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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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