Knee Extensor Mechanism Research Articles

Clinical and Biomechanical Outcomes following Knee Extensor Mechanism Reconstruction

PurposeTo evaluate clinical and biomechanical outcomes after knee extensor mechanism reconstruction (KEMR).MethodsPatients who underwent KEMR at our institution from 2011 to 2018 were identified. Patient-reported outcomes (Kujala, Lysholm, Tegner Activity Scale) were compiled at clinical follow-up. Isokinetic testing was conducted using the BioDex system 4 pro dynamometer at slow (60°/s), intermediate (180°/s), and fast (300°/s) speeds in a 9-patient subset.ResultsFrom 2011 to 2018, 12 patients (12 knees, 10 male, 5 right, mean age: 54.3 ± standard deviation: 15.2 years) with KEM injuries requiring tendon reconstruction with a 1-year minimum follow up were identified. Postoperative follow-up was 42.6 months (range: 12.0-93.0 months). Procedures included patellar (7) and quadriceps tendon reconstruction (5). Postoperative versus preoperative Tegner Activity Scale scores demonstrated significant improvement (3.5 ± 2.5 vs 1.5 ± 1.2, n = 8, P = .05). Postoperative versus preoperative Kujala scores significantly improved (70.3 ± 11.7 vs 43.6 ± 15.7, n = 8, P = .010). There was significant improvement in preoperative to postoperative KEMR extension lag (29.4 ± 22.2° vs 0.83 ± 1.9°, P = .002). Clinically, there was no difference in passive range of motion between the operative and contralateral knee. BioDex testing demonstrated decreased maximum work generated from the operative versus contralateral knee at slow (70.4 ± 30.4 Joules vs 101.9 ± 40.6 J; P = .028), intermediate (52.0 ± 45.4 J vs 69.8 ± 63.7 J; P = .038), and fast (43.8 ± 41.7 J vs 57.5 ± 53.8 J; P = .050) speeds. Range of motion was less in the operative versus contralateral knee at all speeds: P = .011, .038, and .024. The average peak torque generated per body weight was smaller in the operative versus contralateral knee at slow speed (P = .038).ConclusionsPatients undergoing KEMR in this study have significantly improved clinical outcomes despite having strength deficits that persist postoperatively.Level of EvidenceTherapeutic Case Series, Level IV.

Surgical management of transverse fractures of patella by cannulated screws combined with tension band wiring: Prospective study

Introduction: The patella plays an important role in range of motion of the knee joint. In a country like India where the social habits like squatting, sitting cross legged require full range of knee flexion. The most significant effect of patella fracture are loss of continuity of extensor mechanism of knee and potential incongruity of patello-femoral articulation. So it is necessary to preserve the patella and extensor apparatus. Materials and method: It is a prospective study which was carried out from November 2015 to May 2017 in MVJ Medical College and Research Hospital, Bengaluru. In this study period 30 cases of transverse fracture patella were treated by cannulated cancellous screws with tension band wiring. Results: In our study, majority of the patients were males, middle aged, with road traffic accidents being the commonest mode of injury. The fractures united in all 30 patients. Excellent results were in 25 patients (84%), 4(13%) patients having good results and 1(3%) patient having fair results. Conclusion: In view of the above results obtained from our study 84% excellent results: we concluded by mentioning that 4mm Cannulated cancellous screw fixation combined with tension band wiring is an effective treatment modality in the management of transverse fractures of the patella.

Knee Extensor Mechanism Disruptions: A Review

Native extensor mechanism (EM) injuries are rare but disabling injuries and can present significant treatment challenges, especially in cases of chronic injury or re-rupture. The goal of this review was to provide an overview of the evaluation and management pertaining to a spectrum of extensor mechanism disruptions. Quadriceps and patellar tendon ruptures comprise less than half of EM failures and are usually amenable to predictable repair and recovery regardless of repair method. While suture anchor and cortical button fixation may be biomechanically superior, no high-level clinical evidence exits to recommend a particular method at this time. Chronic tears and re-ruptures are complex problems for which multiple novel techniques have been described, most with acceptable outcomes. No comparative studies exist to recommend a particular method. Patellar fractures are the most common EM injuries and vary in complexity. Tension band wiring, fixed angle plating and mesh plating can be used successfully depending on the fracture pattern, with plating favored as comminution increases. Important considerations include stable fixation, restoration of articular surface, re-establishment of the EM and minimal hardware prominence. In this review, we highlight pertinent anatomy, surgical indications and methods of fixation for acute and chronic injuries of the native extensor mechanism with the goal of providing a concise, thorough understanding of the subject.

