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Extensor Mechanism Failure Associated With Total Knee Arthroplasty: Prevention and Management

Dr. Parker is Orthopaedic Fellow, University Hospital, University of Western Ontario, London, ON, Canada. Dr. Dunbar is Assistant Professor, Department of Orthopaedics, QE II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada. Dr. Rorabeck is Professor, Department of Orthopaedic Surgery, University Hospital, University of Western Ontario.

Reprint requests: Dr. Rorabeck, 339 Windermere Road, London, ON N6A 5A5, Canada.

Extensor mechanism complications are the most commonly reported reasons for revision surgery after total knee arthroplasty and are a frequent source of postoperative morbidity. Patellofemoral instability is the most commonly reported extensor mechanism complication and has multiple etiologies, including prosthetic malalignment and soft-tissue imbabalce. Patellar fracture or rupture of either the quadriceps or patellar tendon can cause catastrophic disruption of the extensor mechanism. Although some stable fractures can be successfully managed nonsurgically, displaced fractures or tendon rupture often lead to poor results. Other complications include patellar clunk and soft-tissue adhesions, prosthetic wear or loosening, and osteonecrosis. Increased understanding of implant alignment, rotation, and soft-tissue balance, as well as improved design of the trochlear groove of femoral implants and patellar components, has resulted in a decline in extensor mechanism complications. Appropriate prosthetic selection and meticulous surgical technique remain the keys to avoiding unsatisfactory results and revision surgery.

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