Five-pointed star lattice sutures for fixation of patella transverse fractures: a clinical study

Tension band high-strength suture combined with absorbable cannulated screws for treating transverse patellar fractures: finite element analysis and clinical study

Objective: Few reports exist on the treatment of transverse patellar fractures (TPFs) using absorbable cannulated screws and high-strength sutures, and most screws and sutures lack good biomechanics and clinical trials. Therefore, this study aimed to demonstrate the biomechanical stability and clinical efficacy of tension-band high-strength sutures combined with absorbable cannulated screws (TBSAS) in treating TPFs (AO/OTA 34 C1). Methods: Finite element models of five internal fixation schemes were established: tension-band wire with K-wire (TBW), TBW with cerclage wire (TBWC), TBW with headless pressure screws (TBWHS), TBW with full-thread screws (TBWFS), and TBSAS. We comprehensively compared the biomechanical characteristics of the TBSAS treatment scheme during knee flexion and extension. Forty-one patients with TPFs in our hospital between January 2020 and August 2022 were retrospectively enrolled and divided into the TBSAS (n = 22) and TBWC (n = 19) groups. Clinical and follow-up outcomes, including operative time, visual analog scale (VAS) pain score, postoperative complications, Bostman score, and final knee range of motion, were compared between both groups. Results: Finite element analysis (FEA) showed that TBWHS and TBWFS achieved the minimum mean fracture interface relative displacement during knee flexion (45°, 0-500 N bending load) and full extension (0°, 0-500 N axial load). There was no significant difference between TBSAS (0.136 mm) and TBWC (0.146 mm) during knee flexion (500 N); however, TBSAS displacement was smaller (0.075 mm) during full extension (500 N). Furthermore, the stress results for the internal fixation and the patella were generally lower when using TBSAS. Retrospective clinical studies showed that the TBSAS group had a shorter operative time, lower VAS pain score at 1 and 2 months postoperatively, better Bostman knee function score at 3 and 9 months postoperatively, and better final knee joint motion than the TBWC group (all p < 0.05). There were five cases (26.3%) of internal fixation stimulation complications in the TBWC group. Conclusion: TBSAS demonstrated excellent safety and effectiveness in treating TPFs. It is sufficient to meet the needs of TPF fixation and early functional exercise and effectively reduces metal internal fixation-induced complications and secondary surgery-induced trauma.

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

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

The clinical outcomes and complications of combined fixation with cannulated screws and the modified Pyrford technique for the treatment of transverse patellar fractures: a case series study

Background

Transverse patellar fractures can be fixed using various techniques. The purpose of the current study was to assess the clinical outcomes and complication rate of a combined fixation technique using cannulated screws and the modified Pyrford technique with nonabsorbable polyester sutures.

Methods and patients

Between January 2015 and February 2021, 26 transverse patellar fractures were fixed with this combined technique. Preoperative data were collected from patients with transverse patellar fractures who were followed up for at least 12 months. At each follow-up visit, plain radiographs were taken. At the 12-month postoperative follow-up, range of motion of the affected knee joint and clinical outcomes, as evaluated by the Bostman scoring system, were recorded.

Results

The average Bostman score at the 12-month postoperative follow-up was 28.3 ± 1.5. Furthermore, the average extension and flexion of the knee joint were 1.2 ± 2.1 and 125.6 ± 6.7 degrees, respectively. One patient experienced delayed bone union and one experienced superficial wound infection. There were no other postoperative complications. One patient required removal of the device for social-psychological reasons.

Conclusions

The combined fixation technique with cannulated screws and the modified Pyrford technique with suture materials produced excellent clinical outcomes and a low rate of complications in the treatment of transverse patellar fractures.

Impairment characteristics of static balance and plantar load distribution of patients undergoing tibial cortex transverse distraction for diabetic foot ulcers

OBJECTIVE

Tibial cortex transverse distraction (TCTD) has been recently reported for the treatment of diabetic foot ulcers. Herein, we explored the characteristics of the impairments in static balance and plantar load distribution in patients.

METHODS

We performed a retrospective study of 21 patients with diabetic foot ulcers who underwent TCTD, who were regularly followed up for > 1 year after surgery, and 20 healthy individuals (control group). A pressure platform was used to assess the standing balance functions of the lower extremities and the plantar load distribution.

RESULTS

One patient underwent amputation because of severe infection. In patient group, center of pressure (COP) ellipse sway area, COP path length and angle θ were all larger, compared with those of control group (250.15 ± 98.36 mm2 vs. 135.67 ± 53.21 mm2, 145.15 ± 67.43 mm vs. 78.47 ± 34.15 mm, 39.75 ± 17.61° vs. 22.17 ± 14.15°), with statistically significant differences (P < 0.01). The average plantar load and backfoot load of the unaffected side was significantly larger than that of the affected side (58.4 ± 5.5% vs. 41.6 ± 5.5%, 45.3 ± 6.4% vs. 36.5 ± 5.6%), but they were similar for the two feet of members of the control group.