Suture Anchor Repair with V-Y Plasty and Achilles Allograft Augmentation for Chronic Quadriceps Tendon Injury

Despite an overall incidence that remains low, quadriceps tendon injuries represent a common disorder of the knee extensor mechanism. Persistent pain, weakness, and loss of terminal extension can lead to poor clinical outcomes and significant functional impairment. In the acute setting, approach to management often includes primary repair of the injured tendon that can lead to excellent clinical outcomes. However, a delayed or missed diagnosis can bring forth a clinical scenario that can be difficult to manage thereafter. In the chronically injured tendon, challenges can be linked to limited tendon excursion, poor tissue quality, and increased risk of reinjury.

Bilateral Quadriceps Tendon Repair with Suture Anchors: Case Series.

Bilateral and simultaneous quadriceps tendon rupture is rarely observed. This case series evaluates 3 patients with bilateral ruptures of the quadriceps tendon. The purpose of this case series is to display the effectiveness of the suture anchor surgical repair technique in these patients. Three obese male patients experienced some type of traumatic injury to the knee extensor mechanism, resulting in bilateral quadriceps tendon ruptures. Each of the patients was evaluated and given operative and nonoperative treatment options, and they all elected to undergo surgical tendon repair. Two double-loaded anchors were placed into the superior pole of the patella, allowing the tendons to be reduced back to their original positioning. Postoperatively, all patients were given the same guidelines for physical therapy, and their progress was monitored periodically. Each patient returned to his normal level of physical activity. Range of motion at the knee and weight bearing were reestablished in all 3 patients. These quadriceps tendon ruptures occurred in patients with a predisposition to injury as a result of excessive weight bearing. When addressing bilateral quadriceps tendon ruptures in this patient population, we found that a suture anchor-based construct allows for a secure repair, early initiation of physical therapy, and a noted improvement in pain scores on the Visual Analog Scale.

Rates and Risk Factors for Failure of Surgical Repair of the Knee Extensor Mechanism.

To evaluate rates and risk factors for failed surgical repair of the knee extensor mechanism. Retrospective cohort study. Academic medical center. Two hundred ninety-four patients and a total of 303 extensor mechanism repairs were included. This encompassed 113 quadriceps tendon repairs (QTR), 112 fracture repairs (FR), and 68 patellar tendon repairs (PTR). Repair failure. There were 6 failures (5%) in the QTR group, 21 failures (17%) in the FR group, and 2 failures (3%) in the PTR group. The difference in failure rates between the groups was significant (P = 0.001), but the rate of revision fixation or repair was not (P = 0.315). In the QTR group, a history of inflammatory arthritis was found to be significantly different between patients who had repair failure and patients who did not (P = 0.014) with a relative risk for failure of 17.8 (confidence interval 4.5-70.4). In the FR group, patient age (P = 0.001) and comorbid diabetes mellitus (P = 0.046) were found to be significantly different between patients with and without repair failure in univariate analysis, but only patient age (P = 0.005) was significant in multiple logistic regression analysis. The relative risk for FR failure was 6.6 (confidence interval 2.3-18.3) for age greater than 60. No risk factors for failure were identified in the PTR group. Overall, patients with fractures were more likely experience repair failure than patients with tendon injuries, but all patients underwent similar rates of reoperation. Inflammatory arthritis in patients with QTRs and older patient age in FRs are risk factors for repair failure. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A clinical study of fractures of patella treated with modified tension band wiring

Background & Objectives: In a country like India where the social habits and needs, require full range of knee flexion, the patella plays an important role. The most significant effect of patella fracture are loss of continuity of extensor mechanism of knee and potential incongruity of patello-femoral articulation. So it is necessary to preserve the patella and extensor apparatus. Hence the main objectives of this study are: To study the functional outcome by early mobilization, to study the complications of tension band wiring, to clinically evaluate the tension band wiring technique for fracture patella, to study the mode of injury for fracture patella. Methods: The present study consists of 30 selected cases of fractured patella treated by modified tension band wiring at Shri B M Patil Medical College Hospital and Research Centre, Vijayapur from December 2014 to March 2016. Results: In the present study 21 (70%) had excellent results, 7 (23.33%) had good results and 2(6.66%) had poor result. Interpretation and Conclusion: Early mobilization of the knee restores quadriceps power and range of Kneemotion within a short period. Excellent range of movement was achieved in 70%of cases, which is comparable to previous literature. In a country like India where the social habits and needs, require full range of knee flexion, the patella plays an important role.

