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Extensor mechanism repair: A synthetic mesh approach
SE
M I N A R S I N
A
R T H R O P L A S T Y
26 (2015) 100–103
Available online at www.sciencedirect.com
www.elsevier.com/locate/semanthroplasty
Extensor mechanism repair: A synthetic mesh approach Keith A. Fehring, MD, Arlen D. Hanssen, MD, and Matthew P. Abdel, MDn Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905
article info
abstract
Keywords:
Complications involving the extensor mechanism have a devastating effect on overall
Extensor mechanism disruption
function following a primary or revision total knee arthroplasty. There are intraoperative,
Synthetic mesh
postoperative, and patient-related risk factors that can increase the occurrence of this
Marlex mesh
complication. The results of previously described techniques utilizing direct repair,
Total knee arthroplasty (TKA)
allograft reconstruction, and/or autograft reconstruction have been discouraging. The purpose of this article is to describe a technique utilizing a synthetic mesh for reconstruction of extensor mechanism disruptions after total knee arthroplasty. & 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Extensor mechanism disruptions are a devastating complication following total knee arthroplasty (TKA), with a reported incidence of approximately 0.1–1.1% for quadriceps tendons and 0.17–1.4% for patellar tendons. In addition, patellar fractures after TKA have been reported to occur at a rate of 0.68% [1]. These rates are higher in the revision setting. Risk factors include systemic factors, such as chronic steroid use or diabetes mellitus, and local factors such as significant scarring, stiffness, or a multiply operated knee. Extensor mechanism disruptions typically require surgical intervention. However, previously described techniques such as primary repair, autograft reconstruction, allograft reconstruction, and local flaps have shown varied results [2–7]. In contemporary practice, there is no single recommended method for reconstruction, highlighting the difficult nature of managing this complication. The majority of intraoperative patellar tendon disruptions occur at the tibial tubercle insertion during exposure of the knee. The stiff knee poses particular difficulties during exposure, especially when coupled with patella baja. n
Corresponding author. E-mail address: [email protected] (M.P. Abdel).
http://dx.doi.org/10.1053/j.sart.2015.08.014 1045-4527/& 2015 Elsevier Inc. All rights reserved.
Postoperative extensor mechanism disruptions can occur with a traumatic fall onto a flexed knee, or repetitive contact of the patellar tendon on the polyethylene tibial insert [6]. Over resection of the patella is also a risk factor for postoperative patella fracture. While extensor mechanism allografts have been favored by some due to their ability to incorporate host tissue, concerns with immune reactions, disease transmission, availability, and cost have tempered use [5,8]. On the other hand, the use of a synthetic mesh (Marlex Mesh; CR Bard Inc.; Murray Hill, NJ) has been shown to be an efficient, a viable, and a costeffective surgical technique [8]. As such, the goal of this article is to describe the preoperative evaluation, surgical technique, rehabilitation protocol, and results of using a synthetic mesh for extensor mechanism reconstructions.
2.
Preoperative evaluation
All patients should have a thorough history and physical examination. Inflammatory markers, as well as an aspiration (sent for culture, gram stain, and cell count), should also be
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M I N A R S I N
AR
T H R O P L A S T Y
26 (2015) 100–103
101
performed to rule out infection. On physical examination, patients with extensor mechanism disruptions will exhibit an extensor lag, as well as a palpable soft-tissue defect. All patients should have a standing anteroposterior radiograph, true lateral view, and patellar views of both knees. Patella alta can be noted in patellar tendon disruptions, and patella baja is often seen with quadriceps ruptures. From a classification standpoint, these can be described as acute, subacute or chronic, and also as partial or complete.
3.
