# Quad tendon repair with medial & lateral retinacular repairs



## gsteeves (Dec 17, 2009)

Good Morning,

Having problem coding this op report; I have 27.85 for quad tendon but having trouble with retinacular repairs. The op note is below.  Thanks for your help
.
An anterior longitudinal incision was made centered over the left knee. A gush of hematoma was expressed from the knee through the tear in the quadriceps which had avulsed from the superior pole of the patella. After proceeding down through the deep fascia it was obvious that there was a complete avulsion of the quadriceps tendon from the superior pole of the patella. There was also a gush of hematoma from the knee joint which was expressed up through this defect between the quadriceps and the patella. There were also transverse tears in the medial and lateral retinaculum at the level of the superior patella/quadriceps rupture site. We expressed all the hematoma from the wound and also removed it from the knee joint. We irrigated the knee with Bacitracin irrigation. 

A #15 blade was used to incise the peritenon covering the quadriceps tendon. We exposed the tendon medially and laterally by developing the layer between the peritenon and the tendon. We also exposed the proximal half of the patella tendon by incising the peritenon longitudinally and developing that as a separate layer as well. The superior pole of the patella was freshened with a rongeur back to bare bone. We also used a #15 blade to remove some of the frayed tissue at the distal end of the quadriceps tendon. Not only had the rectus and portions of the vastus lateralis and vastus medialis ruptured from the superior pole of the patella but the vastus intermedius had also ruptured and was a separate deeper layer which was retracted as well.  
We decided to repair the quadriceps back to the superior pole of the patella with sutures through drill holes in the patella. #5 Tycron suture was utilized and we visually split the tendon in half and ran a Krakow suture from distal to proximal and then proximal to distal down one half of the tendon and we repeated that step with another #5 Tycron suture in the other half of the quadriceps. We were careful to not only grasp the superficial aspects of the tendon including the rectus femoris but also the deep layer which included the vastus intermedius layer. This gave us a nice grasp of the entire quadriceps mechanism. We then visually divided the patella into thirds. We used our anterior cruciate ligament guide to drill a small, 2 to 2.5 mm, hole from proximal to distal. One hole was drilled longitudinally down the middle of the patella and two other holes were drilled parallel, one medial and one lateral. We were careful to start our holes near the articular surface at the proximal end to prevent any tilting of the patella once our repair was complete. A Houston suture passer was used to pass the central two sutures through the middle hole and the lateral suture  through the lateral hole and the medial suture through the medial hole. We also used 0 Vicryl at this stage to repair the medial and lateral retinaculum. Sutures were passed but not tied until we repaired our quadriceps back to the patella. At this time we tied our Tycron sutures and placed the appropriate amount of tension to bring the quadriceps down to the superior pole of the patella in an anatomic fashion. After that repair was complete we tied all of our 0 Vicryl sutures medially and laterally to repair the retinaculum. 

Gail Steeves,CPC


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## mbort (Dec 17, 2009)

This was posted by Margie Vaught on an orthopedic forum not too long ago:

"The EXTENSOR MECHANISM of the knee includes the following: EXTENSOR MECHANISM: Quadriceps tendon Patella Medial / lateral retinaculum Patellar tendon "

"The extensor mechanism of the knee consists of the quadriceps muscle group, quadriceps tendon, patella, patellar RETINACULUM, patellar ligament, and adjacent soft tissues. "


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## gsteeves (Dec 17, 2009)

Thanks, Mary for your response.  I appreciate it.

Gail Steeves, CPC


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