Extensor Lag Research Articles

CORR Insights®: Allograft or Synthetic Mesh Extensor Mechanism Reconstruction After TKA Carries a High Risk of Infection, Revision, and Extensor Lag.

CORR Insights®: Allograft or Synthetic Mesh Extensor Mechanism Reconstruction After TKA Carries a High Risk of Infection, Revision, and Extensor Lag.

Vascularized Toe Proximal Interphalangeal Joint Transfer in Posttraumatic Fingers: Analysis of Prognostic Factors for Suboptimal Outcomes.

Posttraumatic finger osteoarthritis of the proximal interphalangeal joint (PIPJ) is a difficult problem. Over the past decade, we have reported several methods for improving the outcomes of vascularized toe joint transfer (VJT). In this study, we focused on determining poor prognostic factors which lead to a suboptimal outcome. A consecutive series of patients with posttraumatic osteoarthritis of the PIPJ who received VJT between January 2008 and January 2021 were enrolled in this study. The senior surgeon (Y.-T.L.) performed the surgery in all cases. In this retrospective study, we reexamine the initial trauma-related soft tissue and bony structure injuries of the recipient finger, to assess the baseline tissue quality before VJT. The injuries were classified into five major categories according to their anatomic region. The functional outcome parameters (including range of motion, percentage of use, and extensor lag of the transferred PIPJ) were collected. Univariate and multivariate linear regression analyses were performed using the generalized estimated equation model to identify the correlation between the injury category involved and functional outcome. A total of 59 digits were enrolled. Our results revealed that the fingers with previous vascular injury that received revascularization procedures had relatively suboptimal functional outcomes. These fingers had a significantly lower percentage of use both before (β = -0.222, P = 0.006) and after (β = -0.177, P = 0.006) receiving secondary procedures to improve functional outcome. Patients with prior revascularization surgery were associated with a poor functional outcome after VJT.

Limited Durability of Extensor Mechanism Reconstruction Following Total Knee Arthroplasty: Mesh and Allograft Show Equivalent Outcomes at Five-Year Follow-Up

BackgroundExtensor mechanism disruption is a challenging complication following total knee arthroplasty. The purpose of this study was to compare outcomes between patients who received mesh versus allograft extensor mechanism reconstruction. MethodsAll patients who underwent extensor mechanism reconstruction at a single institution were screened. Demographic and surgical variables were recorded, including technique (ie, synthetic mesh versus allograft reconstruction). Patients were assessed for preoperative and postoperative extensor lag, revision, and duration of follow-up. Analyses, including Kaplan-Meier survivorships, were performed to compare mesh to allograft reconstruction. In total, 50 extensor mechanism reconstructions (30 mesh and 20 allograft) were conducted between January 1st, 2001, and December 31st, 2022. ResultsThere were no differences between the cohorts with respect to revision (26.7 [8 of 30] versus 35.0% [7 of 20], P = .680) or failure defined as above knee amputation or fusion (6.7 [2 of 30] versus 5.0% [1 of 20], P = .808). There were also no differences in time to reoperation (average 27 months [range, 6.7 to 58.8] versus 29 months [range, 1.2 to 84.9], P = .910) or in postoperative extensor lag among patients who did not undergo a reoperation (13 [0 to 50] versus 11° [0 to 30], P = .921). The estimated 5-year Kaplan-Meier survival with extensor mechanism revision as the endpoint was similar between the 2 groups (52.1, 95% confidence interval [CI] = 25.4 to 73.3 versus 55.0%, 95% CI = 23.0 to 78.4%, P = .990). ConclusionsThe purpose of this study was to present the findings of a large cohort of patients who required extensor mechanism reconstruction. Regardless of the reconstruction type, the 5-year outcomes of patients requiring extensor mechanism reconstruction are suboptimal.

