A Novel and Effective Surgical Technique for Reconstruction of Extensor Mechanism with Iliotibial Band Tendon Graft After Patellectomy for Primary Patella Tumor

Abstract

Background: Amongst primary patella tumor Campanacci grade 3 tumor of Giant cell tumor of bone (GCTB) and malignant tumors requires patellectomy. We had a patient with huge recurrent GCTB of patella with involvement of skin. We reconstructed extensor mechanism of Knee with long iliotibial band (ITB) tendon graft.

Material and methods: After patellectomy, we harvested long ITB graft (length 22 cm; width proximally 6 cm, distally 1.5 cm) through patellectomy wound and small "L" shaped incision proximally. We passed ITB graft from patella tendon and quadriceps tendon in figure of 8 manner and sutured it back to itself and host tendon with fiber Wire and closed both the wounds primarily. We started ROM and quadriceps strengthening in graded manner. We measured functional outcome with Musculoskeletal Tumour Society (MSTS) scoring system.

Results: There were no post-operative complications. At 10 weeks follow up, patient had no extension lag and knee ROM was 90°. At final follow up of 7 months patient regained pre-operative functional status without knee instability. Her MSTS score was 30 and she was disease free.

Conclusion: Reconstruction of extensor mechanism of knee with ITB graft doesn't have donor site morbidity and gives excellent function with graded physiotherapy protocol.

Keywords: Extensor defect; Giant cell tumor of Patella; Iliotibial band graft; Knee extensor mechanism reconstruction; Tumor of patella.

Fig. 1

Huge recurrent GCT of the patella with a previous surgical scar with wide hatch marks. The overlying skin was stretched out and involved. Marking of skin incision with sacrifice of involved skin and previous surgical scar

Fig. 2

Radiograph of the patient in both AP and lateral plane a, b showing lytic lesion with soft tissue component and only some remnant of patella bone. MRI in axial plane c showing disease involving all of the retinaculum and in sagittal plane d showing involvement of part of quadriceps and patella tendon

Fig. 3

Huge defect in extensor mechanism after patellectomy. F femur condyle, PT patella tendon cut end, ITB iliotibial band. The quadriceps tendon cut end is retracted, so not seen in the image

Fig. 4

Showing the planning for harvesting facia lata graft in continuation with ITB. T transverse red line, showing proximal transverse incision (2 cm) which is the proximal limit for graft harvest. It is 13 cm from ASIS. V vertical red line, showing vertical incision (5 cm) which is the lateral limit of graft harvest. It is 3 cm anterior to LIS. ASIS anterior superior iliac spin, LIS lateral intermuscular septum, LJL lateral joint line

Fig. 5

Diagrammatic representation of graft harvest. Proximally graft was broad (6 cm) and extended distally till Gerdy’s tubercle where its width was 1.5 cm

Fig. 6

The Proximal part of the graft was quadruple folded to make its width homogeneous. The gap between QT and PT was reconstructed with the figure of 8 construct. Graft to tendon and graft to graft junction were secured with fiber-wire. QT quadriceps tendon, PT patella tendon, F femur condyle, G tendon graft

Fig. 7

Post-operative function: at 5-week follow-up, patient had 30° knee ROM (a) and was able to do active SLR (b). At 10-week follow-up, knee ROM was 90° (c) and there was no extension lag (d). At 4-month follow-up, patient achieved pre-surgery functional status and was able to sit cross leg also (e)