INNOVATIONS IN PRACTICE

Acellular dermal graft augmentation in quadriceps tendon rupture repair

Ross M. Wilkins

INTRODUCTION cific pain and swelling of the indicative of other more nstability of the knee from failure of the extensor frequent soft-tissue maladies such as ligament rupture, mechanism is a debilitating problem. Extensor mechan- partial tears, and the presence of intact medial and lateral 19 ism failure frequently is the result of patellar retinacula and iliotibial band. The purpose of this I retrospective review was to describe a ‘‘stent’’ augmentation rupture, quadriceps tendon rupture, patellar fracture or avulsion of the patellar tendon.1,2 Such failures have method for rupture of the quadriceps tendon and evaluate been linked to underlying pathologies such as diabetes the effects of quadriceps tendon augmentation in both the mellitus, gout, corticosteroid use, autoimmune inflamma- presence and absence of a TKA. tory diseases, hyperthyroidism, obesity and end-stage renal disease.3--8 Often, the treatment of this problem is com- MATERIALS AND METHODS pounded by the presence of a total knee arthroplasty (TKA) Eight in seven patients were treated using acellular or the need for a TKA.7 Depending on the root cause of the human dermal matrix, (AHDM; GRAFT JACKETs Matrix, instability, there are a variety of ways to treat this soft-tissue Wright Medical Technology, Arlington TN) for chronic insufficiency. Historically, problems of the extensor me- quadriceps tendon rupture at a single institution. Four chanism have been operatively treated using primary repair, of these patients presented with a TKA, with one patient tendon autografts, , extensor mechanism allografts, having had bilateral TKA. One patient had an Illizarov allografts, whole patellar allografts and fixator placed at the same time as the AHDM to assure synthetic reinforcing materials.9--14 In acute situations, immobilization. The patient had refused postoperative extensor mechanism failure related to rupture of the patellar splinting or casting. The patient population consisted of tendon or the quadriceps tendon treated operatively and two women and five men. The median age of the patients early have yielded satisfactory results.15--19 Unfortunately, at the time of surgery was 62 years (range, 38--84 years; in chronic situations, including those involving a TKA, Table 1). the results have been less satisfactory.1,4,9,14,20,21 Chronic or During surgery, the extensor mechanism was exposed in delayed repair of these tendons is complicated by muscu- such a way as to allow access to the entire mechanism from lature retraction, fatty infiltration of the tendon, scar tissue the tibial tubercle to the musculocutaneous junction of formation, muscle atrophy and poor tendon quality from the quadriceps (Figure 1). Once skin flaps were dissected previous surgeries.22--24 medially and laterally, the degree of damage was assessed. Although problems with the extensor mechanism of the There were three distinct portions of the quadriceps knee are not uncommon, there are few reports detailing mechanism that were evident. The medial portion, com- the effects of treatment with TKA. Furthermore, because of prised of the , the central slip of the rectus the proximity of tendons and their overall effects on the femoris, and vastus lateralis, and the central portion of the knee joint, quadriceps and patellar tendon ruptures often rectus tendon were dissected free proximally (Figure 2). are lumped into one category along with other difficulties When divided, there were three distinct tendinous portions leading to patellofemoral instability. This generalization of belonging to the vastus medialis, the rectus femoris and results makes it difficult to isolate the individual effects the vastus lateralis. At this point, we examined the patellar of treatment on specific tendon tears. The limited data on mechanism for avulsion location. Usually the avulsion quadriceps tendon tears is further confounded by misdiag- occurred at the superior pole of the . Large non- nosis rates reported as high as 38%.6,17 Misdiagnosis of absorbable sutures were placed in the body of the rectus quadriceps tendon rupture has been attributed to palpable tendon, which then went circumferentially around the tendon gaps eclipsed by swelling and hematoma, nonspe- patella to reapproximate the end of the rectus from the superior patella (Figure 2). Generally, incisions also were made in both medial and lateral borders of the extensor The Denver Clinic for Extremities at Risk, At Presbyterian/St Luke’s retinaculum adjacent to the patella. If, with the digital and Medical Center, Denver, Colorado blunt dissection, the quadriceps mechanism could not be Correspondence to Ross M. Wilkins, MD, MS, The Denver Clinic for mobilized enough to approximate the rectus in the patella, Extremities at Risk, Colorado Limb Consultants, 1601 East 19th Ave., the tourniquet was let down to give more muscle length. At Suite #3300, Denver, CO 80218 Tel: þ 303 839 6051; fax: þ 303 839 6399; this point, tissue that could be placed in apposition between e-mail: [email protected] the patella and the rectus was found. Usually, two of these 1940-7041 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins large sutures were used between the patella and the rectus