Adjustable Cortical Fixation Repair Is a Safe and Effective Technique for Quadriceps Tendon Rupture

To report the clinical outcomes of quadriceps tendon repair using adjustable cortical fixation devices at a minimum 2-year follow-up. A retrospective chart review identified patients who underwent quadriceps tendon repair using adjustable cortical fixation devices between January 2017 and March 2020. Patients with a partial tendon rupture were excluded. Demographic and injury-specific variables were gathered preoperatively and postoperatively from the electronic medical record and patient-reported outcomes (Lysholm Knee Questionnaire, Lower Extremity Functional Scale, and SF-12) were collected via telephone at a minimum of 2 years postoperatively. Fourteen quadriceps tendon repairs were included in a total of 13 patients. The average time to follow-up was 3.5 ± 1.2 years with a range of 1.9 to 5.7 years. The mean age of this cohort was 55.7 ± 11.6 years, and the mean body mass index was 32.9 ± 6.0. Ten injuries (71.4%) were sustained by mechanical fall, 2 patients (14.3%) suffered a direct blow to the knee, and 2 patients (14.3%) reported a noncontact injury mechanism. Thirteen quadriceps ruptures (13/14, 92.9%) underwent surgery within 10 days of their injury. One knee (7.1%) had a postoperative extensor lag of 5°, whereas another knee (7.1%) required a reoperation for manipulation under anesthesia and arthroscopic lysis of adhesions at 3 months' postoperatively. None of the included patients (0.0%) developed a tendon re-rupture, venous thromboembolism, delayed wound healing, surgical-site infection, neuropraxia or nerve injury, hardware irritation, patella fracture, or heterotopic ossification. In this study, adjustable cortical fixation was a safe and effective surgical technique for quadriceps tendon repair, with adequate restoration of quadriceps function and a low rate of adverse events at 2 years postoperatively. Level IV, therapeutic case series.

Allograft or Synthetic Mesh Extensor Mechanism Reconstruction After TKA Carries a High Risk of Infection, Revision, and Extensor Lag.

Extensor mechanism disruption is a devastating complication after TKA. Extensor mechanism reconstruction can be performed using an allograft or synthetic mesh. Recent studies have disagreed about the durability of these reconstructions. Evaluating a larger series of reconstructions that use current popular techniques and principles provides information to guide patient and surgeon expectations while bringing to light the potential fate of patients who experience an infection postoperatively. (1) What was the 5-year survival free of repeat revision surgery or persistent extensor lag of more than 30° after allograft or synthetic mesh reconstruction of extensor mechanism disruptions after TKA, and did this differ between techniques? (2) What was the 5-year survival free of infection after allograft or mesh reconstruction, and what proportion of those patients experienced a secondary severe complication (arthrodesis or amputation)? Between April 2008 and December 2020, 123 patients underwent extensor mechanism reconstruction after TKA at one center. Of those, 37% (45) were lost to follow-up before 2 years, had not been seen in the past 5 years, did not reach a study endpoint (repeat revision or extensor lag > 30°) before that time, or underwent primary repair and thus could not be analyzed, leaving 63% (78) for analysis here. During the study period, we considered extensor mechanism surgery when acute or chronic disruption of the patellar or quadriceps tendon was present or there was a fracture of the patella resulting in extensor lag. The decision to use either mesh or an allograft largely depended on surgeon experience and familiarity with either technique. We collected patient demographics, operative details (location of disruption and presence of a hinged prosthesis), subsequent periprosthetic joint infection (PJI), and postoperative SF-12 and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, scores. We used Kaplan-Meier survivorship analysis, with endpoints of extensor lag more than 30° or revision of the reconstruction and PJI. The mean follow-up duration was 5.3 ± 3.2 years. Survivorship free from revision or recurrent extensor lag was 54% (95% CI 44% to 66%) at 5 years. There was no difference between those undergoing reconstruction with allografts and those with mesh in terms of survivorship free from those endpoints at that timepoint (52% [95% CI 40% to 68%] versus 57% [95 CI% 41 to 78%]; p = 0.99). Survivorship free from PJI was 81% (95% CI 73% to 90%) at 2 years. There was no difference between those with allografts and those with mesh in terms of survivorship free from PJI at that timepoint (79% [95% CI 69% to 92%] versus 83% [95% CI 71% to 98%]; p = 0.75). Of the 17 patients who experienced PJI, four ultimately underwent arthrodesis and three more underwent transfemoral amputation. Allograft and synthetic mesh reconstructions commonly left patients with persistent limb dysfunction, while several patients had PJI and some underwent salvage procedures. Although improvements have been made with regard to treating extensor mechanism disruptions, patients and surgeons should be well aware of the potential adverse outcomes when determining management and use these findings to conduct risk-benefit analyses. There is a need for future studies to identify protocols that improve the durability of reconstructions and to determine whether interventions such as prolonged prophylactic antibiotic therapy have a role in minimizing the risk of PJI. Level III, therapeutic study.

