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C OPYRIGHT  2018 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Extensor Mechanism Reconstruction with Use

of Marlex Mesh
A Series Study of 77 Total Knee Arthroplasties
Matthew P. Abdel, MD, Christopher G. Salib, MD, Kristin C. Mara, MS, Mark W. Pagnano, MD,
Kevin I. Perry, MD, and Arlen D. Hanssen, MD

Investigation performed at the Mayo Clinic, Rochester, Minnesota

Background: Disruption of the extensor mechanism after total knee arthroplasty (TKA) is debilitating, and the reported
Downloaded from http://journals.lww.com/jbjsjournal by BhDMf5ePHKbH4TTImqenVDJivV4JHtPRh8HF//KxbPq37JPaneWwUInjeDSPosWT on 08/01/2018

results of numerous reconstructive options have varied. We previously reported the early results of 13 patients who
underwent reconstruction of the extensor mechanism with use of Marlex mesh. The purpose of the current study was to
assess results in a larger cohort of patients, with an emphasis on the survivorship of the mesh, clinical results, and
complications.
Methods: During the period of 2000 to 2015 at a single tertiary care academic institution, 77 patients (77 TKAs)
underwent reconstruction with use of Marlex mesh for an extensor mechanism disruption (27 quadriceps tendon dis-
ruptions, 40 patellar tendon disruptions, and 10 patellar fractures). The mean patient age at the time of reconstruction
was 65 years; 70% of the patients were female. The mean body mass index was 35 kg/m2. The mean follow-up was 4
years. Eighteen (23%) of the patients underwent mesh reconstruction with the primary TKA in place, and 59 (77%) had
mesh reconstruction at the time of revision TKA. The mean time between disruption and reconstruction was 7 months.
Twenty (26%) of the patients had previously undergone attempted extensor mechanism reconstruction at outside
institutions.
Results: Sixty-five of the 77 mesh reconstructions were in place at the time of the latest follow-up. Twelve patients
experienced a failure that required mesh revision: 5 for patellar tendon rupture, 5 for quadriceps tendon rupture, and 2 for
symptomatic lengthening. Four additional patients with mesh failure were treated nonoperatively with bracing. The 2-year
survivorship free of mesh revision was 86% for patients with no prior reconstruction and 95% for patients with previous
reconstructions of the extensor mechanism that did not involve Marlex mesh. Knee Society Score (KSS) results signifi-
cantly improved following reconstruction (p < 0.001). Extensor lag improved by a mean of 26
, with mean postoperative
extensor lag measuring 9
(p < 0.001).
Conclusions: Reconstruction of the extensor mechanism with use of Marlex mesh is a viable option in patients with
catastrophic disruption after TKA. At the time of the latest follow-up, 84% of the mesh reconstructions were in place and
the functional outcomes were excellent, with mean improvement in extensor lag of 26
. Extended follow-up is required, but
the results of this large series with a mean follow-up of 4 years are encouraging.
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of
evidence.

D
isruption of the extensor mechanism after total knee
arthroplasty (TKA) is rare, with reported prevalence
ranging from a rate of 0.1% to 3%1-3. Multiple series
have demonstrated inconsistent results of a host of surgical
repair and reconstructive techniques, including primary
repair4,5 and the use of rotational muscle flaps6,7, Achilles ten-
don allografts8,9, and whole extensor mechanism allografts
(EMAs)10,11. Given the extremely poor results of primary repair
for chronic disruptions12,13, such a technique is reserved only
for acute disruptions4,14. For chronic disruptions, the mainstay

Disclosure: There was no external funding for this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online
version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena
outside the submitted work (http://links.lww.com/JBJS/E815).

J Bone Joint Surg Am. 2018;100:1309-18 d http://dx.doi.org/10.2106/JBJS.17.01165

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of treatment is reconstruction. Achilles tendon allograft can be

