Abstract
Objective
To assess the biomechanical properties and failure mode of 3 different repair methods in simulated midsubstance canine patella ligament rupture on cadavers.
Methods
The sample was paired hindlimbs of 9 adult mixed-breed dogs. The study design was an experimental study on cadavers. Patellar ligaments were transected and sutured using a Bunnell and simple interrupted epitendinous pattern. They were then randomly reinforced with 1 of 3 techniques: a circumpatellar suture loop anchored distally to the tibial tuberosity (group 1), the same loop combined with a fascia lata strip (group 2), or a polyethylene synthetic implant sutured over the patella proximally and secured distally with an interference screw (group 3). Yield, peak, and failure load, stiffness, and mode of failure were evaluated.
Results
Six hindlimbs were assigned to each group. Augmentation with the synthetic implant (group 3) showed significantly greater yield, peak, and failure load than group 1. There were no significant differences between group 2 and either group 1 or group 3.
Conclusions
Patellar ligament repair augmented with a synthetic ultrahigh-molecular-weight polyethylene implant offered greater tensile strength than a Bunnell suture with an adjunction of a circumpatellar repair.
Clinical Relevance
The use of a synthetic ultrahigh-molecular-weight polyethylene implant may offer a viable surgical option for patellar ligament repair. Further studies are warranted to assess the long-term outcome in vivo in patients with injured patellar ligament.
Patellar ligament rupture (PLR) is an uncommon condition in small animals, with several reported cases and 2 larger case series including 43 dogs and 7 cats.1–11 Patellar ligament rupture results in significant lameness due to the inability to support weight on the hindlimb.12 In humans, it occurs generally secondary to trauma,13 but factors such as the use of local corticosteroids,14 previous knee surgery,15,16 or various syndromes associated with collagen abnormalities17–20 have been reported as risk factors. In dogs and cats, PLR is generally the result of direct trauma or laceration,5,11 sometimes iatrogenic as a complication of patellar luxation, tibial osteotomies for the treatment of cranial cruciate ligament disease, or secondary to forceful simultaneous stifle flexion and quadriceps femoris muscle contraction. No predisposing factors have been identified to date.4
Surgical management is advised, but the scarcity of the literature leads to the absence of consensus regarding the best surgical option. Current repair recommendations include a primary suture of the ligament, reinforced with circum- or transpatellar suture or wire passed through a hole in the tibia or with a fascia lata autograft. The primary suture alone cannot withstand weight-bearing forces, so external joint support is needed, which increases the risk of complications.2 To stabilize the stifle joint, external coaptation or a transarticular external fixator is recommended for 4 to 6 weeks.2–4,21
To overcome issues associated with gap formation and failure of the repair, and to reduce the need for joint immobilization and its potential complications, a synthetic implant composed of braided medical-grade ultrahigh-molecular-weight polyethylene (UHMWPE)2,22,23 has been tested ex vivo and in clinical cases in patellar ligament (PL) or gastrocnemius tendon rupture repair with promising results. However, to the authors’ knowledge, this synthetic implant has not been tested in an experimental PLR model.
The first objective was to assess and compare biomechanically the strength of 3 methods of repair (group 1: Bunnell and circumpatellar suture loop; group 2: Bunnell, circumpatellar and fascia lata reinforcement; and group 3: Bunnell and synthetic implant augmentation) in a canine midsubstance ligament rupture model. The second objective was to document the mode of failure of these repairs. The authors hypothesized that the repair reinforced with the synthetic implant would be biomechanically superior to the other techniques, with greater stiffness and yield, peak, and failure loads, and that it would fail at the proximal fixation point to the quadriceps tendon.
Methods
Sample acquisition and preparation protocol
Canine pelvic limbs (n = 18) were collected from 10 adult dogs that were euthanized for reasons unrelated to the present study. The protocol was approved by the ethical committee of the University of VetAgroSup, Lyon. Data regarding the age, weight, and sex of the patient were not reported, but all dogs were in the 20- to 40-kg range. All pelvic limbs were collected within 4 hours of death and stored at −20 °C. Each limb was thawed at 4 °C for approximately 24 hours and then dissected to leave the tibia, the PL, the patella and parapatellar fibrocartilages, and 5 cm of the distal quadriceps femoris muscles, including the fascia lata.21 The tibia was freed from the femur by section of the ligamentous support and cut at mid-diaphysis to keep only the proximal part. Stifles with osteoarthritis or with signs of degenerative changes were excluded from the study. During dissection, saline (0.9% NaCl) was used with a spray bottle to keep specimens moist. After dissection, each specimen was wrapped with saline-soaked gauze, stored at −20 °C in an impervious bag, and labeled.24
Twenty-four hours before biomechanical testing, the dissected samples were thawed again at 4 °C. Three wood screws were implanted in the tibia in different planes to allow a better grip in the inclusion environment. The most distal part of the cut tibias was inserted into squared metal plots (30 X 30 by 70-mm height) and fixed with resin (by mixing polyol and isocyanate; Sika; Axson Technologies) to secure the fixation in the testing machine. During the drying process of the resin, each specimen was wrapped with a saline-soaked gauze and left at room temperature of 18 °C. On each sample, a bone tunnel was drilled in the center of the patella from the caudal to the cranial surface using a 2-mm drill bit.
