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Vastus Medialis and Lateralis Flaps for Quadriceps Insufficiency Post TKA by Dr. Anoop Jhurani
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Vastus Medialis and Lateralis Flaps for Quadriceps Insufficiency Post TKA by Dr. Anoop Jhurani
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T00H13M02S
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https://cadmoreoriginalmedia.blob.core.windows.net/943ae359-2147-47d7-baae-5deb7733b3b8/Vastus medialis and lateralis flaps for quadriceps insuffici.mp4?sv=2019-02-02&sr=c&sig=X1fvLWMJau3YM4bFXOuQ7AZdHfrcV8mPQSLNqQZv37g%3D&st=2024-11-21T14%3A27%3A12Z&se=2024-11-21T16%3A32%3A12Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about soft tissue reconstruction for proximal quadriceps deficiency or insufficiency post TKA. So we all know that there can be implant related, bone related causes causing failure of PCA and the reconstruction has been well outlined for revision decay. But when there is soft tissue insufficiency, quadriceps insufficiency or extensor mechanism insufficiency, that's a major challenge to reconstruct.
ANOOP JHURANI: It can happen about the patella before the tendonis insertion or in the tendonis insertion below the patella. Now this particular patient presented after bilateral TKA with inability to walk. The x-rays looked pretty all right. The patella is not resurfaced, but there is nothing to explain in the bone or in the implant that the patient cannot walk. Now, this patient could not progress his gait, and he had a palpable gap just proximal to the patella in the main musculotendinous area of the quadriceps mechanism.
ANOOP JHURANI: There is no neurological cause. We eliminated all neurological cause, other muscular causes, though he has diabetes and slightly overweight. But the main problem was quadriceps insufficiency proximally above the patella. And you can see there is a palpable gap in the main quadriceps muscle and patient cannot perform a salat or cannot walk really progress in gait.
ANOOP JHURANI: There is no infection, no neurological cause, implants look, OK, alignment is reasonable and you can see bilateral palpable gap in the quadriceps mechanism and patient cannot do as a salat and he has that kind of extension lag and that is why he is not able to walk. He has controlled diabetes, he has some varicose pigmentation on the right lower limb, but nothing major other to explain this kind of quadriceps insufficiency except a poor closure.
ANOOP JHURANI: So you can see this patient is barely able to walk. Somebody is holding him and he's holding a stick and his knee gives away and goes back into slight hyperextension and he cannot hold his weight on the legs and he complains of both the legs giving away. So that's classical of quadriceps insufficiency. Now the plan is to reconstruct this with Vastus Medialis and Lateralis Flap as described by Whiteside in court in 2013.
ANOOP JHURANI: So there is no gross instability, medially, laterally, there is no instability. You can see anteroposterior, he's quite all right. He's got reasonable range of motion and the main thing is quadriceps insufficiency. So before we take on to soft tissue reconstruction, we have to eliminate all bony causes, implant related causes, some old/cold fractures, everything before we come to this diagnosis.
ANOOP JHURANI: And here you can see that there is a palpable gap in the quadriceps mechanism proximal to the patella and you can see that area is just soft, fibrous tissue and fat. So this is poor closure. Truly, somebody hasn't closed it well and that is causing this whole defect. You can see that finger there in the quadriceps mechanism.
ANOOP JHURANI: And the plan is to reconstruct it, reconstruct that deficit by Vastus Medialis and Lateralis flap. Now we don't have allografts in our country and allografts have their own set of challenges of infection, loss of uptake and extension lags. So best is to use the patient's own local based flaps, which are Vastus Medialis and Lateralis so to really do extensile dissection, that's the Vastus Medialis, that's directives and this is the lateral.
ANOOP JHURANI: So M and L are Medialis and Lateralis. And then we excised the fibrous tissue, mobilized the Vastus Medialis and Lateralis, one needs to understand these is not advancement of Vastus Medialis and Lateralis, these are two flaps. That means we are going to dissect them off their vascular pedicle and take their tendon this insertion and come into the center where their deficit is.
