Secondary reconstruction of the extensor mechanism using part of the quadriceps tendon, patellar retinaculum, and gore-tex strips after proximal tibial resection

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The Journal of Arthroplasty Vol. 19 No. 3 2004

Secondary Reconstruction of the ExtensorMechanism Using Part of the Quadriceps Tendon,Patellar Retinaculum, and Gore-Tex Strips After

Proximal Tibial Resection

Yehuda Kollender, MD, Benjamin Bender, MD, Avi A. Weinbroum, MD,Alexander Nirkin, MD, Isaac Meller, MD, and Jacob Bickels, MD

Abstract: Competence of the extensor mechanism is the major determinant offunctional outcome of patients after proximal tibia resection. A method of secondaryreconstruction of the extensor mechanism using the middle third of the quadricepstendon and the patellar retinaculum augmented with Gore-Tex strips and gastroc-nemius flap is described. Between 1981 and 1997, 7 patients with extension laggreater than 20° at least 1 year after the initial surgery underwent secondaryreconstruction of the extensor mechanism. All patients were followed up for aminimum of 2 years. Full extension to an extension lag of 10° was achieved in threepatients, and an extension lag between 10° and 20° was achieved in 4 patients. Allpatients had good to excellent functional outcomes and reported no limitations indaily life activities. Key words: extensor mechanism, proximal tibia, quadricepstendon, Gore-Tex graft, gastrocnemius flap.© 2004 Elsevier Inc. All rights reserved.

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he proximal tibia is the second most common sitef primary bone sarcomas and giant cell tu-ors [1,2], and overall it is the second most com-on site of bone tumors [3]. The treatment ofigh-grade sarcomas of the proximal tibia is com-licated. The difficulty arises from the anatomiceatures of this region. Extensor disruption pre-ludes normal knee function and ambulation; sur-ical intervention almost always is necessary.

From the National Unit of Orthopedic Oncology, Tel Aviv Souraskyedical Center, Sackler Faculty of Medicine, Tel Aviv University, Telviv, Israel.

Submitted April 24, 2003; accepted November 14, 2003.No benefits or funds were received in support of this study.Reprint requests: Benjamin Bender, MD, The National Unit of

rthopedic Oncology, Tel Aviv Sourasky Medical Center, 6eizman Street, Tel-Aviv 64239, Israel.© 2004 Elsevier Inc. All rights reserved.0883-5403/04/1903-0016$30.00/0

sdoi:10.1016/j.arth.2003.11.004

354

liber [4] reported on 83 patients with malignantkeletal tumors treated by preoperative chemother-py and limb salvage. He suggested that patientsith proximal tibial lesions might require primary

mputation because the patellar tendon could note reattached and the function of the extensorechanism was severely impaired. Proximal tibia

esections with endoprosthetic reconstruction havehe least favorable outcome of all limb-sparing pro-edures [5]. Extensor mechanism fitness is an im-ortant determinant of functional outcome afterroximal tibia endoprosthetic reconstruction. Com-romised active extension of the knee and exten-ion lag is a common problem after proximal tibiandoprosthetic reconstruction [6,7]. Several meth-ds for reconstruction of the extensor mechanismre described in the literature, among them primaryirect repair by turndown of the quadriceps tendonr a xenogarft [8], reconstruction with autogenous

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Extensor Mechanism Reconstruction After Proximal Tibial Resection • Kollender et al. 355

econstruction with a medial gastrocnemius muscleransposition flap [11], augmented attachment byynthetic material [12], reconstruction with an ex-ensor mechanism allograft [13], and reconstruc-ion with an Achilles tendon allograft [14]. Otherechniques of extensor mechanism reconstructionsed in orthopedic oncology include direct suture tohe prosthesis or allograft and osteotomy of thebula with attachment to the lateral collateral lig-ment [15,16].Petschnig and Baron et al. [17] compared differ-

nt techniques for extensor mechanism reconstruc-ion in 17 patients after proximal tibial resection.he 3 methods used were fibular transposition withuturing of the patellar tendon to the biceps tendonnd collateral ligament [15], transposition of theastrocnemius muscle [7], and a combined methodf gastrocnemius shift with fibular transposition.he authors [17] favored the combined technique.igher strength of the extensor muscles at angleositions between 60° and 20° as well as betterunction results were obtained in patients treatedith this method.All the patients reported in this article underwent

