A Novel Technique for Supplementing Transosseous Suture Repair of Inferior Pole Patella Fractures with a Tension Band

Comparison of Fixation Methods Between Transosseous Pull-Out Suture and Separate Vertical Wiring for Inferior Pole Fracture of Patella: A Systematic Review and Meta-Analysis

OBJECTIVES

To compare, in a systematic review, Krakow transosseous (KT) suturing and separate vertical wiring (VW) fixation methods in inferior pole fractures of the patella and to evaluate whether the supplementary fixation affected bone union.

METHODS

DATA SOURCES

The MEDLINE, Embase, and Cochrane databases were searched from inception to January 15, 2023. The keywords were "patella inferior pole fracture", "patella distal pole fracture", "transosseous", "pull-out suture", "reattachment", and "vertical wiring".

STUDY SELECTION

All clinical studies describing KT or VW techniques for inferior pole fracture of the patella and reporting bone union-related complications were included.

DATA EXTRACTION

This meta-analysis included 16 studies with 274 patellae. Demographic data, surgical techniques, clinical outcomes, and complication rates were recorded. The Methodological Index for Non-Randomized Studies criteria were used to assess their quality.

DATA SYNTHESIS

A meta-analysis was performed using random-effects models and meta-regression. The meta-analytic estimate of bone union-related complications was 3.8% (95% CI, 1.6%-6.0%) for either PO or VW techniques in inferior pole fractures of the patella. The bone union-related complication rates did not differ significantly between the two techniques (KT, 5.7%; VW, 3.0%; P = .277). Meanwhile, supplementation fixation was significantly associated with decrease in bone union-related complication rates ( p = .013).

CONCLUSIONS

Fixation of inferior pole fractures of the patella using either KT or VW techniques provided satisfactory and similar clinical results with minimal bone union-related complications. Supplementary fixation has a positive impact on reducing bone union-related complications in inferior pole fractures of the patella following KT and VW techniques.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcome of rim-plate-augmented separate vertical wiring with supplementary fixation for the treatment of patellar fracture associated comminuted inferior pole

Despite the variety of treatment methods, comminuted inferior pole fractures of the patella remain difficult and technically demanding to achieve stable internal fixation. The purpose of this study is to evaluate the clinical outcomes of rim plate-augmented separate vertical wiring with supplementary fixation in the management of comminuted inferior pole fractures, AO/OTA 34-A1, C2, and C3, which has the secondary horizontal fracture line on lower articular boundary. From our study, bony union was achieved in all patients at an average of 3.1 ± 1.4 months after surgery. There was no patient with loss of reduction, fixation failure, or infection during follow-up. The average final range of motion was 131.6° ± 7.2°. Lysholm knee scores gradually increased over 3, 6, 9, and 12 months postoperatively by 58.7, 74.0, 82.9, and 89.4, respectively. Isokinetic peak torque deficit of the knee extensor muscles in 3, 6, 9, and 12 months postoperatively was 59.9%, 49.7%, 35.7%, and 28.1%, respectively. The rim plate-augmented separate vertical wiring with supplementary fixation for the treatment of patellar fracture associated comminuted inferior pole is effective and can be safely applied AO/OTA 34-C2 or C3 with favorable outcomes.

Surgical treatment of inferior pole fractures of the patella: a systematic review

PURPOSE

This study aimed to comprehensively review the existing evidence concerning surgical treatment of inferior pole fractures of the patella and to report the outcomes and complications of different fixation techniques.

METHOD

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches of PubMed, Scopus, and Web of Science were conducted in March 2023. Studies were screened against predecided inclusion and exclusion criteria. The extracted data included fracture characteristics, surgical techniques, and radiographic and functional outcomes. The Methodological Index for Non-Randomized Studies (MINORS) quality assessment tool was used to assess the eligible literature. The primary outcome was postoperative range of motion of different surgical methods, and the secondary outcomes were other clinical results and complications.

RESULTS

A total of 42 studies satisfied all the inclusion criteria and were deemed suitable for review. Fourteen case-control studies and 28 case series were selected, for a total of 1382 patients with a mean age of 51.0 years (range = 11-90). The follow-up period ranged from 6 to 300 months. The surgical techniques were categorized based on the device used as follows: (1) rigid fixation device; (2) tensile fixation device; (3) mixed device; and (4) extra-patella device.

CONCLUSION

Regarding the outcomes following surgical treatment of inferior pole fractures of the patella, the postoperative range of motion (ROM) of each technique ranged from 120° to 135°, with the exception of that involving the patellotibial wire which had poorer outcomes. The lowest functional score was also found in those using the patellotibial wire. Complications after surgery are rare, but approximately half of the patients required additional surgery for implant removal, particularly those whose initial surgery involved rigid fixation devices. It's worth noting that bony fragment excision is no longer recommended, and the combined use of multiple surgical devices is now more common.

"Fishing net" suture augmenting tension-band wiring fixation in the treatment of inferior pole fracture of the patella

INTRODUCTION

Inferior pole fracture of the patella (IPFP) is difficult to repair and stabilize clinically. Although various fixation techniques have been developed, fixation strength and mobility remain daunting challenges to orthopedic surgeons. The goal of this research is to evaluate the biomechanical strength and clinical outcomes of a novel "fishing net" suture fixation procedure.

MATERIALS AND METHODS

Four finite element models, modified tension-band wiring fixation, anchor suture fixation, basket plate fixation and "fishing net" suture fixation were built to compare the fixing efficacy of "fishing net" suture fixation with three other fixation methods during IPFP fixation. From January 2018 to February 2019, 17 patients who suffered IPFP and treated by "fishing net" suture (FNS) fixation were compared with 20 patients treated by tension-band wiring (TBW) fixation in database and the two groups were evaluated postoperatively using the modified Cincinnati knee rating system.

RESULTS

Biomechanical evaluation showed that the relative displacement values of proximal patella measured by three pairs of points on both sides of the fracture line were the lowest using the "fishing net" suture fixation, while fixation using tension-band wiring and basket plate showed similar levels of stability that were less desirable than the "fishing net" method. As to clinical outcomes, there were 17 (100%) patients exhibited excellent or good results with no internal fixation failures in the FNS group compared to three internal fixation failures in the TBW group.

CONCLUSION

The biomechanical and clinical results suggest that the "fishing net" suture fixation is a viable candidate for fixation of IPFP.