utilized, but high rates of mechanical failure, infection, and
unsatisfactory clinical outcomes have been demonstrated8,9.
Similarly, reconstruction with the use of EMA has been asso-
ciated with complications including symptomatic lengthening
at mid-term follow-up11,15-17.
Our group previously reported early favorable results of
extensor mechanism reconstruction with use of a knitted
monofilament polypropylene mesh (Marlex; C.R. Bard) and a
stepwise surgical approach18. That study included the 3.5-year
results for 13 patients with chronic or subacute patellar ten-
don rupture who underwent extensor mechanism recon-
struction with use of Marlex mesh18. In that series, 3 patients
showed evidence of graft failure, 1 patient with previous
periprosthetic joint infection (PJI) developed recurrent PJI
requiring arthrodesis, and the remaining 9 patients were
Fig. 1
considered to have had successful reconstruction at the time Intraoperative photograph showing the 10 · 14-in (approximately
of the latest follow-up. Additionally, we recently reported the 25 · 35.5-cm) sheet of Marlex mesh that has been rolled onto
results of the use of this technique for acute and subacute
itself 8 to 10 times and then sewn together with a running-locked
quadriceps tendon ruptures19. In that series, clinical success
closure.
was noted for 7 of 8 knees.
Several synthetic mesh options exist for the surgical
reconstruction of anatomical defects. Historically, Marlex mesh (range, 0.1 to 8.1 years). Reconstruction was performed
has been utilized in inguinal hernia repairs20-22 and gyneco- within 6 weeks of the knee arthroplasty for 5 patients, between 6
logical procedures23 because it has exceptional tensile strength and 12 weeks for 11 patients, and at >12 weeks for the remaining
and decreased foreign-body response compared with other 61 patients. Twenty (26%) of the patients had previously under-
synthetic biomaterials. The use of this and other synthetic gone attempted reconstruction of the extensor mechanism at an
meshes (such as Prolene; Ethicon) in the surgical specialties has outside institution, with a multitude of reconstructive techniques
recently declined, in part, because of the propensity of the mesh including primary suture repair (10 patients), whole EMA
to stimulate fibroblastic proliferation and form dense adhe- (6 patients), Achilles tendon bone block allograft (2 patients),
sions24,25. In general surgery, excessive scar formation may be patellar tension wire repair (1 patient), and hamstring tendon
unappealing, but in the setting of an extensor mechanism autograft (1 patient).
disruption, the increased scar-tissue formation may enhance All demographic data were obtained from retrospective
integration of the mesh to the host soft tissue to provide a more chart review (see Appendix). The mean patient age at the time
durable reconstruction. of mesh reconstruction was 65 years (range, 37 to 85 years), and
The purpose of the current study was to investigate the 69% of the patients were female. The mean body mass index
results of a much larger group of patients with extensor (BMI) was 35 kg/m2 (range, 20 to 52 kg/m2). At the time of the
mechanism disruption (including of the quadriceps tendon) latest follow-up, 6 (8%) of the patients had died, including 2
after primary and revision TKA who underwent reconstruction within 2 years of the reconstruction, and 4 (5%) had <2 years of
with use of Marlex mesh and a well-established surgical pro- follow-up and were thus considered lost to follow-up. The
tocol. In particular, we were interested in survivorship free of remaining 67 patients had a mean follow-up of 4 years (range, 2
mesh revision, clinical results, and complications. to 10.5 years).
Clinical outcomes were assessed with use of the Knee
Materials and Methods Society Score (KSS)27, and all complications, reoperations, and

W e identified 77 patients with extensor mechanism dis-

ruption after TKA who underwent reconstruction with
use of Marlex mesh during the period of 2000 to 2015 at a
revisions were documented following individual review of the
medical records.

single tertiary care academic institution. Eighteen (23%) of the
77 patients were treated with primary TKA components in
place and 59 (77%) were treated during or after revision TKA.
Patients were identified through the total joint registry that has
prospectively followed all arthroplasty patients at our institu-
tion since 196926. Institutional review board approval was ob-
tained prior to initiation of the study.
The mean time from the extensor mechanism dis-
ruption after TKA to the mesh reconstruction was 0.6 year
Surgical Techniques
The surgical technique utilizing the Marlex mesh reconstruc-
tion was performed in a fashion similar to that originally
described by Browne and Hanssen18. First, a 10 · 14-in
(approximately 25 · 35.5-cm) sheet of Marlex mesh was rolled
onto itself 8 to 10 times and sewn together with 1 to 2 heavy,
nonabsorbable sutures with a running-locked closure (Fig. 1).
The tibial component was not revised at the time of the Marlex
mesh reconstruction in 25 patients; in such cases, a trough was
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Fig. 2
When components are maintained, a tibial trough is created with a high-speed burr, as illustrated (Fig. 2-A) and as shown in an intraoperative photograph
(Fig. 2-B). Intraoperative photographs show the cementation of the mesh into the trough, with the mesh reflected proximally (Fig. 2-C) and distally (Fig. 2-D).
(Fig. 2-A reproduced by permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

