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Revision TKA Managing Extensor Mechanism Disruption Giles R. Scuderi, MD Orthopaedic Institute Disclosures Consultant and Society BOD Royalties Op Walk USA Zimmer Biomet Book Royalties Consultant Elsevier


  1. Revision TKA Managing Extensor Mechanism Disruption Giles R. Scuderi, MD Orthopaedic Institute

  2. Disclosures  Consultant and • Society BOD Royalties • Op Walk USA  Zimmer Biomet  Book Royalties  Consultant  Elsevier  Medtronic  Springer  Convatec  Thieme  Pacira  World Scientific  Merz Pharmaceuticals  Research Support  Pacira

  3. 1 year following TKA: Snap and cannot lift the knee

  4. Patella Tendon Rupture • Incidence 0.17 -1.4% • Avulsion tibial tubercle • Avulsion fracture inferior pole of patella • Intersubstance tear • Etiology • Multi-operated knee • Stiff knee • Difficult exposure • Trauma with hyperflexion • Manipulation • System Diseases • Steroid use Harwin: J. Arthroplasty 13, 1998 Rand et al: CORR 244, 1989

  5. Patella Tendon Rupture • Partial avulsion • Intact periosteal sleeve can be reattached • Drill holes, suture anchors, staples • Direct Repair • Autograft augmentation • Allograft augmentation • Repair of late ruptures • Poor results • Extensor lag • Limited ROM Rand et al: CORR 244, 1989 Cadambi et al: JBJS 74A, 1992

  6. Acute Patella Tendon Repair • Krackow stitch • #2 Fiberwire • Adequate bone • Prosthesis-bone interface • Secure in full extension • Immobilize for 6 weeks • Gradual ROM in brace Scuderi: The Patella, Springer Verlag, 1995

  7. Patellar Tendon Repair with Semitendinosus Tendon Autograft Scuderi: The Patella, Springer Verlag, 1995 Cadambi & Engh: JBJS 74A, 1992

  8. Quadriceps Tendon Rupture • Extremely rare • Incidence 0.1 - 1.1% • Usually at distal quad insertion • Direct repair if adequate bone stock • Allograft augment if deficient extensor mechanism • Results Variable • Extensor lag • Limited ROM Dobbs et al: JBJS 87, 2005 Lynch et al: J Arthroplasty 2, 1987 Healy et al: J Arthroplasty 10, 1995

  9. Acute Quadriceps Tendon Repair • Krackow stitch • #2 fiberwire • Adequate bone • Prosthesis-bone interface • Secure in full extension • Immobilize for 6 weeks • Gradual ROM in brace Scuderi: The Patella, Springer Verlag, 1995

  10. Chronic Rupture of the Quadriceps Tendon or Patella Tendon

  11. Extensor Mechanism Allograft

  12. Courtesy of Dr. Robert Booth

  13. Courtesy of Dr. Robert Booth

  14. Patella Tendon Rupture following TKA

  15. Extensor Mechanism Reconstruction

  16. Patella tendon rupture with instability

  17. Revision TKA with Extensor Allograft

  18. 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

  19. Post-op Following Extensor Mechanism Allograft Courtesy of Dr. Robert Booth

  20. Marlex Mesh Graft Tubularized 10 ” x 14 ” Synthetic Mesh Brown, Hanssen: JSJS 93(12)2011

  21. Marlex Mesh Closure of extensor, pants over Anchor mesh to tibia with cement and screw vest Mesh VMO VL Brown, Hanssen: JSJS 93(12)2011

  22. Revision TKA with Marlex Mesh

  23. Revision TKA with Marlex Mesh

  24. Revision TKA with Marlex Mesh

  25. Postoperative Immobilization • Long leg cast in extension for 6-10 weeks • Restricted flexion brace 6-8 weeks • Gradual increase in ROM

  26. Chronic Patellar Tendon Rupture • Average Age: 60 yrs (37-77 yrs) • 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

  27. Patellar Tendon Rupture • Isolated Marlex reconstruction 5 knees • Concomitant procedures • component revision 5 1 • upsizing tibial polyethylene 2 • reimplantation infection Brown, Hanssen: JBJS 93(12)2011

  28. Results FU: 3.5 yr (1- 9.8 yrs) 3 failures (1st 6 months) p=0.001 p=0.0003 p=0.007 p=0.66 120 Pre-op 100 80 36 vs 1.7 Post-op 60 40 20 0 KS Pain KS Function Flexion Extension Brown, Hanssen: JBJS 93(12)2011

  29. Functional Activities • 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) Brown, Hanssen: JBJS 93(12)2011

  30. Gastrocnemius Rotational Flap for Reconstruction of the Extensor Mechanism Jaureguito et al: JBJS 79A(6), 1997 Busfield et al: CORR 428, 2004 Bates & Springer: JAAOS 23(2), 2015

  31. Summary 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

  32. THANK YOU

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