Name: Extensor Mechanism Trauma
Uploaded: 2020-05-19T00:00:00Z
Channel: Arthrex
Description: James M. Paci, MD (Long Island, NY), discusses extensor mechanism trauma.

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<p>James M. Paci, MD (Long Island, NY), discusses extensor mechanism trauma.</p>

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VID1-000948-en-US | A | Extensor Mechanism Trauma

James M. Paci

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Extensor Mechanism Trauma

I'm going to cover quad tendon, patellar tendon and patella fracture in this lecture. Why should you consider changing what you do in your everyday practice? Will. Our patients are getting bigger, so there's more stress on their repairs. We know earlier motion yields better function, and we can leverage our better technology here at Arthrex for a better outcome. Quad tendon ruptures tend to happen in elderly patients, usually around three millimeters from the proximal pole of the patella. These patients have higher comorbidities. Their tissues are worse than our younger patients, and traditional repairs risk extension lag SuperMX suture through bone tunnels tend to fail at the notch stack or pull through the bone tunnels and tied sutures to suture. Anchors tend to fail at the knots or the suture tissue interface. So why consider being knotless? Well, you get the reliability of knotless fixation. And you can use tape which has less pull through. So our Nautilus quad tendon repair. You take a long. Fibertape suture and you're doing a Krakow locking stitch. Five throws each side and basically. Drilling two tunnels in the proximal pole of the patella. Make sure that you tap these. Twice. The bone is exceedingly hard. And basically, what you're going to do is dock those FiberTape sutures into the proximal pole of the patella. You can then use the core strands as a backup fixation, throwing a mattress stitch back up into the quad. We took this to the lab and tested it against bone tunnels with FiberWire and against suture anchors with FiberWire. And there was a significant advantage to the Nautilus repair with FiberTape. That's great, but does it actually work? So here's one of my patients, three and six months out from this repair. And you can see No extension lag at six months out. Here's a different patient. Six weeks post-op. Just about equal extension. Same patient. Four and a half months out. Starting to get up on his surfboard already. So now we'll move forward to patellar tendon. Patellar tendon repair, incorporating internal brace. I had the misfortune of having this gentleman walk into my office on Long Island. He was a six foot, 330 pound long haul truck driver. He decided after tearing his quad or his patellar tendon in Wyoming to come back to Long Island. So after we scanned his calf to make sure he didn't have a blood clot, we sort of had to figure out what to do because realizing this guy was going to be non-compliant, I didn't want to have to operate on him more than once. So our options for repair this nasty tear were a primary repair side by side. Primary repair with augmentation, be it biologic with a graft or non biologic with a metallic wire or an internal brace. These tears generally are mid substance or can be off of the patella but tend to be in younger patients traditionally repaired with super sutures, cracked and tied side by side and potentially augmented. So we tested our internal brace construct at one point. And I'll go through all that with you. But you have to know these these injuries are bad patellar tendon tears. So if you look at professional athlete cohort, the return to play statistics are abysmal. Nfl return to play is about 50% after a patellar tendon tear. So and when they do get back they don't do that. Well so I've got to figure out what to do with this guy. And my choice was to repair him with an internal brace construct so I don't have to worry about a cast, which I know is not going to be great on a guy this big. I can just put an external brace on him. And compliance would Compliance would potentially be an issue. Prostop the index patient I actually put in a cast, but since then I've only used extension brace. So here's the technique. You're going to make two tunnels in the distal pole of the patella and place two swivel locks with FiberTape sutures. You can see they're then passed to the anterior surface of the patellar tendon. We then do side by side. Krakow's using. I now use SutureTape. At that point we were using FiberWire and tie those side by side. You then bring down the internal brace construct in a box index configuration. You set the patellar height based on the opposite leg. So I always x ray the opposite leg to figure out what their patellar tendon height should be. And here's that leg in the 330 pound gentleman. In up close and personal, we took this to the lab and tested it against a metallic cerclage wire or just a side by side repair, and it was equivalent to a metallic cerclage wire which would need to be removed. And in this case, you save the second surgery and no need for X-ray. These are the results of that study which was published in Ajsm. The modes of failure are important to know. So in the straight FiberWire repair, suture breakage was the issue with the stainless wire. It actually unwound eventually. And then the internal brace eight of the tendons actually tore. So that's how strong this repair becomes. There were five anchor pull outs and three suture breakages. So basically it's stronger than an augmented repair. You don't need to use x ray, and you don't need a second procedure to take it out. Here's this gentleman, two weeks post-op. Here he is, six weeks out from a patellar tendon repair. And this giant leg with full active extension at six weeks post-op. Here he is again. 12 weeks full active extension. And here he is, a year out. Yeah, but full active hyperextension at a year out. So what if it comes off the patella again? Same technique as the quad tendon. Two bone tunnels. And you can run those swivel locks right up into the distal pole of the patella. You can actually incorporate an internal brace into this as well, by adding SutureTape sutures and then bringing them down to two anchors in the tibia. And I'll show you this is a gentleman six weeks out from a proximal avulsion of the patellar tendon. And he had this internal brace construct added as well. Chronic patellar tendinitis had to go in and repair his patellar tendon. Debrided it. It was almost like a lobster tail. It was so thick. So I wanted to add a little bit more. So what we did in addition to the internal braces, we added a patch to augment it using the ArthroFLEX patch with an internal brace over the top. It was nice because you could bridge that area up onto the onto the patella. Here he is, two weeks post-op. Here he is at his three month post-op visit. Full range of motion at three months out. And here he is, nine months out. I think we did all right there. And here he is at his 12 month post-op visit. What about patella fracture? So, great patellar fracture system here at Arthrex. This was a three week status post, and ACL had his brace off, jumped over a puddle and fractured his patella. So the patellar fracture system is great for transverse patella fractures. Basically, it's cannulated screws and FiberTape suture passing through the screws for a cerclage. It sets up very easily. There's a nice guide. The tips of the screws are blunt, so it doesn't fret the suture at all. You're basically going to pass your screws, then pass your sutures through your screws and then tie them down over the top. And that's actually this patient's picture is down on the bottom right here. Here is intra op. You can see the screws in place, guide wires, and then sutures coming through. And here he is, six months post op with complete healing. So goals of extensive mechanism repair. First off, restore the anatomy. To get the the best function and use the strongest technique you can. So you can mobilize them early and aggressively rehab them. Quadriceps tendon with SutureTape is certainly stronger. Using the FiberTape and SwiveLock than using FiberWire and tying knots. Patellar tendon. You know, sometimes you have to be creative there, but incorporate an internal brace. It'll save you. Just make sure you set that patellar height properly. And for patella fracture this is very strong fixation and very reliable. And if you can avoid second surgeries, there's a lot of cost saving in all of these. Thanks.

Extensor Mechanism Trauma

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