Functional assessment of outcome of surgery to correct patellofemoral instability in human patients

A case-control study with 6 months of patient follow up. This study sought to determine if surgery followed by rehabilitation for patellar instability could restore normal gait function. A previous study has established abnormalities in gait pattern and joint congruence in patients with a history of patellar instability. We hypothesised that surgery for patellofemoral instability would improve knee function. Eight human patients (mean age 29, range 17-42) who were awaiting patella stabilisation surgery (5 tibial tuberosity osteotomy, 2 medial patellofemoral ligament reconstruction, 1 trochleoplasty) were compared against eight normal Controls (mean age 28, range 19-31). Patients were assessed pre-operatively and six months after surgery by biomechanical gait analysis. Gait trials involved simultaneous collection of kinematic and force data. Patients were grouped into two subgroups pre-operatively based on knee joint net moment during stance, and their joint moments during stance pre- and post-operatively were compared against the Control subjects. In pre-operative gait analysis, four patients (P1) produced some extensor moment in early stance and four (P2) demonstrated a severe gait deficiency with failure to generate a knee extensor moment during stance. Normalisation in gait pattern was observed in all patients post-operatively. Those who had the most severe gait abnormality (P2) demonstrated the most improvement in their knee joint moments. Improvements were observed in the milder (P1) cases, but these were less dramatic. Patella stabilisation by surgery can restore normal gait function. Normalising the anatomy of the knee extensor mechanism is the objective of surgery. Normal anatomy facilitates the rehabilitation objectives of optimising extensor function during the weight-bearing phase of gait.

Biplanar ascending opening-wedge high tibial osteotomy increases tibial tubercle–trochlear groove distance and decreases patellar height

ObjectivesTo assess the impact of a biplanar ascending opening-wedge high tibial osteotomy (OWHTO) on the alignment of the knee extensor mechanism and patellar height using preoperative and postoperative MRI.MethodsMedical records of all patients submitted to ascending biplanar OWHTO between July 2008 and March 2017 were retrospectively assessed. Five parameters of the patellofemoral joint—tibial tubercle–trochlear groove distance (TT-TG), patellofemoral (PF) axial engagement index, lateral patellar tilt, Blackburne-Peel index (BPI) and Caton-Deschamps index (CDI)—were measured by two blinded independent observers on both preoperative and postoperative MRIs. Interobserver reliability was assessed with the intraclass correlation coefficient (ICC). Paired t-test was performed to compare preoperative and postoperative measurements. The association of the amount of HTO opening and the assessed PF joint parameters was also investigated with Pearson correlation coefficient.Results26 patients who underwent ascending biplanar OWHTO were enrolled in this imaging analysis (63.4%) with a mean follow-up of 16.3 months (SD, 16.9). ICC for all measurements ranged between 73.3% and 89.3%. Postoperatively, TT-TG distance significantly increased by 2.0 mm±2.3 mm (p<0.001). Patellar height significantly decreased when evaluated by the BPI (p<0.001) and CDI (p=0.001). The amount of osteotomy opening significantly correlates with the postoperative BPI (p=0.023) and CDI (p=0.013).ConclusionThis study comprehensively reports significant increase on TT-TG distance after an ascending biplanar OWHTO using MRI. Small but significant decreases in patellar height were also observed and are correlated to the amount of axis correction.Level of evidenceLevel IV, retrospective case study.

Knee Extensor Mechanism Disruptions: A Review

Knee Extensor Mechanism Disruptions: A Review

Reconstruction of knee extensor with patellar tendon autograft following intraoperative radiotherapy