Surgical technique
The surgical technique preferred by the authors was originally described by Browne and Hanssen [8]. This technique utilizes a synthetic mesh (Marlex Mesh; CR Bard Inc.; Murray Hill, NJ) for reconstruction of the extensor mechanism. In our practice, it has been used for reconstruction of patellar tendon disruptions, quadriceps tendon disruptions, as well as whole extensor mechanism reconstructions. While the patient is being prepped and draped in the usual sterile fashion, the synthetic graft is fashioned on the back table. This is completed by folding a 10 14-in sheet of mesh on itself to create an 8–10 ply tubular graft. This is then secured with heavy non-absorbable sutures (Fig. 1). Once formed, the surgical procedure is initiated. The previous incision is typically utilized. Full thickness medial and lateral skin flaps are raised, and a medial parapatellar arthrotomy is traditionally utilized. It is essential to mobilize the vastus medialis and vastus lateralis both dorsally and ventrally. Two heavy non-absorbable sutures can be placed on each of the muscle bellies to help mobilization (Fig. 2). A burr is then used to create a trough in the anteromedial tibia if an implant is in place. The graft is then inset into the trough and secured with polymethyl methacrylate (PMMA) bone cement, as well as a screw and washer after the cement has cured (Fig. 3A–B). This is typically a 40–60 mm cancellous screw that goes through host bone, cement, and the mesh to the posterior aspect of the tibia. Oftentimes, the screw must be directed either medial or lateral to avoid the tibial keel and/or stem. If a tibial implant is not in place yet, such as during a revision procedure, the graft is placed in between the bone and tibial implant when the tibial component is cemented into place. In either situation, the graft is then tunneled through a portal laterally to the patellar tendon and inlayed
Figure 1 – Intraoperative picture of a 10 14-in sheet of mesh folded on itself to create an 8–10 ply tubular graft. This is then secured with heavy non-absorbable suture.
Figure 2 – Intraoperative image of the vastus medialis being mobilized both ventrally and dorsally so that it may be placed atop the mesh which is already secured to the vastus lateralis.
atop the remaining extensor mechanism and vastus lateralis in full extension (Fig. 3D–G). This is secured with heavy nonabsorbable sutures. Once the mesh is secured to the vastus lateralis, the vastus medialis is brought atop the mesh. Again, this is done in full extension. This results in a construct in which the mesh is in between host tissue. Special effort is then spent to cover the entire mesh with host soft tissue with heavy non-absorbable sutures.
4.
Rehabilitation
Patients are placed in a long-leg cast for 10–12 weeks. After that, they are treated with a hinged knee brace and partial weight bearing for an additional 16 weeks. The specific protocol includes flexion from 01 to 451 1 month, 01 to 601 for the second month, 01 to 751 for the third month, and 01 to 901 for the fourth month. The knee is locked in extension at all times when ambulating during this progressive period.
5.
Results
Utilizing this synthetic mesh technique, Browne and Hanssen [8] reported on 13 patients with nine having an extensor lag of o101 and significant improvements in Knee Society (KS) scores for both pain and function. Three of the patients studied had failures of the graft, and one patient had recurrent infection treated with arthrodesis. All of these patients had previously failed extensor mechanism surgery. This technique was successful in five out of five patients without a history of previous extensor mechanism surgery. Mean KS pain scores improved from 36 points preoperatively to 75 points postoperatively (p ¼ 0.0004), and mean KS function scores improved from 20 points preoperatively to 50 points postoperatively (p ¼ 0.0007). At our institution, the cost of a single 10 14-in sheet of synthetic mesh is approximately one-tenth that of the cost of a tendinous allograft.
102
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Figure 3 – (A) The tibial trough is created with the use of a high-speed burr. (B) It is then secured with bone cement and a cancellous screw. (C) The mesh is then incorporated with host tissue distally utilizing heavy non-absorbable sutures. (D) After being passed deep the inferior host tissue, the mesh is pulled proximally. (E) Next, the mesh is secured atop the vastus lateralis with non-absorbable sutures. (F) The vastus medialis is then secured atop the mesh with heavy non-absorbable sutures and the wound is closed (G). Reprinted with permission from JBJS Am.