FUNCTIONAL OUTCOME OF ISOLATED MEDIAL FEMORAL CONDYLE FRACTURES MANAGED WITH PLATE OSTEOSYNTHESIS - A CASE SERIES

Purpose: Isolated medial condyle fractures of femur with metaphyseal extension are a rare type of injury around knee joint. Most common mode of injury is high-energy trauma (road traffic accident, fall from height, sports injury) and is commonly seen in younger age group. Is open reduction and internal fixation with locking plates is the treatment of choice for sagittal plane medial femur condyle fractures with metaphseal extension? Methods: We conducted a prospective study from 1st January 2018 to 31st December 2021 including 12 patients (seven males and five females) with isolated medial femur condyle fractures (AO 33B2.1). In our study, open reduction and internal fixation was performed with medial femur plates or T-buttress plates in all 12 cases. At final follow-up, functional outcome was evaluated using ‘functional criteria’, ‘IKS knee and function score’ and radiological assessment. Results: At final follow-up, out of 12 patients, 11 had excellent to good outcome according to ‘Kolmert Functional score’ and ‘IKS knee and function score’ were 83.33 and 78.33. At final follow-up, one out of twelve patients had extensor lag of 10 and flexion around 90. Conclusion: Isolated fractures of medial condyle with metaphyseal extension have good outcome in terms of function if proper anatomical reduction is achieved and supplemented with locking plates.

Outcomes and Complications Following Chronic Patellar Tendon Repair: A Systematic Review.

The purpose of this systematic review is to report outcomes and complications following the reconstruction of chronic patellar tendon ruptures. Four databases (Cochrane Database of Systematic Reviews, PubMed, Embase, MEDLINE) were searched from inception to July 2021. Inclusion criteria included articles that (1) analyzed outcomes and complications following chronic patellar tendon reconstruction (>4 weeks from injury to repair), (2) were written in English, (3) greater than five patients, and (4) a minimum 2-year follow-up. Exclusion criteria included (1) non-original research and (2) patellar tendon repair/reconstruction with prior total knee arthroplasty. Data on outcome metrics and complications were extracted from the included studies and reported in a qualitative manner. Nine studies (number of patients = 96) were included after screening. Seven studies analyzed autograft reconstruction, and three of those seven studies analyzed reconstructions with additional augmentation. The remaining two studies evaluated reconstruction utilizing a bone-tendon-bone (BTB) allograft. Four of the autograft studies (n=40 patients) showed a range of post-operative mean Lysholm scores of 74-94. Additionally, four studies reported a post-operative extensor lag of 0-3°. Post-operative protocol for autograft studies included delayed motion and was either contained to a bivalved cast or a hinged knee brace for six weeks. The two allograft studies reported a range of mean Lysholm scores from 62 to 67, and each immobilized the leg in full extension until six weeks. While chronic patellar tendon ruptures are a rare injury of the extensor mechanism, there are viable options for reconstruction. Overall, chronic patellar tendon ruptures reconstructed with both autograft and allograft will provide fair to good outcomes with low complication rates. Following surgery, immobilization for at least six weeks should be emphasized to protect the graft and optimize patient outcomes.

Successful Multiple Finger Replantation; Procedure and Considerations

Multiple finger amputations require challenging surgeries and special approach. At least, the thumb and middle finger should be replanted to maintain minimal hand functions. Technically, multiple amputations are more difficult than single finger amputation and distal amputations are more difficult than proximal ones. Herein, we present a case of four finger amputation. All fingers were successfully replanted. The patient required a long period of physical rehabilitation. The patient underwent another operation because of the extensor lag of the four fingers. In the second operation a four-tail FDS transfer to the lateral bands was performed. The rehabilitation process is still ongoing.

