ORTHOPAEDIC SUMMIT 2016

Transcription

1 Injuries to the Extensor Mechanism Quadriceps & Patellar tendon Pearls and Pitfalls M.Mike Malek, M.D. Washington Orthopaedic and Knee Clinic ORTHOPAEDIC SUMMIT 2016 Las Vegas, Nevada December 8, 2016

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3 Extensor Mechanism Injuries Injury to the quadriceps tendon usually results from hyper flexion, vigorous quadriceps contraction, or a direct blow. Injury to the patellar tendon usually involves flexion, sudden contraction and external rotation. Direct blow to the patella mostly creates fracture.

4 Quadriceps Tendon Rupture Hyperparathyroidism Chronic Renal Failure Gout Obesity Leukemia Rheumatoid Arthritis Immobilization Diabetes Mellitus Systemic Lupus Infection Metabolic Disease Steroid Abuse Tumors Iatrogenic

5 Pathophysiology Quadriceps tendon rupture usually occurs 0-2 cm from the superior pole of the patella, through pathologic tissue. Kannua and Jozsa examined histopathologic changes in 891 ruptured tendons; about 97% of the pathologic changes were degenerative. The degenerative changes included hypoxic degenerative tendinopathy, mucoid degeneration, tendolipomathosis, and calcifiying tendinopathy.

6 Quadriceps Tendon Rupture Complete rupture is infrequent Strong association with a systemic disease Most often unilateral Partial ruptures in young athletes Usually occur in 40 or older Best result with early surgery

7 Patients typically present with acute knee pain, swelling, and functional loss following a stumble, fall, or giving way of the knee. Presentation

8 Presentation

9 Presentation

10 Diagnosis Pain Swelling/Ecchymosis Giving way Absence of active knee extension in the presence of passive extension is pathognomonic for the injury. Painful resisting knee extension Tendon defect.

11 Quadriceps Tendon Rupture X- Ray MRI

12 Diagnosis If patient is not seen in the acute phase, diagnosing the rupture becomes more difficult, and it can be easily missed. Ramsey and Muller reported misdiagnosis in 7 of 17 ruptures. Patients with quadriceps tears, especially elderly patients, have been identified as having been treated for strokes, radiculopathy, and myelopathy. Many patients are thought to have only simple knee sprains during their examination in the emergency room and are not given appropriate, immediate follow-up.

13 Surgical History In 1878, Lister was the first to report on surgical repair. In 1887, McBurney reported on the first surgical repair in the United States using catgut and silver wire. After several other reports on surgical repair of extensor mechanism injuries were published in the early 1900s, operative management became standard.

14 Indications Providing that the patient is a suitable surgical candidate, early operative repair is indicated for all acute and complete quadriceps ruptures. Surgery is also indicated for most chronic, complete quadriceps ruptures. Although repair/reconstruction is technically more difficult and results are inferior to those of early repair.

15 Technique

16 Technique

17 Technique

18 Presentation

19 Rehabilitation

20 Complications Quadriceps insufficiency Rerupture Calcific Tendinitis Myositis Ossificans Patella Baja Arthrofibrosis Patellofemoral Malalignment

21 Pitfalls Extent of injury not recognized Delay in surgical repair. Inadequate repair and augmentation when necessary. Inadequate postop protection of the repair. Early return to activity and sport which may lead to rerupture.

22 Patellar Tendon Rupture The patellar tendon ruptures infrequently. However, the complications of an untreated rupture to the extensor mechanism can be extremely disabling. Surgical intervention allows for excellent recovery of motion and strength, provided that the injury is diagnosed in a timely fashion and repaired immediately.

23 Patellar Tendon Rupture Less frequent than rupture of quadriceps Usually occurs in those younger than 40 The rupture is the final result of chronic tendon degeneration due to repetitive microtrauma excluding direct sharp trauma Usually unilateral. Traumatic athletic injury.

24 Etiology Athletic injuries Auto accidents Steroid injections Diabetes Mellitus Chronic Renal Failure Systemic Lupus Posterior knee dislocations Following Total knee Arthroplasty Following ACL Reconstruction

25 A sudden eccentric contraction of the quadriceps, usually with the foot planted and the knee flexed as the person falls. Mechanism

26 Biomechanic In 1992 Nisell and Ericson measured extension forces isokinetically from 90 degrees to full extension using CYBEX. At the slower speed the patellofemoral compressive force and the suprapatellar tendon force reached values about 12 bodyweights while the infrapatellar tendon force did not exceed 9 bodyweights. At the faster speed, the corresponding force magnitudes were 7.5 and 5.5 body weights respectively. R.Nisell and M.Ericson: Patellar force during isokinetic knee extension: Clinical Biomecahnics, Volume 7. Issue 2. May 1992,

27 Presentation Immediate pain Loud pop or tearing sensation Immediate swelling Difficulty in rising and bearing weight Ecchymosis Tenderness Palpable defect Proximal displacement of patella Lack of active extension Hemarthrosis Quadriceps atrophy in chronic cases

28 Presentation

29 Presentation

30 Presentation

31 Technique

32 Technique

33 Technique

34 Complications Patella Alta. Patella Baja. Arthrofibrosis. Chondromalacia Patella. Anterior knee Pain. Quadriceps Insufficiency.

35 Complications

36 Complication

37 Complications

38 Complications

39 Pitfalls Extent of injury not recognized. Lack of augmentation. Distal transfer of the tendon end more than 0.5 cm. Early motion in absence of augmentation which leads to development of patella alta.

40 Summary Quadriceps and patellar tendon ruptures should be diagnosed immediately and treated surgically for optimum functional recovery. Partial disruptions should also be recognized with the help of MRI and protected until complete healing has taken place. Restoration of the anatomical and functional integrity of the extensor mechanism is most important for a full and complete recovery and return to pre-injury level of activity and sport.

41 THANK YOU A presentation of the National Knee Research and Education Foundation