Quadriceps or patellar ligament reconstruction with artificial ligament after total knee replacement
Keywords:
LARS, artificial, ligament, knee, arthroplasty, quadriceps, patellarAbstract
Background and aim of the work: Ruptures of the quadriceps or patellar tendon after TKA implantation are a fearful and disabling complication. Direct reconstructions highlighted various problems, such as the decrease in extensor force, failure, need for prolonged post-operative immobilization. So augmentation techniques have been proposed with autologous tendons, allografts, artificial ligaments. Among these, the LARS seems the most modern and promising. For this reason, we have retrospectively reviewed a case series patients operated with this artificial ligament, to evaluate the results and highlight the tips and tricks for this procedure.
Methods: Ten patients with a mean age of 69.4 years suffered an extensor apparatus lesion after knee replacement. These patients underwent primary reconstruction and augmentation with LARS. They were retrospectively reviewed at a mean follow-up of 3.8 years, by measuring active flexion and extension, and by Lysholm scoring scale.
Results: We did not observe any problems with healing of the surgical wound, nor phenomena of intolerance to the implanted material, such as inflammation, skin rashes or fistulas. The mean flexion was 117 degrees. Active extension was allowed in all patients, but with a mean extensor lag of 18 degrees. The mean Lysholm score was 74.2.
Conclusions: LARS offers good results without completely solving the problem of extensor lag, linked to the softness of the tissues in the quadriceps. The major advantages of LARS reside in the good tissue ingrowth, the absence of adverse tissue reactions, the ubiquitous availability, the possibility of stable fixation with early rehabilitation.
References
Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture after total knee arthroplasty. Prevalence, complications, and outcomes. J Bone Joint Surg Am 2005; 87(1): 37-45.
Bates MD, Springer BD. Extensor mechanism disruption after total knee arthroplasty. J Am Acad Orthop Surg 2015; 23: 95–106.
Maffulli N, Spiezia F, La Verde L, Rosa MA, Franceschi F. The management of extensor mechanism disruption after total Knee Arthroplasty: A systematic review. Sports Med Arthrosc 2017; 25: 41–50.
Mont MA, Yoon TR, Krackow KA, Hungerford DS. Eliminating patellofemoral complications in total knee arthroplasty: clinical and radiographic results of 121 266 consecutive cases using the Duracon system. J Arthroplasty 1999; 14: 446–55.
Harwin SF. Patellofemoral complications in symmetrical total knee arthroplasty. J Arthroplasty 1998; 13: 753–62.
Nam D, Abdel MP, Cross MB, et al. The management of extensor mechanism complications in total knee arthroplasty. AAOS exhibit selection. J Bone Joint Surg Am 2014; 96(6): e47.
Brown NM, Murray T, Sporer SM, Wetters N, Berger RA, Della Valle CJ. Extensor mechanism allograft reconstruction for extensor mechanism failure following total knee arthroplasty. J Bone Joint Surg Am 2015; 97(4): 279-83.
Rand JA, Morrey BF, Bryan RS. Patellar tendon rupture after total knee arthroplasty. Clin Orthop Relat Res 1989; 244: 233-8.
Hsu KY, Hsu WW, Ho WP, Wang KC. Traumatic patellar tendon ruptures--a follow-up study of primary repair and neutralization wire. Changgeng Yi Xue Za Zhi 1994; 17(1): 39-43.
Brooks P. Extensor mechanism ruptures. Orthopedics 2009; 32(9): orthosupersite.com/view.asp?rID=42852.
Mahoney MR, Veravalli K, Mofidi A. Treatment of neglected quadriceps tendon ruptures using LARS™ ligament augmentation: A case series. Trauma Case Rep 2021; 32: 100437.
Greis PE, Lahav A, Holmstrom MC. Surgical treatment options for patella tendon rupture, part II: chronic. Orthopedics 2005; 28(8): 765-9.
Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am 1981; 63(6): 932-7.
Meyer Z, Ricci WM. Knee extensor mechanism repairs: Standard suture repair and novel augmentation technique. J Orthop Trauma 2016; 30: S30–1.
Ramsey RH, Muller GE. Quadriceps tendon rupture: a diagnostic trap. Clin Orthop Relat Res 1970; 70: 161-4.
KELIKIAN H, RIASHI E, GLEASON J. Restoration of quadriceps function in neglected tear of the patellar tendon. Surg Gynecol Obstet 1957; 104(2): 200-4.
Ecker ML, Lotke PA, Glazer RM. Late reconstruction of the patellar tendon. J Bone Joint Surg Am 1979; 61(6A): 884-6.
Roidis N, Varitimidis S, Poultsides L, Liakou P, Karachalios T, Malizos K. A "biologic technique" for the treatment of a disruption of the extensor mechanism after revision total knee arthroplasty: a case report. Knee Surg Sports Traumatol Arthrosc 2008; 16(7): 661-5.