ANOOP JHURANI: And you can see that is the deficit and that is our arthroscopy. We'll obviously send cultures, examine the implants for anything that we might have missed on the x-ray, though we meticulously analyze the X-ray and the clinical situation to come to a conclusion that this is a quadriceps mechanism problem. Now first is to elevate the Vastus Medialis and that is done by taking the Vastus Medialis off the
ANOOP JHURANI: muscular septum and then taking it off the medial collateral ligament and off the medial retinaculum. Same for Vastus Lateralis is to save the vascular pedicle underneath, take it of the lateral intramuscular septum and take the tendonis insertion off and both these tendonis insertion will come in the center for closure that we will describe. Important thing on the medial side is to save the adductor fascia because below that lies the main and adductor canal where the vessel is.
ANOOP JHURANI: So one has to be careful about that on the lateral side, also, we have to be careful below the lateral intramuscular septum. So that is the tendonis insertion of the vastus lateralis and you take the tendonis insertion of the septum and do the same for vastus medialis. So this is important this is not advancement of vastus medialis, lateralis. These are flaps.
ANOOP JHURANI: So we have to take the whole flap off, mobilize it on its must on the vascular pedicle and take it off the tendonis insertion and then bring it to the center where the main quadriceps pull is, where the main defect is. So this is an important point here and this is the way you have to mobilize it, really take the dissection proximally, take it off the lateral intramuscular septum, release it off the vastus intermedialis, same for vastus
ANOOP JHURANI: medialis, be very careful of the adductor fascia to prevent vascular injury adductor canal and then mobilize. It's not very difficult, it can be easily done by an orthopedic surgeon and we should know how to do this. So you can see here, vastus lateralis and vastus medialis coming very nicely, the tendonis insertion is off the intramuscular septa and of the retinicular head
ANOOP JHURANI: and then it comes in the center over the patella. We have two drill holes in the patella and then get both the flaps into it by a Graco suture that will just show. And this is important to get the suturing right in absolute extension, because otherwise the patient may fail again. So the suturing technique is very important. It's a continuous lock as described by Graco. So you take a suture in, come in, and then take a locking suture like that, as you can see, make two drill holes in the superior pole of patella and then get both the flaps in along the direction of the pull, bringing it to the center so that the patient can bear weight and does not buckle under his own weight.
ANOOP JHURANI: This is important and the suturing techniques is extremely important and one has to be meticulous with the suturing technique that's the vastus medialis. You can see the locking suture as described by Graco, this is well described in Whiteside's paper, you can refer to it also, it's in CORA. So there you can see you've made a tendon out of it, but it's not rollover.
ANOOP JHURANI: It's important that you don't suture it in a way that it all becomes a big, big roll. It has to be in shape, it has to spread nicely over the superior pole of patella. Those are two holes in the superior hole of patella, you take a thick needle, fill it, take a thick needle, and then pass your suture through it. You can hold the patella with the dowel clamp, as you can see here.
ANOOP JHURANI: So that's stable and you are able to pass two sutures into reverse directions for both the flaps and then tie them. So that's how the sutures pass through the patella and then you tie them very tight with the knee in full extension, because if the flap is loose, it's not going to serve any purpose. It's going to be, it has to be tight and it has to be tied in complete extension with a number five suture
ANOOP JHURANI: so there you can see a number five non absorbable suture. This patient has a bilateral problem. We are doing only one side to see how the result is, how the patient complies, how the patient walks, and then we do the other side. Unfortunately, the patient was to travel to India from outside for the second knee, but he could not because of the corona crisis.
ANOOP JHURANI: And we have not done the second side, he will come whenever he can once the corona crisis is over. If the defect is below the patella and the tendonis insertion, one can replace the medial gastrocnemius flap for a tendonis effect. So these three flaps; that is vastus medialis, lateralis, this is for proximal quadriceps deficiency and medial gastrocnemius flap for a tendonis deficiency should be known by every arthroplasty surgeon to reconstruct extensor mechanism problems, especially in our country where extensor mechanism allograft is not that widely available.
