Report Details Use of Marlex Hernia Mesh for Reconstruction of Failed Extensor Mechanism in TKA

Complete disruption of the extensor mechanism, including periprosthetic quadriceps tendon rupture, patella tendon rupture, and patella fracture with loss of active extension, is one of the most challenging complications in adult knee reconstruction. Abdel et al published a long-term report of the use of Marlex hernia mesh for reconstruction of the failed extensor mechanism in total knee arthroplasty in the Journal of Bone and Joint (JBJS). At a mean 8-year follow-up, they demonstrated favorable results with a mean extensor lag of 9 degrees. This is an important study because it provides arguably the only technique for treating this challenging problem that has demonstrated good results at long-term follow-up.

Failure of the knee extensor mechanism in a primary or revision total knee replacement is a surgical nightmare. As described by the authors, current techniques to treat this problem have had very poor outcomes.

These techniques include direct repair with or without the use of allograft tissue, extensor mechanism allograft, and muscle flaps. These methods have had failure rates exceeding 60 percent. The most promising of these techniques, extensor mechanism allograft reconstruction, demonstrated excellent outcomes at early follow-up with minimal extensor lag. However, the authors noted that survivorship for extensor allograft reconstruction fell to 56 percent at 10 years with extensor lag of more than 30 degrees. Approximately 40 percent of these reconstructions were considered failures.

Abdel et al previously reported on short-term outcomes of the Marlex mesh technique for extensor reconstruction. In a series of 77 patients, they noted a 26-degree improvement in extensor lag with a mean postoperative extensor lag of 9 degrees at a mean 4-year follow-up. Perry et al reported on 16 patients who underwent extensor mechanism reconstruction using the Marlex mesh technique during a two-stage exchange procedure for infection. These patients had a 28-degree improvement in their extension and a mean extensor lag of 3 degrees at 4-year mean follow-up.

In the JBJS article, Abdel et al retrospectively reviewed 93 patients who underwent Marlex mesh reconstruction for complete extensor mechanism disruption between 2000 and 2015. The indication for reconstruction was patella tendon disruption in 42 knees, quadriceps tendon disruption in 39 knees, and patella fractures in 12 knees. Seventy-seven reconstructions were aseptic, and 16 reconstructions were performed for periprosthetic knee infections as part of a two-stage exchange procedure. The mean age of the patients at the time of Marlex mesh reconstruction was 64 years. At the time of their most recent follow-up, 32 patients (34 percent) had died and an additional 4 patients (4 percent) had <2 years of follow up and were therefore excluded. this left 57 patients with a mean follow-up of 8 years.>

The Marlex mesh technique has previously been well described. Briefly, the technique involves folding a 10-inch by 14-inch sheet of Marlex hernia mesh on itself eight to nine times and sewing it together with a running locked absorbable suture. The distal end of the mesh is cemented into a tibial trough at the proximal-anterior aspect of the tibia or cemented into the medullary canal of the tibia if the tibial component is being revised.

After the cement has hardened and the distal fixation is secure, the mesh is covered completely on its ventral and dorsal surfaces with host tissue. The mesh is essentially “sandwiched” between the vastus lateralis and vastus medialis obliquus (VMO). Specifically, the vastus lateralis is mobilized and the mesh is sewn to it with non-absorbable sutures. The VMO is then pulled distally and laterally and sewn to the mesh and vastus lateralis in a “pants-over-vest” manner (Fig. 1).

The authors prescribe a strict rehabilitation protocol for these patients. The patients are kept in a long leg cylinder cast with the knee in extension for 12 weeks postoperatively. After that time, patients can begin weight bearing in a hinged-knee brace locked in extension. Physical therapy is then initiated to work on range-of-motion exercises with 0 to 45 degrees of knee flexion for the first month of therapy. Increased flexion is allowed for subsequent months, with up to 60 degrees allowed for the second month, 75 degrees for the third month, and 90 degrees for the fourth month.

Of their 93 cases, 28 patients had failure of the mesh. Seventeen mesh failures were treated with mesh revision. The 10-year cumulative incidence of mesh revision for mesh failure was 20 percent. Patient age, sex, BMI, previous extensor mechanism reconstruction, component revision at the time of mesh reconstruction, and location of the extension mechanism disruption were not statistically correlated with mesh revision. Knee Society scores demonstrated significant improvements from the index surgery up to the most recent follow-up.

The authors noted several limitations of their study, including the retrospective nature of the study, the lack of a control group, and the large number of patients (n = 32) who had died at the time of recent follow-up. They also acknowledged that multiple experienced surgeons performed these procedures, therefore limiting the generalizability of the results to orthopaedic surgeons with less familiarity with this technique.

Nevertheless, this study demonstrates the durability of Marlex mesh reconstruction to treat periprosthetic knee extensor mechanism disruptions at several locations (i.e., quadriceps tendon, patella tendon, and patella fracture) in both septic and infected settings. The low revision rate and limited extensor lag maintained at long-term follow-up provide increasing support for the use of this technique to reconstruct the failed extension mechanism after total knee arthroplasty.

Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania, and serves as a resident member of the AAOS Now Editorial Board.

Paul S. Issack, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery at Weill Cornell Medical College and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian/Lower Manhattan Hospital. He is chief of orthopaedic surgery and orthopaedic trauma at Richmond University Medical Center. He is also a member of the AAOS Now Editorial Board.

References

1. Burnett RS, Berger RA, Paprosky WG, et al: Extensor mechanism allograft reconstruction after total knee arthroplasty. A comparison of two techniques. J Bone Joint Surg Am 2004;86(12):2694-9.
2. Brown NM, Murray T, Sporer SM, et al: Extensor mechanism allograft reconstruction for extensor mechanism failure following total knee arthroplasty. J Bone Joint Surg Am 2015;97(4):279-83.
3. Abdel MP, Salib CG, Mara KC, et al: Extensor mechanism reconstruction with use of Marlex mesh: a series study of 77 total knee arthroplasties. J Bone Joint Surg Am 2018;100(15):1309-18.
4. 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;93(12):1137-43.
5. Abdel MP, Pagnano MW, Perry KI, et al: Extensor mechanism reconstruction with use of Marlex mesh. JBJS Essent Surg Tech 2019;9(2):e21.
6. Abdel MP, Carender CN, Bedard NA, et al: Marlex mesh reconstruction of the extensor mechanism: a consise 5-year follow-up of 2 previous reports. J Bone Joint Surg Am 2024;106(7): 608-16.