Elsevier

The Journal of Arthroplasty

Volume 35, Issue 12, December 2020, Pages 3747-3753
The Journal of Arthroplasty

Complications - Other
Extensor Mechanism Reconstruction Using Marlex Mesh: Is Postoperative Casting Mandatory?

https://doi.org/10.1016/j.arth.2020.06.037Get rights and content

Abstract

Background

Extensor mechanism (EM) disruption after total knee arthroplasty is a catastrophic complication. Reconstruction using monofilament polypropylene mesh (Marlex Mesh; CR Bard, Franklin Lakes, NJ) has emerged as the preferred treatment, but reports are limited to the designing institution. This study describes a nondesigner experience and compares 2 postoperative immobilization strategies: long leg cast vs knee immobilizer.

Methods

A retrospective review of consecutive EM reconstructions between 2012 and 2019 was performed. Primary repairs and allograft reconstructions were excluded, leaving 33 knees (30 patients) who underwent Marlex reconstruction. Mean time from disruption to reconstruction was 14 months, and 14 of 33 (42%) had previous repair or reconstruction attempts. The mean age was 69 years, and mean body mass index was 35 kg/m2. Postoperatively, extension was maintained using a knee immobilizer in 19 of 33 (58%) patients, whereas 14 of 33 (42%) patients were long leg casted. Kaplan-Meier analysis determined all-cause survivorship free of mesh failure.

Results

At mean 25-month follow-up, 19 of 33 (58%) EM reconstructions were functioning. Excluding explanted infections (5 recurrent and 2 new), 19 of 26 (73%) EM reconstructions were in situ. Six-year survivorship was 69% and not influenced by immobilization type (cast: 67%, immobilizer: 71%; P = .74). Extensor lag was not associated with immobilization type, improving from a mean preoperative lag of 43° to a mean postoperative lag of 9°. Among successes, University of California at Los Angeles activity and Knee Injury and Osteoarthritis Outcome Score - Joint Replacement score improvements exceeded minimal clinically important difference (2.2-3.3 and 52.5-64.0, respectively).

Conclusion

Marlex mesh EM reconstruction is a durable and reliable treatment with acceptable clinical results achievable outside the designer institution. Provided sufficient duration and compliance with postoperative immobilization, similar outcomes can be obtained with either a cast immobilizer or a knee immobilizer.

Section snippets

Study Sample

This study used our prospectively collected and institutional review board–approved total joint replacement registry to retrospectively review consecutive patients with EM compromise at a single tertiary referral center. Patients were included in the study if they underwent EM reconstruction with Marlex mesh. Patients were excluded if they underwent EM reconstruction using allograft or underwent EM repair. Additional preoperative diagnoses, including cases of septic revisions for periprosthetic

Results

During the study period, a total of 45 patients were treated for EM disruption. Three patients were treated with EM reconstruction using allograft, and 12 patients underwent EM repair for an acute rupture and were excluded from analysis. A total of 33 knees (30 patients) underwent Marlex mesh reconstruction of an EM disruption and were included in the final analysis. In 10 knees, the existing implants were retained, and in 23 knees, the implants were revised. Among the 23 EM reconstructions in

Discussion

Disruption of the EM of the knee is a devastating complication with significant associated patient morbidity, including decreased walking ability, instability and, by definition, the inability to extend the knee. Multiple strategies exist to address an EM disruption after TKA. Nonsurgical management and primary repair strategies have uniformly resulted in poor functional outcomes and high rates of revision for chronic EM disruptions [1,4,9,13]. Traditionally, allograft augmentation has been

References (29)

  • A.G. Rosenberg

    Management of extensor mechanism rupture after TKA

    J Bone Joint Surg Br

    (2012)
  • L.A. Whiteside

    Surgical technique: vastus medialis and vastus lateralis as flap transfer for knee extensor mechanism deficiency knee

    Clin Orthop Relat Res

    (2013)
  • C.W. Siwek et al.

    Ruptures of the extensor mechanism of the knee joint

    J Bone Joint Surg Am

    (1981)
  • Z. Meyer et al.

    Knee extensor mechanism repairs: standard suture repair and novel augmentation technique

    J Orthop Trauma

    (2016)
  • Cited by (0)

    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2020.06.037.

    Funding: This research received no specific funding/grant from any funding agency in the public, commercial, or not-for-profit sectors.

    Conflict of Interest: Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

    Ethical Board Review: This study received institutional review board approval before initiation. The study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki. This study was carried out in accordance with relevant regulations of the US Health Insurance Portability and Accountability Act.

    View full text