ANOOP JHURANI: There you can see that the whole tendon and the retinicular closure will be on this flap. Now you can see the vastus medialis and lateralis has nicely come on the patella and both the tendons insertions are there. The rehabilitation is a challenge. We need to keep this patient in complete extension for six weeks. The patient will go partial weight bearing after three weeks, full weight bearing after six weeks
ANOOP JHURANI: but the knee bending will be very gradual after six weeks and very guarded till about three months till the patient gets a full extension. This patient is still in the rehabilitation and now has a complete acelat. So there you can see that the tendon is there and the knee needs to be closed meticulously otherwise it may lead to infection because we have raised both the vastus medialis and lateralis flaps.
ANOOP JHURANI: So we have to get the soft tissue, both the intramuscular septum, the retiniculum over the new tendonis insertion so that the knee joint bursa is not exposed otherwise, that will create some other kind of a complication like infection. So it's very important the whole procedure is a soft tissue based procedure, the raising of flaps, the tying of the tendon and meticulous closure,
ANOOP JHURANI: so there is no dead space left after raising both the flaps. This is critical for the success of this operation. So there you can see that there is no deficiency below the patella. That is, there is no tendonis deficiency and then after that is the standard closure of the osteotomy, the soft tissues over the drain. So unfortunately these flaps have not been given that much attention even in international literature or in meetings, et cetera and mostly talk is about extensor mechanism, allograft, which has its own set of problems of uptake, transmitted infection or extension lag or rejection.
ANOOP JHURANI: best is to use patient's own muscles, which are always there.
ANOOP JHURANI: All we need to do is to mobilize, take local flaps, and in male patients, especially somebody like this, the quantum of both the muscles is pretty good because the muscular man. So you get a lot of muscle mass, strong tendonis attachments to give us a reasonable result. The expectation should be that the patient would have 5 degree to 90 or 100 degree range of motion, patient may still have high degree of an extension lag.
ANOOP JHURANI: And you can see that it's nice healing. And this patient in this particular picture that you'll see next has about 5 or 10 degree of extension lag, but can perform a silaris, started feeling more stable in his last follow up that he's sent to us, he's able to walk and has got only 5 degree of extension lag. He's awaiting the other side and I'm sure once the other side is done, the patient will feel far better and will have quadriceps sufficiency after this reconstruction.
ANOOP JHURANI: Well, thank you very much.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about soft tissue reconstruction for proximal quadriceps deficiency or insufficiency post TKA. So we all know that there can be implant related, bone related causes causing failure of PCA and the reconstruction has been well outlined for revision decay. But when there is soft tissue insufficiency, quadriceps insufficiency or extensor mechanism insufficiency, that's a major challenge to reconstruct.
ANOOP JHURANI: It can happen about the patella before the tendonis insertion or in the tendonis insertion below the patella. Now this particular patient presented after bilateral TKA with inability to walk. The x-rays looked pretty all right. The patella is not resurfaced, but there is nothing to explain in the bone or in the implant that the patient cannot walk. Now, this patient could not progress his gait, and he had a palpable gap just proximal to the patella in the main musculotendinous area of the quadriceps mechanism.
ANOOP JHURANI: There is no neurological cause. We eliminated all neurological cause, other muscular causes, though he has diabetes and slightly overweight. But the main problem was quadriceps insufficiency proximally above the patella. And you can see there is a palpable gap in the main quadriceps muscle and patient cannot perform a salat or cannot walk really progress in gait.
ANOOP JHURANI: There is no infection, no neurological cause, implants look, OK, alignment is reasonable and you can see bilateral palpable gap in the quadriceps mechanism and patient cannot do as a salat and he has that kind of extension lag and that is why he is not able to walk. He has controlled diabetes, he has some varicose pigmentation on the right lower limb, but nothing major other to explain this kind of quadriceps insufficiency except a poor closure.
