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Extensor mechanism lesions after total knee arthroplasty

Extensor mechanism lesions after total knee arthroplasty. Sergio Loscos R1 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%

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Extensor mechanism lesions after total knee arthroplasty

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

  2. Extensor apparatus • Quadriceps tendon • Periprosthetic patellar fractures • Patellar tendon Incidence Etiology Treatment

  3. 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 http://www.orthopaedicsone.com

  4. 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 Conservative Suture nonabsorbible (Fiberwire, Ethibon, Arthrex, Naples, FL in full extension) Surgery + immobilization 6 weeks

  5. 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

  6. 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 http://www.orthopaedicsone.com • Supplemental autograft reconstruction • (semitendinosus/gracilis/tibialis anterior) +

  7. Acute proximal patellar rupture Transosseous fixation at patella Primary repair is attempted with suture tied over bone bridge 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 http://www.orthopaedicsone.com

  8. + Supplementalautograftreconstruction http://z0mbie.host.sk/Patella-Fractures-and-Extensor-Mechanism-Injuries.html

  9. 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 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 The calcaneal bone is prepared to snugly fit into osteotomy site http://www.orthopaedicsone.com

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

  11. 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

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

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