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TABLE 1. Patient demographics for participants in the study Patient Sex Age (year) TKA? Follow-up (month) MSTS (1 month) MSTS (recent) ROM (degree) 1 M 37 No 41 50 100 0-110 2 F 77 Yes 42 43 47 0-95 3 M 56 No 29 83 93 0-135 4 F 38 Yes 16 60 70 10-100 5 M 47 (D) No 2 23 20 10-15 6 M 84 Yes 29 50 30 30-110 7 M 49 Yes 22 20 57 0-110 8 M 84 Yes 22 37 23 Fused (infected)

D indicates deceased; MSTS, musculoskelatal tumor society; ROM, range of motion; TKA, total knee arthroplasty. tendon (Figure 3). This repair was done with the knee in full sutured with nonabsorbable suture, and then sutures were extension. placed approximately every 5--10 mm circumferentially, Once the approximation of the central rectus in the patella anchoring the allograft dermis to the reconstruction and was accomplished, the acellular dermal material (Graftjacket, serving as a stent onto which the other tendinous insertions WMT, Arlington, TN), which had been rehydrated, was were sutured. Once the graft was sutured in place, both the placed anteriorly and over the rectus tendon, the repair, vastus medialis tendon and the vastus lateralis tendon were and onto the patellar retinaculum. First the corners were brought toward the midline on top of the dermal matrix and were sutured with nonabsorbable suture through the graft into the rectus or retinaculum beneath. The last sutures were placed through the vastus lateralis and vastus medialis tendons, capturing the rectus tendon and the graft (Figure 4). The objective was to form a ‘‘sandwich’’ between the posterior structures and the anterior tendons with the acelluar dermal graft in between. Once the construct was completed, the knee was carefully flexed to approximately 451, with close observation of the reconstruction (Figure 5). The sutures remained stable. At this point, we controlled the bleeding, placed a drain and closed the superficial tissues. Patients were then placed in a knee splint in full extension.

Postoperative Care Since these patients generally have had multiple failures of repair, the objective with their postoperative rehabilitation was to obtain a working quadriceps mechanism without stretching out the reconstruction. This was accomplished by placing the patient’s knee in a splint and instructing them to keep the knee straight at all times. Physical therapy during the first 3 weeks consisted of the patients doing quadriceps contractions in the knee immobilizer and touchdown weightbearing. After 3 weeks patients began straight leg raises only in the knee immobilizer. How long the patient kept the knee completely extended depended on his situation. In patients who had multiple procedures and formed no appreciable scar tissue with those procedures, the knee was held in extension for 10 to 12 weeks. However, in patients who appeared to have normal scar tissue formation, the knee was kept in extension for 6 to 8 weeks. Once the patient came out of the knee immobilizer, active knee flexion and extension were carried out. There was no concerted effort with physical therapy to forcibly flex the knee at this point, but the patient generally stretched out the reconstruction during its maturation process. As the patient slowly gained flexion, they were able to begin FIGURE 1. An incision is made along each side of the central insertion of activities as tolerated, such as low weight knee extensions each of these muscles to allow advancement of the central portion (rectus and bicycle. As patients gained strength while in motion, femoris). their activities were advanced. Current Orthopaedic Practice www.c-orthopaedicpractice.com | 317

otherwise. There was no clinical evidence of repair failures, and no revisions were necessary with the AHDM.