Poster 247: Predictors of Poor Outcomes Following Quadriceps Tendon Repair

Objectives: Ruptures of the quadriceps tendon can lead to significant morbidity and are nearly always treated with surgical repair. Although relatively uncommon, they present most frequently in older adults and individuals with underlying medical conditions. Specifically, spontaneous bilateral ruptures have been shown to be associated with gout, diabetes, or steroid use. In other areas of orthopedics, factors such as an obese BMI have been shown to be predictive of poor outcomes after surgical treatment. To date, there has been little published literature to demonstrate how factors such as age, BMI, and smoking status are associated with quadriceps tendon tear or outcomes. The purpose of this study was to examine the relationship between patient factors such as age, sex, BMI, and smoking status, as well as intraoperative factors and the outcome of quadriceps tendon repair. We hypothesize that older age, higher BMI, and poor smoking habits will be associated with worse range of motion and complication rates following quadriceps tendon repair. Methods: All patients undergoing Quadriceps tendon repair from 1/1/2016-9/1/2021 were retrospectively identified at our institution using CPT codes, and patients who had definitive documentation of a quadriceps tendon tear within the operative report were included in the study. Patients under the age of 18 years were excluded. Physician clinical notes were reviewed, recording detailed information regarding the presenting symptoms and physical exam findings. Pre-operative demographic information and intraoperative findings were evaluated. Poor outcomes were defined as a need for revision, complications, post-operative range of motion (ROM) of less than 110 degrees of knee flexion, and extensor lag greater than 5 degrees. Parametric continuous data was presented as mean(SD) and p values were calculated by performing T tests. Nonparametric continuous data was also presented as mean(SD) for easier interpretation and p values were calculated by performing Mann- Whitney tests. P values less than 0.05 were deemed significant. All statistical analyses were done using R Studio (Version 4.1.2, Vienna, Austria). Results: There were 235 patients who met the inclusion criteria. Patients had an average age of 59 (13.3) years at time of surgery consistent of predominantly males (90.2%). The mean BMI for this cohort was 32.1(6.34). The most common surgical procedure was Transosseous fixation (81.5%) followed by suture anchors (16%) and simple sutures (2.6%). The most common mechanism of injury was trauma (57.6%) followed by spontaneous injury (39.8%). On post-operative physical exam, 18.4% of patients experienced loss of range of motion, 15.4% experienced extension lag, 9.52% had post-operative complications, and 4.7% underwent revision. Three sets of logistic regressions were run for subgroups of poor outcomes showing BMI (OR, 1.07, 95% CI, 1.01 – 1.14) and Age (OR, 1.05, 95% CI, 1.02 – 1.08) were significantly associated with loss of range of motion. Post-operative extension lag was also associated with greater BMI (OR, 1.63, 95% CI, 1.17 – 2.91). Complications were found to be significantly associated with patients found to have pre-operative tendon degeneration via MRI (OR, 4.74, 95% CI, 1.65 – 14.67) and those who were current smokers (OR, 7.84, 95% CI, 2.32 – 27.12). Amount of retraction, degree of pre-operative osteoarthritis, retinacular involvement, tear thickness and location were not significantly associated with poor outcomes. Conclusions: This study demonstrates that patient specific characteristics can play a significant role in outcomes following quadriceps tendon repair. Advanced age, BMI, tendon degeneration and current smokers are all at risk for poor outcomes following quadriceps tendon repair.

A Rare Case of Complete Sequestration of the Patella: an Unusual Presentation of Patellar Tuberculosis

Abstract Osteoarticular tuberculosis affecting the knee with isolated involvement of the patella is rare, accounting for less than 0.09% to 0.15% of cases. We present a case of 48-year-old man presenting with chronic knee swelling, pain, and stiffness. Radiographs revealed a completely sclerotic patella with erosions and irregular margins. Magnetic resonance imaging revealed chronic synovitis, joint effusion, and bony erosions with full-thickness cartilage defects in the patella. He underwent surgical debridement with extensive synovectomy, and a total patellectomy was performed. Intraoperative samples conclusively diagnosed it as a tubercular infection of the patella and synovium. The patient was started on antitubercular chemotherapy. A 2-year follow-up revealed good knee function with an extensor lag of 100. There has been no recurrence of infection. This report is a rare case of complete patellar sequestration secondary to tuberculosis patella, which was successfully treated with radical debridement and patellectomy.

Extensor indicis proprius to extensor pollicis longus transfer in spontaneous rupture of extensor pollicis longus following non displaced fracture distal end radius

Exact incidence of extensor pollicis longus (EPL) ruptures following distal radius fracture is not known. Peculiarly it’s common in nondisplaced fracture of the distal radius with an incidence of EPL rupture of 0.2-5%. Cortical irregularities from distal radius fractures or osteophytes easily abrade the tendon, causing gradual attrition and ultimately rupture. Compromised blood supply is also related to EPL rupture which is supported by microcirculatory anatomic studies. We present a case of 49 year old female who presented with spontaneous rupture of the EPL following a nondisplaced fracture of the distal radius managed by extensor indicis proprius (EIP) transfer. EIP transfer gives promising outcome. Optimum tension of the tendon is crucial for good functional outcome. We recommend suturing the tendon with thumb in extension and wrist in neutral position for optimum tension of tendon to avoid extensor lag and to prevent loss of IP flexion.

