the present study may help team physicians of professional football clubs when dealing with proximal rectus femoris avulsions.

Conclusion Suture anchor repair of complete proximal rectus femoris avulsions with retracted tendons allows unrestricted return to play in professional elite football players. Rehabilitation after surgery should strictly follow an individual training plan with increasing intensity and regular follow-up examinations. Return to play can be expected at approximately 4 months post-operatively.

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