created in the proximal-anterior aspect of the tibia for the
Marlex mesh to be cemented in place (Fig. 2). After the cement
cured, a lag screw was placed across the mesh and cement and
into the host bone for additional fixation. However, if the tibial
component was revised at the time of the mesh reconstruction,
the mesh was cemented in the canal during the cementation
of the tibial component (Fig. 3). The mesh was then passed
through a distal tunnel and incorporated with the remaining
aspects of the host patellar tendon (Fig. 4). As previously
described, the vastus medialis and vastus lateralis were mobi-
lized both dorsally and ventrally, which allowed the mesh to be
joined to the vastus lateralis proximally18. The vastus medialis
was then closed over the mesh in a classic “pants-over-vest”
fashion (Fig. 5).
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Fig. 3
When components are revised, the mesh can be cemented in an intramedullary position with the tibial component and stem, as shown in intraoperative
photographs, with the mesh reflected proximally (Fig. 3-A) and distally (Fig. 3-B).

Rehabilitation Protocol was typically changed every 2 to 3 weeks to prevent any pres-
A long leg cast (that included the foot) was applied to all sure ulcers. During this period, patients were toe-touch weight-
patients, with the knee in full extension for 12 weeks. The cast bearing and remained on anticoagulation. At 12 weeks, patients

Fig. 4
The mesh is incorporated into remaining host tissue distally, as illustrated (Fig. 4-A) and as shown in an intraoperative photograph (Fig. 4-B). The goal is to
have the mesh pass through the host tissue via a tunnel, but to have host tissue ventral and dorsal to the mesh to avoid any portion of the mesh rubbing on
the prosthesis. (Fig. 4-A reproduced by permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)
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Fig. 5
Figs. 5-A and 5-B The mesh is incorporated with the proximal tissue after aggressive ventral and dorsal mobilization of the vastus medialis obliquus and
vastus lateralis. Fig. 5-A Illustration showing the mesh incorporated between the vastus lateralis dorsally and the vastus medialis obliquus ventrally. Fig. 5-B
The remaining proximal mesh is excised, and the arthrotomy is closed. (Fig. 5-A reproduced by permission of the Mayo Foundation for Medical Education and
Research. All rights reserved.)
began a partial progressive weight-bearing protocol that in-
cluded the use of a hinged knee brace, locked in extension at all
times while walking. Therapy was initiated at this point as well,
with 0
to 45
of motion allowed the first month; 0
to 60
, the
second month; 0
to 75
, the third month; and 0
to 90
, the
fourth month. Thereafter, patients could weight-bear as tolerated
without any limitations on motion. Patients were recommended
to continue the use of a cane to avoid any catastrophic falls.
Statistical Analysis
Descriptive statistics are reported as the mean and standard devi-
ation, as the mean and range, or as the number and percentage, as
appropriate. The Kaplan-Meier28 and Cox proportional hazards
regression methods were used to assess survivorship; the time-to-
event outcomes of failure of the mesh, revision of the mesh,
revision of any component, reoperation for any reason, and other
complications were evaluated. Potential risk factors for these events
included age, sex, BMI, and prior attempts at surgical repair. All
statistical tests were 2-sided, and a p level of <0.05 was considered
significant. Analysis was performed using SAS (version 9.4; SAS
Institute) and R (version 3.2.0; R Core Team, R Foundation for
Statistical Computing).
Results
Survivorship
S ixteen patients experienced mesh failure. Failure was
defined as a rerupture or as a symptomatic lengthening of
the Marlex mesh at any time after reconstruction. Twelve of
those patients required mesh revision: 5 for patellar tendon
rupture, 5 for quadriceps tendon rupture, and 2 for sympto-
matic lengthening (Table I). At the time of the most recent
EXTENS OR MECHANISM RECONSTRUCTION WITH USE OF MARLEX
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follow-up, 7 of the 12 patients demonstrated no further com-
plications and demonstrated good clinical function, 3 required
the use of a walking aid, and 2 eventually underwent amputation
after recalcitrant infection. Four of the 12 patients had had
previous extensor mechanism disruptions treated with a method
other than Marlex mesh reconstruction, 3 after failed extensor
mechanism allografts and 1 after a failed primary suture repair.
The mean time to failure from Marlex mesh reconstruction to
mesh revision was 2 years (range, 2 months to 5 years). An
additional 4 patients with mesh failure did not undergo mesh
revision but were treated nonoperatively with use of a brace.
The 2-year survivorship free of mesh revision was 89%
for the overall cohort (95% confidence interval [CI]: 81% to
97%), 86% among patients with no prior extensor mechanism
reconstruction (95% CI: 76% to 97%), and 95% among pa-
tients with prior non-Marlex reconstructive attempts (95%
CI: 84% to 100%) (Fig. 6).
The 2-year survivorship free of mesh failure (with or
without revision of the mesh) was 85% for the overall cohort
(95% CI: 76% to 94%), 83% among patients with no prior
extensor mechanism reconstruction (95% CI: 72% to 94%),
and 90% among patients with prior reconstructive attempts
(95% CI: 77% to 100%) (Fig. 7).
The overall 2-year survivorship free of aseptic revision
was 89% (95% CI: 82% to 97%). The overall 2-year survi-
vorship free of reoperation for any reason was 73% (95% CI:
63% to 83%). Six patients developed PJIs within 2 years
after mesh reconstruction and were treated with 2-stage
exchange arthroplasty and use of organism-specific antibi-
otics for a minimum of 6 weeks. Two of these patients were
infection-free at the time of the latest follow-up, 2 patients
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TABLE I Patients with Mesh Failure Who Underwent Mesh Revision ä

