Fixation Of Patellar Fractures Research Articles

Adjunct neutralization plating in patella fracture fixation: a technical trick.

Patella fracture outcomes are positive overall; however, in some cases, traditional fixation methods result in complications, including loss of fixation and irritable hardware requiring removal. We present a technique of plate fixation that we believe has the potential to improve stability and is less offensive in more comminuted fracture patterns. Improved stability should allow unfettered advancement of rehabilitation without concern for loss of fixation. Lower profile fixation offers a potential for diminishing the presence of irritating hardware requiring removal. We present our technique for using plate fixation to augment more complex patella fracture patterns.

Surgical Management of Patella Fractures: A Review

Patella fractures are a common orthopaedic injury caused by either a direct blow to the anterior knee or excessive tension through the extensor mechanism. These fractures can result in acute disruption of the knee extensor mechanism, knee stiffness, and post-traumatic patellofemoral arthritis. Indications for operative fixation of patellar fractures are either disruption of the extensor mechanism or >2-3mm articular step-off and >1-4 mm of fracture displacement.

Association of Nerve Block and Opioid Administration for Patellar Surgery

Introduction: Multimodal pain control after orthopaedic surgery is a topic of growing interest in opioid-related risk mitigation. However, little evidence exists in the orthopaedic trauma setting. We aim to analyze the impact of perioperative peripheral nerve blocks (PNB) on opioid pain management in patients undergoing open reduction and internal fixation (ORIF) of patella fractures. Methods: This analysis included 47 patients with isolated patella fractures who underwent ORIF (2017-2021). Our dedicated PNB service provided 28 cases with PNBs. Extracted variables during hospitalization included demographic data, pain scores on visual analog scale (VAS), intra-, and postoperative opioid administration measured as morphine milligram equivalents (MME). Follow-up data included prescription refills, ED visits for pain within 90 days, and VAS pain scores. Chi-squared and logistic regression analyses were performed to evaluate the impact of PNB on opioid based pain management. Results: Patients with a PNB had lower average total MME (126.54±18.96) than those without a PNB (160.62±35.81); however, this was not statistically significant (p = 0.201). Use of PNB was not associated with total prescription refills, ED visits, or pain on VAS for all time points. However, at two-weeks follow-up, patients without PNB had 4x higher odds of receiving a refill (OR:4.13, CI:1.13-15.10). Subgroup analysis revealed no significant association between PNB timing (preoperative/postoperative) and intraoperative, postoperative, or total inpatient MME. Conclusion: With the observed inconsequential effect of PNB, findings suggest that opioid administration in the orthopaedic trauma population is multifaceted. Continued conscious prescribing practices with multimodal pain control should be encouraged to mitigate opioid-related risks.

Fixation of patella fractures with metallic implants is associated with a significantly higher risk of complications and re-operations than non-metallic implants: a systematic review and meta-analysis.

The use of metallic implants for the treatment of patella fractures often involves complications related to the hardware. As a result, there has been a considerable focus on the use of non-metallic implants. The aim of this study was to determine the differences in clinical outcomes, including the rates of complications and re-operations following the surgical management of patellar fractures with metallic versus non-metallic implants. The systematic review was conducted in accordance with PRISMA guidelines. Two investigators independently applied the search strategy to PubMed, SCOPUS, Google Scholar, and Cochrane databases, limited to publications between 1st January 2000 to 30st September 2021. The search strategy identified studies in which there was a comparison between the clinical outcome of the metallic and non-metallic fixation. Meta-analysis was conducted according to the Cochrane Collaboration and Quality of Reporting of Meta-Analysis (QUORUM) guidelines. A total of 19 studies were selected for the systematic review and seven studies for the meta-analysis. Two hundred ninety-sixt patients formed the pooled study population for the meta-analysis. The outcomes evaluated in the meta-analysis were range of motion (ROM), complications, and re-operation rates. There was no significant difference between groups regarding ROM, but the risk ratio (RR) of re-operation (RR 0.19, 95% CI [0.09-0.41]) and complications (RR 0.30, 95% CI [0.17-0.55]) was significantly in favor of fixation with non-metallic implants. The use of non-metallic implants for fixation of patella fractures was associated with significantly lower risk of complications and re-operations than fixation with metallic implants, without any difference between groups with respect to the final range of motion or functional outcome measures.