ANOOP JHURANI: So you can see this patient is barely able to walk. Somebody is holding him and he's holding a stick and his knee gives away and goes back into slight hyperextension and he cannot hold his weight on the legs and he complains of both the legs giving away. So that's classical of quadriceps insufficiency. Now the plan is to reconstruct this with Vastus Medialis and Lateralis Flap as described by Whiteside in court in 2013.
ANOOP JHURANI: So there is no gross instability, medially, laterally, there is no instability. You can see anteroposterior, he's quite all right. He's got reasonable range of motion and the main thing is quadriceps insufficiency. So before we take on to soft tissue reconstruction, we have to eliminate all bony causes, implant related causes, some old/cold fractures, everything before we come to this diagnosis.
ANOOP JHURANI: And here you can see that there is a palpable gap in the quadriceps mechanism proximal to the patella and you can see that area is just soft, fibrous tissue and fat. So this is poor closure. Truly, somebody hasn't closed it well and that is causing this whole defect. You can see that finger there in the quadriceps mechanism.
ANOOP JHURANI: And the plan is to reconstruct it, reconstruct that deficit by Vastus Medialis and Lateralis flap. Now we don't have allografts in our country and allografts have their own set of challenges of infection, loss of uptake and extension lags. So best is to use the patient's own local based flaps, which are Vastus Medialis and Lateralis so to really do extensile dissection, that's the Vastus Medialis, that's directives and this is the lateral.
ANOOP JHURANI: So M and L are Medialis and Lateralis. And then we excised the fibrous tissue, mobilized the Vastus Medialis and Lateralis, one needs to understand these is not advancement of Vastus Medialis and Lateralis, these are two flaps. That means we are going to dissect them off their vascular pedicle and take their tendon this insertion and come into the center where their deficit is.
ANOOP JHURANI: And you can see that is the deficit and that is our arthroscopy. We'll obviously send cultures, examine the implants for anything that we might have missed on the x-ray, though we meticulously analyze the X-ray and the clinical situation to come to a conclusion that this is a quadriceps mechanism problem. Now first is to elevate the Vastus Medialis and that is done by taking the Vastus Medialis off the
ANOOP JHURANI: muscular septum and then taking it off the medial collateral ligament and off the medial retinaculum. Same for Vastus Lateralis is to save the vascular pedicle underneath, take it of the lateral intramuscular septum and take the tendonis insertion off and both these tendonis insertion will come in the center for closure that we will describe. Important thing on the medial side is to save the adductor fascia because below that lies the main and adductor canal where the vessel is.
ANOOP JHURANI: So one has to be careful about that on the lateral side, also, we have to be careful below the lateral intramuscular septum. So that is the tendonis insertion of the vastus lateralis and you take the tendonis insertion of the septum and do the same for vastus medialis. So this is important this is not advancement of vastus medialis, lateralis. These are flaps.
ANOOP JHURANI: So we have to take the whole flap off, mobilize it on its must on the vascular pedicle and take it off the tendonis insertion and then bring it to the center where the main quadriceps pull is, where the main defect is. So this is an important point here and this is the way you have to mobilize it, really take the dissection proximally, take it off the lateral intramuscular septum, release it off the vastus intermedialis, same for vastus
ANOOP JHURANI: medialis, be very careful of the adductor fascia to prevent vascular injury adductor canal and then mobilize. It's not very difficult, it can be easily done by an orthopedic surgeon and we should know how to do this. So you can see here, vastus lateralis and vastus medialis coming very nicely, the tendonis insertion is off the intramuscular septa and of the retinicular head
ANOOP JHURANI: and then it comes in the center over the patella. We have two drill holes in the patella and then get both the flaps into it by a Graco suture that will just show. And this is important to get the suturing right in absolute extension, because otherwise the patient may fail again. So the suturing technique is very important. It's a continuous lock as described by Graco. So you take a suture in, come in, and then take a locking suture like that, as you can see, make two drill holes in the superior pole of patella and then get both the flaps in along the direction of the pull, bringing it to the center so that the patient can bear weight and does not buckle under his own weight.
