Extensor Mechanism Reconstruction with Use of Marlex Mesh

Abdel, Matthew P.; Salib, Christopher G.; Mara, Kristin C.; Pagnano, Mark W.; Perry, Kevin I.; Hanssen, Arlen D.

doi:10.2106/jbjs.17.01165

Cited by 56 publications

(77 citation statements)

References 30 publications

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“…Disruption of the extensor mechanism is an infrequent but potentially devastating complication associated with total knee arthroplasty (TKA). [1][2][3] Although the occurrence of this injury is rare, with an incidence between 0.1 and 4%, the treatment of these injuries is challenging due to the high potential for catastrophic outcomes. [4][5][6][7] Nonsurgical management of these injuries often results in chronic pain, difficulty with ambulation, extensor lag, decreased range of motion, limb instability, and increased fall risk.…”

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confidence: 99%

“…[4][5][6][7] Nonsurgical management of these injuries often results in chronic pain, difficulty with ambulation, extensor lag, decreased range of motion, limb instability, and increased fall risk. 1 Unlike extensor mechanism disruption in native knees, primary repair of extensor mechanism disruption in the setting of TKA has high failure rates. 8 As a result, recent treatment modalities have focused on extensor mechanism reconstruction using rotational muscle flaps, autograft, allograft, or polypropylene synthetic mesh.…”

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confidence: 99%

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Meta-analysis Comparing Allograft to Synthetic Reconstruction for Extensor Mechanism Disruption after Total Knee Arthroplasty

et al. 2019

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Extensor mechanism disruption following total knee arthroplasty (TKA) is a devastating complication that causes high failure rates. There is controversy on what is the best way to do an extensor mechanism reconstruction. This study aims to compare both allograft and synthetic reconstructive techniques for success, reoperation, and infection rates and functional outcomes. The search on PubMed, MEDLINE, Embase, BIOSIS, and Cochrane databases was performed on March 15, 2019, using the following keyword groups: (1) “extensor mechanism” and “total knee arthroplasty,” (2) “extensor mechanism” and “knee arthroplasty,” (3) “extensor mechanism” and “revision total knee arthroplasty,” and (4) “extensor mechanism” and “revision knee arthroplasty”. Only studies on extensor mechanism disruption after TKA that included sufficient data to compare these two surgical techniques were included. Meta-analysis was performed with random effect model using the DerSimonian–Laird method. Thirty studies were included. The overall success rate of the reconstruction was 73.3% (95% confidence interval [CI]: 0. 651, 0.814). The success rate of allograft (72.8%, 95% CI: 0.626, 0.829) was not significantly different from synthetic material (78%, 95% CI: 0.707, 0.852, p = 0.416). There was no significant difference in revision rates between allograft (14.2%, 95% CI: 0.095, 0.189) and synthetic material (16%, 95% CI: 0.096, 0.223, p = 0.657). The overall relative risk of infection was 4.301 (95% CI: 1.885, 9.810). There was no significant difference in relative risk of infection between allograft (3.886, 95% CI: 1.269, 11.903) and synthetic material (4.851, 95% CI: 1.433, 16.419, p = 0.793). No statistically significant difference was found in mean postoperative Knee Society score (73.109 [95% CI: 67.296, 78.922] vs. 72.679 [95% CI: 69.184, 76.173], p = 0.901) between allograft and mesh reconstruction groups. There were no significant differences in overall failures, infections, functional outcomes, or revision reconstructions between allograft and synthetic material extensor mechanism reconstructions. Our results demonstrate the difficulty in treating this serious injury, independent of technique, as well as the significant risk for overall failure and infection.

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Meta-analysis Comparing Allograft to Synthetic Reconstruction for Extensor Mechanism Disruption after Total Knee Arthroplasty

et al. 2019

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“…However, owing to advances in total joint arthroplasty techniques, problems that previously posed issues to the orthopaedic surgeon, such as extensive bone defects, insufficiency of extensor apparatus, and persistent PJI, are only relative indications for arthrodesis today. Modern treatment techniques such as highly porous metaphyseal cones to address bone deficiency [28] and extensor mechanism reconstruction by using a particular monofilament polypropylene mesh [29,30] are lessening the instances where knee arthrodesis is needed. Along with technological advancements, new diagnostic and PJI management concepts, realized by an MDT, enable new treatment options for this subset of patients.…”

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confidence: 99%

Conversion From Knee Arthrodesis Back to Arthroplasty: A Particular Challenge in Combination With Fungal Periprosthetic Joint Infection

et al. 2020

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A 58-year-old female treated at an outside facility with knee arthrodesis due to persistent periprosthetic joint infection fulfilled all prerequisites for a conversion back to arthroplasty, as part of a 2-stage revision. Owing to the detection of Candida parapsilosis , the treatment concept was converted to a three-stage procedure. A scheduled spacer exchange with additional amphotericin B–loaded polymethylmethacrylate was conducted as an intermediate revision before reimplantation. Conversion in the setting of fungal periprosthetic joint infection presents a challenge, and successful treatment hinges on the use of proper antifungal and antimicrobial protocols, advanced surgical techniques, and a multidisciplinary team approach. At the 3-year follow-up, successful infection eradication as measured by the Delphi-based consensus definition was achieved with a range of motion of 0°-100°.

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“…• Quadriceps tendon rupture during or after total knee arthroplasty (TKA) leading to extensor lag (either partial or complete), including aseptic and septic etiologies [1][2][3][4] .…”

Section: Indications and Contraindications Indicationsmentioning

confidence: 99%

“…Extensor mechanism reconstruction with Marlex mesh using a stepwise surgical approach, which is performed in a similar manner for both quadriceps tendon and patellar tendon rupture, has resulted in excellent functional outcomes, with a mean improvement in extensor lag of 26°and 84% of the mesh reconstructions remaining in place at a mean of 4 years 1 .…”

Section: Introductory Statementmentioning

confidence: 99%

Extensor Mechanism Reconstruction with Use of Marlex Mesh

Abdel

Pagnano

Perry

et al. 2019

JBJS Essential Surgical Techniques

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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).

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Extensor Mechanism Reconstruction with Use of Marlex Mesh

Abstract: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cited by 56 publications

References 30 publications

Meta-analysis Comparing Allograft to Synthetic Reconstruction for Extensor Mechanism Disruption after Total Knee Arthroplasty

Meta-analysis Comparing Allograft to Synthetic Reconstruction for Extensor Mechanism Disruption after Total Knee Arthroplasty

Conversion From Knee Arthrodesis Back to Arthroplasty: A Particular Challenge in Combination With Fungal Periprosthetic Joint Infection

Extensor Mechanism Reconstruction with Use of Marlex Mesh

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