A Double Cerclage and Tension band Wiring Technique Fixation for Comminuted Patellar Fractures

Background: When the patella is fractured it should be repaired and patellectomy should be avoided as much as possible even in comminuted fractures. In comminuted patellar fractures, a combination of cerclage wiring and tension band fixation is confirmed to provide good mechanical stability. The objective of the present work was to find out the effectiveness of comminuted patellar fracture fixation with combined cerclage and tension band wiring technique. Method and patient: Forty- six patients underwent surgical stabilization for comminuted patellar fracture between year 1996 to 2016. All fractures were classified as 34-C3 according to the Orthopedic Trauma Association Classification. All the patients were underwent open reduction- internal fixation with combined Cerclage and tension band wiring technique. Result: Fracture healing was occurred within an average of 3- 5 months, while in bilateral cases it was 4 - 8 months. Full range of knee movements was seen in 42 (91.3 %) cases and knee flexion more than 120º was seen in 4 (8.7 %) cases. Quadriceps power was normal in 44 (95.6 %) cases, but 2 cases had quadriceps power of grade-IV. No extensor lag and no quadriceps atrophy were seen in any cases. Forty four (95.6 %) patients could squat fully and two (4.3 %) patients could squat up to half of the normal level. All patients were able to climb up and down stairs without any problem. Most patients have no subjective complaints like pain, difficulty in walking, difficulty in squatting and climbing. The clinical results after operation were evaluated by the clinical grading scales of Böstman including range of movement, pain, work, atrophy, assistance in walking, effusion, giving way, and stair-climbing during follow-up. There were no significant complications, such as infection, knee stiffness, and non-union or implant failure in any of the cases. The average follow-up period was 8 months (Ranged 6 – 18 months). Conclusions: This study had concluded that combined Cerclage and tension band wiring technique was a successful surgical treatment for comminuted fractures of the Patella.

High rate of failure after revision extensor mechanism allograft reconstruction

BackgroundPatients who fail initial extensor mechanism allograft (EMA) reconstruction for extensor mechanism disruption after total knee arthroplasty (TKA) are left with few options. This study evaluated outcomes in patients that underwent revision EMA reconstruction following a failed EMA. MethodTen patients that underwent revision EMA for failed index EMA with minimum 1-year follow-up were retrospectively reviewed. Patients receiving fresh-frozen EMA (quadriceps tendon, patella, patellar tendon, and tibial tubercle) at index and revision EMA were included. The primary outcome was EMA failure defined as revision surgery, extensor lag > 30°, or Knee Society Score (KSS) < 60 at last follow-up. Descriptive statistics were performed, with p < 0.05. ResultsMean extensor lag improved from 55.6°±26.7° pre-revision to 32.8°±29.6° (p = 0.13) at mean follow-up of 43.8 months (range, 12–124 months). Mean KSS improved from 41.0 ± 9.5 pre-revision to 73.4 ± 14.5 at last follow-up (p < 0.001). All patients required assistive devices for ambulation at final follow-up: one (10.0%) required a wheelchair, five (50.0%) required a walker, and four (40.0%) required a cane. Seven (70.0%) patients experienced EMA failure at a mean of 33.6 months (range, 2–124) following revision EMA: three (30.0%) were revised for periprosthetic joint infection (one of which also had extensor lag > 30°), three (30.0%) additional patients had extensor lag > 30°, and one (10.0%) patient had KSS < 60 (this patient developed PJI and was treated nonoperatively with chronic antibiotic suppression). ConclusionsRevision EMA reconstruction fails at a high rate despite leading to improvements in KSS. Further research is needed to develop effective prevention and treatment strategies for failure after initial EMA reconstruction.