DISCUSSION Primary repair of the ruptured quadriceps tendon in chronic situations or in the presence of TKA has not demonstrated favorable results. In an analysis of 35 patients treated for quadriceps primary repair, Wenzl et al.25 found the only factor that significantly contributed to outcome was time to surgery. Patients operatively treated within 14 days of injury did better than those treated 14 days after injury. Siwek and Rao17 also reported unsatisfactory results in three of six delayed quadriceps repairs while all 30 ruptures treated within 7 days of injury had good or excellent outcomes. Rasul and Fischer16 reported good outcomes in the two patients with delayed surgery while the 17 patients with early repair had excellent outcomes. Dobbs et al.4 analyzed FIGURE 2. The central portion of the conjoined tendon (rectus femoris) is the results of 34 patients with partial or complete quadriceps sutured to the superior pole of the patella with two circumferential heavy rupture with a TKA during a 28-year period. Within the non-absorbable sutures (#5 Ethibond, Ethicon Corp, Somerville, NJ). partial tear group of 23 patients, 16 were treated with primary operative repair. There were four major complica- tions with unsatisfactory results within the operatively RESULTS treated group while the nonoperatively treated group Eight knees were operated on, and five of these procedures (n ¼ 7) all experienced good results. Because of the high were done with TKA in place. Patients had undergone an complication rate within the operative treatment group for average of four previous surgeries on the treated knee (range, partial tears, the authors suggested nonoperative treatment 1--12). One patient died 6 months after repair secondary for partial tears of the quadriceps tendon. In the group of to myocardial infarction unrelated to knee surgery. One 11 complete ruptures, ten were treated operatively. Four of knee required reoperation because of recurrent infection 16 the 10 operatively treated complete tears had a re-rupture. months after repair with placement of an antibiotic spacer; Within the complete rupture group, only four patients had a this was unrelated to the graft that appeared well incorpo- satisfactory outcome. With the poor results obtained with rated intraoperatively. The Illizarov fixator was removed suture repair alone, the investigators changed their protocol 4 months after surgery, and the graft was well incorporated to augment all complete quadriceps tears in the presence of at this time. TKA and treat partial tears in this population nonopera- To assess patient progress, we used a modified tively.4 Although autogenous tissue can be a source of Musculoskeletal Tumor Society (MSTS) functional survey augmentation material in traumatic or acute situations, when patients came for a clinical examination. Preopera- patients who have undergone previous knee surgeries will tively, the patients all had scores less than 10% because of have compromised local tissue.9,10 For this reason, many their quadriceps mechanism insufficiency. Both the TKA investigators have turned to allograft or synthetic alter- and non-TKA groups showed improvement after surgery. natives. The TKA group had an average score of 42% (range, 20--60%) Synthetic reinforcement has been attempted using the 1 month postoperatively and improved to 45% (range, Leeds-Keio ligament. Although the initial reports by 23--70%) at most recent follow-up. These scores are slightly Fujikawa et al.3 were excellent, subsequent studies involving lower than the non-TKA group, which averaged 52% (range, more complex cases of extensor mechanism repair did not 23--50%) 1 month postoperatively and improved to 71% produce the same level of results. The results achieved in (range, 20--100%) at most recent follow-up. The follow-up these other studies were considered a success, given the time averaged 25 months (range, 2--42 months). Excluding patient population.12,14 A case report of quadriceps rupture the patient who died, follow-up time increased to 29 after TKA treated with primary repair reinforced with months (range, 16--42 months). If only patients with at Dacron tape cerclage offered pain free ambulation with least a 1 year follow-up were included (n ¼ 6), the average good range of motion at 1 year.26 While these materials scores improved for both groups. Average postoperative seem to offer promise, the data regarding their use are patient active range of motion was 84.41 (range, 0--1351). somewhat limited, and the results have not been consistent. Dividing the range of motion into the two groups was not In extensor mechanism repair, different allografts have relevant, as values were not obtained for the patient who been studied with varying results. Burnett et al.1 evaluated died and thus the sampling population was too small. By the use of extensor mechanism allografts in a series of excluding the patient with the infection which resulted in a 20 patients comparing the minimally tensioned protocol fusion, this overall average value increased to 96.41.Two of Emerson et al.13 to the tightly tensioned protocol of patients experienced an extensor lag of 101 and one patient Nazarian and Booth.24 Of the seven minimally tensioned exhibited an extensor lag of 301 but could actively extend allografts, six required repeat surgery and three of the 13 318 | www.c-orthopaedicpractice.com Volume 21  Number 3  May/June 2010

FIGURE 3. The acellular human dermal matrix (GRAFTJACKET Matrix, FIGURE 4. The vastus medialis and lateralis are then brought together in Wright Medical Technology, Arlington, TN) is laid over the central tendon the midline with the acellular human dermal matrix (GRAFTJACKET Matrix, repair from the patellar ligament to the intact rectus tendon and sutured in Wright Medical Technology, Arlington, TN) graft as a ‘‘stent’’ through which place with multiple interrupted sutures (#1 Ethibond, Ethicon Corp, the sutures are placed. Somerville, NJ). highly tensioned allografts required another procedure. this technique in nine patients over a 2-year period. In their Many of these subsequent procedures due to allograft failure series, the average postoperative Knee Society knee score was were conducted within the first postoperative year. In their 85 and the average Knee Society functional score was 67. analysis, all seven minimally tensioned knees were clinical The investigators could not recommend this technique for failures with an average postoperative Hospital for Special general use because of its high failure rate. Of the nine knees Surgery (HSS) knee score of 52 while all 13 of the highly studies two required amputation and one required allograft tensioned allografts were clinical successes with an average patellar revision. HSS knee scores of 88.1 Similarly, Leopold et al.7 evaluated Because of the variability of reported results, it is under- seven patients treated with Emerson’s technique in the standable that the standard of care for this type of injury is presence of a TKA. Of the seven knees treated, all were somewhat unclear. Different outcomes with allografts have clinical failures at an average of 39 months after the been attributed to the demanding operative technique, procedure. They could not find a difference between allograft availability, and compliance with the rehabilitation preoperative and postoperative extensor lag or HSS knee protocol.1,7,9,11,13,21,24 The use of large allograft constructs can scores, and four revisions were required.7 In a later analysis require the sacrifice of healthy adjoining tissues. Since the by Burnett et al.,10 extensor mechanism allografts and surrounding tissues may be tenuous because of multiple Achilles tendon allografts offered overall satisfaction levels previous surgeries, the unnecessary removal of healthy in 17 of 19 patients treated; however, quadriceps tendon constructs is of concern. The technique described herein rupture was not the cause of instability in this population. offers the advantage of retaining uninvolved components of Whole patellar allografts have been studied in TKA patients the extensor mechanism. In comparison to other operative with previous patellectomy. Busfield and Ries11 reported options, this technique is relatively straightforward. The Current Orthopaedic Practice www.c-orthopaedicpractice.com | 319