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M I N A R S I N
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T H R O P L A S T Y
Conclusion
Extensor mechanism disruptions following primary and revision total knee arthroplasties pose significant challenges for reconstruction. The use of a synthetic mesh has proven to be technically straightforward, cost-effective, and durable at mid-term follow-up. In addition, it avoids the limitations of allografts.
re fe r en ces
[1] Ortiguera CJ, Berry DJ. Patellar fracture after total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume 2002;84-A:532–40. [2] Brown NM, Murray T, Sporer SM, Wetters N, Berger RA, Della Valle CJ. Extensor mechanism allograft reconstruction for extensor mechanism failure following total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume 2015;97:279–83.
26 (2015) 100–103
103
[3] Cadambi A, Engh GA. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. A report of seven cases. The Journal of Bone and Joint Surgery. American Volume 1992;74:974–9. [4] Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture after total knee arthroplasty. prevalence, complications, and outcomes. The Journal of Bone and Joint Surgery. American Volume 2005;87:37–45. [5] Nam D, Abdel MP, Cross MB, et al. The management of extensor mechanism complications in total knee arthroplasty. AAOS exhibit selection. The Journal of Bone and Joint Surgery. American Volume 2014;96:e47. [6] Parker DA, Dunbar MJ, Rorabeck CH. Extensor mechanism failure associated with total knee arthroplasty: prevention and management. The Journal of the American Academy of Orthopaedic Surgeons 2003;11:238–47. [7] Schoderbek RJ Jr, Brown TE, Mulhall KJ, et al. Extensor mechanism disruption after total knee arthroplasty. Clinical Orthopaedics and Related Research 2006;446:176–85. [8] Browne JA, Hanssen AD. Reconstruction of patellar tendon disruption after total knee arthroplasty: results of a new technique utilizing synthetic mesh. The Journal of Bone and Joint Surgery. American Volume 2011;93:1137–43.
M I N A R S I N
A
R T H R O P L A S T Y
26 (2015) 100–103
Available online at www.sciencedirect.com
www.elsevier.com/locate/semanthroplasty
Extensor mechanism repair: A synthetic mesh approach Keith A. Fehring, MD, Arlen D. Hanssen, MD, and Matthew P. Abdel, MDn Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905
article info
abstract
Keywords:
Complications involving the extensor mechanism have a devastating effect on overall
Extensor mechanism disruption
function following a primary or revision total knee arthroplasty. There are intraoperative,
Synthetic mesh
postoperative, and patient-related risk factors that can increase the occurrence of this
Marlex mesh
complication. The results of previously described techniques utilizing direct repair,
Total knee arthroplasty (TKA)
allograft reconstruction, and/or autograft reconstruction have been discouraging. The purpose of this article is to describe a technique utilizing a synthetic mesh for reconstruction of extensor mechanism disruptions after total knee arthroplasty. & 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Extensor mechanism disruptions are a devastating complication following total knee arthroplasty (TKA), with a reported incidence of approximately 0.1–1.1% for quadriceps tendons and 0.17–1.4% for patellar tendons. In addition, patellar fractures after TKA have been reported to occur at a rate of 0.68% [1]. These rates are higher in the revision setting. Risk factors include systemic factors, such as chronic steroid use or diabetes mellitus, and local factors such as significant scarring, stiffness, or a multiply operated knee. Extensor mechanism disruptions typically require surgical intervention. However, previously described techniques such as primary repair, autograft reconstruction, allograft reconstruction, and local flaps have shown varied results [2–7]. In contemporary practice, there is no single recommended method for reconstruction, highlighting the difficult nature of managing this complication. The majority of intraoperative patellar tendon disruptions occur at the tibial tubercle insertion during exposure of the knee. The stiff knee poses particular difficulties during exposure, especially when coupled with patella baja. n
Corresponding author. E-mail address: [email protected] (M.P. Abdel).
http://dx.doi.org/10.1053/j.sart.2015.08.014 1045-4527/& 2015 Elsevier Inc. All rights reserved.