Evaluation of Internal Fixation of Patellar Fractures Using Cannulated Screws with Tension Band versus Modified Tension Band Wiring

Evaluation of Internal Fixation of Patellar Fractures Using Cannulated Screws with Tension Band versus Modified Tension Band Wiring

Biomechanical comparison of a novel tensioned cable construct versus tension band wiring for transverse patella fracture fixation.

Tension band wiring (TBW) is the most widely accepted method for patella fracture fixation. The purpose of our study was to compare the biomechanical efficacy of a novel cable construct to TBW for the fixation of transverse patella fractures. The tensioned cable construct was hypothesized to have less fracture gapping after cyclic flexion-extension loading and greater ultimate load to failure as compared to TBW. Transverse patellar osteotomies (AO/OTA 34C1.1) were performed on nine pairs of fresh-frozen human cadaveric whole legs (mean age 82.2years, range 71-101). Treatment with TBW or tensioned cable construct was randomized within each specimen pair. Fracture site displacement was measured after 5000 flexion-extension cycles from 0° to 90° at 0.5Hz. In load to failure testing, the knee was fixed at 45° of flexion and the quadriceps tendon was pulled proximally at 0.5mm/sec until patella fixation failure. Comparisons were made using paired t-tests with alpha values of 0.05. Eight paired specimens completed the cyclic loading. The tensioned cable construct had significantly less fracture gapping than TBW (2.9 vs 10.9mm; p = 0.020). Seven paired limbs underwent load to failure testing, which revealed no significant difference between the tensioned cable construct and TBW (1551.6N vs 1664.0N; p = 0.26). In this study of transverse patella fracture fixation, a tensioned cable construct demonstrated significantly less fracture gapping compared to TBW in response to cyclic loading with no significant difference in load at failure.

The radiographic soft tissue thickness is associated with wound complications after open reduction and internal fixation of patella fractures

BackgroundDisplaced patella fracture is commonly treated with open reduction and internal fixation (ORIF). Wound complications after surgery often lead to prolonged hospitalization and dissatisfaction of patients. Periarticular adiposity and swelling may be associated with wound complications. The purpose of this study is to determine the relationship between periarticular soft tissue thickness and wound complications after ORIF of patella fractures.MethodsWe retrospectively studied 237 patients undergoing ORIF for patella fractures from June 2017 to February 2021 at our institution. We established periarticular soft tissue thickness ratio (PSTTR) to evaluate soft tissue status on lateral knee X-ray radiographs. Univariate analysis was performed to identify the association between PSTTR and postoperative wound complication. A receiver-operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of PSTTR.ResultsThe incidence of postoperative wound complication was 10.5%. Minor wound complication occurred in 24 patients, and major wound complication occurred in one patient. The average femoral PSTTR (fPSTTR) was 0.94 ± 0.17 and the average tibial PSTTR (tPSTTR) was 0.66 ± 0.16. fPSTTR proved to be associated with postoperative wound complication. In the ROC analysis of fPSTTR predicting postoperative wound complication, the area under curve (AUC) was 0.676, which indicated a moderate predictive value.ConclusionsPSTTR was a feasible method to assess periarticular soft tissue. The increased fPSTTR was associated with wound complications after ORIF of patella fractures.

Suture tension band fixation vs. metallic tension band wiring for patella fractures – A biomechanical study on 19 human cadaveric patellae

PurposeTraditional tension band fixation of patella fracture is associated with high reoperation rates. The purpose of the study was to assess strength of fixation in patella fractures treated with either a non-metallic all suture-based technique or traditional metallic tension band wiring. MethodsTen paired human cadaveric specimens were included. A transverse fracture was created, reduced and fixated with a non-metallic or metallic approach. Non-metallic fixation was done according to a previously published technique, metallic fixation was done according to AO description. Specimens were fixed in 90° of flexion and underwent 200 cycles of loading by pulling the Quadriceps tendon to 300 Newton. Fracture displacement was optically monitored. Primary outcome was fracture displacement after 200 cycles compared to the first cycle. Subsequently, load-to-failure was assessed by a monotonic pull to 1000 N. ResultsFor cyclic loading analysis, one specimen from each group was excluded due to machine synchronization, resulting in a total population of 18 specimens. Median (min-max) fracture displacement was 0.65 mm (0.06-1.3) in the non-metallic group and 0.68 mm (0-1.23), (p=0.931) in the metallic group. No difference in displacement was found between the two groups in the repeated measures analysis of variance (p=0.5524). For load-to-failure analysis one specimen was excluded due to machine synchronization, resulting a total population of 19 specimens. 2/9 specimens failed in the non-metallic group (at 979 and 635 N) and 2/10 failed in the metallic group (745 and 654 N). ConclusionNon-metallic technique is a biomechanically viable alternative to traditional tension band fixation and it can hopefully lead to fewer implant-related complications.