Previous Extensor
Mechanism
Sex, Age (yr) BMI (kg/m2) Comorbidities Reconstruction Anatomical Location

F, 65 26 Metastatic adenocarcinoma Primary suture repair Patellar tendon

M, 80 42 Morbid obesity, diabetes None Quadriceps tendon
F, 61 43 Hypertension, diabetes, bilateral breast Extensor mechanism allograft Patellar tendon
carcinoma
F, 63 36 Hypertension, coronary artery disease None Patellar fracture
F, 70 20 Hyperthyroidism, mental illness Extensor mechanism allograft Patellar tendon

M, 53 37 Coronary artery disease, hypertension, None Quadriceps tendon

obesity, obstructive sleep apnea
F, 54 33 Multiple joint osteoarthritis None Quadriceps tendon
M, 71 32 Coronary artery disease, bladder cancer None Quadriceps tendon

F, 67 36 Obesity, diabetes None Patellar tendon

F, 61 33 Opioid dependence None Patellar tendon
F, 63 37 Opioid dependence, fibromyalgia None Patellar tendon

F, 59 44 Morbid obesity, multiple joint osteoarthritis Extensor mechanism allograft Patellar tendon

eventually underwent arthrodesis for recalcitrant infection, and
2 patients underwent amputation following mesh revision for a
series of recalcitrant infections, as previously mentioned.
The overall 2-year survivorship free of other complica-
tions was 89% for all patients (95% CI: 80% to 97%). Age, sex,
BMI, and previous attempts at nonsynthetic extensor mecha-
nism reconstruction were not significant risk factors for any of
our time-to-event outcomes (Table II).
Clinical Outcomes
The mean extensor lag prior to reconstruction was 35
± 17

(range, 10
to 70
), which improved by a mean of 26
to

Fig. 6
Kaplan-Meier curves showing survivorship free of mesh revision for patients with a prior reconstructive attempt and for patients with no prior reconstructive
attempt.
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TABLE I (continued)

Extensor Lag
Time to After Mesh Latest
Reason for Mesh Revision Failure (mo) Revision (
) Follow-up (yr) Final Outcome

Symptomatic lengthening 36 15 4.4 No further complication to date

Quadriceps tendon rerupture 2 0 5.2 No further complication to date
Patellar tendon rerupture 7 40 8 Ambulates with cane full time

Quadriceps tendon rerupture 18 20 2.5 No further complication to date

Repeat mesh and revision TKA due to quadriceps 60 0 2.3 No further complication to date
tendon rerupture
Revision mesh and tibial insert due to 30 0 3.7 Death 5 yr after mesh revision
symptomatic lengthening
Patellar tendon rerupture 7 20 4 No further complication to date
Quadriceps tendon rerupture 10 — 3.4 Amputation due to repeat infection
4 yr after mesh revision
Patellar tendon rerupture 18 0 6.7 No further complication to date
Patellar tendon rerupture 8 20 2.8 Ambulates with walker
Quadriceps tendon rerupture 36 — 2.8 Amputation 3 yr after 2nd mesh re-
revision due to repeat infection
Patellar tendon rerupture 33 60 3.9 Ambulates with walker