rimarily reconstruction of the extensor mecha-ism after proximal tibia endoprosthetic arthro-lasty by reattaching the patellar tendon to therosthesis using Dacron tape (Deknatel, Falls River,A) and reinforcement with an autologous bone

raft and a gastrocnemius flap. Bickels and Wittingt al. [18] used this procedure to treat 55 patients.ull extension to an extension lag of 20° waschieved in 44 patients (78%), extension lag of 20°o 30° was found in 10 patients (19%), and exten-ion lag of 40° was found in 1 patient (3%). Func-ional outcome was measured according to themerican Musculoskeletal Tumor Society Sys-

em [19]. All patients who had extension lag of �0° had good to excellent functional outcomes andeported no limitations with activities of daily livingxtension lag of �20 was not compatible withctivities of daily living; it was found in 11 patients22%).

Overall functional outcome was good to excellentn 48 patients (87%). Eight of 55 patients requiredecondary reinforcement of the patellar tendon,ne patient underwent simple plication of the ten-on, and 7 others underwent reconstruction of theatellar tendon with a part of the quadriceps ten-on and the patellar retinaculum reinforced withore-Tex (Gore, Flagstaff, AZ) strips. The reason for

he failure of the extensor mechanism was a non-pecific rupture of the patellar tendon–prosthesisttachment, which was evident in the explorations

ensor mechanism and the results of its use for 7atients are described in this article.

Materials and Methods

Between 1981 and 1997, 7 patients with exten-ion lag of more than 20° underwent reconstructionf the extensor mechanism. All patients previouslynderwent reconstruction of the extensor mecha-ism after proximal tibia endoprosthetic arthro-lasty by reattaching of the patellar tendon to therosthesis using Dacron tape and reinforcementith an autologous bone graft and a gastrocnemiusap. The time was at least 1 year after the primaryurgery for all patients. Patients included 4 womennd 3 men with an age range of 17 to 23 yearsmean, 20). Five patents had primary bone sarcomastage IIB according to the Musculoskeletal Tumorociety [MTST] staging system), 2 had benign-ag-ressive tumor (giant cell tumor) of the proximalibia.

Function was evaluated according to the MTSTystem [19]. this system of functional evaluationssigns numerical values (0–5) for each of 6 cate-ories: pain, function, emotional acceptance, walk-ng and gait ability, use of external supports, andatient satisfaction.

urgical Technique

A single anterior incision from the distal third ofhe femur to the proximal third of the tibia is made.he fascia is incised in the same plane as the skinncision. The quadriceps tendon and the gastrocne-

ius flap covering the endoprosthesis are exposed.he gastrocnemius flap is lifted and separated fromts attachment to the failed structure of the patellarendon and the joint capsule, thus exposing thertificial tibial tubercle (Fig. 1). The failed structuref the patellar tendon is excised. The middle third ofhe quadriceps tendon is separated from the rest ofhe tendon. This middle third of the quadricepsendon together with the patellar retinaculum isarvested and rotated toward the endoprosthesisFig. 2). This structure is looped over the artificialibial tubercle and sutured back to itself, recon-tructing the extensor mechanism. The edges of theemaining quadriceps tendon are sutured togethero mend the gap in the quadriceps tendon (Fig. 3).he reconstructed patellar tendon structure is aug-ented on it sides by Gore-Tex strips.Gore-Tex strips are attached to the patella on one

nd and looped over the artificial tibial tubercle on

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356 The Journal of Arthroplasty Vol. 19 No. 3 April 2004

utured to the reconstructed extensor mechanismFig. 5). The gastrocnemius flap previously lifted isutured back to the reconstructed patellar tendonnd the capsule, providing additional augmentationo the extensor mechanism (Fig. 6).

ostoperative Management

The extremity was kept in extension in a kneemmobilizer for at least 6 weeks. Partial weightbear-

Fig. 1. Disrupted extensor mechanism.

ig. 2. Reconstruction of the patellar tendon with the medial thi

ng was allowed a few days after the surgery. Grad-al active and passive knee motions were initiatedfter 6 weeks. For the first 6 months, the patientsere evaluated on a monthly basis. Thereafter,atients were evaluated every 3 months in the firstear. Follow-up evaluation included physical, ra-iologic, and functional examination. All patientsere followed up for more than 2 years.

