Extensor mechanism lesions after total knee arthroplasty Sergio Loscos R1 COT Hospital Universitari Sagrat Cor

▫ Quadriceps tendon ▫ Periprosthetic patellar fractures ▫ Patellar tendon IncidenceEtiologyTreatment Extensor apparatus

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 ▫ Individual  Body mass index  Osteoporosis  DM, AR  Metalosis

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

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 Transosseous fixation at patella Acute quadriceps tendon rupture

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

Transosseous fixation at patella Acute proximal patellar rupture The patella tendon rupture from inferior pole of patella is identified Heavy, non-absorbable suture (#5 ethibond or fiberwire) is utilized for the repair. Parallel drill holes are made through the patella using 2.0-mm drill bit Parallel drill holes made through patella Primary repair is attempted with suture tied over bone bridge

Supplemental autograft reconstruction +

Chronic patellar rupture Achilles tendon allograft reconstruction Osteotomy is performed below the tibial tubercle using oscillating saw: rectangular/trapezoidal cavity 2.5 cm long by 1.5 cm wide by 1cm deep The calcaneal bone is prepared to snugly fit into osteotomy site Two 3.5-mm screws are utilized to stabilize allograft into the tibia. The Achilles tendon is draped over the native patella tendon, patella and quadriceps tendon. The allograft tendon is then sutured the native extensor mechanism Final repair using non- absorbable suture

Periprosthetic patellar fractures Incidence: 1% Etiological factors: ▫ Technique  Excision fat pad  Lateral release  Patellar resurfacing ▫ Gender (men) ▫ Traumatic episodes Classification (Ortiguera and Berry) ▫ Type I ▫ Type II: extensor rupture ▫ Type III: loose component z0mbie.host.sk

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

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