Extensor Mechanism Disruption Remains a Challenging Problem

BackgroundExtensor mechanism disruption (EMD) following total knee arthroplasty (TKA) is a devastating problem commonly treated with allograft or synthetic reconstruction. Understanding of reconstruction success rates and patient recorded outcomes is lacking. MethodsPatients who have an EMD after TKA undergoing mesh or whole-extensor allograft reconstruction between 2011 and 2019, with minimum 2-year follow-up were reviewed at two tertiary care centers. Functional failure was defined as extensor lag >30 degrees, amputation, or fusion, as well as revision extensor mechanism reconstruction (EMR). Survivorship was assessed using Kaplan–Meier curves, and factors for success were determined with logistic regressions. ResultsOf fifty-six EMRs (49 patients), 50.0% (28/56) were functionally successful at 3.2 years of mean follow-up (range, 0.2 to 7.4). In situ survivorship of the reconstructions at 36 months was 75.0% (42 of 58). There were 50.0% (14 of 28) of functionally failed EMRs that retained their reconstruction at last follow-up. Mean extensor lag among successes and failures was 5.4 and 71.0° (P = .01), respectively. Mean Knee Injury and Osteoarthritis Outcome Score, Joint Replacement scores were 67.1 and 48.8 among successes and failures (P = .01). There were 64.0% (16 of 25) of successes and 1 of 19 failures that obtained a Knee Injury and Osteoarthritis Outcome Score, Joint Replacement score above the minimum patient-acceptable symptom state for TKA. Survivorship and success rates were similar between reconstruction methods (P = .86; P = .76). All-cause mortality was 8.2% (4 of 49), each with EMR failure prior to death. All-cause reoperation rate was 42.9% (24 of 56), with a 14.3% (8 of 56) rate of revision EMR and 10.7% (6 of 56) rate of above-knee-amputation or modular fusion. ConclusionsThis multicenter investigation of mesh or allograft EMR demonstrated modest functional success at 3.2 years. Complication and reoperation rates were high, regardless of EMR technique. Therefore, EMD after TKA remains problematic.

Treatment of chronic mallet finger with swan neck deformity using a modified Spiral Oblique Retinacular Ligament (SORL) reconstruction procedure: A case series and technical note.

Chronic terminal extensor tendon injury produces mallet deformity and secondary swan neck deformity. It can be found in neglect cases and in a failed cases after conservative treatment or primary surgical repair. Surgery is considered in cases with extensor lag of more than 30° and functional deficit. Reconstruction of the spiral oblique retinacular ligament (SORL) has been reported in literatures to correct swan neck deformity by a dynamic mechanical basis. Three cases of chronic mallet finger associated with swan neck deformity were treated by the modified technique of SORL reconstruction. Range of motion (ROM) of distal interphalangeal (DIP) joints and proximal interphalangeal (PIP) joints were measured along with the complications. The clinical outcome was reported using the Crawford's criteria. All patients had an average age of 34years (20-54). Average time to surgery was 16.67months (2-24) and average of DIP extension lag was 66.67°. All patient gave excellent Crawford criteria at the latest follow up (average 15.3months). The average PIP joint ROM were -1.60 (00 to -50) of extension and 1100 (1000-1200) of flexion for the PIP joint and -1.60 (00 to -50) of extension and 83.330 (800-850) of flexion for the DIP joint. We present our technique to manage chronic mallet injury which only utilized two skin incisions and one button at the distal phalanx to minimize risk of skin necrosis and patient discomfort. This procedure can be considered as one of the options for the treatment of chronic mallet finger deformity associated with swan neck deformity.

POST SURGICAL STIFFNESS OF KNEE JOINT IN PIGMENTED VILLONODULAR SYNOVITIS: A RARE CASE REPORT

Introduction: Post-surgical knee stiffness is a debilitating complication and its treatment ranges from simple arthroscopic adhesiolysis to more extensive Quadricepsplasty. Physiotherapy rarely sufces in most cases. We are presenting a case of surgically intervened pigmented villonodular synovitis (PVNS) with stiff knee treated by open intraarticular adhesiolysis and a modied V-Y quadricepsplasty and extensor mechanism release, a rst of its kind. An Indian male in his 20s, a surgically intervened case Case Presentation: of PVNS lost to follow-up due to COVID-19 Lockdown presented with a stiff knee with movement of 0-30o exion in early 2022. An open adhesiolysis of the joint arthrobrosis using the previous incision was performed, and a separate full thickness V-shaped incision at proximal Musculo-tendinous junction of quadriceps tendon was given to achieve exion of 130°.The tendon was repaired in its lengthened position, giving the appearance of a V to Y. Post-operatively, muscles strengthening, and Range of motion (ROM) exercises including continuous passive motion (CPM), were included following a specic physiotherapy protocol immediately after surgery. 10 weeks post-op, the patient has 0-120° active and passive ROM of the knee with an extensor lag of 7°. A planned and proper surgical approach targeting the primary cause of sti Conclusion: ffness augmented with direct extensor mechanism lengthening procedures (quadricepsplasty) if needed, can achieve good per-operative knee ROM. Aggressive surgery specic postoperative physiotherapy and rehabilitation play a major role in achieving satisfactory results

