Extensor Mechanism Repair(Patellar Tendon)

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TECHNIQUE STEPS
 
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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

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

F

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.
G

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
H

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.
I

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)
J

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
K

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.
L

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

N

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
Postoperative Patient Care
 

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