Extensor Mechanism Reconstruction with Use of Marlex Mesh

Abstract

Background: Marlex mesh reconstruction of the extensor mechanism via a stepwise surgical approach is a viable option to treat disruption of the extensor mechanism after total knee arthroplasty (TKA). Description: Extensor mechanism reconstruction with mesh involves a stepwise surgical approach with a particular monofilament polypropylene mesh (Marlex; C.R. Bard). Prior to incision, the 10 3 14-in (25 3 36-cm) sheet of Marlex mesh is rolled onto itself 8 to 10 times and sewn together. If the tibia is not being revised, a burr is utilized to create a trough in the tibia. Five centimeters of the tapered portion of the mesh are predipped in bone cement. The remaining cement is inserted into the trough. The tapered portion of the mesh is inserted into the tibial trough, ensuring that the mesh is fully seated. After the cement has cured, a lag screw is placed across the mesh and cement and into host bone. If the tibia is being revised at the time of the Marlex mesh reconstruction, the 5 cm of predipped mesh is placed anteriorly in the medullary canal in line with the tibial crest. The remaining procedure is similar regardless of whether the components are revised. At the level of the joint, it is essential to ensure that the mesh is covered with host tissue. Next, the proximal reconstruction, which involves mobilizing the vastus lateralis and vastus medialis obliquus (VMO) distally by releasing all ventral and dorsal soft-tissue adhesions off the muscle bellies, is completed. Finally, the mesh is unitized to the vastus lateralis. With the limb maintained in full extension, the mesh is pulled directly proximally while another assistant pulls the vastus lateralis distally and medially. The vastus lateralis is deep, and the mesh is directly on top of it. Multiple nonabsorbable sutures are placed through the mesh and vastus lateralis. The VMO is then pulled distally and laterally over the mesh (which is now unitized to the vastus lateralis) by an assistant. Multiple nonabsorbable sutures (usually 8) are placed through the VMO, through the mesh, and through the vastus lateralis, unitizing the entire construct. Alternatives: Nonoperative treatments include a drop-lock hinge brace or knee immobilizer. Operative treatments include whole extensor mechanism allograft reconstruction or Achilles tendon allograft reconstruction. Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked "yes" to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJSEST/A253).

Complex ruptures of the quadriceps tendon: a systematic review of surgical procedures and outcomes

“…While several protocols are available for acute QTR rehabilitation, there is a lack of studies about rehabilitation and follow-up after treatment of chronic ruptures, ruptures after TKA, and re-ruptures. In this study, the mean period of immobilization reported was 5.7 weeks, even though Abdel et al and Nodzo et al, who performed tendon augmentation using synthetic mesh in patients with QTR after TKA, reported longer immobilization periods of respectively 12 and 8 weeks [ 37 , 38 ]. The choice of the best procedure is closely linked to the type of lesion.…”

“…(2019) Shi et al 23 10 M 13 F 61 Fall from a standing height after TKA 21 days (range, 14 to 56 days) Complete quadriceps tendon rupture following TKA + 1rerupture Obesity, diabetes, chronic dialysis, steroid dependence (12pt) V-Y turndown flap 1 hematoma and delayed wound healing 1 fall and rerupture after 24 months [ 47 ] A simultaneous bilateral quadriceps and patellar tendons rupture in patients with chronic kidney disease undergoing long-term hemodialysis: a case report. (2020) Tao et al 2 M 33,5 1 fall down the stairs 1 sudden twist bilateral QT ruptures Chronic renal failure, with hemodialysis dependence for 9 and 11 years Krackow sutures None [ 37 ] Extensor Mechanism Reconstruction with Use of Marlex Mesh. (2019) Abdel et al 27 10 M 17 F 67 Rupture after TKA 219 days Complete QT rupture Obesity, diabetes, coronary artery diease, hypertension, OA, rheumatoid arthritis, Parkinson, cancer (leukemia, breast cancer, bladder cancer) Marlex Mesh augmentation 5 QT re-ruptures that required mesh revision [ 38 ] Polypropylene mesh augmentation for complete quadriceps rupture after total knee arthroplasty.…”

“…of reference No. of patients Gender Mean age Comorbidities [ 37 ] Extensor mechanism reconstruction with use of Marlex Mesh. (2019) Abdel et al 27 10 M 17 F 70 Obesity, diabetes, coronary artery diease, hypertension, OA, rheumatoid arthritis, Parkinson, cancer (leukemia, breast cancer, bladder cancer) [ 25 ] Bilateral quadriceps tendon rupture in a seasoned marathon runner with patellar spurs.…”

“…(2008) Rust et al 1 F 86 4 months after TKA revision surgery 120 days Chronic full-thickness + 10-cm QT retraction None Leeds-Keio graft inserted in an 8 shape and sutured to the periosteum None [ 23 ] Modified V-Y turndown flap augmentation for quadriceps tendon rupture following total knee arthroplasty: a retrospective study. (2019) Shi et al 23 10 M 13F 61 Fall from a standing height after TKA 21 days (range, 14 to 56 days) Complete quadriceps tendon rupture following TKA + 1rerupture Obesity, diabetes, chronic dialysis, steroid dependence (12pt) V-Y turndown flap 1 hematoma and delayed wound healing 1 fall and rerupture after 24 months [ 37 ] Extensor mechanism reconstruction with use of Marlex Mesh. (2019) Abdel et al 27 10 M 17 F 67 Rupture after TKA 219 Complete QT rupture Obesity, diabetes, coronary artery diease, hypertension, OA, rheumatoid arthritis, Parkinson, cancer (leukemia, breast cancer, bladder cancer) Marlex Mesh augmentation 5 QT re-ruptures that required mesh revision [ 38 ] Polypropylene mesh augmentation for complete quadriceps rupture after total knee arthroplasty.…”

“…One patient (1%) was treated with a tibialis anterior allograft, showing good functional results at the latest follow-up [ 36 ]. Furthermore, 35 patients (36%) with a complete QTR after TKA underwent synthetic mesh tendon reconstruction, but reported nine re-ruptures, of which five required a MESH revision and 2 developed a deep infection [ 37 , 38 ]. The past medical history plays a crucial role in the choice of surgical strategy: in patients with chronic QTRs with no history of TKA, end-to-end sutures produce a good clinical outcome, even if the timing of the rupture is longer than 6 weeks.…”