Supplementary Posteromedial Plating for the Fixation of Complex Tibial Plateau Fractures: A Prospective Study.

Introduction The management of complex tibial plateau fractures (CTPF) involving the posterior tibial plateau remains challenging and achieving maintenance of an axially stable construct with a single lateral locked plate is uncertain. Dual plating for such fractures via separate incisions can provide better fixation with superior clinical and radiological outcomes. This prospective study aimed to evaluate the results of the management of Schatzker type V and VI complex tibial plateau fractures using a conventional anterolateral plate along with a posteromedial buttress plate via two separate approaches and the potential complications associated with it. Methods Fifty-six patients presenting with tibial plateau fractures to the Department of Orthopaedics at a tertiary care center in the northern part of the state of Uttar Pradesh, India, between January 2018 and July 2022 were screened. Subsequently, 28 patients with CTPFs (AO/OTA types 41C1, 41C2, AND 41C3) were included in the study, managed with dual plating, and followed up for a duration of 12 months. The clinico-radiological outcome was assessed using Rasmussen's Functional Grading System (RFS), Oxford Knee Score (OKS), knee range of motion achieved, and Rasmussen's Radiological Scoring System (RRS), and statistical analysis of the data was performed. Results A total of 24 (85.71%) patients had excellent OKS and good to excellent RFS at the final follow-up. The average knee range of motion was 3.21° to 122°, with only two patients reporting an extensor lag of more than 10°. The final follow-up radiographs showed a mean medial proximal tibial angle (MPTA) of 83.98° ± 6.89 (75.44-89.21) and a mean posterior tibial plateau angle (PTPA) of 12.31 ± 4.69 (5.12 to 16.49) with the RRS showing excellent or good radiographic results with a mean score of 14.1 ± 1.7 (range 8-16). None of the patients showed signs of deep infection, whereas superficial infection was reported in two patients. A single case of secondary loss of particular reduction was seen. Conclusion Supplementary posterior buttress plating, along with the conventional anterolateral plate for the management of CTPF, achieves rigid fixation with superior articular reduction, a high knee score, a good range of motion, lower complication rates, and limited deformities with a good radiological outcome, with a few demerits of prolonged operative time, technically demanding procedure, increased blood loss, and a protracted hospital stay which can be minimized in most instances using minimally open reduction techniques and careful soft-tissue handling.

Extensor Mechanism Centralization Using Autograft Hamstring for Laterally Dislocating Patella.

Patellofemoral complications following total knee arthroplasty (TKA) are some of the most commonly cited complications in the literature, accounting for up to 50% of secondary procedures in the literature. Lateral dislocation of the patella, while rare, is one of many causes of extensor mechanism dysfunction. We sought to evaluate a novel patellar centralization procedure by comparing patients' pre- and postoperative clinical and radiographic data. A retrospective case-series study was performed on 12 patient knees (5 male and 7 female) presenting with ambulatory dysfunction due to laterally dislocating patella. All of the knees had component revision combined with hamstring autograft tendon weave and medial reefing of the retinaculum and vastus medialis. The results revealed reliable stabilization of the patella and improved extensor lag at a mean 2.2±2.2 years' short-term follow-up, which correlated with improved postoperative radiographic measurements. Range of motion in both flexion and extension was improved postoperatively. Improvements in radiographic measures of patellar tilt and patellar displacement were statistically significant, with reductions in the mean patellar tilt from 41.5°±25.9° to 3.9°±13.7° (P=.004), and in the mean patellar displacement from 2.8±2.1 cm to 0.8±0.9 cm (P=.012). Our study findings support the use of the extensor mechanism centralization procedure with autograft hamstring in management of laterally dislocating patella after TKA. [Orthopedics. 2023;46(3):e186-e188.].

