2016. Disclosures. Patella Tendon Rupture. Patella Tendon Rupture. Acute Patella Tendon Repair

12/13/2016 Disclosures Revision TKA Managing Extensor Mechanism Disruption Giles R. Scuderi, MD  Consultant and Royalties  Zimmer Biomet  Cons...
Author: Shannon Maxwell
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12/13/2016

Disclosures Revision TKA Managing Extensor Mechanism Disruption Giles R. Scuderi, MD

 Consultant and

Royalties

 Zimmer Biomet

 Consultant  Medtronic  Convatec  Pacira  Merz Pharmaceuticals

• Society BOD • Op Walk USA  Book Royalties  Elsevier  Springer  Thieme  World Scientific

 Research Support  Pacira Orthopaedic Institute

Patella Tendon Rupture

Patella Tendon Rupture

• Incidence 0.17 -1.4% • Avulsion tibial tubercle • Intersubstance tear

• Partial avulsion • Intact periosteal sleeve can be reattached

• Etiology • Multi-operated knee • Stiff knee

• Direct Repair • Autograft augmentation • Allograft augmentation • Repair of late ruptures • Poor results • Extensor lag • Limited ROM

• Difficult exposure

• Trauma with hyperflexion • Manipulation • System Diseases

• Drill holes, suture anchors, staples

• Steroid use

Harwin: J. Arthroplasty 13, 1998 Rand et al: CORR 244, 1989

Acute Patella Tendon Repair

Rand et al: CORR 244, 1989 Cadambi et al: JBJS 74A, 1992

Patellar Tendon Repair with Semitendinosus Tendon Autograft

• Krackow stitch • Adequate bone • Prosthesis-bone

interface • Secure in full

extension • Immobilize for 6 weeks • Gradual ROM in brace

Scuderi: The Patella, Springer Verlag, 1995

Scuderi: The Patella, Springer Verlag, 1995 Cadambi & Engh: JBJS 74A, 1992

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Quadriceps Tendon Rupture • Extremely rare • Incidence 0.1 - 1.1% • Usually at distal quad insertion • Direct repair if adequate bone

Acute Quadriceps Tendon Repair • Krackow stitch • Adequate bone • Prosthesis-bone

interface

stock

• Allograft augment if deficient extensor

mechanism • Results Variable • Extensor lag • Limited ROM

• Secure in full

extension • Immobilize for 6 weeks • Gradual ROM in brace

Dobbs et al: JBJS 87, 2005 Lynch et al: J Arthroplasty 2, 1987 Healy et al: J Arthroplasty 10, 1995

Chronic Rupture of the Quadriceps Tendon or Patella Tendon

Courtesy of Dr. Robert Booth

Scuderi: The Patella, Springer Verlag, 1995

Extensor Mechanism Allograft

Courtesy of Dr. Robert Booth

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Patella Tendon Rupture following TKA

Extensor Mechanism Reconstruction

Patella tendon rupture with instability

Revision TKA with Extensor Allograft

Extensor Mechanism Allograft

Post-op Following Extensor Mechanism Allograft

• Variable and dependent on surgical technique • Tibial bone block fixation • Tight pressfit into tibial trough • Wire or screw fixation

• Intra-op tensioning of graft in full extension • Never too tight • Post-op immobilization for 6 weeks followed by gradual resumption

of ROM

Nazarian & Booth: CORR 367, 1999 Emerson et al: CORR 303 1994

Courtesy of Dr. Robert Booth

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Marlex Mesh Graft

Marlex Mesh Anchor mesh to tibia with cement and screw

Closure of extensor, pants over vest

Tubularized 10” x 14” Synthetic Mesh

VL

Brown, Hanssen: JSJS 93(12)2011

Revision TKA with Marlex Mesh

Mesh

VMO

Brown, Hanssen: JSJS 93(12)2011

Revision TKA with Marlex Mesh

Revision TKA with Marlex Mesh

Video courtesy of Dr. Arlen Hanssen

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Postoperative Immobilization

Chronic Patellar Tendon Rupture

• Long leg cast in extension for 6-10 weeks • Average Age: 60 yrs (37-77 yrs) • Restricted flexion brace 6-8 weeks • Gradual increase in ROM

• 13 cases: Female (8); Male (5)

• BMI 36 (26.4 - 49.7) 10 pts > 30 BMI • DM 4; RA 1; Steroids 1; 5 prior infection • 12 Revision; 1 primary TKR • 10 prior extensor surgery • 2 failed primary repair w staple fixation • 5 at least one attempt at allograft reconstruction

Brown, Hanssen: JBJS 93(12)2011

Results

Patellar Tendon Rupture

FU: 3.5 yr (1- 9.8 yrs)

• Isolated Marlex reconstruction

5 knees

3 failures (1st 6 months) p=0.0003

• Concomitant procedures • component revision

Pre-op

5

1

• upsizing tibial polyethylene • reimplantation infection

p=0.007

p=0.66

p=0.001

120 100 80 Post-op

2

36 vs 1.7

60 40 20 0

Brown, Hanssen: JBJS 93(12)2011

Functional Activities

Brown, Hanssen: JBJS 93(12)2011

KS Pain

KS Function

Flexion

Extension

Summary • Walking ability • unlimited (1) • > 10 blocks (2) • 5 - 10 blocks (3) •

< 5 blocks (3)



indoors (3)

• Assistive devices (no regression) • None (6) • cane for long walks only (2) •

cane full-time (2)

• walker (2)

• Ability to use stairs (10)

1. Extensor mechanism rupture functional disability 2. Acute tear patella tendon and quadriceps tendon • Primary repair • Primary repair with autograft augmentation

3. Chronic tear patella tendon and quadriceps tendon • Extensor allograft • Marlex mesh

4. All repairs or reconstruction require prolonged

immobilization in extension • Followed by gradual resumption of ROM

5. Clinical Results are variable and technique dependent

Brown, Hanssen: JBJS 93(12)2011

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THANK YOU

Gastrocnemius Rotational Flap for Reconstruction of the Extensor Mechanism

Quadriceps Tendon Repair

Jaureguito et al: JBJS 79A(6), 1997 Busfield et al: CORR 428, 2004 Bates & Springer: JAAOS 23(2), 2015

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