A New Antirotation Strategy of K-Wire Tension Band Therapy for Patellar Fracture.

BackgroundPatellar fracture is a common phenomenon observed in orthopedic clinics. Many methods have been shown to be effective in the fixation of patellar fracture. However, there are few studies on the antirotation effect of these methods. The purpose of this study is to present a new strategy of K-wire tension band therapy for patellar fracture and explore the antirotation effect of the modified tension band method on patellar fracture.MethodsA retrospective clinical observation study was conducted on 75 patients with patellar fracture. Totally, 46 patients were enrolled to the traditional group, who received the traditional K-wire tension band therapy. The modified group included 29 patients on whom our new strategy was implemented. The operation time, intraoperative blood loss, and fracture healing time were collected to compare the two operations and the knee society score (KSS) scores after the operations, and complications were recorded and retrieved to indicate the effectiveness of the two treatments.ResultsThe preoperative baseline data (gender, age, fracture types) of the two groups showed no significant statistical difference. Similarly, there was no significant difference in the operation time, intraoperative blood loss, and fracture healing time between the two groups. The KSS clinical scores 1 year after operation was 90 (84, 95) for the traditional group as compared with 99 (97, 100) for the modified group (p < 0.05). The KSS functional scores 1 year after operation in the two groups were 90 (65, 90) and 100 (90, 100) (p < 0.05). The incidences of complications due to the rotation of K-wires in the traditional group and the modified group were 76.1% (35 of 46) and 6.9% (2 of 29) with a significant statistical difference (p < 0.05).ConclusionThis study shows that our modified tension band therapy is an effective strategy for antirotation in the treatment of patellar fracture and proves that it can achieve better clinical outcomes than the traditional K-wire tension band method. This new strategy may be a safe and effective clinical technique for the treatment of patellar fracture. However, more prospective randomized controlled trials with larger sample sizes are still needed to further prove its efficacy.

A Modified Tension Band Fixation Technique for the Management of Patellar Fractures Using Crossed Pins and a Lateral Parapatellar Approach.

The use of the tension band technique for patellar fracture fixation has been associated with a loss of the rigidity of the construct after cyclic loading. Biomechanical studies have shown the biomechanical superiority of the crossed pin configuration relative to the traditional parallel one. Here, we describe a modified tension band technique that involves the use of crossed pins and a figure-of-eight passed as close to the bone as possible through a lateral parapatellar approach. The basic surgical technique and our case series are reviewed.

An improvement on the technique of transosseous tunnels for the fixation of lower pole patella fracture: Cerclage around the patella.

The technique of transosseous tunnels is widely used in lower pole patella fracture (LPP). Though the extensor mechanism can be restored, distal avulsion fragments are usually unstable. The subsequent fracture gap and nonunion impair the extensor mechanism in turn. Cerclage is a promising method for treating the condition. The aim of this prospective cohort study is to determine if cerclage around the patella combined with the technique of transosseous tunnels stabilizes the avulsion fragments and brings out improved outcomes on LPP.Twenty two patients with LPP were treated with the hybrid technique. The patients were followed up and evaluated clinically and radiographically. The functional outcome was assessed by the average range of knee movement and Lysholm knee rating system at 6 months after surgery, as well as the final follow-up. Radiologically, Insall-Salvati ratio and the time from surgery to bone union were assessed.Postoperatively, with a mean followed-up of 12 months. All of the patients regained stability of the knee with an average range of movements of 131.8 degrees at 6 months after operation and 138.2 degrees at the final follow-up. On the Lysholm knee rating system, all cases were classified as excellent. The average score was 93.2 at 6 months after operation and 95.9 at the final follow-up. In radiological assessment, no fracture gap or nonunion occurred. The average Insall-Salvati ratio (I-S ratio) was 1.03.The hybrid technique offers further stabilization for the avulsion fragments and strengthens attachment of the patellar tendon, which brings forward time of rehabilitation and achieves good clinical outcomes.