BackgroundPatellar tendon autograft after intraoperative extracorporeal radiotherapy has been used for reconstruction of the extensor mechanism following limb-sparing wide tumor resection around the knee. The purpose of this study was to determine the clinical outcome of this reconstruction technique. MethodsWe retrospectively reviewed six consecutive patients with peripatellar tendon and proximal tibial sarcoma who underwent reconstruction of the knee extensor mechanism. The resection area was planned to be contained with the patellar tendon in order to obtain a wide margin. First, the patella was osteotomized at the midline, and the inferior half of patella, patellar tendon, and tibial tuberosity were excised en bloc. The resected segments were devitalized with intraoperative extracorporeal radiotherapy and reimplanted into the original site. A follow-up evaluation included an assessment of the range of motion, extensor lag, the International Society of Limb Salvage score, and complications. ResultsSix patients were followed up for 121–270 months. One patient underwent an additional reconstruction with total knee arthroplasty due to a collapse of the tibial subchondral bone. A supracondylar fracture of the femur occurred in two patients, and a delayed union of the osteosynthesis site of the tibial shaft was observed in one patient. At the latest follow up, extensor lag had a median of five degrees, and International Society of Limb Salvage scores had a median of 83%. No local recurrence or rupture of the patellar tendon was observed. ConclusionsReconstruction of the knee extensor mechanism using a patellar tendon treated with intraoperative radiotherapy is a reliable and successful method.

Murine patellar tendon transplantation requires transosseous cerclage augmentation\xa0\u2014\xa0development of a transplantation model for investigation of systemic and local drivers of healing

BackgroundTendon injuries are common musculoskeletal injuries that heal with scar tissue formation, often achieving reduced biomechanical and functional properties. The murine patellar tendon is a research tool that holds potential for investigating tendon healing and can be useful for exploring therapeutic strategies. Since healing is a complex process that results from the collaboration between the systemic and local tissue environment, a murine tendon transplantation model that can be applied to transgenic mice and genetic mutants would allow isolation of systemic versus local tendon factors in driving effective tendon healing. Preliminary studies have shown that transplantation with simple tendon sutures results in a proximalization of the patellar bone due to the involuntary quadriceps muscle force leading to tearing of the graft and failure of the knee extensor mechanism. To avoid this elongation of the graft, two cerclage techniques for murine patellar tendon transplantation were introduced and validated.MethodsThree developed surgical techniques (no-cerclage-augmentation (NCA)), transfascial suture cerclage with encirclement of the patellar tendon (TFSC), and dual-cerclage-augmentation with a transosseous bone-to-bone cerclage through the patella bone and an additional musculotendinous cerclage (DCA)) were compared at 4 and 8 weeks macroscopically in regards to graft continuity, cerclage integrity, gap formation, and radiologically by measuring the patello-tibial distance and using a patella bone position grading system.ResultsThe NCA group showed complete failure at 5–7 days after surgery. The TFSC has led to 69% functional failure of the cerclage. In contrast, the DCA with a has led to 78% success with improvement in patellar bone position and a similar patello-tibial distance to the naïve contralateral murine knees over the time period of 8 weeks.ConclusionsThis study shows that a bone-to-bone cerclage is necessary to maintain a desired graft length in murine patellar tendon models. This surgery technique can serve for future graft trans- and implantations in the murine patellar tendon.

Graft of allogeneic knee extensor mechanism in treatment of giant cell tumor of the patella

Introduction: Cancer of the patella is a rare condition. Giant cell tumor of the patella is an extremely rare and a difficult to solve therapeutic problem. Depending on the degree of bone destruction, it may cause significant knee joint dysfunction. It is assumed that surgery is the treatment of choice. Material/Methods: This study presents an innovative treatment of a giant cell tumor of the patella in a 40-year-old male with significant dysfunction of the knee extensor mechanism. Complex therapy included neoadjuvant treatment using a human monoclonal antibody IgG2 that binds to RANKL (Denosumab) and follow-up allogeneic grafting of knee extension mechanism. Results: Follow-up CTs showed correct positioning and healing of grafted knee extensor mechanism. Early functional outcome was perfect. Seven weeks after the surgery, reduction of pain, improvement of the contour of the joint, full active extension and flexion of 110° were noticed. Fifteen months after the surgery, the patient presented complete active extension and flexion of the knee joint, actively participated in professional life and CT tests did not reveal features of tumor recurrence. Conclusions: Treatment of isolated giant cell tumor of the patella with destruction of patella and joint dysfunction does not have a clear solution in the available literature. Such a condition may also exclude traditional procedures. In such cases, grafting of the whole extensor mechanism appears to be the appropriate treatment.

