Reconstruction of the Extensor Apparatus After Total Patellectomy in Orthopedic Oncology: A Systematic Literature Review

Abstract

Background: Patellar resection is recommended in cases of massive cortical bone disruption or malignancies. Modern literature lacks a consensus surgical reconstruction after total patellectomy. Our study reviews the surgical techniques described in the literature and summarizes the reported functional outcomes and complication rates. Materials: We systematically reviewed the existing literature, searching the PubMed, Embase, and Scopus databases for articles published between 1950 and 2024. We recorded age, diagnosis, tumor size, Lodwick classification, soft tissue involvement, and pre-operative fractures for each case or case series. We also recorded the reconstructive approaches. Complications, local recurrences, MSTS scores, and knee range of motion (ROM) were considered when reported. Results: Twenty-eight articles met our inclusion criteria. Among these, 4 were case series and 24 were case reports. A total of 47 cases treated with total patellectomy were reviewed. Reconstruction was performed with direct suture in 8 cases, while 17 had local augments, including allograft (10 cases), muscle flaps or transportations (4), autologous bone (1), or a composite (2). Reconstruction was not mentioned in 22 cases. ROM was reported for 17 cases, and the MSTS score was reported for 9 cases. Conclusions: In cases of relatively small tissue defects, a direct suture of the extensor apparatus can allow adequate functional recovery. In cases of larger gaps, surgeons should use muscle flaps, transfers, or soft tissue augments. Massive bone and tendon allografts should mainly be considered in cases where the neoplasm was not confined to the patella but extensively involved the patellar ligament or the quadriceps tendon.

Keywords: complications; functionality; local recurrence; patella; patellar ligament; quadriceps tendon; range of motion.

Figure 1

PRISMA flow diagram of our study.

Figure 2

Intra-operative image of a patella enlarged and deformed by a malignant tumor after total patellectomy.

Figure 3

A gap in the extensor apparatus after total patellectomy associated with soft tissue sacrifice. The two ends of the damaged extensor apparatus could not be sutured directly, and the anterior articular surface of the distal femur is exposed.

Figure 4

A mesh and fascia lata allograft folded (A) and sutured (B) to replace the original extensor apparatus according to the Andreani technique (C).

Figure 5

(A) A massive tendon-bone allograft including a quadriceps tendon (on the right), a patella (in the middle), and a patellar tendon (on the right). The graft is sutured to the patellar retinacles and the proximal tibia (B), and later to its proximal end, also passing through what remained of the native quadriceps tendon (C). The result is pictured on the bottom figure (D).