Comminuted Patella Fracture and its Non-union Treated with Modified Cerclage Wiring (Wire Mesh Technique): A Case Series

Background: When the patella is fractured it should be repaired and patellectomy should be avoided as much as possible even in comminuted fractures. In comminuted patellar fractures, a combination of cerclage wiring and tension band fixation is confirmed to provide good mechanical stability. The objective of the present work was to find out the effectiveness of comminuted patellar fracture fixation with combined cerclage and tension band wiring technique. Method and patient: Forty- six patients underwent surgical stabilization for comminuted patellar fracture between year 1996 to 2016. All fractures were classified as 34-C3 according to the Orthopedic Trauma Association Classification. All the patients were underwent open reduction- internal fixation with combined Cerclage and tension band wiring technique. Result: Fracture healing was occurred within an average of 3- 5 months, while in bilateral cases it was 4 - 8 months. Full range of knee movements was seen in 42 (91.3 %) cases and knee flexion more than 120º was seen in 4 (8.7 %) cases. Quadriceps power was normal in 44 (95.6 %) cases, but 2 cases had quadriceps power of grade-IV. No extensor lag and no quadriceps atrophy were seen in any cases. Forty four (95.6 %) patients could squat fully and two (4.3 %) patients could squat up to half of the normal level. All patients were able to climb up and down stairs without any problem. Most patients have no subjective complaints like pain, difficulty in walking, difficulty in squatting and climbing. The clinical results after operation were evaluated by the clinical grading scales of Böstman including range of movement, pain, work, atrophy, assistance in walking, effusion, giving way, and stair-climbing during follow-up. There were no significant complications, such as infection, knee stiffness, and non-union or implant failure in any of the cases. The average follow-up period was 8 months (Ranged 6 – 18 months). Conclusions: This study had concluded that combined Cerclage and tension band wiring technique was a successful surgical treatment for comminuted fractures of the Patella.

Compare anterior hook plating to established fixation constructs biomechanically and report outcomes and complications in a cohort of patella fractures treated with the technique. Lab based biomechanical study and clinical multicenter retrospective cohort study. Two US level one trauma centers.Patients/Participants: 51 patients (28M, 23F) with 30 simple transverse and 21 comminuted patella fractures. 36 cadaveric patellae for the biomechanical study. Biomechanical- Compared dorsal plating with cerclage wiring and modified tension band cable fixation in a comminuted patella fracture model in 36 cadaveric patellae. Constructs were tested in 0° and 45° of flexion. Clinical - We reviewed a consecutive series of patella fractures in two centers for outcome and complications. Biomechanical - construct stiffness. Clinical - reduction, union, complications, range of motion. Stiffness greatest in dorsal plating in both 0° and 45°. Dorsal plating (976 N, 1643 N) > modified tension band (317, 297) > cerclage (89.8, 150.3). 51 patients with patella fractures fixed with dorsal 2.7 mm mini-fragment plates including a distal to proximal lag screw through the plate from the nose of the patella. 9 Cases were small distal fragments not easily managed with screws and cables. All patients were followed to union. There were 2 infections (1 superficial, 1 deep with nonunion) and 5 had hardware removal (9.8%). Dorsal plating is biomechanically and clinically superior to modified tension band and cerclage techniques in comminuted patella fractures. This method allows for fixation of small distal pole fractures.

Tension band wiring supposedly is the most commonly used technique for displaced patella fractures, but is not effective in comminuted fractures and osteoporotic bones. It often leads to loosening of wires, dislocation of fracture, hardware problem and failure of osteosynthesis, resulting in knee stiffness and post-traumatic osteoarthritis. The aim of the study is to evaluate clinical outcome in patients with acute patella fractures (< 3week) treated with unidirectional angle fixed low-profile titanium patella locking plate. Twenty patients who presented with displaced patella fractures, aged between 18-70years were included in the study. All fractures were reduced and fixed with unidirectional angle fixed stable low-profile titanium patella locking plate. Knee Range of motion and Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL) was used to evaluate the outcome. We were able to achieve union in 19 out of 20 patients. One patient with comminuted patella fracture had failure of fixation, which was revised. Mean flexion at final follow-up was 124° (110°-130°) and none of the patients had extensor lag. The final radiograph revealed complete union in all patients. This technique offers an option of fixation in comminuted patella fracture and in osteoporotic individuals. It provides mechanical stability for fracture fixation resulting in anatomical reduction, good functional outcome, lower incidence of symptomatic implant or failure of osteosynthesis.