Traumatic injury of the knee extensor mechanism in skeletally immature patients: Outcome and classification

BackgroundThe literature is limited on the etiology and outcome of acute traumatic knee extensor mechanism injuries in skeletally immature patients with lack of a reliable classification system. MethodsData on patients who sustained an acute traumatic injury of the knee extensor mechanism were reviewed with a minimum of 12-month follow-up. Functional outcome was evaluated regarding knee active range of motion. Functional outcome was described using the Knee Society Score (KSS). Data were expressed as mean ± standard deviation. ResultsSeventy-two patients with 74 knee extensor mechanism injuries were identified. The age at the time of injury was 13.9 ± 1.9 years. They included 59 injuries with tibial tubercle avulsion fracture, six injuries with patellar tendon avulsion without bone injury, six injuries with combined patellar tendon avulsion with tibial tubercle fracture, two injuries with sleeve fracture, and one injury with quadriceps tendon avulsion. According to our classification, type IB1 injury was the commonest injury (79.7%). The time to return to sports was 5.23 ± 2.98 months. The flexion was 128.7° ± 13.3°. A mean terminal extension lag of 5.6° was detected in three patients (4.1%). The KSS was 94.8 ± 8.1 and the functional outcome was graded excellent in 64 patients (88.9%), good in seven patients (9.7%), and fair in one patient (1.4%). ConclusionsTraumatic injuries of the knee extensor mechanism in skeletally immature patients represent a wide variety of injuries including bony injuries in 82.4% of cases reviewed, tendinous injuries in 9.5%, and both bone and tendinous injuries in 8.1%. Our proposed classification system provides a more precise description of the injury pattern.

Towards a Dynamic Model of the Kangaroo Knee for Clinical Insights into Human Knee Pathology and Treatment: Establishing a Static Biomechanical Profile

There is limited understanding of how patella realignment or patellectomy to surgically manage patellofemoral pain (PFP) affects knee biomechanics. By analysing marsupials like kangaroos that lack an ossified patella, actionable biomimetic insight for the management of end-stage PFP could be gained. This study aimed to provide the foundation of a multi-stage approach, by establishing a static biomechanical profile of the kangaroo stifle that informs the inputs and factors requiring consideration for future dynamic analyses. Volumetric CT and MRI sequences were obtained for four hindlimbs from two Macropus giganteus specimens, from which three-dimensional models of the stifles were created. Two limbs were dissected to visualise the insertion points, origins and lines of action of the quadriceps muscles and the knee extensor mechanism. Static measurements were obtained from the three-dimensional models to establish the biomechanical profile. The results confirmed structural differences in the kangaroo stifle with lack of an ossified patella, a prominent tuberosity and a shorter femur, which functionally affect the mechanical advantage and the torque-generating capability of the joint. The data reported in this study can be used to inform the inputs and constraints of future comparative analyses from which important lessons can be learned for the human knee.

Combined Soft Tissue Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon–Femoral Ligament

Patellar dislocation is a major orthopaedic concern in pediatric and adult populations, with both conservative and surgical options available. Several surgical techniques of the combined or isolated reconstruction of the medial patellofemoral ligament are described in the literature using different grafts, locations, and types of fixations, providing different advantages and disadvantages. New recent developments in cadaveric dissection studies have unveiled the importance of structures that were neglected until recently, such as the medial quadriceps tendon–femoral ligament, which provides a connection between the medial femur and the quadriceps tendon component of the knee extensor mechanism. Hence, we present a surgical technique with combined reconstruction of the medial patellofemoral ligament and medial quadriceps tendon–femoral ligament without the use of hardware and with no need for patellar or femoral drilling (no physis compromise or risk of patellar fracture), which can be used concomitantly with other bony procedures.

Reconstruction using artificial ligament for disruption of the knee extensor mechanism caused by fracture

Reconstruction using artificial ligament for disruption of the knee extensor mechanism caused by fracture

Rotational Malalignment of the Knee Extensor Mechanism: Defining Rotation of the Quadriceps and Its Role in the Spectrum of Patellofemoral Joint Instability.