5. O’Shea K, Kenny P, Donovan J, et al. Outcomes following quadriceps tendon ruptures. Injury. 2002; 33:257--260. 6. Shah MK. Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. South Med J. 2002; 95:860--866. 7. Leopold SS, Greidanus N, Paprosky WG, et al. High rate of failure of allograft reconstruction of the extensor mechanism after total knee arthroplasty. J Bone Joint Surg. 1999; 81: 1574--1579. 8. Konrath GA, Chen D, Lock T, et al. Outcomes following repair of quadriceps tendon ruptures. J Orthop Trauma. 1998; 12: 273--279. 9. Barrack RL, Lyons T. Proximal tibia---extensor mechanism FIGURE 5. The sutures pass through the tendinous portion of the vastus composite allograft for revision TKA with chronic patellar medialis through the acellular human dermal matrix (AHDM) (GRAFTJACK- tendon rupture. Acta Orthop. 2000; 71:419--421. ET Matrix, Wright Medical Technology, Arlington, TN), into the deep layer, 10. Burnett RS, Butler RA, Barrack RL. Extensor mechanism allograft out again through the AHDM and finally through the vastus lateralis. reconstruction in TKA at a mean of 56 months. Clin Orthop Relat Res. 2006; 452:159--165. 11. Busfield BT, Ries MD. Whole patellar allograft for total knee AHDM augmenting material used was an off-the-shelf product arthroplasty after previous patellectomy. Clin Orthop Relat Res. 2006; 450:145--149. that has a greater availability than larger allograft constructs. 12. Toms AD, Smith A, White SH. Analysis of the Leeds-Keio The results in this small series indicate good limb func- ligament for extensor mechanism repair: favourable mechanical tion without evidence of rerupture. However, no post- and functional outcome. The Knee. 2003; 10:131--134. operative imaging was done to evaluate the anatomy of 13. Emerson RH Jr, Head WC, Malinin TI. Reconstruction of the reconstruction. These patients represent those with patellar tendon rupture after total knee arthroplasty with an extensor mechanism allograft. Clin Orthop Relat Res. 1990; 260: recurrent tear of the quadriceps tendon that had failed with 154--161. other attempts. The range of motion and the little extensor 14. Aracil J, Salom M, Aroca JE, et al. Extensor apparatus lag present were good, especially in light of the poor tissue reconstruction with Leeds-Keio ligament in total knee arthro- quality from previous surgery. The author realizes that this plasty. J Arthroplasty. 1999; 14:204--208. 15. Ramseier LE, Werner CM, Heinzelmann M. Quadriceps and study is limited in size and the retrospective nature of its patellar tendon rupture. Injury. 2006; 37:516--519. design; however, the length of time these patients have 16. Rasul AT Jr, Fischer DA. Primary repair of quadriceps tendon gone without the need for revision surgery highlights the ruptures. Results of treatment. Clin Orthop Relat Res. 1993; 289: potential benefits of this technique. 205--207. This analysis indicates that the AHDM augmented quad- 17. Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg. 1981; 63:932--937. ricepsplasty is a feasible operative option for patients 18. Larsen E, Lund PM. Ruptures of the extensor mechanism of the with recurrent quadriceps tendon rupture. The technique knee joint. Clinical results and patellofemoral articulation. Clin is straightforward and induces less morbidity to surrounding Orthop Relat Res. 1986; 213:150--153. tissues than whole allograft options. Overall, this study 19. McGrory JE. Disruption of the extensor mechanism of the knee. shows that AHDM-augmented quadricepsplasty for recur- J Emerg Med. 2003; 24:163--168. 20. Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism rent quadriceps tendon rupture, either in the presence or complications following total knee arthroplasty. 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