Extensor Mechanism Reconstruction with Use of Marlex Mesh.

BACKGROUND

Marlex mesh reconstruction of the extensor mechanism via a stepwise surgical approach is a viable option to treat disruption of the extensor mechanism after total knee arthroplasty (TKA).

DESCRIPTION

Extensor mechanism reconstruction with mesh involves a stepwise surgical approach with a particular monofilament polypropylene mesh (Marlex; C.R. Bard). Prior to incision, the 10 × 14-in (25 × 36-cm) sheet of Marlex mesh is rolled onto itself 8 to 10 times and sewn together. If the tibia is not being revised, a burr is utilized to create a trough in the tibia. Five centimeters of the tapered portion of the mesh are predipped in bone cement. The remaining cement is inserted into the trough. The tapered portion of the mesh is inserted into the tibial trough, ensuring that the mesh is fully seated. After the cement has cured, a lag screw is placed across the mesh and cement and into host bone. If the tibia is being revised at the time of the Marlex mesh reconstruction, the 5 cm of predipped mesh is placed anteriorly in the medullary canal in line with the tibial crest. The remaining procedure is similar regardless of whether the components are revised. At the level of the joint, it is essential to ensure that the mesh is covered with host tissue. Next, the proximal reconstruction, which involves mobilizing the vastus lateralis and vastus medialis obliquus (VMO) distally by releasing all ventral and dorsal soft-tissue adhesions off the muscle bellies, is completed. Finally, the mesh is unitized to the vastus lateralis. With the limb maintained in full extension, the mesh is pulled directly proximally while another assistant pulls the vastus lateralis distally and medially. The vastus lateralis is deep, and the mesh is directly on top of it. Multiple nonabsorbable sutures are placed through the mesh and vastus lateralis. The VMO is then pulled distally and laterally over the mesh (which is now unitized to the vastus lateralis) by an assistant. Multiple nonabsorbable sutures (usually 8) are placed through the VMO, through the mesh, and through the vastus lateralis, unitizing the entire construct.

ALTERNATIVES

Nonoperative treatments include a drop-lock hinge brace or knee immobilizer. Operative treatments include whole extensor mechanism allograft reconstruction or Achilles tendon allograft reconstruction.

RATIONALE

The procedure avoids the limitations of allograft with regard to availability, cost, and risk of disease transmission. The technique is reproducible and cost-effective, and it has excellent functional and survivorship outcomes.