ANOOP JHURANI: This is important and the suturing techniques is extremely important and one has to be meticulous with the suturing technique that's the vastus medialis. You can see the locking suture as described by Graco, this is well described in Whiteside's paper, you can refer to it also, it's in CORA. So there you can see you've made a tendon out of it, but it's not rollover.
ANOOP JHURANI: It's important that you don't suture it in a way that it all becomes a big, big roll. It has to be in shape, it has to spread nicely over the superior pole of patella. Those are two holes in the superior hole of patella, you take a thick needle, fill it, take a thick needle, and then pass your suture through it. You can hold the patella with the dowel clamp, as you can see here.
ANOOP JHURANI: So that's stable and you are able to pass two sutures into reverse directions for both the flaps and then tie them. So that's how the sutures pass through the patella and then you tie them very tight with the knee in full extension, because if the flap is loose, it's not going to serve any purpose. It's going to be, it has to be tight and it has to be tied in complete extension with a number five suture
ANOOP JHURANI: so there you can see a number five non absorbable suture. This patient has a bilateral problem. We are doing only one side to see how the result is, how the patient complies, how the patient walks, and then we do the other side. Unfortunately, the patient was to travel to India from outside for the second knee, but he could not because of the corona crisis.
ANOOP JHURANI: And we have not done the second side, he will come whenever he can once the corona crisis is over. If the defect is below the patella and the tendonis insertion, one can replace the medial gastrocnemius flap for a tendonis effect. So these three flaps; that is vastus medialis, lateralis, this is for proximal quadriceps deficiency and medial gastrocnemius flap for a tendonis deficiency should be known by every arthroplasty surgeon to reconstruct extensor mechanism problems, especially in our country where extensor mechanism allograft is not that widely available.
ANOOP JHURANI: There you can see that the whole tendon and the retinicular closure will be on this flap. Now you can see the vastus medialis and lateralis has nicely come on the patella and both the tendons insertions are there. The rehabilitation is a challenge. We need to keep this patient in complete extension for six weeks. The patient will go partial weight bearing after three weeks, full weight bearing after six weeks
ANOOP JHURANI: but the knee bending will be very gradual after six weeks and very guarded till about three months till the patient gets a full extension. This patient is still in the rehabilitation and now has a complete acelat. So there you can see that the tendon is there and the knee needs to be closed meticulously otherwise it may lead to infection because we have raised both the vastus medialis and lateralis flaps.
ANOOP JHURANI: So we have to get the soft tissue, both the intramuscular septum, the retiniculum over the new tendonis insertion so that the knee joint bursa is not exposed otherwise, that will create some other kind of a complication like infection. So it's very important the whole procedure is a soft tissue based procedure, the raising of flaps, the tying of the tendon and meticulous closure,
ANOOP JHURANI: so there is no dead space left after raising both the flaps. This is critical for the success of this operation. So there you can see that there is no deficiency below the patella. That is, there is no tendonis deficiency and then after that is the standard closure of the osteotomy, the soft tissues over the drain. So unfortunately these flaps have not been given that much attention even in international literature or in meetings, et cetera and mostly talk is about extensor mechanism, allograft, which has its own set of problems of uptake, transmitted infection or extension lag or rejection.
ANOOP JHURANI: best is to use patient's own muscles, which are always there.
ANOOP JHURANI: All we need to do is to mobilize, take local flaps, and in male patients, especially somebody like this, the quantum of both the muscles is pretty good because the muscular man. So you get a lot of muscle mass, strong tendonis attachments to give us a reasonable result. The expectation should be that the patient would have 5 degree to 90 or 100 degree range of motion, patient may still have high degree of an extension lag.
ANOOP JHURANI: And you can see that it's nice healing. And this patient in this particular picture that you'll see next has about 5 or 10 degree of extension lag, but can perform a silaris, started feeling more stable in his last follow up that he's sent to us, he's able to walk and has got only 5 degree of extension lag. He's awaiting the other side and I'm sure once the other side is done, the patient will feel far better and will have quadriceps sufficiency after this reconstruction.
ANOOP JHURANI: Well, thank you very much.
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