Extensor mechanism lesions after total knee arthroplasty Sergio

Extensor mechanism lesions after total knee arthroplasty Sergio Loscos R 1 COT Hospital Universitari Sagrat Cor

Extensor apparatus ▫ Quadriceps tendon ▫ Periprosthetic patellar fractures ▫ Patellar tendon Incidence Etiology Treatment

Quadriceps tendon rupture • Incidence: 0, 1 -1, 1% • Etiological factors: ▫ Traumatic episodes (hyperflexion) ▫ Technique Excessive bony resection Malalignment prosthesis Lateral release Patellar resurfacing Excision fat pad http: //www. orthopaedicsone. com ▫ Individual Body mass index Osteoporosis DM, AR Metalosis

Quadriceps tendon rupture Conservative • Treatment (surgery: 76, 5%) ▫ Partial: immobilization in knee extension 6 -8 weeks ▫ Complete or lag of 20º extension: surgery Surgery Acute Transosseous fixation (1 st election) Anchors prox. patella (few evidence) Direct suture (rerupture 40%) Suture nonabsorbible (Fiberwire, Ethibon, Arthrex, Naples, FL in full extension) Chronic: Reconstruction (graft) Autograft: semitendinosus/gracilis Allograft: Achilles tendon Synthetic: Dacron/Marlex + immobilization 6 weeks

Acute quadriceps tendon rupture Transosseous fixation at patella http: //www. orthopaedicsone. com 1. Quadriceps tendon rupture 2. Suture weaved through quadriceps tendon using Krackow Technique #5 Ethibon 3. Parallel drill holes made through patella 4. Sutures tied over bone bride - note that knee is in full-extension 5. The repair is reinforced with #1 ethibon suture

Patellar tendon rupture • Incidence: 1% • Etiological factors: same as quadriceps • Treatment (surgery 98, 6%), no conservative ▫ Acute Partial http: //www. orthopaedicsone. com ▫ Direct suture (mid-substance tear) Complete or inst. TTA/Patella ▫ Transosseous fixation (TTA/Patella) ▫ Anchors (TTA/Patella distal) + Supplemental autograft reconstruction (semitendinosus/gracilis/tibialis anterior) ▫ Chronic: Reconstruction (graft) Allograft: Achilles tendon with calcaneous bone block Gastrocnemius transposition Complete allograft extensor reconstruction Synthetic: Dacron/Marlex

Acute proximal patellar rupture Transosseous fixation at patella http: //www. orthopaedicsone. com Primary repair is attempted with suture tied over bone The patella tendon bridge rupture from inferior pole of patella is identified Heavy, non-absorbable suture (#5 ethibond or fiberwire) is utilized for Parallel drill the repair. holes made Parallel drill holes are through made through the patella using 2. 0 -mm drill bit

+ Supplemental autograft reconstruction http: //z 0 mbie. host. sk/Patella-Fractures-and-Extensor-Mechanism-Injuries. html

Chronic patellar rupture Achilles tendon allograft reconstruction Osteotomy is performed below Two 3. 5 -mm screws are the tibial to tubercle using Final repair utilized stabilize allograft oscillating saw: using into the tibia. non. The calcaneal bone is cavity rectangular/trapezoidal absorbable The Achilles tendon is prepared fit wide into 2. 5 cm draped longtobysnugly 1. 5 cm by suture over the native osteotomy sitedeep patella and 1 cm patella tendon, quadriceps tendon. The allograft tendon is then sutured the native extensor mechanism http: //www. orthopaedicsone. com

Periprosthetic patellar fractures • Incidence: 1% • Etiological factors: ▫ Technique Excision fat pad Lateral release Patellar resurfacing • Classification (Ortiguera and Berry) ▫ Type II: extensor rupture ▫ Type III: loose component ▫ Gender (men) ▫ Traumatic episodes z 0 mbie. host. sk

Periprosthetic patellar fractures Conservative • Treatment (surgery: 28, 1% cases) ▫ Type I: immobilization (excellent results) Surgery ▫ Type II: extensor apparatus repair + internal fixation/patellectomy ▫ Type III Good stock bone: revision Poor stock bone: component removal/patellectomy

Conclusion Quadriceps tendon rupture Partial Patellar tendon rupture Type I Complete or lag ext. > 20º Conservative (immobilization) Repair • Transosseous fixation patella • Anchors prox. patella • Direct suture Acute Chronic Reconstruction: • • Autograft • • Allograft • Synthetic Type II/III Conservative (immobilization ) Surgery Acute Periprosthetic patellar fx. Surgery Chronic Reconstruction: Partial: direct suture • Autograft Complete: - Transosseous fixation (TTA/patella) • Allograft (Achilles) • Synthetic - Anchors (TTA/ dist. patella) + Supplemental autograft reconstruction (semitendinosus/gracilis/tibialis anterior)