Preoperative Patient Care A 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 baja look for interruption of the quadriceps soft tissue tendon shadow 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 B 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 C 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 Operative Techniques E Preoperative Plan 1 Preoperative Plan Assess location of extensor mechanism injury Use physical exam, xray, and MRI if available MRI is rarely needed 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 quad tendon distal prior to placing the tourniquet. G Medial Parapatellar Approach 1 Mark and make midline incision The incision will need to allow access to the injured quadriceps tendon and the inferior pole of the patella. A tourniquet may be inflated prior to incision. One single incision can be made extending from the inferior pole of the patella to the ruptured portion of the quadriceps tendon. Make the incision H Deep Dissection 1 Dissect through subcutaneous tissue Dissect through subcutaneous tissue Carry the incision through the subcutaneous tissue until the quadriceps tendon rupture and the patella are identified Evacuate the hematoma and irrigate the joint. 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 exit from the distal portion of the quadriceps tendon (2 medial and 2 lateral) J Prepare the Patella 1 Expose cancellous bone debride the superior 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 Retinaculum 1 Inspect and repair retinaculum identify and repair tears in the medial and lateral retinaculum N Wound Closure 1 Irrigation, hemostasis, and drain copiously irrigate the wound 2 Deep closure close the deep fascia with 0 interrupted absorbable suture 3 superficial closure close the superficial subcutaneous tissue with 2-0 absorbable suture skin can be closed with absorbable or nonabsorbable sutures. 4 dressing and immediate immobilization place sterile dressing over incision place in a hinged knee brace locked in extension Postoperative Patient Care O 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 R Complex Patient Care 1 Develops unique, complex post-operative management plans 2 Capable of evaluating and treating postoperative complications 3 Surgically treats complex complications
A 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 baja look for interruption of the quadriceps soft tissue tendon shadow 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 B 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 C 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
E Preoperative Plan 1 Preoperative Plan Assess location of extensor mechanism injury Use physical exam, xray, and MRI if available MRI is rarely needed 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 quad tendon distal prior to placing the tourniquet. G Medial Parapatellar Approach 1 Mark and make midline incision The incision will need to allow access to the injured quadriceps tendon and the inferior pole of the patella. A tourniquet may be inflated prior to incision. One single incision can be made extending from the inferior pole of the patella to the ruptured portion of the quadriceps tendon. Make the incision H Deep Dissection 1 Dissect through subcutaneous tissue Dissect through subcutaneous tissue Carry the incision through the subcutaneous tissue until the quadriceps tendon rupture and the patella are identified Evacuate the hematoma and irrigate the joint. 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 exit from the distal portion of the quadriceps tendon (2 medial and 2 lateral) J Prepare the Patella 1 Expose cancellous bone debride the superior 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 Retinaculum 1 Inspect and repair retinaculum identify and repair tears in the medial and lateral retinaculum N Wound Closure 1 Irrigation, hemostasis, and drain copiously irrigate the wound 2 Deep closure close the deep fascia with 0 interrupted absorbable suture 3 superficial closure close the superficial subcutaneous tissue with 2-0 absorbable suture skin can be closed with absorbable or nonabsorbable sutures. 4 dressing and immediate immobilization place sterile dressing over incision place in a hinged knee brace locked in extension
O 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 R Complex Patient Care 1 Develops unique, complex post-operative management plans 2 Capable of evaluating and treating postoperative complications 3 Surgically treats complex complications