GELENKZENTRUM ZÜRICH

Extensor mechanism repair in total knee arthroplasty

Muscoloskeletal Conference Bern

Dr. Urs Munzinger

GELENKZENTRUM ZÜRICHProblems

GELENKZENTRUM ZÜRICHWhich pathology?

GELENKZENTRUM ZÜRICHLiterature Rosenberg JBJS 2012

• patellar or quadriceps tendon rupture• patella fracture • tubercle avulsion

occuring intra-operatively or post-operatively can be difficult to manage and is associated with a significant rate of failure and associated complication

GELENKZENTRUM ZÜRICHLiterature II Burnett JBJS 2004

GELENKZENTRUM ZÜRICHLiterature II Burnett JBJS 2004

• n=20• Check components – Rotational alignement!!! • Rule out infection!

• Tight tensioning in full extension leads to good clinical results• Mean extension lag 4°• No loss of flexion

GELENKZENTRUM ZÜRICHZones of pathology

GELENKZENTRUM ZÜRICHAcute Rupture refix. & augmentation

GELENKZENTRUM ZÜRICHQT-recon with pedicled Fascia lata I

+ Extensive release of the quadriceps

GELENKZENTRUM ZÜRICHQT-recon Facia lata II

GELENKZENTRUM ZÜRICHQT-recon Fascia lata III

1.5 a FUVAS 0Ø Quadriceps:Right / left52.5 cm vs 50cm

GELENKZENTRUM ZÜRICHPT-recon pedicled Achilles’ tendon

Vascularized Achilles’tendon as part of a medial gastrocnemius flap

Jaureguito JW, et al. J Bone Joint Surg 1997

First choice or only in case of failure with direct suture or tendon augmentation?

GELENKZENTRUM ZÜRICHRecon II vasc. M. gastrocnemius

Jaureguito JW, J Bone Joint Surg 1997

GELENKZENTRUM ZÜRICHRecon II vasc. M. gastrocnemius

GELENKZENTRUM ZÜRICHRecon II vasc. M. gastrocnemius

GELENKZENTRUM ZÜRICHPatellar tendon rupture

With contraction

GELENKZENTRUM ZÜRICHRecon of patellar tendon rupture

Reconstructing the anatomical length of the tendon requires orthopaedic skill!

GELENKZENTRUM ZÜRICHRecon. QT-rupture

Prognostic factors

• Delay since rupture

• Number of previous surgery (scarred tissue)

• Quadriceps atrophy and retraction +++

GELENKZENTRUM ZÜRICHPatella recon with illiac crest autograft

5 Cases

GELENKZENTRUM ZÜRICHTechnique illiac crest “sandwich”

GELENKZENTRUM ZÜRICHRadiological result illiac crest

GELENKZENTRUM ZÜRICHClinical results illiac crest

Mean preop / postop LCS Score (100 max) 48 to 92

Mean postop patella score (30 max) 27

All had excellent or good results 7 and 2

Follow up 21y

GELENKZENTRUM ZÜRICHRecon Ext. mech. allograft I

GELENKZENTRUM ZÜRICHAugmentation LARS Band

Polyester Ligament 40x5cm

GELENKZENTRUM ZÜRICHRecon Ext. mech. allograft II

GELENKZENTRUM ZÜRICHRecon Ext. mech. allograft III

GELENKZENTRUM ZÜRICHRecon Ext. mech. allograft III

GELENKZENTRUM ZÜRICHRecon Ext. mech. allograft III

GELENKZENTRUM ZÜRICHRecon Ext. mech. allograft III

GELENKZENTRUM ZÜRICHRecon Ext. mech. allograft III

GELENKZENTRUM ZÜRICHRecon Ext. mech. allograft III

GELENKZENTRUM ZÜRICHRupture ext. apparatus & TKA

Risk factor: patellar resurfacingrheumatoid arthritis

Classical treatments:• Suture• Tendon augmentation• Allograft

Associated with high rate of re-rupture

Lynch AF, J Arthroplasty 1987, 2:135-140Leopold SS, J Bone Joint Surg 1999, 81A:1574-1579

GELENKZENTRUM ZÜRICHTreatment algorithm

Acute QT/PT ruptureAcute QT/PT rupture Chronic insufficencyChronic insufficency

Repair andbio. augmentation

Repair andbio. augmentation

Muscular‐tendinous flapMuscular‐

tendinous flap

Ext.mech. allograftExt.mech. allograft

Lynch AF, J Arthroplasty 1987, 2:135-140Leopold SS, J Bone Joint Surg 1999, 81A:1574-1579Rosenberg AG, J Bone Joint Surg 2012;94-B, Supple A:116–19

Cave:High rate of re-ruptureCave:High rate of re-rupture

Cave: Save –Tight tensioning is crucial!

Cave: Save –Tight tensioning is crucial!

+ Patella pathology+ Patella pathology

GELENKZENTRUM ZÜRICH

GELENKZENTRUM ZÜRICHwww.gelenkzentrum.cominfo@gelenkzentrum.com

Thank you for your kind attention!