Transosseous Suture With an All-FiberWire Technique in Patellar Fracture Fixation

Background: Patellar fractures account for 0.5% to 1.5% of all bone fractures. Tension band wiring with heavy gauge steel wire and K-wires is traditionally procedure for treating patellar fractures. However, this method is associated with implant-related complications. Present study aimed to evaluate functional clinical outcomes of patellar fracture fixation with transosseous suture using an all-FiberWire technique. Methods: This was a retrospective study involving 16 patellar fractures patients were repaired by open reduction and internal fixation with FiberWire using a 3-transosseous tunnel technique. The functional outcomes were evaluated with Tegner-Lysholm and Bostman scoring. We also evaluated clinical and radiologic outcomes. Results: The mean time to bony union was 8.87±1.54 weeks (range, 7 to 12 wk). The mean Bostman score at final follow-up was 27.13±2.5 (range, 21 to 30), and mean Lysholm score at final follow-up was 90.69±5.75 (range, 83 to 100). Fractures healed in all patients, with no fixation failures. Minor loss of reduction (&lt;2 mm) were observed in 3 patients (18.75%). No patient has reoperation. One patient developed knee stiffness, with an infected hematoma 10 weeks postoperatively. None of patients developed anterior knee pain postoperatively. Two patients (12.5%) developed mild localized pain from prominent suture knots. There were no significant implant-related complications and no repeat surgery was necessary. Conclusions: The use of nonmetallic sutures with an all-FiberWire technique in patellar fracture fixation avoids implant-associated complications and possibility of a second surgery to remove metal implants. Nonmetallic high-resistance FiberWire matches traditional metallic fixation, with a reduced risk of postoperative complications. Level of Evidence: Level IV (therapeutic).

Nonabsorbable transosseous sutures for lower pole patella fractures: An effective surgical technique to prevent implant complications

Background: Treatment alternatives for patella fractures with the inferior pole are still being deliberated. In addition to tension-band wiring, metal implant-related complications are also not uncommon to occur in patellar fracture treatment. It is common to encounter implant-related complications such as implants failing, palpable hardware which require supplementary techniques to resolve. We evaluated participants with inferior poles of patella fracture treated with transosseous nonabsorbable sutures on functional outcomes. Methodology: This study encompasses observation of patients having transosseous suture fixation by no. 5 Ethibond for fixation of distal pole patella fractures. This was a longitudinal study piloted at a tertiary care center between January 2020 and June 2022. Patients' functional outcomes were assessed using the Bostman score. Results: The Bostman scoring system was used to evaluate the outcome at the final follow-up. In 19 patients, 7 (36.84%) patients showed outstanding and 11 (57.89%) patients showed good outcomes at the termination of 9 months follow-up. Only one patient established an unsatisfactory result. Conclusion: Distal pole patella fractures can be effectively fixed via transosseous suturing with unabsorbable sutures. Fast recovery and minimal implant-related complications are possible with this procedure. The resurgery rate is also significantly reduced.

Functional outcome among patients treated by percutaneous cannulated screw with tension band for transverse patella fracture

Introduction: Tension band wiring is the most commonly used treatment method for transverse patella fracture. Tension band construct can be achieved by various modifications. Percutaneous cannulated screw with tension band is a minimally invasive technique with stiffer fixation that follows tension band principle. This study aims to assess the clinical and radiological outcome using percutaneous cannulated screw with tension band for the management of transverse patella fracture. Methods: This was a prospective study among 30 adult patients who had closed displaced transverse patella fracture. Patients with polytrauma, comminuted fracture, neurovascular injury and prior injury to the limb were excluded from the study. Each patient was followed up at 2 weeks, 4 weeks, 3 months and 6 months postoperatively. Results: Among all surgically treated patients using this technique, Pain gradually decreased over time and was less than VAS score of 1 in all patients at 6 months follow-up with an average score of 0.3. The final range of motion at 6 months was: flexion ranging from 122 to 145 degrees and extension lag from of 0 to 8 degrees. There was significant improvement in range of motion of knee in each follow up. The mean duration for fracture union was 11.4±2.3 weeks. There were no cases of nonunion and hardware failure. The mean Lyshom score was 82.5 at final follow up. Conclusions: The percutaneous fixation of transverse patella fracture with cannulated screw and SS wire is safe and effective method which gives good functional outcome.