Background:Osseous rotational malalignment of the lower limb is widely accepted as a factor contributing to patellofemoral instability, particularly in pediatric patients. Patellar instability occurs when the lateral force vector generated by the quadriceps exceeds the restraints provided by osseous and soft-tissue anatomy. The anatomy and activation of the quadriceps are responsible for the force applied across the patellofemoral joint, which has previously been measured using the quadriceps (Q)-angle. To our knowledge, the contribution of the quadriceps anatomy in generating a force vector in the axial plane has not previously been assessed. The primary aim of this study was to introduce the quadriceps torsion angle, a measure of quadriceps rotational alignment in the juvenile population. The secondary aims of this study were to determine the inter-assessor and intra-assessor reliability of the quadriceps torsion angle in the juvenile population and to investigate whether a large quadriceps torsion angle is a classifier of patellar dislocator group membership in a mixed cohort of patellar dislocators and typically developing controls.Methods:Participants between the ages of 8 and 19 years were recruited as either controls or recurrent patellar dislocators. A total of 58 knees in both groups were assessed from magnetic resonance imaging scans of the entire lower limbs. Axial cuts midway between the superior aspect of the femoral head and the articular surface of the medial femoral condyle were used to calculate the proximal reference for the quadriceps torsion angle. The quadriceps torsion angle was defined as the angle between the line connecting the anterior aspect of the sartorius and the junction of the anterior and posterior compartments at the lateral intermuscular septum and the posterior condylar axis line. Inter-assessor reliability was calculated using the intraclass correlation coefficient. The relationship between the quadriceps torsion angle and the femoral torsion was assessed in the entire cohort. These values were compared between the control group and the dislocator group to determine if the raw values or an interplay between the 2 factors played a role in the pathoanatomy of recurrent patellofemoral dislocation.Results:The quadriceps torsion angle was a reproducible assessment in both inter-assessor and intra-assessor reliability analyses. A moderate positive correlation (r = 0.624; p < 0.01) was found between the femoral torsion and the quadriceps torsion angle. Although the quadriceps torsion angle was a fair classifier of patellar dislocation group membership, femoral torsion was not.Conclusions:This study has quantified the rotational alignment of the extensor mechanism using the quadriceps torsion angle. The measurement is shown to be reliable and reproducible and a fair classifier of patellofemoral instability.Clinical Relevance:This article introduces an objective measure of soft-tissue rotational malalignment in the pathogenesis of recurrent patellar dislocation.

Surgical management of patellofemoral instability. I. Imaging considerations.

The patellofemoral joint is a complex joint that relies on both bone and soft tissues for its stability. Dysfunction of the patellofemoral joint, whether pain or instability, is a common cause of medial consultation. Thorough clinical and imaging assessment is important for managing these patients, who may require a combination of a bony and soft tissue surgical procedure. Trochlear dysplasia, a cause of anterior knee pain and patellar instability, has been classified using conventional radiography. Radiographic signs on a lateral projection, such as the "double contour" sign and the "crossing sign", can alert the radiologist to the grade of trochlear dysplasia. Magnetic resonance imaging (MRI) is the gold standard for accurately assessing the soft tissue around the patellofemoral joint, such as the medial patellofemoral ligament and the medial and lateral patella retinacula, especially in the context of a transient patella dislocation. Risk factors for patellofemoral instability, such as patella alta, an increased tibial tubercle to trochlear groove distance and trochlear dysplasia, can all be assessed on MRI. Advanced imaging techniques such as dynamic MRI and CT are able to demonstrate patellar maltracking. These techniques can also be employed to reliably assess the outcomes of treatment. In this article, we review the normal and abnormal pre-operative imaging findings of the knee extensor mechanism in relation to patellofemoral joint instability. This review provides a useful tool for the reporting radiologist and highlights the imaging findings that are of relevance to the orthopaedic surgeon.

ALT flap with vascularized fascia lata for one-stage functional patellar tendon reconstruction

Composite anterolateral thigh (ALT) flap with vascularized fascia lata can reconstitute patellar tendon integrity and knee soft tissue coverage in one stage. However, long-term evidence of outcomes is lacking. This work analyzes long-term functional results, compares subtotal and total reconstruction of patellar tendon, and assesses the respective function of the extensor apparatus. Outcomes of reconstruction using 10 ALT flaps in 9 patients (age range 21-87 years) were analyzed (mean follow-up 30 ± 6 months). Knee Society Scores, isometric knee extensor strength (M1-M5), and sensory recovery were evaluated, together with active range of motion and extensor lag of the reconstructed limb, compared to contralateral. Ten flaps were used for tendon replacement in 9 patients. Eight (80%) free flaps and 2 (20%) propeller distally based flaps were used. Complications requiring the harvest of a second flap were seen in 2 patients. All patients could return to their daily activities without the use of walking supports. Mean active ROM was 94.4° with an extensor lag of 9.4°, without a significant difference between partial and total patellar tendon reconstruction. The mean knee and functional scores of the Knee Society were 81/100 and 77/100, respectively. Composite ALT flap with fascia lata can satisfy the twofold needs of functional restoration and soft tissue coverage, thus ensuring stable results in total and subtotal knee extensor mechanism reconstruction. Distally based flaps should be carefully considered, as they lead to higher complication rates.