Results

Seven patients with extension lag of more than0° at least 1 year after resection of the proximalibia underwent reconstruction of the extensorechanism. Reconstruction was performed using a

art of the quadriceps tendon and the patellar ret-naculum augmented by Gore-Tex strips and a gas-rocnemius flap. Average surgical time was 1.5 to 2ours.All patients were followed up for a minimum of 2

ears (range, 29–83 months; mean, 58 months).o postoperative bone or soft tissue infections were

een. One patient experienced a prolonged periodf wound healing. The patient was treated conser-atively with good end result. An improvement waseen in the range of motion; this improvementepended on the extension value achieved, becausehe flexion ability was not disrupted or changedompared with the preoperative status.Markedly increased muscle strength, especially of

he hamstrings, was noted after surgery. After sur-ery, all patients regained active extension; fullxtension-to-extension lag of less than 20° waseen in all patients. Full extension to an extension

rd of the quadriceps tendon and the patellar retinaculum.

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Extensor Mechanism Reconstruction After Proximal Tibial Resection • Kollender et al. 357

ag of less than 10° was achieved in 3 patients, andn extension lag between 10° and less than 20° waschieved in 4 patients (Table 1). All patient werembulatory, and all patients reported no limitations

ig. 3. Quadriceps tendon and the patellar retinaculumooped over the artificial tibial tubercle and sutured.

ig. 4. Augmentation of the newly formed extensor

n daily life activities. Overall function was esti-ated to be good to excellent. The MTST score was

6 to 30, with a median value of 29 (Table 1).

Discussion

This article describes a new surgical procedure foreconstruction of the extensor mechanism used af-er the failure of the primary reconstruction proce-ure in patients after proximal tibia endoprostheticeconstruction. Patients with tibial tumors have anverall higher survival rate than those with femoralumors. The reason is probably because tibial tu-ors are smaller and are generally detected ear-

ier [20,21,22]. Tibial sarcomas have a smaller ex-raosseous component than such lesions in otherocations. Posterior extension and vascular involve-

ent are rare. When extension does occur, theopliteus muscle often acts as a barrier to involve-ent of the popliteal and tibioperoneal arter-

es [23].Despite the technical difficulty and the need for

dequate soft tissue coverage and reconstruction ofhe extensor mechanism, limb saving proceduresor tibial lesions are widely accepted and performed.

e use endoprosthesis for reconstruction becausef the high rates of complications associated withhe use of allograft for reconstruction. With time,

ig. 5. Mechanical and biological reinforcement of thextensor mechanism is provided by a gastrocnemius flap.

hese allografts are associated with significant rates

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358 The Journal of Arthroplasty Vol. 19 No. 3 April 2004

f infection, nonunion, instability; fracture, andubchondral collapse [24–26]. Some authors haveuggested that osteoarticular reconstruction shoulde considered as a temporary measure of recon-truction at best, because of its low survivalate [27]. The gait adaptations needed for walkingith an incompetent extensor mechanism, includ-

ng hyperextension of the knee and abnormal mus-le forces, dramatically increase the stresses on anee arthroplasty [28]. These abnormal forces canead to failure and loosening of the prosthesis asell as stress fractures [29]. That is why the resto-

ation of the active extension is considered an im-ortant determinant of functional outcome.Looping the harvested part of the quadriceps

endon and the patellar retinaculum over the arti-cial tibial tubercle on the prosthesis reconstructshe extensor mechanism. The loose end encirclinghe artificial tibial tubercle is sutured to the har-ested part of the quadriceps tendon. Two Gore-Textrips sutured to the reconstructed patellar tendoneinforce this structure on its sides. The gastrocne-

ig. 6. The reconstructed extensor mechanism.