Comparison between tension band and cerclage with X-Plate and lag screws in treatment of comminuted patellar fractures

Surgical fixation of comminuted patella fractures is technically challenging. Despite the fact that tension band wiring or screw fixation are the most common surgical procedures, these surgical techniques have crucial limitations for laterally scattered fragments. We demonstrate two cases with comminuted patella fractures undergoing surgical fixation with self-locking pin and circumferential wiring, confirming the rigid fixation achieving deep knee flexion. After midline longitudinal skin incision, 2.0 mm stainless pins (AiMedic MMT, Tokyo, Japan) were inserted radially to penetrate each fragment and 1.2 mm stainless wire was circumferentially looped and self-locked in the holes on the pins, which satisfied rigid fixation. Any restrictions in range of motion and weight bearing were required postoperatively and 3- to 6-month postoperative cares achieved seiza-style sitting with deep knee flexion.

Fracture patella is a breach in the extensor mechanism of the knee and needs to be fixed. Comminuted fractures of patella are a challenge given the difficulty in restoring the extensor mechanism. Introduction: Treatment options have evolved over the years from sacrifice to salvage i.e., from total or partial patellectomy to patellar preserving surgery. The challenge remains to fix the fragments optimally and also to have a tailor-made physiotherapy and rehabilitation program for the patient to provide a satisfactory functional outcome. A 14-year-old female presented to the casualty with a history of domestic fall, injuring her right knee. X-ray was done which revealed a comminuted fracture of right patella, classified as 34C3 OA/OTA classification. Salvage procedure for severely comminuted patella fracture has a successful functional outcome following a stable fixation of fragment.

BackgroundAlthough there are several different kinds of fixation techniques for displaced comminuted patellar fracture, the treatment remains a challenge for orthopaedic surgeons. The purpose of this study is to evaluate the effectiveness and safety of a fixation technique for comminuted patellar fracture fixation using modified cerclage wiring.MethodsFrom February 2016 to April 2018, 38 cases of simple unilateral closed comminuted patellar fracture were treated by modified cerclage wiring. Among these cases, 16 patients were males and 22 were females, aged 23–68 years (average 40.4 ± 9.1 years). Comminuted patellar fractures were classified according to the AO/OTA classification: 10 cases were type 34-C2 (three fragments), 28 cases were type 34-C3 (more than three fragments). Postoperative complications including loosening of internal fixation, fragment re-displacement, nonunion, infection, breakage of internal fixation and traumatic osteoarthritis were assessed. The clinical results after operation were evaluated by the clinical grading scales of Böstman including range of movement, pain, work, atrophy, assistance in walking, effusion, giving way, and stair-climbing during follow-up.ResultsA total of 38 patients were followed up for 6–36 months (mean time 16.1 ± 5.8 months). The bone union radiographically occurred at approximately 2.5–3.5 months (mean time 2.92 ± 0.25 months). No postoperative complications, such as infection, dislocation, breakage of the implants, painful hardware, and post-traumatic osteoarthritis, were observed. According to the clinical grading scales of Böstman, satisfactory results were obtained, and the mean score at the final follow-up was 28.7 (range 20–30) points. Thirty-two patients (84.2%) with excellent results had a mean score of 29.5 ± 0.7 (range 28–30) points, and six patients (15.8%) with good results had a mean score of 24.5 ± 2.2 (range 20–27) points. The patients with excellent and good scores had active flexion of 130° (110–140).ConclusionsModified cerclage wiring can effectively treat comminuted patellar fracture and offers a new strategy resulting in satisfactory results without obvious complications.

In comminuted patellar fractures, a combination of cerclage wiring and tension band fixation is said to provide good mechanical stability. This is a retrospective review of four patients treated with this method. All fractures described herein were classified as 45-C3 (based on Orthopaedic Trauma Association classification) and were fixed with a 1.25mm cerclage wire and tension band wire proximally looped through the quadriceps tendon and distally through the patellar ligament in a figure-of-eight configuration. The average follow-up period was 10 months. The Activity of Daily Living Scale (ADLS) of the Knee Outcome Survey was used to assess symptoms and functional capability of the knee. In all the cases, fracture union was achieved at an average of 11 weeks. The average ADLS score was good (92.5 %). Full range of knee motion was achieved by end of the third postoperative month. None of the patients had complications, such as infection and implant failure.