Inferior results at long-term follow-up after extensor mechanism allograft reconstruction in septic compared to aseptic revision total knee arthroplasty.

Extensor mechanism lesion after total knee arthroplasty (TKA) is a catastrophic complication. Reconstruction with extensor mechanism allograft (EMA) has been described as a sound salvage procedure. Its effectiveness at long term and in septic cases is still under scrutiny. The long-term results of EMA reconstruction for chronic extensor mechanism failures following aseptic and septic revision TKA have been analysed. From the institutional database, 35 patients with a revision TKA (RevTKA) undergoing EMA reconstruction from 2005 to 2015 have been retrospectively identified. A history of periprosthetic joint infection (PJI) was found in 13 (37%) patients. The mean follow-up was 81.2months (± 34.7, range 3-120). EMA failures were considered for lag more than 20°, Knee Society Score (KSS) less than 60 points, and/or in the case of revision of the allograft. The mean KSS improved from 35.9 (± 16.9, range 0-54) to 86.6 (± 10.4, range 54-99) points in the aseptic group (p < 0.001) and from 27.5 (± 11.6, range 10-44) to 79.4 (± 16.3, range 48-94) points in the septic group (p < 0.001). The extensor lag changed from 48.4° (± 14.5, range 30-90) to 4.6° (± 10.8, range 0-50) in the aseptic group (p < 0.001) and from 56.5° (± 20.8, range 30-90) to 6.1° (± 6.8, range 0-20) in the septic group (p < 0.001). The mean postoperative flexion was 105.2° (± 13.2, range 75-130) in the aseptic group and 102.7° (± 12.5, range 80-120) in the septic group (p = 0.32). Three failures (14% of the cases) occurred in the aseptic group and five in the septic group (38% of the cases). The overall survivorship at 10 years was 83.3% (22 cases, CI95 94.2-121.7) vs 58% (13 cases, CI95 67.2-111.7) in the aseptic and septic group, respectively (p = 0.01). EMA reconstruction after extensor mechanism disruptions in TKA is a reliable salvage procedure. The septic nature of the revision decreased the functionality of the knee joint after EMA, but it did not represent a risk factor for re-ruptures or recurrence of infection. Level III.

A Prospective Study on Surgical Management of Closed Distal End Femoral Fracture in Adults Using Distal Femur Locking Compression Plate

Background: Distal Femur fractures are a highly incident complex case and pose a challenge to the treatingorthopedician.Aims and Objectives: The aims and objectives of this study were to assess radiological union of distal femoralfractures by open reduction and internal fixation with locking compression plate, To study the functionaloutcome for internal fixation of fractures of the distal end femur by Locking Compression Plate and Toevaluate the effectiveness and complications of distal end femur fractures treated with Locking CompressionPlate based on, time till union, rate of infection, and fixation failures, functional outcome using NEER’S SCORE.Materials and Methods: The present study was done from April 2017 to April 2018 which comprised offifteen patients with closed Distal end Femoral Fractures who where treated by Locking Compression plate.Overall final outcome was assessed in terms of radiological union, clinical assessment and regaining the lostknee function using NEER’S Score.Results: Out of 15 patients, 12 patients were males and 3 patients were females.Out of 15 patients, 14 were due toRTA. Maximum number of cases was of Muller type C2-60%. Internal fixation was considered after patientsgeneral and medical condition was stabilized. The average operative time was 90 minutes. The size of plate wasselected based on the type of fracture. 6 to 10 hole plate were used most commonly. Of 15 patients, 10(66.66%)showed radiological union within 16 weeks. 9 (60%) of the patients achieved weight bearing at the end of 14weeks. Average flexion in this study was 100 degree with more than 3 (20%) patients having knee range ofmotion more than 110 degree. 1 Patient had stiff knee. More than 80% patients were extensor lag less than 5degree. 2 patients had VARUS MALALIGNMENT out of 15 patients.Results according to NEER’S SCORE wereExcellent in 20% patients, Good in 60% , Satisfactory in 6.6% and unsatisfactory in 13.3% patients. 2 patients hadsuperficial infection and 1 patient had delayed union.Conclusion: Locking compression plate is an optimal tool for Distal end femoral fractures. It provides rigidfixation in the region of femur, where a wide canal, thin cortices and frequently poor bone stock make fixationdifficult.