Avoidance is best strategy for patellar tendon rupture, avulsion during primary TKA
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CHICAGO — Should an acute rupture or avulsion of the patellar tendon occur in primary total knee arthroplasty, surgeons should know a variety of techniques to manage this challenging problem, a presenter said.
However, prevention of this problem intraoperatively and having a plan for managing it are most important, Michael P. Bolognesi, MD, FAAOS, said at the Knee Society Specialty Day held during the American Academy of Orthopaedic Surgeons Annual Meeting.
“Just like an [medial collateral ligament] MCL” injury in the setting of primary TKA, patellar tendon rupture and avulsion should be avoided, Bolognesi said, noting when this has occurred in his patients, it has either been during exposure or related to aggressive retractor placement.
Preoperatively, patients with limited range of knee motion, scarring or patella baja are at risk for these ruptures or avulsions. “Be aware of that up front,” he said.
Bolognesi discussed various methods to fix a patellar tendon that is avulsed from the distal pole of the patella — a “midsubstance injury, a rupture so to speak — or an avulsion off of the tip of the tibial tubercle distally.
Exposure options
Specific exposure techniques, like the “banana peel,” should be learned, as well as ways to prevent and approach these avulsions and ruptures. “Some people like to put a pin in the distal tendon. I think that, again, making sure you get as much of a release medial to take tension off the insertion to the tubercle is important,” he said.
Regarding the peel exposure, which Bolognesi learned from Aaron A. Hofmann, MD, there are differing opinions about it. Bolognesi said its best use is in the revision TKA setting because it makes it easy to expose and access a large portion of the tubercle. “Certainly, in our practice, this is excessively done for revision knee exposure,” he said.
According to Bolognesi, Hofmann taught him to leave the peeled-back portion in place, let it heal back and repair what you normally would.
However, Bolognesi said today he is more conservative. “Often, I will make two drill holes. Just a quick output and then run sutures sort of outside of the tendon through those two holes and then back out to the front to tie that down, just to hold it against the tubercle,” he said, noting this is followed by an otherwise normal repair.
Bolognesi warned against using a heated device for the peel exposure. He said, “You push the extensor mechanism out of the way and peel off the tubercle. Do not employ ‘fire.’”
Augmentation of primary repair
Because patella tendon ruptures and avulsions are rarely seen intraoperatively, primary surgical repair after TKA may be needed. Anchors, autograft, allograft or surgical mesh may be used to supplement the repair, Bolognesi said.
Depending on the extent of the injury, direct repair can be performed with anchors and drill holes can be used, which works well in the native knee, according to Bolognesi.
However, there are “historically poor results in total knee depicted here. You’ve just got to remember that it is sort of a different situation when you have this occur in the primary TKA setting,” he said.
Orthopedic surgeons at the Mayo Clinic have championed the use of mesh in this setting, Bolognesi said. “I think understanding how to do this can help you out in the OR. If you do encounter this, and you think it is a big enough injury, you might want to employ the entire mesh. I think that is, again, something that you want to be able to do and understand how to do.”
Postoperatively, the patient’s activity should be restricted as the avulsion or rupture heals, Bolognesi said. Surgeons should discuss this problem with patients to make sure they are “aware of the difference in their outcome and what’s expected and what will happen, particularly 6 to 12 weeks after the surgery,” he said.
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Bolognesi MP. Patellar tendon avulsion or rupture. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 22-26, 2022; Chicago.
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