Functional and radiological outcomes following plating for displaced fractures of patella: A pilot study

Introduction: Patellar fractures constitute almost 1% of total skeletal injuries. Existing common operative methods include the use of different types of Tension band wiring techniques like cannulated screws and K-wires. The Patellar plating construct is a relatively newer operative method for patellar fracture fixation with promising outcomes with fewer complications.Method: We conducted a pilot prospective study at our Apex Trauma center in twenty patients aged 18–65years with displaced patellar fractures, AO type A2, A3, B2, B3, C1, C2, C3. Fractures were fixed with low profile patellar plates (1.8 mm). Radiological and functional follow-up was done using X-rays, CT scans and BKS scoring (Bostman-Knee-Scale), Knee Society Score(KSS), and Tegner Lysholm knee scores respectively for two years.Result: Mean functional outcome scores at 6 weeks, 3 months, 6 months and 2 years was 25.5, 28.3, 29.05 and 29.9 for BKS; 64.62, 84.12, 90.6, and 97.5 for KSS; 73.75, 89.7,94.8, and 99.3 for Tegner Lysholm knee score respectively. Radiological union, confirmed by CT scan, was observed in all patients at 3 months. Two patients had superficial surgical site infection (SSI) at 2 weeks. Implant impingement was also found in 2 patients at 3 months. None of the patients had a failure of fixation at the end of the study.Conclusion: Patients with low profile patellar plate constructs have favorable clinical and radiological outcomes with minimal non-specific complications.

Evaluation of patella fractures managed by augmented cannulated cancellous screw fixation: A prospective study

Patella is an important part of the extensor mechanism of the knee hence proper management of patellar fractures is necessary to prevent any complications. We conducted this study to evaluate cannulated cancellous screws as a modality of fixation for transverse fractures of patella. 63 patients of patella fracture were admitted, operated and followed who were managed by the above mentioned technique and based on our observation and results we recommend augmented cannulated cancellous screw as a better implant as compared to other contemporary implants for patella fracture fixation.

No difference in clinical and radiological outcomes following fixation of transverse patella fractures with either suture tape or metallic cerclage: A retrospective comparative study

IntroductionSeveral surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). HypothesisThe hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-operation than metallic cerclage but no differences in other clinical outcomes. Patients and methodsA retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months postoperatively to evaluate clinical scores and complications. ResultsA total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at 2 months postoperatively due to painful prominence. There was no significant difference in re-operation rates between the STCC and MWCC groups (p=1). There were no cases of non-union, malunion or loss of fixation throughout the series. At the final clinical follow-up of 18months, there were no significant differences in KSS, KOOS or Böstman scores between the groups. ConclusionNo significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. Level of evidenceIII.

Open Reduction and Internal Fixation of Patella Fracture With Contoured Dorsal Plating

In this article, we present a novel patella fixation technique using a low-profile highly contoured dorsal mini-fragment locking plate. This procedure is ideally indicated in patients with fracture patterns that are transverse without significant comminution. Long-term clinical studies are being performed to evaluate the effectiveness of this surgical technique.

Anterior Locking Plate Osteosynthesis of Patellar Factures - Analysis of Complications and Functional Outcome.

Tension band wiring is the standard procedure for patellar fractures, but is associated with a high rate of implant related complications and implant failure. Tension band wiring may fail, especially with multifragmentary and comminuted fractures. Plate fixation of complex patellar fractures seems to be superior to wiring, both clinically and biomechanically. The aim of this study was to evaluate complications after locking plate fixation in patellar fractures two years after surgery and to access the functional outcome. As part of a prospective case series, all patients who had received locking plate fixation of a patellar fracture between April 2013 and May 2018 were clinically examined two years postoperatively and potential complications were evaluated. A total of 38 patients aged 19 - 87 years were included. Complications occurred in a total of five patients (13%), including one reactive prepatellar bursitis, one chronic infection and loss of reduction due to a dislocated pole fragment in three cases. The average active range of motion of the affected knee joint two years postoperatively was 133°. The Tegner activity scale score reached 3 points, the Lysholm score 95 points and the Kujala score 95 points. With an overall relatively low complication rate and good clinical outcome, dislocated distal pole fragments are a common complication after plate fixation of patellar fractures. If preoperative diagnostic testing shows a pole fragment, a modified hook-plate can be used, with the possibility of fixing the pole fragment.

Migration of a broken kirschner wire to the popliteal fossa following tension band wiring of a patellar fracture

Kirschner wires (K-wires) are commonly used in the orthopedic trauma practice and liable to breakage and migration. We report the case of a middle-aged man with the migration of K-wire to the popliteal fossa after 11 years of patella fracture fixation and describe the technique of removal of the migrated and retained K-wires. A regular radiographic follow-up should be done to identify the presence of hardware breakage or migration following the use of K-wires. Once the wire migration is identified, it should be removed on an urgent basis regardless of symptoms, to avoid any major or minor complications.