Autologous Patellar Tendon Reconstruction after Total Knee Arthroplasty Infection with Skin Loss: Anatomical Study and Case Report

Abstract

Disruption of patellar tendon after total knee arthroplasty (TKA) is a devastating complication. If associated with infection or soft tissue defect, knee arthrodesis is usually indicated. The purpose of this study is to analyze, by means of an anatomical study, the feasibility of our novel technique for reconstruction of extensor apparatus after TKA infections with skin defects, combining gracilis (G) and semitendinosus (ST) tendon autografts and chimeric medial gastrocnemius-sural artery perforator (SAP) flap. In addition, to report on the use of this reconstruction, we described an illustrative clinical case. Ten fresh cadaver lower limbs were dissected. The width of the gastrocnemius, number of medial SAP, length of hamstrings tendons, and distance from the lower pole of the patella to anterior tibial tuberosity (ATT) were measured. A mean of 1.37 perforator branches (range 1–3) was found. In all cases, the tendon length for gracilis and ST, and the width in the middle third of gastrocnemius related to the patella-ATT distance were enough to make the reconstruction. We performed this technique in a 78-year-old man with an infected TKA with skin defect. After 1 year and two-stage procedure, the patient achieved full active knee extension and was able to ambulate without aids. Extensor apparatus reconstruction combining tendon autografts and chimeric medial gastrocnemius-SAP flap is an available technique and may be considered as an alternative to arthrodesis in extensor mechanism ruptures after infection in TKA.

Orthoplastics in Periprosthetic Joint Infection of the Knee: Treatment Concept for Composite Soft-tissue Defect with Extensor Apparatus Deficiency

“…Three different reconstructive techniques were described: (i) a pedicled lateral gastrocnemius muscle with an attached lateral Achilles tendon, (ii) a pedicled MSAP gastrocnemius flap with a distally pedicled gracilis and semitendinosus tendon, and (iii) a free composite ALT flap that included vastus lateralis and FL [10,16,20,21]. The functional outcome reported was good at 12 and 18 months, and no other complications [16] apart from knee pain [20] were seen; instead, rather favourable outcomes [10,21] were observed. In particular, recurrence of infection was denied, which in our series led to arthrodesis 1.8 and 2 years after plastic surgical reconstruction.…”

“…This resulted in seven articles [10,[16][17][18][19][20][21] of which three [17][18][19] were excluded, as they elaborated on cases with PJI after TKA and extensor apparatus deficiencies but failed to include concomitant soft-tissue envelope defects. The remaining four articles [10,16,20,21] included a total of four patients. It appeared likely that the described orthoplastic techniques were performed by a team of orthopaedic and plastic surgeons together, although this was not explicitly stated.…”

“…Pérez-García et al used a myocutaneous MSAP gastrocnemius flap to reconstruct the skin and hypodermis and a pedicled gracilis and semitendinosus tendon to reconstruct the patellar tendon [16]. An active range of motion (extension/flexion) of 0-0-100° was reported after 12 months.…”

“…The curative orthopaedic treatment concept for chronic PJI of the knee frequently differentiates between a one-stage and a two-stage approach. For the combined orthoplastic approach, Chiou et al, di Summa et al, and Sapino et al described a one-stage approach [10,20,21], whereas Pérez-García et al reconstructed the soft-tissue envelope and extensor apparatus at the first stage of a two-stage approach [16]. Despite these differences in stages, all institutions reported that they aimed to reconstruct the soft-tissue defect as early as possible.…”

Patellar Tendon Reconstruction Using Hamstring Tendon and Adjustable Suspensory Cortical Fixation

“…Several alternative techniques have been reported, but no large series exist and late treatment of patellar tendon rupture is still controversial. Contralateral bone-tendon-bone graft, 5 ipsilateral gracilis and semitendinosus graft,1, 6 artificial ligament,7, 8 and allograft9, 10 have been described for this surgical procedure. The influence of graft choice on knee function has not been evaluated.…”