9
± 14
(range, 0
to 60
) at the time of the latest follow-up
(p < 0.001). Forty-six of the 66 patients with in-clinic mea-
surements at the latest follow-up achieved full extension or near-
full extension (lag of <10
) (Fig. 8). Active flexion was a mean
of 105
(range, 45
to 135
) prior to reconstruction and was
also 105
(range, 35
to 130
) at the time of the latest follow-up
(p = 0.82).
Patients demonstrated significant improvement in the
KSS after reconstruction (p < 0.001). The mean KSS prior to
reconstruction was 32 (range, 0 to 100), which improved to

Fig. 7
Kaplan-Meier curves showing survivorship free of mesh failure for patients with a prior reconstructive attempt and for patients with no prior reconstructive
attempt.
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valgus constraint prosthesis, which was successfully treated

TABLE II Analysis of Survivorship Risk Factors
with closed reduction approximately 10 months after mesh
Variable Hazard Ratio (95% CI) P Value reconstruction.

Age (per decade) 1.2 (0.7-2.2) 0.5 Discussion

Sex
Female
Male
1.2 (0.34-4.6)
1
BMI (per unit of kg/m2) 1 (0.9-1.1)
Prior reconstruction
Yes 1.2 (0.4-3.9)
No 1
72 (range, 18 to 95) at the time of the latest follow-up. The
mean KSS functional score prior to reconstruction was 28
(range, 0 to 100), which improved to 44 (range, 0 to 100) at
the time of the latest follow-up (p = 0.0009). Three patients
required the use of support during walking when they were
last seen in the clinic (2, a walker; and 1, full-time use of a
cane).
Complications
Two patients developed postoperative arthrofibrosis within
6 months after mesh reconstruction. Both patients were man-
aged with manipulation under anesthesia within 10 months of
the reconstruction. Prior to manipulation, flexion was 65

for 1 patient and 25
for the other, which improved to 95

and 50
, respectively, following manipulation. One patient
experienced superficial wound dehiscence, which was trea-
ted nonoperatively with immobilization for 6 weeks. One
patient experienced a posterior dislocation of the varus-
0.8 T he treatment of extensor mechanism disruption after
TKA has remained a challenge for decades29,30. This
condition is debilitating and can be complicated by chronic
0.9 ruptures, previous attempts at repair, the availability of
host tissue, and the functional demands of the patient6,31.
Although pain may improve following various reconstructive
0.8
techniques, many patients struggle to return to their pre-
disruption functional capacity and range of motion13,29. In
the present study on Marlex mesh reconstruction of the
extensor mechanism, we found excellent survivorship among
patients with patellar or quadriceps tendon rupture or patellar
fracture in the setting of acute, subacute, or chronic extensor
mechanism disruption. Our findings suggest that Marlex mesh
reconstruction provides substantial functional benefit with
excellent survivorship to patients with extensor mechanism
disruption.
To our knowledge, this series is the largest to date that
involves a stepwise surgical technique with a single type
of mesh—that is, Marlex mesh, a knitted monofilament
polypropylene—with mid-term follow-up. Similar recon-
structive techniques, such as the use of EMA, have demon-
strated poorer survivorship11,32. For example, Ricciardi et al.32
reported a 69% survivorship free of failure at a mean of 5.6
years among 25 patients who underwent reconstruction with
EMAs. The surgical technique used in that study was based on
the technique reported by Brown et al.11, who noted a rate of
56% for 10-year survivorship free of failure for any reason

Fig. 8
Clinical photographs made 6 months after reconstruction with a knitted monofilament polypropylene mesh, showing a patient with the lower limb at full
extension (Fig. 8-A), 30
of active elevation (Fig. 8-B), 60
of active elevation (Fig. 8-C), and 90
of active elevation (Fig. 8-D).
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among a cohort of 50 patients with EMAs. Siwek and Rao12
studied more conservative techniques, such as primary repair.
In their study, the authors found that the time to recon-
struction was a more important factor for survivorship than
was the technique used for repair among patients with tendon
ruptures, and that acutely treated ruptures demonstrated
better survivorship than did ruptures with delayed treatment.
Interestingly, in the present study, patients who had previ-
ously undergone a non-Marlex reconstruction of the extensor
mechanism demonstrated better survivorship at 2 years
compared with patients with no prior reconstruction (95%
and 86%, respectively). We believe this may be because of
greater scar-tissue formation surrounding the host tissue in
patients with prior reconstructive attempts. Increased host-
tissue availability may contribute to a more durable
reconstruction for mesh incorporation and survival. Al-
though the 89% 2-year survivorship free of mesh revision in
the present study represents an excellent result, achieving
longer-term survivorship for this type of reconstruction
remains an ongoing process of refining surgical technique,
optimizing patient rehabilitation, and managing modifiable
risks factors.
The clinical results of this study are consistent with those
reported by Browne and Hanssen18, validating the reproduci-
bility of this technique. In that study, patients demonstrated
a similar improvement in extensor lag, with a mean post-
reconstruction extensor lag of 10
among a smaller subset of
patients18. Moreover, in the present study, the mean active
flexion prior to reconstruction was the same as that after a
mean of 4 years of follow-up, with significant functional im-
provement demonstrated. According to the findings of Brown
et al.11, nearly 40% of patients who underwent reconstruction
with use of EMA were reported to have an extensor lag of >30

