INNOVATIONS IN PRACTICE Acellular dermal graft augmentation in quadriceps tendon rupture repair Ross M. Wilkins INTRODUCTION cific pain and swelling of the knee 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 tendon 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 knees 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, fascia, extensor mechanism allografts, having had bilateral TKA. One patient had an Illizarov Achilles tendon 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 vastus medialis, 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 patella. 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 Volume 21 Number 3 May/June 2010 Current Orthopaedic Practice 315 316 | www.c-orthopaedicpractice.com Volume 21 Number 3 May/June 2010 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.