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ExtensorMechanismRuptureRepairor

Augmentation

MichaelJ. StuartMD

Mayo ClinicRochester, MN

Financial Relationships• Consultant & Royalties- Arthrex

Research Funding• Stryker• USA Hockey Foundation

Off Label Usage• None

Michael J. Stuart MDFebruary 25, 2018

ExtensorMechanismRepairPrimaryrepair remainsthetreatmentof

choice foracute,patellar&quadricepstendonruptures…

• Non‐absorbable,lockingwhipstitches

• Trans‐osseousdrillholes

• SutureanchorsKuechle &Stuart:Isolated

ruptureofthepatellartendoninathletes.AmJSportsMed1994

Bi‐directional fixation

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ComplexExtensor Mechanism

Disruption

Patellar TendonAugmentation

Reconstruction

Patellar TendonAugmentation

Reconstruction

Quadriceps TendonAugmentation

Reconstruction

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Patellar Tendon Augmentation

Patellartendonrepair &semitendinosusautograftaugmentationutilizingadistalpatellarsocket

• Selectedcasesoffailedprimarypatellartendonrepair

• Chronicpatellartendinopathy withrupture&poortissuequality

8cadaverickneesusedtoanalyzetwomethodsofrepair:hamstringautograftaugmentationvs.standardrepair

• Allkneescycledonactuatorfor250totalcycles

• Gapformationmeasuredatrepairsite @250cycles(standardactiverehabprotocol)

Augmented=7.2mm

Standard=13.2 mm

40yo recreationalvolleyballplayer

• rehabilitatingher rightkneeinfrapatellar tendinopathy

• landedfromajump&herleft kneegaveway

• immediatepain&lossofkneeextension

Patellar Tendon AugmentationPatellar Tendon Augmentation

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Patellar TendonReconstruction

Patellar Tendon Reconstruction

Achilles Tendon Allograft

• tibial tubercle bone trough• bi-directional fixation to the

distal pole• incorporation into the quad

tendon• high strength, doubled

Achilles allograft

37yearmalepoliceofficer

• Fell20feetfromadeck

• Leftkneepatellartendonrupture

• Repair(primarysuture)failed at2months

• Reconstruction (semitendinosis)failed

• Kneegivesway,unabletoclimbstairs

Patellar Tendon ReconstructionPatellar Tendon Reconstruction

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1. Create a trapezoidal trough in the tibial tubercle.

1. Create a trapezoidal trough in the tibial tubercle.

2. Drill 3 parallel,longitudinal holes in the patella

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3. Inset the calcaneusbone block into the tubercle.

3. Inset the calcaneusbone block into the tubercle.

4. Fix the bone with acountersunk lag screw & secure the tendon with 2 suture anchors.

5. Place two #2nonabsorbable, locking whip stitches in the Achilles tendon (match the length of the contralateral patellar tendon).

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5. Place two #2nonabsorbable, locking whip stitches in the Achilles tendon (match the length of the contralateral patellar tendon).

6. Pass the 4 sutureends through the 3drill holes.

7. Place 2 sutureanchors in the distal pole of the patella (bi-directional graft fixation).

8. Pull the patelladistally & tension the sutures.

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8. Pull the patelladistally & tension the sutures.

9. Sequentially tiethe drill hole sutures at the proximal pole& the anchor sutures at the distal pole.

10. Bring the graftup to the quad tendon then flip distally.

10. Bring the graftup to the quad tendon then flip distally.

11. Suture the graft circumferentially to the quad tendon, retinaculum, native patellar tendon & distal allograft.

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0‐ 4Weeks• Partialweightbearing,rehabilitationbracelockedinfullextension

• Activeflexionto30 degrees,passiveextension• Quadricepsisometricexercises&straightleglifts‐ bracelocked

4‐ 8Weeks• Fullweightbearing,rehabilitationbracelockedinfullextension

• Activeflexionto60degrees,passiveextension

Rehabilitation

8‐ 12Weeks• Activeflexionto90degrees,passiveextension• Quadricepsisometricexercises&straightleglifts‐ braceunlocked

12‐ 16Weeks

• Discontinuebrace• Full,active rangeofmotion• Closed‐chain resistanceexercises

16Weeks‐ 12Months• Progressiveresistancequadstrengthening

Rehabilitation

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Semitendinosis Augmentation

Patellar & quadriceps tendon repair & augmentation utilizing a patellar socket & suture anchors for bi-directional fixation:

• allows for accelerated rehabilitation

• avoids risk of fracture from transverse or longitudinal patellar tunnels

• no hardware complications

Achilles Reconstruction

Patellar & quadriceps tendon reconstruction with bone incorporation, longitudinal patellar drill holes & suture anchors for bi-directional fixation:• allows for early, controlled

knee motion• restores collagen with a

biologic graft• bridges defect with a

doubled, Achilles tendon

ThankYou