Naim S, Gougoulias N, Griffiths D. Patellar tendon reconstruction using LARS ligament: surgical technique and case report. Strategies Trauma Limb Reconstr 2011; 6(1): 39-41.
Diaz-Ledezma C, Orozco FR, Delasotta LA, Lichstein PM, Post ZD, Ong AC. Extensor mechanism reconstruction with achilles tendon allograft in TKA: Results of an abbreviate rehabilitation protocol. J Arthroplasty 2014; 29: 1211–5.
Crossett LS, Sinha RK, Sechriest VF, Rubash HE. Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty. J Bone Joint Surg Am 2002; 84(8): 1354-61.
Springer BD, Della Valle CJ. Extensor Mechanism Allograft Reconstruction After Total Knee Arthroplasty. J Arthroplasty 2008; 23: 35–8.
Parker DA, Dunbar MJ, Rorabeck CH. Extensor mechanism failure associated with total knee arthroplasty: prevention and management. J Am Acad Orthop Surg 2003; 11: 238–47.
Nazarian DG, Booth RE, Jr. Extensor mechanism allografts in total knee arthroplasty. Clin Orthop Relat Res 1999; 367: 123–9.
Karas V, Sherman S, Hussey K, et al. Allograft reconstruction for extensor mechanism injuries. J Knee Surg 2014; 27(6): 489-96.
Burnett RS, Berger RA, Paprosky WG, Della Valle CJ, Jacobs JJ, Rosenberg AG. Extensor mechanism allograft reconstruction after total knee arthroplasty. A comparison of two techniques. J Bone Joint Surg Am 2004; 86(12): 2694-9.
Calori GM, Mazza EL, Vaienti L, et al. Reconstruction of patellar tendon following implantation of proximal tibia megaprosthesis for the treatment of post-traumatic septic bone defects. Injury 2016; 47 Suppl 6: S77-S82.
Robertson A, Nutton RW, Keating JF. Current trends in the use of tendon allografts in orthopaedic surgery. J Bone Joint Surg Br 2006; 88: 988–92.
Ricciardi BF, Oi K, Trivellas M, Lee Y yu, Della Valle AG, Westrich GH. Survivorship of Extensor Mechanism Allograft Reconstruction After Total Knee Arthroplasty. J Arthroplasty 2017; 32: 183–8.
Leopold SS, Greidanus N, Paprosky WG, Berger RA, Rosenberg AG. High rate of failure of allograft reconstruction of the extensor mechanism after total knee arthroplasty. J Bone Joint Surg Am 1999; 81(11): 1574-9.
Eastlund T. Bacterial infection transmitted by human tissue allograft transplantation. Cell Tissue Bank 2006; 7: 147–66.
Giannoudis PV, Calori GM, Bégué T, Schmidmaier G. Tissue loss and bone repair: Time to develop an international strategy? Injury 2015; 46(Suppl 8): S1–2.
Burnett RS, Butler RA, Barrack RL. Extensor mechanism allograft reconstruction in TKA at a mean of 56 months. Clin Orthop Rel Res 2006; 452: 159–65.
Murgier J, Boisrenoult P, Pujol N, et al. Knee extensor mechanism allograft reconstruction following chronic disruption. Orthop Traumatol Surg Res 2015; 101: 867–70.
Malhotra R, Garg B, Logani V, Bhan S. Management of extensor mechanism deficit as a consequence of patellar tendon loss in total knee arthroplasty: a newsurgical technique. J Arthroplasty 2008; 23: 1146–51.
Cadambi A, Engh GA. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. A report of seven cases. J Bone Joint Surg Am 1992; 74: 974–9.
Abdel MP, Salib CG, Mara KC, Pagnano MW, Perry KI, Hanssen AD. Extensor Mechanism Reconstruction with Use of Marlex Mesh: A Series Study of 77 Total Knee Arthroplasties. J Bone Joint Surg Am 2018; 100(15): 1309-1318.
Browne JA, Hanssen AD. Reconstruction of patellar tendon disruption after total knee arthroplasty: results of a new technique utilizing synthetic mesh. J Bone Joint Surg Am 2011; 93(12): 1137-43.
Winston LA, Terry AF, Jardine JH, Parrish FF. The result of replacement of partial or total collateral ligaments with Marlex mesh in the knees of dogs. Clin Orthop Relat Res 1978; 137: 287-90.
Naveen NB, Deckard ER, Buller LT, Meneghini RM. Enhanced Biomechanical Performance of a Modern Polyester Surgical Mesh for Extensor Mechanism Reconstruction in Total Knee Arthroplasty. J Arthroplasty 2020; 35(11): 3311-7.