Table 1. Extension Lag Before and After Su

atient Age Sex

ExtensionLag Before

Surgery

ExtensionLag AfterSurgery

GEx

1 17 F 20°–30° 0°–10°2 19 F 20°–30° 10°–20°3 19 M 20°–30° 10°–20°4 20 F 20°–30° 0°–10°5 23 M 20°–30° 0°–10°6 23 F 20°–30° 10°–20°7 21 M �30° 10°–20°

Abbreviations: MSTS, musculoskeletal tumor society system; OS, ost

ius flap that provides a biologic reinforcement ise-sutured to the patella and the joint capsule.

The gastrocnemius flap is a viable muscle tissueacing the reconstructed patellar tendon-prosthesisonstruct, and it provides the necessary blood sup-ly for healing. After soft tissue healing is com-leted, the gastrocnemius flap provides mechanicalnd biologic reinforcement to the extensor mecha-ism.Extensor strength is the functional goal of prox-

mal tibia endoprosthetic reconstruction. This is inontrast to total knee arthroplasty, in which flexions the main objective of physical rehabilitation. Aension-free environment in which complex heal-ng of bone and soft tissue occurs is provided byeeping the knee joint immobilized for at least 6eeks. Gradual passive and active flexion is prac-

iced after this period.Horowitz and Lane et al. [6] reported on a series

f 16 patients who underwent extra-articular prox-mal tibia resection with endoprosthetic reconstruc-ion for a primary bone sarcoma. In an effort to

and the Functional Outcome in 7 Patients

onal Outcome

MSTSScore

HistologicalDiagnosis Follow Up, mFair Poor

29 OS 3626 OS 7530 OS 7628 OS 2830 GCT 3030 GCT 7928 OS 83

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Extensor Mechanism Reconstruction After Proximal Tibial Resection • Kollender et al. 359

aintain part of the extensor mechanism, the pa-ella and quadriceps were divided in a coronal fash-on. The resultant quadriceps tendon–patella con-truct was used to reconstruct the extensorechanism by attaching the patella with a screw to

he porous pad on the anterior surface of the tibialomponent of the prosthesis. This reconstructionas performed in 10 patients; no reconstructionas performed in the remaining six.Long-term functional evaluation was feasible in

nly 11 patients in this series, 6 of whom had anxtension lag of �80° to �90° [4]. As previouslyited Bickels and Witting et al. [18] used endopros-hetic reconstruction after proximal tibia resectionn 55 patients. Reconstruction of the extensorechanism included reattachment of the patellar

endon to the prosthesis with Dacron tape, rein-orcement with autologous bone graft, and attach-

ent of an overlying gastrocnemius flap.Functional failure of the extensor mechanism

extension lag �20° was not compatible with dailyiving activities) was found in only 11 patients22%) after a minimum follow-up period of 2ears. Extension lag correlated with overall func-ional outcome, which was good to excellent in 48atients (87%). Eight patient required secondaryeinforcement of the patellar tendon. One patientnderwent plication of the patellar tendon, and 7atients underwent reconstruction of the patellarendon using part of the quadriceps tendon and theatellar retinaculum, which were augmented byore-Tex strips. This latter method is described in

his article. The technique used for these patients asrimary and secondary reconstruction of the exten-or mechanism accomplishes a biologic reconstruc-ion of muscle-to-muscle attachment.

Thus, the transferred medial gastrocnemius pro-ides 2 important functions: coverage of the pros-hesis, which avoids secondary infection, and aeans for reconstruction of the extensor mecha-ism. The 7 patients treated with this methodained an extension lag of �20°. All had good toxcellent functional outcomes and reported no lim-tations with activities of daily living. Secondaryeconstruction of the patellar tendon using part ofhe quadriceps tendon and the patellar retinacu-um, augmenting this structure using Gore-Textrips, and covering it with the gastrocnemius flap,ollowed by prolonged postoperative immobiliza-ion of the knee joint and gradual flexion maneu-ers, lowers the extent of extension lag and pro-ides good functional outcome after the primaryeconstruction of the extensor mechanism has

Acknowledgment

The authors thank Zsofia Kurovszky for provid-ng the artwork.

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