While the number of deaths from vehicle accidents is declining, probably because of mandatory seat belt laws and air bags, a high frequency of lower extremity injuries from frontal crashes still occurs. For the years 1979-1995 the National Accident Sampling System (NASS) indicates that knee injuries (AIS 1-4) occur in approximately 10% of cases. Patella and femur fractures are the most frequent knee injuries. Current literature suggests that knee fractures occur in seated cadavers for knee impact forces of 7.3 to 21.0 kN. Experimental data shown in a study by Melvin et al. (1975) further suggests that fracture tolerance of the knee may be reduced for an impact directed obliquely to the axis of the femur. The current study hypothesized that the patella is more vulnerable to fracture from an oblique versus an axial impact (directed along the femoral axis), and that the fracture pattern would vary with impact direction. Isolated, 90 degrees flexed, paired human knee joints (73 -/+ 16.9 years) were impacted at sequentially higher loads either axially or obliquely from the medial aspect with a rigid interface on the patella. The peak load at fracture for each case was recorded, and a detailed description of the fracture pattern was documented. For axial impacts all nine knees failed by linear and comminuted patella fracture with an average peak load of 5.9 -/+ 1.4 kN. Seven of nine obliquely impacted knees also failed by linear and comminuted patella fracture with a significantly lower peak load of 3.5 -/+ 1.4 kN. The peak load data from fracture experiments for all knees showed a strong correlation with age and direction of the impact. Additionally, the fracture pattern for the axial impacts was generally oriented along a horizontal plane on the patella, while the fractures for oblique impacts were generally oriented along a vertical plane. In two oblique experiments patella fracture did not occur, as the patella dislocated at a load of 3.4 -/+ 0.2 kN. In one of these cases the medial aspect of the patello-femoral joint capsule was visibly torn, and in the other case surface damage was noted on the articular cartilage covering the lateral femoral condyle. In addition to the acute injuries described in this study, these data may suggest a potential for chronic diseases of the knee in cases where similar injuries are produced. Clinical studies have shown an increased risk of osteoarthritis in patients suffering patella fractures and damage to joint cartilage. Also, acute dislocation of the patella may cause soft tissue injury of the knee leading to chronic mal-tracking of the patella. These data may be particularly relevant in cases where occupants sit with abducted lower limbs prior to a frontal crash.

Comminuted patella fractures pose a challenge to orthopaedic surgeons , since tension band wiring and cerclage is not effective and often lead to loosening of wires, hardware problem, dislocation of fracture and failure of osteosynthesis resulting in post-traumatic osteoarthritis and knee stiffness. The aim of this study is to evaluate the clinical outcome in patients with AO 34C2 and 34C3 highly comminuted patella fractures treated with unidirectional fixed angle titanium patella locking plate. Twelve patients who presented with AO 34C2 and 34C3 comminuted patella fractures, aged between 18-79 years were included in the study. All fractures were reduced and fixed with unidirectional angle fixed stable titanium patella locking plate. Knee range of motion and knee outcome survey activities of daily living scale (KOS-ADL) was used to evaluate the outcome. Union of fracture was achieved in all twelve patients. Mean flexion at final follow-up was 123° (110°-130°). None of the patients had extensor lag. One patient had hardware irritation which resolved at final followup. This technique serves as an effective option in highly comminuted patella fractures by providing excellent mechanical stability resulting in anatomical reduction , excellent functional outcome , lower incidence of hardware irritation or failure of osteosynthesis.

Estudos anteriores têm mostrado que o nível aeróbico e de força pré-treinamento influenciam os ganhos obtidos após um período de treino. Nenhum estudo investigou esta relação em um programa de flexibilidade. O objetivo deste estudo foi observar a influência da limitação da amplitude de movimento (ADM) sobre a melhora da ADM de rotação externa de ombro após um programa de alongamento de seis semanas. 30 voluntários, estudantes de fisioterapia, com limitação da ADM de rotação externa de ombro foram divididos de forma randomizadas em três grupos: grupo controle (GC), grupo experimental 1 (GE1), com maior limitação de ADM e grupo experimental 2 (GE2), com menor limitação de ADM. Os sujeitos do grupo experimental foram submetidos a um programa de seis semanas de alongamento ativo para melhora da ADM de rotação externa de ombro. Na análise dos resultados, o teste de ANOVA one-way mostrou uma diferença significativa entre a média do ganho de ADM de rotação externa de ombro entre os três grupos (p=0,001), sendo que o GE1 teve o maior ganho de ADM (30,1° ± 8,6°) seguido pelos grupos GE2 (15,2° ± 7,5°) e GC (1,1° ± 5,8°). O teste de correlação de Pearson mostrou uma correlação negativa significativa entre ADM prévia e ganho de ADM (r= -0,70, p=0,001). Os resultados deste estudo mostraram que a ADM prévia de rotação externa de ombro influencia o ganho de ADM deste movimento após um programa de alongamento de seis semanas em uma população jovem e saudável. Indivíduos com maior limitação de ADM respondem com um ganho de ADM mais pronunciado.