CONCLUSIONS

Although TCTD may represent an appropriate method for the treatment of diabetic foot ulcers, postoperative impairments in static balance and plantar load distribution remain in the long term. These potential long-term problems should be taken into account in further rehabilitation planning.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Comparison of the Kirschner Wire Tension Band with a Novel Nickel-Titanium Arched Shape-Memory Alloy Connector in Transverse Patellar Fractures: A Retrospective Study

This study aims to compare the clinical outcomes of the nickel-titanium arched shape-memory alloy connector (hereafter referred to as the ASC) and tension band fixation for the treatment of transverse patellar fractures. We retrospectively analyzed a total of 257 patients with transverse patellar fractures who were treated at our emergency orthopaedics department from March 2010 to March 2017. Either an ASC or the Kirschner wire (K-wire) tension band had been used to treat these fractures according to surgeons' experience and preference. We compared operative details, postoperative recovery, and postoperative knee function at 6 months. In terms of surgical duration, blood loss, incision length, length of hospital stay, and postoperative complications, patients in the ASC group showed significantly better results than patients in the K-wire group (p < 0.05). There were no significant differences between the two groups in terms of fracture healing time, knee mobility, and the Boström score at the postoperative 6-month evaluation (p > 0.05). Though, there were similar functional outcomes between two groups whose transverse patellar fractures were different methods, we found that the ASC method was a more reliable, more minimally invasive, and safer treatment option than the tension band wiring method using K-wires, resulting in less tissue damage, shorter surgical duration, shorter length of hospital stay, and fewer complications.

Interventions for treating fractures of the patella in adults

BACKGROUND

Fractures of the patella (kneecap) account for around 1% of all human fractures. The treatment of these fractures can be surgical or conservative (such as immobilisation with a cast or brace). There are many different surgical and conservative interventions for treating fractures of the patella in adults. This is an update of a Cochrane Review first published in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of interventions (surgical and conservative) for treating fractures of the patella in adults.

SEARCH METHODS

We searched CENTRAL (2020, Issue 1), MEDLINE, Embase, LILACS, trial registers and references lists of articles to January 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that evaluated any surgical or conservative intervention for treating adults with fractures of the patella. The primary outcomes were patient-rated knee function, knee pain and major adverse outcomes.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected eligible trials, assessed risk of bias and cross-checked data extraction. Where appropriate, we pooled results of comparable trials.

MAIN RESULTS

We included 11 small trials involving 564 adults (aged 16 to 76 years) with patella fractures. There were 340 men and 212 women; the gender of 12 participants was not reported. Seven trials were conducted in China and one each in Finland, Mexico, Pakistan and Turkey. All 11 trials compared different surgical interventions for patella fractures. All trials had design flaws, such as lack of assessor blinding, which put them at high risk of bias, potentially limiting the reliability of their findings. No trial reported on health-related quality of life, return to previous activity or cosmetic appearance. The trials tested one of seven comparisons. In the following, we report those of the main outcomes for which evidence was available for the three most important comparisons. Four trials (174 participants) compared percutaneous osteosynthesis versus open surgery. Very low-quality evidence means that we are uncertain of the findings of no clinically important difference between the two interventions in patient-rated knee function at 12 months (1 study, 50 participants) or in knee pain at intermediate-term follow-up at eight weeks to three months. Furthermore, very low-quality evidence means we are uncertain whether, compared with open surgery, percutaneous fixation surgery reduces the incidence of major adverse outcomes, such as loss of reduction and hardware complications, or results in better observer-rated knee function scores. Two trials (112 participants) compared cable pin system (open or percutaneous surgery) versus tension band technique. The very low-quality evidence means we are uncertain of the findings at one year in favour of the cable pin system of slightly better patient-rated knee function, fewer adverse events and slightly better observer-rated measures of knee function. There was very low-quality evidence of little clinically important between-group difference in knee pain at three months. Very low-quality evidence from two small trials (47 participants) means that we are uncertain of the findings of little difference between biodegradable versus metallic implants at two-year follow-up in the numbers of participants with occasional knee pain, incurring adverse events or with reduced knee motion. There was very low-quality and incomplete evidence from single trials for four other comparisons. This means we are uncertain of the results of one trial (28 participants) that compared patellectomy with advancement of vastus medialis obliquus surgery with simple patellectomy; of one quasi-RCT (56 participants) that compared a new intraoperative reduction technique compared with a standard technique; of one quasi-RCT (65 participants) that compared a modified tension band technique versus the conventional AO tension band wiring (TBW) technique; and of one trial (57 participants) that compared adjustable patella claws and absorbable suture versus Kirschner wire tension band.

AUTHORS' CONCLUSIONS

There is very limited evidence from nine RCTs and two quasi-RCTs on the relative effects of different surgical interventions for treating fractures of the patella in adults. There is no evidence from trials evaluating the relative effects of surgical versus conservative treatment or different types of conservative interventions. Given the very low-quality evidence, we are uncertain whether methods of percutaneous osteosynthesis give better results than conventional open surgery; whether cable pin system (open or percutaneous surgery) gives better results than the tension band technique; and whether biodegradable implants are better than metallic implants for displaced patellar fractures. Further randomised trials are needed, but, to optimise research effort, these should be preceded by research that aims to identify priority questions.