Postoperative extensor mechanism disruptions can occur with a traumatic fall onto a flexed knee, or repetitive contact of the patellar tendon on the polyethylene tibial insert [6]. Over resection of the patella is also a risk factor for postoperative patella fracture. While extensor mechanism allografts have been favored by some due to their ability to incorporate host tissue, concerns with immune reactions, disease transmission, availability, and cost have tempered use [5,8]. On the other hand, the use of a synthetic mesh (Marlex Mesh; CR Bard Inc.; Murray Hill, NJ) has been shown to be an efficient, a viable, and a costeffective surgical technique [8]. As such, the goal of this article is to describe the preoperative evaluation, surgical technique, rehabilitation protocol, and results of using a synthetic mesh for extensor mechanism reconstructions.
2.
Preoperative evaluation
All patients should have a thorough history and physical examination. Inflammatory markers, as well as an aspiration (sent for culture, gram stain, and cell count), should also be
SE
M I N A R S I N
AR
T H R O P L A S T Y
26 (2015) 100–103
101
performed to rule out infection. On physical examination, patients with extensor mechanism disruptions will exhibit an extensor lag, as well as a palpable soft-tissue defect. All patients should have a standing anteroposterior radiograph, true lateral view, and patellar views of both knees. Patella alta can be noted in patellar tendon disruptions, and patella baja is often seen with quadriceps ruptures. From a classification standpoint, these can be described as acute, subacute or chronic, and also as partial or complete.
3.
Surgical technique
The surgical technique preferred by the authors was originally described by Browne and Hanssen [8]. This technique utilizes a synthetic mesh (Marlex Mesh; CR Bard Inc.; Murray Hill, NJ) for reconstruction of the extensor mechanism. In our practice, it has been used for reconstruction of patellar tendon disruptions, quadriceps tendon disruptions, as well as whole extensor mechanism reconstructions. While the patient is being prepped and draped in the usual sterile fashion, the synthetic graft is fashioned on the back table. This is completed by folding a 10 14-in sheet of mesh on itself to create an 8–10 ply tubular graft. This is then secured with heavy non-absorbable sutures (Fig. 1). Once formed, the surgical procedure is initiated. The previous incision is typically utilized. Full thickness medial and lateral skin flaps are raised, and a medial parapatellar arthrotomy is traditionally utilized. It is essential to mobilize the vastus medialis and vastus lateralis both dorsally and ventrally. Two heavy non-absorbable sutures can be placed on each of the muscle bellies to help mobilization (Fig. 2). A burr is then used to create a trough in the anteromedial tibia if an implant is in place. The graft is then inset into the trough and secured with polymethyl methacrylate (PMMA) bone cement, as well as a screw and washer after the cement has cured (Fig. 3A–B). This is typically a 40–60 mm cancellous screw that goes through host bone, cement, and the mesh to the posterior aspect of the tibia. Oftentimes, the screw must be directed either medial or lateral to avoid the tibial keel and/or stem. If a tibial implant is not in place yet, such as during a revision procedure, the graft is placed in between the bone and tibial implant when the tibial component is cemented into place. In either situation, the graft is then tunneled through a portal laterally to the patellar tendon and inlayed
Figure 1 – Intraoperative picture of a 10 14-in sheet of mesh folded on itself to create an 8–10 ply tubular graft. This is then secured with heavy non-absorbable suture.
Figure 2 – Intraoperative image of the vastus medialis being mobilized both ventrally and dorsally so that it may be placed atop the mesh which is already secured to the vastus lateralis.
atop the remaining extensor mechanism and vastus lateralis in full extension (Fig. 3D–G). This is secured with heavy nonabsorbable sutures. Once the mesh is secured to the vastus lateralis, the vastus medialis is brought atop the mesh. Again, this is done in full extension. This results in a construct in which the mesh is in between host tissue. Special effort is then spent to cover the entire mesh with host soft tissue with heavy non-absorbable sutures.