Objectives:To review comminuted patella fracture in the elderly patients and examine the surgical options to avoid complications such as fixation failure and poor functional outcome. To provide an example of mesh augmentation in comminuted patella fracture in the elderly patients.Data Sources:A literature review was conducted by the authors independently using Ovid, Medline, Cochrane, PubMed, and Clinical Key in English. We aimed to review data on patients older than 65 with comminuted patella fracture. Search conducted between July and December 2015.Study Selection:Search terms included patella fracture, elderly, and fixation failure. s were included if they were a case report, cohort series, or randomized control trial. Further inclusion criteria were that they were available in full text and included patient age(s), operative details, follow-up, and outcome discussion.Data Extraction:Each study was assessed according to its level of evidence, number of patients, age of patients, fracture patterns described, complications of treatment, and results summarized.Data Synthesis:Paucity of data and heterogeneity of studies limited statistical analysis. Data are presented as a review table with the key points summarized.Conclusion:In patella fracture, age >65 years and comminuted fracture pattern are predictors of increased fixation failure and postoperative stiffness, warranting special consideration. There is a trend toward improved functional outcomes when augmented fixation using mesh or plates is used in this group. Further level 1 studies are required to compare and validate new treatment options and compared them to standard surgical technique of tension band wire construct.

Treatment of simple and complex patella fractures represents a challenging clinical problem. Controversy exists regarding the most appropriate fixation method. Tension band wiring, aiming to convert the pulling forces on the anterior aspect of the patella into compression forces across the fracture site, is the standard of care, however, it is associated with high complication rates. Recently, anterior variable-angle locking plates have been developed for treatment of simple and comminuted patella fractures. The aim of this study was to investigate the biomechanical performance of the novel anterior variable-angle locking plates versus tension band wiring used for fixation of simple and complex patella fractures.Sixteen pairs of human cadaveric knees were used to simulate either two-part transverse simple AO/OTA 34-C1 or five-part complex AO/OTA 34-C3 patella fractures by means of osteotomies, with each fracture model created in eight pairs. The complex fracture pattern was characterized with a medial and a lateral proximal fragment, together with an inferomedial, an inferolateral and an inferior fragment mimicking comminution around the distal patellar pole. The specimens with simple fractures were pairwise assigned for fixation with either tension band wiring through two parallel cannulated screws, or an anterior variable-angle locking core plate. The knees with complex fractures were pairwise treated with either tension band wiring through two parallel cannulated screws plus circumferential cerclage wiring, or an anterior variable-angle locking three-hole plate. Each specimen was tested over 5000 cycles by pulling on the quadriceps tendon, simulating active knee extension and passive knee flexion within the range from 90° flexion to full knee extension. Interfragmentary movements were captured by motion tracking.For both fracture types, the articular displacements, measured between the proximal and distal fragments at the central aspect of the patella between 1000 and 5000 cycles, together with the relative rotations of these fragments around the mediolateral axis were all significantly smaller following the anterior variable-angle locked plating compared with the tension band wiring, p &lt; 0.01From a biomechanical perspective, anterior locked plating of both simple and complex patella fractures provides superior construct stability versus tension band wiring.

Range of motion (ROM) restriction influences quipazine-induced stepping behavior in postnatal day one and day ten rats

The purpose of this study is to describe the surgical technique and outcomes of transosseous repair of patellar sleeve fractures in a pediatric cohort. A retrospective review was performed on patients younger than 16 years undergoing transosseous repair of distal patellar sleeve fractures. A chart review was performed on demographics, surgical repair technique, and postoperative care. Primary outcomes included intact extensor mechanism function and range of motion (ROM) at final follow-up. In this study, 20 patients, 17 males and 3 females, with a mean age of 11.7 years were included. ROM was initiated at a median of 27.5 days following surgery. All patients had a healed patellar sleeve fracture and intact extensor function at final follow-up. Final mean knee ROM among the 18 patients with minimum 3-month follow-up was 132 degrees. Thirteen patients (72%) achieved full ROM (≥ 130 degrees) and 5 patients (28%) achieved less than 130 degrees knee flexion. Duration of initial immobilization was found to be the only variable strongly associated with final postoperative ROM. Mean duration of immobilization for patients achieving ≥ 130 degrees was 24 days versus 44 days in those patients achieving < 130 degrees, p = 0.009. All patients who began knee ROM within 21 days of surgery obtained full knee ROM. No patients experienced construct failure or extensor lag. Operative management of displaced patellar sleeve fractures with anatomic transosseous suture repair of the sleeve fracture, brief immobilization no more than 21 days, and initiation range of early ROM results in excellent outcomes.