Patellar ligament repair techniques
Specimens were positioned so the PL laid on a flat surface. The width, thickness, and length of the PL were measured by the same operator (RL) at the midlevel between the tibial insertion and the patellar bone using a digital caliper. The measures were repeated 3 times. The cross-sectional area (CSA) of each PL was calculated from the caliper measurement on the assumption that the ligament was elliptical on cross-section25: CSA (in mm2) = width X thickness * π/2. The PL was transected with Mayo scissors at midlevel according to the measures. Each sample was randomly assigned to 1 of 3 treatment groups: group 1 (Bunnell and circumpatellar suture loop; n = 6), group 2 (same as group 1 reinforced with fascia lata; 6), or group 3 (Bunnell and synthetic implant; 6). The homogeneity between groups was accepted by the absence of any significant difference in CSA (P > .05).
In the 3 groups, the primary repair was the same and consisted of a modified double Bunnell-Meyer suture (5-metric UHMWPE thread; Fiber Tech; Novetech Surgery; Figure 1), with 3 passes on each side of the ligament, and a simple interrupted epitendinous suture (3-metric polypropylene monofilament; Prolene; Ethicon). Knots were placed 5 mm apart and 5 mm from the transected tendon ends. Both sutures were tightened to achieve close apposition of the tendon ends, then secured with a square knot followed by four simple knots. Suture ends were cut 3 mm from the knot.
Medial and cranio-caudal view of a 3-dimensional reconstruction illustrating the patellar ligament (PL) repair in group 1. The primary repair included a modified double Bunnell-Meyer suture (black arrow) and a simple interrupted epitendinous suture (black arrowhead). Reinforcement was achieved using a suture loop in a circumpatellar position proximally and passing through a tibial bone tunnel distally (asterisk).
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.25.03.0087
For groups 1 and 2, reinforcement of the primary repair consisted of a suture loop in a circumpatellar position proximally and through a tibial bone tunnel distally (5-metric UHMWPE thread; Fiber Tech; Novetech Surgery; Figure 1), drilled with a 2-mm drill bit 1 cm caudally to the tibial tuberosity. This loop was tightened after the primary repair while an assistant maintained moderate PL tension to evenly distribute forces between the primary repair and reinforcement. It was then secured with a square knot followed by four simple knots, and suture ends were cut 3 mm from the knot.
In group 2, a strip of fascia lata matching the PL in thickness and length was taken from the cranio-lateral thigh, keeping its distal end attached near the patella. It was folded over and then sutured over the patella and its ligament with 6 simple interrupted sutures of 5-metric UHMWPE thread proximally (Fiber Tech; Novetech Surgery): the first pair of sutures included the quadriceps tendon, the second pair crossed the parapatellar cartilages, and the third pair of sutures included the proximal segment of the PL. Distally, the fascia lata was sutured to the distal segment of the PL with 4 simple interrupted sutures with knots placed 5 mm apart (Figure 2).
Medial and cranio-caudal view of a 3-dimensional reconstruction illustrating the PL repair in group 2. The primary repair was the same as in group 1. Reinforcement included the same suture loop plus a fascia lata strip (black arrow).