at the time of mid-term follow-up. Such severity in lag may be
attributed to continued weakness of the extensor mechanism
or attenuation of the graft related to initial intraoperative
tensioning11. An early series of short-term studies by Burnett
et al.16,17 found a direct correlation between the clinical success
of EMA reconstruction and the degree of intraoperative
tensioning.
No unique complications were noted in the cohort of
the present study. Although 6 patients developed PJI within
the first 2 years postoperatively, an 8% infection rate is lower
than the 10% rate of infection reported in the study by Brown
et al. in which EMA was used11. In a large series, Nikolaus
et al.33 reported the cumulative risk of infection after aseptic
revision TKA to be 2.4% at 5 years and 3.3% at 10 years. The
increased risk of PJI after these revision procedures may be
attributed to a combination of poorly vascularized tissue as
a result of multiple operations, increased age, and related
comorbidities34.
An analysis of the 16 failed reconstructions revealed that
all patients had experienced trauma to the knee from a fall,
which led to mesh failure. Nine of the 16 falls seemed to be
unprovoked and likely could be attributed to residual quadri-
ceps muscle weakness following the immobilization period
EXTENS OR MECHANISM RECONSTRUCTION WITH USE OF MARLEX
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after reconstruction. It may be warranted for surgeons to advise
continued knee protection for 1 year to allow quadriceps
strength to return. Additionally, 12 of the 16 patients who
experienced a failure had multiple systemic comorbidities that
have been shown to compromise tissue integrity at tendinous
insertion points35. Four of those 12 patients had had a failed
reconstruction using a method other than Marlex mesh prior
to reconstruction with the Marlex mesh. However, our hazard
risk analysis did not identify any of the tested demographic or
surgical factors as risk factors for mesh failure in this series.
With a mean time to mesh failure of 2 years, the early post-
reconstruction period is a high-risk period for failure. Further
investigation is necessary to define risk factors for mesh failure
and how to mitigate these risks.
This study had limitations. Foremost, the follow-up
was mid-term in length, at 4 years. It is expected that the
survivorship will decrease with continued follow-up. How-
ever, to our knowledge, this is the largest series to date to
utilize a single reconstructive technique with Marlex mesh. In
addition, various extensor mechanism disruptions (patellar
tendon and quadriceps tendon disruption as well as cata-
strophic patellar fracture) were treated with the same tech-
nique. Although some may see this as a heterogeneous cohort,
we see this technique as universal for any extensor mechanism
disruption.
In conclusion, Marlex mesh reconstruction of the
extensor mechanism after primary or revision TKA demon-
strated excellent mid-term survivorship and clinical results
for this catastrophic complication. This surgical reconstruc-
tive technique demonstrated increased functional improve-
ment across a spectrum of extensor mechanism disruption
subtypes and had an acceptable rate of complications.
Appendix
A table showing demographic and clinical data by case is
available with the online version of this article as a data
supplement at jbjs.org (http://links.lww.com/JBJS/E816). n
Matthew P. Abdel, MD1
Christopher G. Salib, MD1
Kristin C. Mara, MS1
Mark W. Pagnano, MD1
Kevin I. Perry, MD1
Arlen D. Hanssen, MD1
