Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation check straight leg raise, note gap in tendon, presence of hematoma document timing and mechanism of injury chronic injuries (>2-3 mo) may require allograft reconstruction Positioning supine on standard OR table bump under ipsilateral thigh with thigh tourniquet knee flexed over triangle or stack of towels Approach anterior approach to patella and tendon incision midline across superior and inferior poles of patella and tendon Tendon Preparation sharply clean off edges of tendon and inferior pole of patella curette bone to get bleeding surface on patella Fixation 3 drill holes from inferior pole to superior pole of patella with 2.0mm drill #2 to #5 non-absorbable suture Krakow stitches x2 into tendon (4 strands exiting tendon) suture passer from superior to inferior to pass suture ends place knee in extension on triangle and tie 2 pairs of knots over patella Retinacular Closure #2 non-absorbable suture to close medial and lateral retinacular tears Postoperative weight-bearing when locked in extension in knee immobilizer or brace begin gentle range of motion exercises within the first 4 weeks Planning & Preparation Extremity Exam check straight leg raise failure indicates lack of extensor mechanism note tendon defects, presence of hematoma, open lesions determine timing and mechanism of injury chronic injuries (>2-3 months) may require allograft reconstruction with tendon V-Y lengthening or allograft supplementation (Achilles, semitendinosus) document distal neurovascular status and associated injuries Imaging evaluate lateral radiograph for patella alta tendon usually avulses at bone-tendon junction at inferior pole of patella MRI can differentiate partial from complete rupture if extensor mechanism intact and partial tear can treat patients in knee extension brace with progressive weight bearing and ROM exercises Equipment & Positioning Equipment 2.0mm drill sterile triangles suture passer #5 and #2 non-absorbable suture Position patient supine with small bump under ipsilateral thigh thigh tourniquet OR Setup standard OR table Approaches Anterior Approach to Patella incision midline 2cm above superior pole to inferior pole and down tendon to tibial tubercle full thickness subcutaneous flaps examine for retinacular tears medial and lateral Surgical Technique Approach flex knee over small triangle or stack of towels mark out poles of patella, borders of patella tendon, joint line, tendon defect, tibial tubercle exsanguinate limb and inflate tourniquet skin incision anterior and midline over patella raise full thickness flaps down to bone with tenotomy scissors and knife incise paratenon carefully with knife preserve paratenon for later closure if possible check for medial and lateral retinacular tears irrigate and suction out synovial fluid and hematoma Tendon Preparation sharply clean off edges of patella tendon with knife and tenotomy scissors identify healthy tendon by linear regular striations clean soft tissue off of inferior pole of patella curette bone to get bleeding bone surface Fixation place large clamp on patella and kocher clamp on patella tendon and bring leg into extension pull patella distally and tendon proximally to determine if adequate length available and necessary tension for fixation may need to deflate tourniquet if inadequate tendon length obtained while pulling patella distally place 3 drill holes from inferior pole of patella to superior pole central, medial, lateral holes with 2.0mm drill exiting anteriorly along superior margin of patella #5 non-absorbable suture Krakow stitches x2 into patella tendon 4 strands exiting tendon for Krakow stitch start by inserting suture into end of tendon then medial to lateral locked throws then transverse across distal tendon then lateral to medial in proximal direction and through end of tendon again suture passer from superior to inferior to pass suture ends pass 1 suture through medial and lateral drill holes 2 sutures through central drill hole place knee back into extension on triangle pull patella distally with clamp and tie 2 pairs of knots over patella tie 5-6 knots clamp first throw with needle driver to make sure knot stays down and tight can add augmentation stitch around patella tendon superior and through drill hole in tibial tubercle distally if needed Retinacular Closure #2 non-absorbable suture to close medial and lateral retinacular tears (deep in gutters) need to use deep retractors to visualize proximal extent of retinacular tears tears propagate in oblique direction distal to proximal along medial and lateral gutters Extremity Exam take knee from full extension to 90° flexion check patellar tracking and integrity of fixation Closure Irrigation & Hemostasis place knee under bump and irrigate with saline bulb irrigation cauterize peripheral bleeding vessels Closure reinforce retinacular closure with 0-vicryl paratenon closure with 0-vicryl subcutaneous with 3-0 vicryl skin closure Dressing soft incision dressings over knee Postoperative Care Immediate Post-operative Weightbearing as tolerated in knee immobilizer or brace 2-4 Weeks wound check staples/sutures removed begin gentle range of motion exercises to knee at 3-4 wks passive extension and active closed chain flexion (heel slides) weight-bearing as tolerated locked in extension Complications Document Complications tendon re-rupture knee stiffness loss of extensor mechanism strength infection