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.25.03.0087
Reinforcement in group 3 was carried out with a synthetic implant made of braided medical-grade UHMWPE (Novaten 4000; Novetech Surgery; Figure 3)2,23,26 sutured over the cranial surface of the PL in a similar way than in group 2 with 5-metric UHMWPE suture (Fiber Tech; Novetech Surgery). This synthetic implant was placed distally through a 3.6-mm oblique bone tunnel drilled 5 mm proximally from the tibial tuberosity through the PL fibers to the distal caudal tibial cortex, using a cannulated drill bit on a 2-mm Kirschner wire. A second 3.6-mm bone tunnel was drilled perpendicular to the first one from the medial to the lateral side, 5 mm distally to the exit point of the first tunnel, close to the caudal cortex. The edges of the bone tunnels were flared with a scalpel blade number 11 (Swann-Morton). The synthetic implant was placed via the puller wire by sliding through grommets, from cranial to caudal through the first tunnel, and from medial to lateral for the second. It was tightened as per the manufacturer's instructions, with the PL held under moderate manual tension by an assistant, and secured using a 4.5-mm interference screw (Novetech Surgery) with a ratchet screwdriver. A 1-mm smooth pin was used as a guide to tighten the screw within the axis of the bone tunnel. The length of the screw was chosen to protrude a few millimeters from each side of the tibia.
Medial and cranio-caudal view of a 3-dimensional reconstruction illustrating the PL repair in group 3. The primary repair was the same as in groups 1 and 2. Reinforcement consisted of a synthetic implant made of braided medical-grade ultrahigh-molecular-weight polyethylene (black arrow) sutured over the cranial surface of the PL. This synthetic implant was placed distally through oblique bone tunnels drilled in the tibia and blocked with an interference screw (asterisk).
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.25.03.0087
All surgical implantations of anatomic samples were performed by the same veterinary surgeon (RL), a resident in small animal surgery, who has been trained in the technique.
Biomechanical testing
A traction system (AGS- X Shimadzu) was used to carry out the tests on constructs at room temperature of 18 °C. A braided metal wire (1.45 mm wide) was passed proximally through the patellar bone tunnel from cranial to caudal and secured to the caliper, which was directly connected to the 5-KN force cell positioned in the linear motion system of the mechanical testing machine. Distally, an 8-mm pin was passed in a lateromedial direction after drilling in each metal/resin/tibia construction and attached to a fixed point. Specimens were oriented so that there was no twisting in the PL with the ligament positioned at a 180° angle with the tibia.25 A preliminary quasistatic traction test was performed at 25 mm/min until 30 N to preload,23,27 maintaining this load for 1 minute, straightening the construct. Each construct was distracted until failure at a rate of 25 mm/min.27,28 Failure was described as the point at which the repair failed owing to breakage of the suture material or slippage of the suture through the tendon tissue as determined by a drop in the applied force observed on the graph.28 Each sample was tested biomechanically in a randomized order following the same mechanical test methodology.
Data acquisition and processing
When performing tests, data acquisition was performed with the TrapeziumX software (Shimadzu), and each test was recorded by video (iPhone 11 Pro; Apple), with the recording system being placed at 50 cm in front of the construct on a camera tripod. Load-displacement curves were drawn (Microsoft Excel v16.84; Microsoft), and stiffness and yield, peak, and failure loads were obtained by a graphic measure on each construct. Stiffness was calculated from the slope on the load/displacement curve in the elastic region of the curve.21,28 Yield load was defined as the load at the point where the first deflection in linearity of the load-displacement curve occurred indicating a visual change from elastic to plastic deformation of the construct.21,28 Peak load was defined as the highest measured load during each test.21,28 Failure load was defined as the load applied at the time of construct failure measured by a sudden drop of the curve of > 50%.21,28 Failure mode was determined by direct examination followed by video confirmation.
Statistical analysis
The normality of the data was not tested, given the small sample size, and a nonparametric model was chosen. Values were reported as medians (first quartile to third quartile). Stiffness and maximum yield, peak, and failure loads were compared between the 3 groups using a Kruskal-Wallis test. A P value of < .05 was considered significant, and post hoc analyses were performed using a Dunn-Bonferroni test where appropriate.
Results
No pelvic limbs were rejected at the time of harvest and dissection.
Eighteen pelvic limbs from 10 dogs, weighing between 20 and 40 kg, were included in the study. Median CSA was 12.8 mm2 (9.4 to 15.2) with a median ligament length of 39.3 mm (37.2 to 44.2), median thickness of 1.5 mm (1.4 to 1.7), and median width of 11.0 mm (10.2 to 11.8). The median stiffness was 17.62 N/mm (14.47 to 19.63) for group 1, 20.76 N/mm (19.45 to 23.17) for group 2, and 24.39 N/mm (22.27 to 26.90) for group 3. No significant difference was observed between groups for stiffness (P = .119). The median yield was 215 N (196 to 248) for group 1, 362 N (319 to 414) for group 2, and 460 N (405 to 521) for group 3. There was a significant difference between groups 1 and 3 (P = .0027). The median peak load was 398 N (384 to 422) for group 1, 504 N (462 to 535) for group 2, and 579 N (540 to 618) for group 3. A significant difference was observed between groups 1 and 3 (P = .0222). The median failure load was 392 N (384 to 416) for group 1, 457 N (416 to 512) for group 2, and 563 N (485 to 577) for group 3. A significant difference was found between groups 1 and 3 (P = .0394). These results are summarized in Table 1 and Figure 4.
