QUADRICEPS AND PATELLAR TENDON PIE-CRUSTING AS A TREATMENT FOR LIMITED FLEXION IN TOTAL KNEE ARTHROPLASTY

Purpose: The pie-crusting method of ligament and tendon lengthening has been used successfully in various tissues but is not reported in the literature as an option for patellar or quadriceps tendons to address flexion limitation. This report reviews the literature on intraoperative treatments, which primarily pertains to the condition of patella baja, and demonstrates that the pie-crusting technique should be included as a treatment option for a tight extensor mechanism while having some advantages over tibial tubercle osteotomy or Z-plasty. Methods: This is a case report and literature review that was done with IRB approval from the University of North Texas Health Science Center. After written informed consent was given by the patient, medical records were provided by the UNT Health Bone and Joint Institute and were kept confidential for this case report. Results: A 58 year old woman presented with bilateral knee pain and stiffness in May 2008. She walked with the use of a rolling walker and a stiff-legged gait at all times. Past medical history included diabetes, obesity, and fibromyalgia. Another orthopaedic surgeon had recommended total knee arthroplasty seven years prior. Her family history contained several family members undergoing bilateral total knee arthroplasty in their 40's. On physical examination, both knees lacked 5 degrees of full extension and flexed roughly 20° bilaterally giving 25° of total range of motion . Radiographs were obtained which showed "bone on bone" medial compartment arthritis. Left total knee arthroplasty was performed in August 2010 through a medial parapatellar approach. The patella was dislocated and no eversion noted. Total Knee Arthroplasty of the right knee was performed in December 2010. Again, the patella was dislocated rather than everted and scar tissue was released. Conclusions: Because the patient lived far from the office, she did not return for her initially scheduled post-operative appointment but returned six weeks after surgery. Although she was non-compliant with the prescribed physical therapy, she had used the continuous passive motion (CPM) machine daily for two weeks after discharge. When she returned two years postoperatively at our request, both knees had improved tremendously to 90° range of motion with 5/5 quadriceps strength. Pie crusting of the quadriceps and patellar tendons is quick and easy, allows standard rehab and strengthening, and avoids the majority of the possible complications of tibial tubercle osteotomy.