1Department of Orthopaedic Surgery (M.P.A., C.G.S., M.W.P., K.I.P., and
A.D.H.) and Health Sciences Research (K.C.M.), Mayo Clinic, Rochester,
Minnesota
E-mail address for M.P. Abdel: abdel.matthew@mayo.edu
E-mail address for C.G. Salib: salib.christopher@mayo.edu
E-mail address for K.C. Mara: mara.kristin@mayo.edu
E-mail address for M.W. Pagnano: pagnano.mark@mayo.edu
E-mail address for K.I. Perry: perry.kevin@mayo.edu
E-mail address for A.D. Hanssen: hanssen.arlen@mayo.edu
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V O L U M E 1 00-A N U M B E R 15 A U G U S T 1, 2 018
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ORCID iD for M.P. Abdel: 0000-0002-2398-1724
ORCID iD for C.G. Salib: 0000-0002-6455-9036
ORCID iD for K.C. Mara: 0000-0001-9824-6049
References
1. Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture
after total knee arthroplasty. Prevalence, complications, and outcomes. J Bone Joint
Surg Am. 2005 Jan;87(1):37-45.
2. Bates MD, Springer BD. Extensor mechanism disruption after total knee arthro-
plasty. J Am Acad Orthop Surg. 2015 Feb;23(2):95-106.
3. Maffulli N, Spiezia F, La Verde L, Rosa MA, Franceschi F. The management of
extensor mechanism disruption after total knee arthroplasty: a systematic review.
Sports Med Arthrosc Rev. 2017 Mar;25(1):41-50.
4. Hsu KY, Wang KC, Ho WP, Hsu RW. Traumatic patellar tendon ruptures: a follow-up
study of primary repair and a neutralization wire. J Trauma. 1994 May;36(5):658-60.
5. Brooks P. Extensor mechanism ruptures. Orthopedics. 2009 Sep;32(9). pii:
orthosupersite.com/view.asp?rID=42852.
6. Rosenberg AG. Management of extensor mechanism rupture after TKA. J Bone
Joint Surg Br. 2012 Nov;94(11)(Suppl A):116-9.
7. Whiteside LA. Surgical technique: vastus medialis and vastus lateralis as flap
transfer for knee extensor mechanism deficiency. Clin Orthop Relat Res. 2013 Jan;
471(1):221-30.
8. Diaz-Ledezma C, Orozco FR, Delasotta LA, Lichstein PM, Post ZD, Ong AC.
Extensor mechanism reconstruction with Achilles tendon allograft in TKA: results of
an abbreviate rehabilitation protocol. J Arthroplasty. 2014 Jun;29(6):1211-5. Epub
2013 Dec 19.
9. Crossett LS, Sinha RK, Sechriest VF, Rubash HE. Reconstruction of a ruptured
patellar tendon with Achilles tendon allograft following total knee arthroplasty. J
Bone Joint Surg Am. 2002 Aug;84(8):1354-61.
10. Karas V, Sherman S, Hussey K, Baker C 3rd, Bach B Jr, Cole B, Bush-Joseph C.
Allograft reconstruction for extensor mechanism injuries. J Knee Surg. 2014 Dec;
27(6):489-96. Epub 2014 Feb 28.
11. Brown NM, Murray T, Sporer SM, Wetters N, Berger RA, Della Valle CJ. Extensor
mechanism allograft reconstruction for extensor mechanism failure following total
knee arthroplasty. J Bone Joint Surg Am. 2015 Feb 18;97(4):279-83.
12. Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J
Bone Joint Surg Am. 1981 Jul;63(6):932-7.
13. Matava MJ. Patellar tendon ruptures. J Am Acad Orthop Surg. 1996 Nov;4(6):
287-96.
14. Meyer Z, Ricci WM. Knee extensor mechanism repairs: standard suture repair
and novel augmentation technique. J Orthop Trauma. 2016 Aug;30(Suppl 2):S30-1.
15. Leopold SS, Greidanus N, Paprosky WG, Berger RA, Rosenberg AG. High rate of
failure of allograft reconstruction of the extensor mechanism after total knee
arthroplasty. J Bone Joint Surg Am. 1999 Nov;81(11):1574-9.
16. Burnett RSJ, Berger RA, Paprosky WG, Della Valle CJ, Jacobs JJ, Rosenberg AG.
Extensor mechanism allograft reconstruction after total knee arthroplasty. A com-
parison of two techniques. J Bone Joint Surg Am. 2004 Dec;86(12):2694-9.
17. Burnett RSJ, Berger RA, Della Valle CJ, Sporer SM, Jacobs JJ, Paprosky WG,