Median yield load, peak load, failure load, and stiffness for the 3 groups (first quartile to third quartile).
| Group | Yield load (N) | Peak load (N) | Failure load (N) | Stiffness (N/mm) |
|---|---|---|---|---|
| Bunnel | 215 (196–248)* | 398 (384–422)** | 392 (384–416)*** | 17.62 (14.47–19.63) |
| Fascia | 362 (319–414) | 504 (462–535) | 457 (416–512) | 20.76 (19.45–23.17) |
| Implant | 460 (405–521)* | 579 (540–618)** | 563 (485–577)*** | 24.39 (22.27–26.90) |
*,**,***Denote values that are significantly different. The varied asterisks correspond to the values tested. There is a significant difference in yield between the Bunnel and Implant groups, and also for peak load and failure load. Please note, yield, peak load and failure load have not been tested against each other within the same group.
Box plots picturing the median and first and third quartiles of the yield load, peak load, failure load, and stiffness by group. *Values that are significantly different.
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.25.03.0087
All constructs in group 1 failed by rupture of the knot of the circumpatellar suture loop (n = 6; 100%). In group 2, 3 constructs failed by rupture of the knot of the circumpatellar suture loop (50%), 1 by unraveling of the knot (16.7%) and 2 by shearing of the tibial bone by the circumpatellar suture loop (33.3%). Three constructs in group 3 failed by proximal PL failure (50%) and the other 3 by shearing of the synthetic implant by the caudal tibial cortex (50%; Figure 5).
Caudal view of a postrupture construct with the synthetic implant sheared by the protruding edge of the medio-caudal tibial cortex (white arrow).
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.25.03.0087
Discussion
Significantly greater yield, peak, and failure loads were documented with the use of a braided medical-grade UHMWPE implant as a reinforcement for the repair of PLR in the canine stifle (group 3) compared to a more conventional surgical method (group 1). The authors validated their first hypothesis. The synthetic implant was sheared in 3 cases by the caudal tibial cortex between the 2 bone tunnels, so their second hypothesis, that the weakest point of the construct would be at the proximal fixation on the quadriceps tendon, was partially rejected.
Two recent biomechanical studies of the PL compared 2 techniques of primary tenorrhaphies28 and 3 techniques of primary repair reinforced with 18-G stainless steel tension band wire with a circumpatellar, transpatellar, or combined fashion.21 Even if it is challenging to compare these studies and the results obtained here because of differences in the study methodology, the results obtained in our study are similar to those of McKay et al21 but showed greater tensile strength than those in the study of Soula et al.28 Reinforcement techniques using tension band wires in the transpatellar and the combined group in the study of McKay et al21 showed greater stiffness than those tested in the actual study, possibly because of proximal fixation through the patella instead of passing around, creating a bone-to-bone interface, but frequently break and require removal in a clinical situation.4 In the 3 techniques tested in our study, the proximal fixation always involved passing through the soft tissue or around the patella for groups 1 and 2, which decreased stiffness by tissue deformation during the test. On the other hand, one could argue that passing around the patella rather than through it minimized the patella fracture risk of complication in clinical cases seen in the combined transpatellar/suprapatellar group, although rare.21 Other studies are needed to potentially improve the stiffness of the reparation with the proximal fixation of the synthetic implant.
An increase in yield, peak, and failure loads for group 3 was observed compared to group 1 (Figure 4). The values obtained in this study were not as strong as a native dog PL, which is able to resist around 2,000 N under a traction load test for medium-weight dogs.25,29 However, physiological forces placed on PL in dogs have not been studied and established. In goats weighing between 57 and 67 kg, it has been observed that 200 N during standing and 1,000 N during trot were applied to the PL.30 It is obvious that at these loads, PL reparation is likely to fail in the 3 groups tested in this study, highlighting the need to use external joint support such as resin or bandages and follow resting instructions during the postoperative period in clinical cases.
