Revision TKA Managing Extensor Mechanism Disruption Giles R. - - PowerPoint PPT Presentation

Orthopaedic Institute

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

Disclosures

 Consultant and

Royalties

 Zimmer Biomet

 Consultant

 Medtronic  Convatec  Pacira  Merz Pharmaceuticals

 Research Support

 Pacira

• Society BOD
• Op Walk USA

 Book Royalties

 Elsevier  Springer  Thieme  World Scientific

1 year following TKA: Snap and cannot lift the knee

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

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

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

Patellar Tendon Repair with Semitendinosus Tendon Autograft

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

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

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

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

Chronic Rupture of the Quadriceps Tendon or Patella Tendon

Extensor Mechanism Allograft

Courtesy of Dr. Robert Booth

Courtesy of Dr. Robert Booth

Patella Tendon Rupture following TKA

Extensor Mechanism Reconstruction

Patella tendon rupture with instability

Revision TKA with Extensor Allograft

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
• f ROM

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

Post-op Following Extensor Mechanism Allograft

Courtesy of Dr. Robert Booth

Marlex Mesh Graft

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

Marlex Mesh

Anchor mesh to tibia with cement and screw

Closure of extensor, pants over vest

VL Mesh VMO Brown, Hanssen: JSJS 93(12)2011

Revision TKA with Marlex Mesh

Revision TKA with Marlex Mesh

Revision TKA with Marlex Mesh

Postoperative Immobilization

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

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

Patellar Tendon Rupture

• Isolated Marlex reconstruction 5 knees
• Concomitant procedures
• component revision 5
• upsizing tibial polyethylene

1

• reimplantation infection

2

Brown, Hanssen: JBJS 93(12)2011

Results

FU: 3.5 yr (1- 9.8 yrs) 3 failures (1st 6 months)

20 40 60 80 100 120 KS Pain KS Function Flexion Extension

p=0.0003 p=0.001 p=0.007 p=0.66

36 vs 1.7 Brown, Hanssen: JBJS 93(12)2011 Pre-op Post-op

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

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

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

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