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Extensor Mechanism Repair(Patellar Tendon)

Planning

B

Preoperative Plan

1

Assess location of patella tendon injury

  • use physical exam and MRI if available

2

Execute surgical walktrough

  • describe key steps of procedure verbally prior to the start of the case

3

Description of potential complications and steps to avoid them

C

Room Preparation

1

Room setup and Equipment

  • standard OR table

2

Patient Positioning

  • supine position
  • place bump on the ipsilateral hip
  • place tourniquet high on the thigh
  • have an assistant milk the patella and quad tendon distal prior to placing the tourniquet.

Technique

D

Midline Incision

1

Mark and make midline incision

  • the incision will need to allow access to the patella tendon and the superior pole of the patella.
  • tourniquet may be inflated prior to incision.
  • one single incision can be made extending from the superior pole of the patella to the proximal portion of the tibial tubercle.
  • make the incision
E

Deep Dissection

1

Dissect through subcutaneous tissue

  • carry the incision through the subcutaneous tissue until the patella and patellar tendon rupture are identified
  • evacuate the hematoma and irrigate the joint.

2

Identify the paratenon

  • create a midline incision in the paratenon, elevating flaps for later closure.
F

Prepare Tendon

1

Remove all nonviable tissue

  • debride tissue as needed
  • disrupt all adhesions that are present

2

Place sutures

  • place two number 5 nonabsorbable sutures using a krackow stitch through the full thickness medial and lateral aspects of the tendon.
  • four strands of sutures should be coming from patella tendon (2 medial and 2 lateral)
G

Prepare the Patella

1

Expose cancellous bone

  • debride the inferior pole of the patella of any remaining tendon
  • use a curet, rongeur or burr to expose cancellous bleeding bone

2

Create bone tunnels

  • use a 2.5 mm drill to create medial, middle and lateral longitudinal holes through the patella
H

Reattach Tendon

1

Pass sutures

  • use a suture passer to pull the four suture limbs through the bone tunnels
  • the two middle sutures (one from medial limb and one from lateral limb)will be passed through the middle patella drill hole.
  • the most lateral suture will pass through the lateral drill hole.
  • the most medial suture will pass through the medial drill hole.

2

Secure the sutures

  • place the knee in full extension.
  • tie the most medial suture to the medial limb of the central two sutures.
  • tie the most lateral suture to the lateral limb of the central two sutures.
I

Repair the Retinaculum and Paratenon

1

Inspect and repair the retinaculum

  • identify and repair tears in the medial and lateral retinaculum if present

2

Repair the paratenon

J

Wound Closure

1

Perform a multilayer closure

  • paratenon
  • usually closed with a running 0 absorbable suture.
  • subcutaneous layer
  • usually closed with interrupted inverted 2-0 absorbable sutures.
  • skin
  • can be closed with non-absorbable or absorbable suture.

2

Dressing and immediate immobilization

  • place sterile dressing over incision
  • place in a hinged knee brace locked in extension

Patient Care

K

Preoperative H & P

1

Perform basic medical and orthopaedic history and physical

  • identify medical co-morbidities that might impact surgical treatment

2

Ensure all studies are required to proceed with surgical intervention

  • radiographs
  • AP
  • lateral
  • oblique
  • merchant view

3

Perform operative consent

  • describe complications of surgery including
  • quadriceps atrophy
  • quadriceps weakness
  • extensor lag
  • anterior knee pain
L

Perioperative Inpatient Management

1

Write admission orders

  • pain meds
  • IV fluids
  • advance diet as tolerated
  • wound care
  • remove dressing POD 2
  • medical management and medical consultation
  • orders appropriate inpatient occupational and physical therapy (weight-bearing, ROM, limitations of physical therapy)

2

Discharges patient appropriately

  • pain meds
  • PT
  • follow up in 2 weeks
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • differential diagnosis and physical exam tests

2

Interprets required diagnostic studies

  • radiographs
  • AP
  • lateral
  • look for patella alta
  • oblique
  • merchant view

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Provides postoperative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and manage early complications
  • start passive range of motion at 4 weeks
  • start active range of motion at 8 weeks
N

Advanced Evaluation and Management

1

Recognizes concomitant associated injuries

2

Appropriately orders and interprets advanced imaging studies

3

Provides complex non-operative treatment

4

Modifies and adjusts post-operative treatment plan as needed

O

Complex Patient Care

1

Develops unique, complex post-operative management plans

2

Capable of evaluating and treating postoperative complications

3

Surgically treats complex complications

 

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