In group 3, a shearing of the synthetic implant by the caudal tibial cortex was observed in 3/6 cases and was not expected. The synthetic implant (Novaten 4000) is reported to fail at 4,000 N by the manufacturer, and previous studies23 showed greater failure load (median of 1,007 N with a SD of 146 N on calcaneum fixation with a Novaten 8000) by progressive slippage of the implant through the interference screw. The protruding nature of the edge of the medio-caudal tibial cortex in the proximal part of the bone sheared the implant at high load. Although a load-to-failure test does not reflect the situation in vivo,31 it would be interesting to investigate if this failure mode would occur in cyclic load tests in future studies. Modification of the actual technique in group 3 could be a distal shift of the exit point of the first bone tunnel to avoid the protruding edge of the proximal part of the tibia. In 2 cases in group 2, failure occurred by shearing of the tibial bone by the circumpatellar suture. These 2 cases happened on both limbs of the same dog; despite the absence of macroscopic anomaly of the joint or the bones, we suspected a decreased bone density in this animal because this failure mode did not occur on other samples. Nevertheless, the authors recommend not to drill the tibial bone tunnel too proximally to limit this risk.
A midsubstance PLR model was chosen for this study for 2 reasons: first, it is reported to be one of the most frequent types of rupture,32 which allows primary tenorrhaphy; and second, the same model was used in 2 recent biomechanical studies on PLR model.21,28 On the other hand, the midsubstance transection model may not be representative of all clinical cases, where tendinous fraying and fibril degeneration are often seen. In these chronic cases, where quadriceps muscles atrophy and tendon retraction might lead to a large gap making reconstruction difficult, using a synthetic graft like this synthetic implant could be a satisfactory reconstructive option. The same synthetic material made of UHMWPE (Fiber Tech; Novetech Surgery) has been chosen for the Bunnell pattern and for the fascia and implant suture to the PL, because of the stronger biomechanical properties in several studies than other materials.33–35 This choice allowed us to only compare the different suture or reinforcement patterns between groups and their tensile strength and not the properties of the materials used for the suture.
This study has several limitations: first, it was a cadaveric study, which does not perfectly reflect the clinical situation. Indeed, the tested tissues were altered and detached from their muscular attachments, which modified their biomechanical properties. Second, larger groups could have increased the statistical power and made the values between the 3 groups significantly different, which could have highlighted the benefit of adding the fascia lata strip for group 2. Third, our study did not include high frame rate video for determination of 1- and 3-mm gap formation. Gap formation in PL is associated with impaired healing and collagenous remodeling, ultimately resulting in patella alta, decreased limb function, and decreased joint range of motion.36 Several factors made this impossible. One technical issue was the absence of a camera directly connected to the testing machine. To address this, black tracers were placed on either side of the ligament ends, but this method proved imprecise. Additionally, the elongation of the constructs observed in the videos made it difficult to accurately categorize the gap. However, since this type of synthetic implant was intended to form a ligament prosthesis, the absence of a gap measurement did not appear to be prohibitive for the study. Fourth, this study tested the ligaments in linear traction to failure, which represents acute cases of traumatic rupture rather than chronic lesions, in which it would have been more interesting to perform cyclic traction tests. Nevertheless, this type of test is interesting because it allows a direct comparison with 2 recently published studies.21,28 Fifth, we chose to drill the patella craniocaudally to limit the risk of patellar fracture during biomechanical testing, an incident we experienced during pretesting. In addition, the use of a proximal soft tissue fixation could have induced soft tissue deformation during testing and thus not properly reflected the situation at the PL level. Finally, those tests were carried out with a 180° traction angle between the PL and the tibia long axis, which is different than the 135° physiological traction angle35; therefore, the values obtained in these tests certainly do not represent the in vivo values. However, traction angle did not differ between the 3 groups, which made them comparable. This choice was dictated to compare the values obtained with the values of the native PL rupture in the study of Biskup et al,25 where the angle of traction of 180° is used.
To the authors’ knowledge, there is no consensus on the best technique for PLR. In this study, 3 patellar ligamentoplasty protocols were tested for the first time, and their biomechanical properties were described in a cadaveric model. Reinforcing a patellar ligamentoplasty with a UHMWPE implant increased yield, peak, and failure loads compared to a more conventional repair. Reinforcement with a fascia lata strip increased stiffness and yield, peak, and failure load values although none of them were significant, which prevents us from drawing any conclusions. Further studies to investigate the cyclical load strength properties and the clinical outcomes in dogs and cats of this type of synthetic implant are warranted.
Acknowledgments
None reported.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the composition of this manuscript.
Funding
IVC Evidensia supported this study financially.
ORCID
Romain Lamère https://orcid.org/0009-0001-5591-0488
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