Fujikawa K, Ohtani T, Matsumoto H, Seedhom BB. Reconstruction of the extensor apparatus of the knee with the Leeds-Keio ligament. J Bone Joint Surg Br 1994; 76: 200–3.
Gosheger G, Hillmann A, Lindner N, et al. Soft tissue reconstruction of megaprostheses using a trevira tube. Clin Orthop Rel Res 2001; 393: 264–71.
Ichikawa J, Matsumoto S, Shimoji T, Ae K, Tanizawa T, Gokita T. A new technique using mesh for extensor reconstruction after proximal tibial resection. Knee 2015; 22: 659–63.
Evans PD, Pritchard GA, Jenkins DH. Carbon fibre used in the late reconstruction of rupture of the extensor mechanism of the knee. Injury 1987; 18(1): 57-60.
Morrey MC, Barlow JD, Abd MP, Hanssen AD. Synthetic mesh augmentation of acute and subacute quadriceps tendon repair. Orthopedics 2016; 39: e9–13.
Wood TJ, Leighton J, Backstein DJ, et al. Synthetic Graft Compared with Allograft Reconstruction for Extensor Mechanism Disruption in Total Knee Arthroplasty: A Multicenter Cohort Study. J Am Acad Orthop Surg 2019; 27: 451–7.
Nau T, Lavoie P, Duval N. A new generation of artificial ligaments in reconstruction of the anterior cruciate ligament. Two-year follow-up of a randomised trial. J Bone Joint Surg Br 2002; 84(3): 356-60.
Dericks G. Ligament advanced reinforcementsystem anterior cruciate ligament reconstruction. Oper Tech Sports Med 1995; 3: 187–205.
Liu ZT, Zhang XL, Jiang Y, Zeng BF. Four-strand hamstring tendon autograft versus LARS artificial ligament for anterior cruciate ligament reconstruction. Int Orthop 2010; 34: 45–9.
Li B, Wen Y, Wu H, Qian Q, Wu Y, Lin X. Arthroscopic single-bundle posterior cruciate ligament reconstruction: Retrospective review of hamstring tendon graft versus LARS artificial ligament. Int Orthop 2009; 33: 991–6.
Parchi PD, Gianluca C, Dolfi L, et al. Anterior cruciate ligament reconstruction with LARSTM artificial ligament results at a mean follow375 up of eight years. Int Orthop 2013; 37: 1567–74.
Lavoie P, Fletcher J, Duval N. Patient satisfaction needs as related to knee stability and objective findings after ACL reconstruction using the LARS artificial ligament. Knee 2000; 7(3): 157-63.
Ibrahim SA, Ahmad FH, Salah M, Al Misfer AR, Ghaffer SA, Khirat S. Surgical management of traumatic knee dislocation. Arthroscopy 2008; 24(2): 178-87.
Trieb K, Blahovec H, Brand G, Sabeti M, Dominkus M, Kotz R. In vivo and in vitro cellular ingrowth into a new generation of artificial ligaments. Eur Surg Res 2004; 36(3): 148-51.
Dominkus M, Sabeti M, Toma C, Abdolvahab F, Trieb K, Kotz RI. Reconstructing the extensor apparatus with a new polyester ligament. Clin Orthop Relat Res 2006; 453: 328-34.
Hobusch GM, Funovics PT, Hourscht C, Domayer SE, Puchner SE, Dominkus M, Windhager R. LARS® band and tube for extensor mechanism reconstructions in proximal tibial modular endoprostheses after bone tumors. Knee 2016; 23(5): 905-10.
Curran AR, Adams DJ, Gill JL, Steiner ME, Scheller AD. The biomechanical effects of low-dose irradiation on bone-patellar tendon-bone allografts. Am J Sports Med 2004; 32: 1131–5.
McNally PD, Marcelli EA. Achilles allograft reconstruction of a chronic patellar tendon rupture. Arthroscopy 1998; 14(3): 340-4.
Morrey MC, Barlow JD, Abdel MP, Hanssen AD. Synthetic Mesh Augmentation of Acute and Subacute Quadriceps Tendon Repair. Orthopedics 2016; 39(1): e9-13.
Abdel MP, Salib CG, Mara KC, Pagnano MW, Perry KI, Hanssen AD. Extensor Mechanism Reconstruction with Use of Marlex Mesh: A Series Study of 77 Total Knee Arthroplasties. J Bone Joint Surg Am 2018; 100(15): 1309-18.
Nodzo SR, Rachala SR. Polypropylene mesh augmentation for complete quadriceps rupture after total knee arthroplasty. Knee 2016; 23(1): 177-80.
Talia AJ, Tran P. Bilateral patellar tendon reconstruction using LARS ligaments: case report and review of the literature. BMC Musculoskelet Disord 2016; 17: 302.
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