Rosenberg AG. Extensor mechanism allograft reconstruction after total knee
arthroplasty. J Bone Joint Surg Am. 2005 Sep;87(Pt 2)(Suppl 1):175-94.
18. Browne JA, Hanssen AD. Reconstruction of patellar tendon disruption after total
knee arthroplasty: results of a new technique utilizing synthetic mesh. J Bone Joint
Surg Am. 2011 Jun 15;93(12):1137-43.
EXTENS OR MECHANISM RECONSTRUCTION WITH USE OF MARLEX
MESH
ORCID iD for M.W. Pagnano: 0000-0003-1679-0046
ORCID iD for K.I. Perry: 0000-0003-1457-442X
ORCID iD for A.D. Hanssen: 0000-0001-8093-1777
19. Morrey MC, Barlow JD, Abdel MP, Hanssen AD. Synthetic mesh augmentation of
acute and subacute quadriceps tendon repair. Orthopedics. 2016 Jan-Feb;39(1):e9-
13. Epub 2015 Dec 28.
20. Usher FC, Gannon JP. Marlex mesh, a new plastic mesh for replacing tissue
defects. I. Experimental studies. AMA Arch Surg. 1959 Jan;78(1):131-7.
21. Usher FC, Fries JG, Ochsner JL, Tuttle LL Jr. Marlex mesh, a new plastic mesh for
replacing tissue defects. II. Clinical studies. AMA Arch Surg. 1959 Jan;78(1):138-
45.
22. Patt HH. Marlex mesh grafts in inguinal hernia repair. Arch Surg. 1967 May;
94(5):734-6.
23. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic
organ prolapse in women. Cochrane Database Syst Rev. 2013 Apr 30;4:
CD004014.
24. Robinson TN, Clarke JH, Schoen J, Walsh MD. Major mesh-related complica-
tions following hernia repair: events reported to the Food and Drug Administration.
Surg Endosc. 2005 Dec;19(12):1556-60. Epub 2005 Oct 5.
25. Junge K, Binnebösel M, von Trotha KT, Rosch R, Klinge U, Neumann UP,
Lynen Jansen P. Mesh biocompatibility: effects of cellular inflammation and
tissue remodelling. Langenbecks Arch Surg. 2012 Feb;397(2):255-70. Epub
2011 Apr 1.
26. Abdel MP, von Roth P, Cross WW, Berry DJ, Trousdale RT, Lewallen DG. Total
knee arthroplasty in patients with a prior tibial plateau fracture: a long-term report at
15 years. J Arthroplasty. 2015 Dec;30(12):2170-2. Epub 2015 Jun 20.
27. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical
rating system. Clin Orthop Relat Res. 1989 Nov;(248):13-4.
28. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J
Am Stat Assoc. 1958 Jun;53(282):457-81.
29. Rand JA, Morrey BF, Bryan RS. Patellar tendon rupture after total knee arthro-
plasty. Clin Orthop Relat Res. 1989 Jul;(244):233-8.
30. Nam D, Abdel MP, Cross MB, LaMont LE, Reinhardt KR, McArthur BA, Mayman
DJ, Hanssen AD, Sculco TP. The management of extensor mechanism complications
in total knee arthroplasty. AAOS exhibit selection. J Bone Joint Surg Am. 2014 Mar
19;96(6):e47-9.
31. Schoderbek RJJ Jr, Brown TE, Mulhall KJ, Mounasamy V, Iorio R, Krackow KA,
Macaulay W, Saleh KJ. Extensor mechanism disruption after total knee arthroplasty.
Clin Orthop Relat Res. 2006 May;(446):176-85.
32. Ricciardi BF, Oi K, Trivellas M, Lee YY, Della Valle AG, Westrich GH. Survivorship
of extensor mechanism allograft reconstruction after total knee arthroplasty. J
Arthroplasty. 2017 Jan;32(1):183-8. Epub 2016 Jun 29.
33. Nikolaus OB, McLendon PB, Hanssen AD, Mabry TM, Berbari EF, Sierra RJ.
Factors associated with 20-year cumulative risk of infection after aseptic index
revision total knee arthroplasty. J Arthroplasty. 2016 Apr;31(4):872-7. Epub 2015
Nov 10.
34. Bae DK, Song SJ, Heo DB, Lee SH, Song WJ. Long-term survival rate of implants
and modes of failure after revision total knee arthroplasty by a single surgeon. J
Arthroplasty. 2013 Aug;28(7):1130-4. Epub 2012 Dec 7.
35. Lee D, Stinner D, Mir H. Quadriceps and patellar tendon ruptures. J Knee Surg.
2013 Oct;26(5):301-8. Epub 2013 Aug 16.