4.
Rehabilitation
Patients are placed in a long-leg cast for 10–12 weeks. After that, they are treated with a hinged knee brace and partial weight bearing for an additional 16 weeks. The specific protocol includes flexion from 01 to 451 1 month, 01 to 601 for the second month, 01 to 751 for the third month, and 01 to 901 for the fourth month. The knee is locked in extension at all times when ambulating during this progressive period.
5.
Results
Utilizing this synthetic mesh technique, Browne and Hanssen [8] reported on 13 patients with nine having an extensor lag of o101 and significant improvements in Knee Society (KS) scores for both pain and function. Three of the patients studied had failures of the graft, and one patient had recurrent infection treated with arthrodesis. All of these patients had previously failed extensor mechanism surgery. This technique was successful in five out of five patients without a history of previous extensor mechanism surgery. Mean KS pain scores improved from 36 points preoperatively to 75 points postoperatively (p ¼ 0.0004), and mean KS function scores improved from 20 points preoperatively to 50 points postoperatively (p ¼ 0.0007). At our institution, the cost of a single 10 14-in sheet of synthetic mesh is approximately one-tenth that of the cost of a tendinous allograft.
102
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AR
T H R O P L A S T Y
26 (2015) 100–103
Figure 3 – (A) The tibial trough is created with the use of a high-speed burr. (B) It is then secured with bone cement and a cancellous screw. (C) The mesh is then incorporated with host tissue distally utilizing heavy non-absorbable sutures. (D) After being passed deep the inferior host tissue, the mesh is pulled proximally. (E) Next, the mesh is secured atop the vastus lateralis with non-absorbable sutures. (F) The vastus medialis is then secured atop the mesh with heavy non-absorbable sutures and the wound is closed (G). Reprinted with permission from JBJS Am.
SE
6.
M I N A R S I N
AR
T H R O P L A S T Y
Conclusion
Extensor mechanism disruptions following primary and revision total knee arthroplasties pose significant challenges for reconstruction. The use of a synthetic mesh has proven to be technically straightforward, cost-effective, and durable at mid-term follow-up. In addition, it avoids the limitations of allografts.
re fe r en ces
[1] Ortiguera CJ, Berry DJ. Patellar fracture after total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume 2002;84-A:532–40. [2] Brown NM, Murray T, Sporer SM, Wetters N, Berger RA, Della Valle CJ. Extensor mechanism allograft reconstruction for extensor mechanism failure following total knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume 2015;97:279–83.
26 (2015) 100–103
103
[3] Cadambi A, Engh GA. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. A report of seven cases. The Journal of Bone and Joint Surgery. American Volume 1992;74:974–9. [4] Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture after total knee arthroplasty. prevalence, complications, and outcomes. The Journal of Bone and Joint Surgery. American Volume 2005;87:37–45. [5] Nam D, Abdel MP, Cross MB, et al. The management of extensor mechanism complications in total knee arthroplasty. AAOS exhibit selection. The Journal of Bone and Joint Surgery. American Volume 2014;96:e47. [6] Parker DA, Dunbar MJ, Rorabeck CH. Extensor mechanism failure associated with total knee arthroplasty: prevention and management. The Journal of the American Academy of Orthopaedic Surgeons 2003;11:238–47. [7] Schoderbek RJ Jr, Brown TE, Mulhall KJ, et al. Extensor mechanism disruption after total knee arthroplasty. Clinical Orthopaedics and Related Research 2006;446:176–85. [8] Browne JA, Hanssen AD. Reconstruction of patellar tendon disruption after total knee arthroplasty: results of a new technique utilizing synthetic mesh. The Journal of Bone and Joint Surgery. American Volume 2011;93:1137–43.