Management of comminuted patellar fracture fixation using modified cerclage wiring

Morphological characteristics and a new classification system of the inferior pole fracture of the patella: A computer-tomography-based study

PURPOSE

The objective of this study was to measure the morphological characteristics of inferior pole fracture of the patella (IPFP) and develop a practical classification system to determine the corresponding treatment protocols for different IPFPs with specific patterns.

METHODS

A retrospective radiographic review was performed on a series of 71 patients with IPFP. The preoperative CT data were collected and measured using image processing software. The number of fragments, maximum fracture fragment anteroposterior length (MFFAL), maximum fracture fragment transverse length (MFFTL), fracture fragment coronal angle (FFCA), fracture fragment sagittal angle (FFSA), maximum fracture fragment height (MFFH) and maximum transverse sectional area (MTSA) were analysed.

RESULTS

The mean number of fracture fragments was 3.8. The average MFFAL was 14.9 mm, the average MFFTL was 23.5 mm, the average FFCA was 92.1°, the average FFSA was 93.0°, the average MFFH was 13.6 mm, and the average MTSA was 299.3 mm2. A new classification system was introduced to describe the varied patterns of IPFP, summarized as (I) simple IPFP; (II) comminuted IPFP; (III) simple IPFP with simple patellar body fracture; and (IV) comminuted patellar fracture involving the inferior pole. With the four-type classification system, 12 type I, 22 type II, 21 type III, and 16 type IV lesions were observed, each with specific morphological characteristics.

CONCLUSION

Most IPFPs exhibited a diversiform pattern, demonstrating that coverage fixation was likely needed. The four-type classification system might offer a valuable approach to help orthopaedic surgeons make individual treatment plans.

Modified cerclage and suture mesh fixation for comminuted patellar fracture - "Cobweb Technique": A case report

Displaced comminuted patellar fractures necessitate surgical treatment to restore the function of the extensor mechanism of the knee. One of the main challenges in the fixation of comminuted fracture of the patella is achieving an anatomic articular reduction with a stable fixation to allow early mobilization and prevent knee stiffness. Various common surgical fixation methods necessitate the use of metallic implants. Due to its superficial location, hardware-related complications and re-operations are common after patellar fixation. We present a case of a comminuted patellar fracture fixed using a modified cerclage and suture mesh fixation technique using high-strength braided nonabsorbable sutures. This provided a rigid fixation that allowed early range of motion while avoiding the risk of having symptomatic hardware.

A Comprehensive Physiotherapeutic Rehabilitation Protocol for Malunited Post-operative Patellar Fractures: A Case Report

A patellar fracture is a fracture of the kneecap. The patella is a shield that plays a vital function in the biomechanics of the knee joint. Traumatic knee injuries produced by direct trauma or quick quadriceps contraction with the knee bent can result in the loss of the extensor mechanism. A 69-year-old female patient presented with pain in her right knee following a slip at her home, which resulted in an injury to her knee. Subsequently, a radiological investigation suggests a patellar fracture. The purpose of this case report is to investigate the rehabilitation techniques and concrete the result. This report emphasizes the value of a comprehensive rehabilitation program designed to assist people with this type of fracture pattern in reaching their peak operational capacity. The patient underwent a comprehensive rehabilitation regimen that included cryotherapy, range of motion exercises, strengthening exercises, gait training, balance and proprioception training. The functional outcomes were assessed using a visual analogue scale, goniometry, manual muscle testing, Berg balance scale and lower extremity functional scale. The patient exhibited significant improvement and a positive response to the therapeutic techniques and outcome assessments. This underscores the necessity for a well-rounded treatment approach to manage patellar fractures and optimize patient outcomes effectively.

Management of comminuted patellar fractures using suture reduction technique combined with the modified Kirschner-wire tension band

OBJECTIVES

Surgical management of comminuted patella fractures remains a major challenge for the surgeon. We developed a suture reduction (SR) technique to better preserve the comminuted patella. The study aimed to compare the suture reduction technique with conventional reduction (CR) technique in the management of comminuted patellar fractures using the modified Kirschner-wire (K-wire) tension band.

METHODS

From May 2016 to September 2020, a total of 75 patients with comminuted patellar fracture were reviewed retrospectively. Among these cases, 35 patients were in the suture reduction group with a mean age of 52 years, while 40 patients were in the conventional reduction group with a mean age of 53 years. All cases were closed fractures. Comminuted patellar fractures were classified as type 34-C3 according to the AO/OTA classification. Radiographs of the knee were obtained at routine follow-up to evaluate the reduction quality and fracture union. Clinical outcomes including range of motion (ROM), visual analog scale (VAS), Lysholm, and Böstman grading scales were measured at the last follow-up. Postoperative complications were also recorded.

RESULTS

The average time from injury to surgery was 5.4 days in suture reduction group and 3.7 days in conventional reduction group (p < 0.05). The surgical time of suture reduction group was less than that of conventional reduction group, but there was no significant difference (p = 0.110) regarding surgical time between the two groups. The average blood loss in suture reduction group was 42.9 ml, while the average blood loss in conventional reduction group was 69.3 ml (p < 0.001). There was no difference regarding fracture union, ROM and knee function score (Lysholm score and Böstman scale) between the two groups. The complication rates were 17.1% in suture reduction group and 12.5% in conventional reduction group respectively (p > 0.05).

CONCLUSIONS

In the treatment of comminuted patellar fractures with modified K-wire tension band, the use of suture reduction technique can shorten the surgical time, reduce the surgical trauma, and obtain satisfactory results. This new surgical technique may be particularly effective in management of comminuted patellar fractures when patellectomy would otherwise be considered.

Predictors of postoperative complications of tension band wiring techniques for patella fracture: A retrospective multicenter (TRON group) study

OBJECTIVE

The relationship between postoperative complications and operative techniques of tension band wiring (TBW) is not well studied. We aimed to evaluate the incidence of implant breakage, implant migration, and loss of reduction in patellar fractures treated with TBW and identify radiographic factors associated with these postoperative complications.

METHODS

This multicenter (named, TRON group) retrospective study included 224 patients who underwent open reduction and internal fixation of patella fractures using TBW from January 2016 to December 2020. Radiographic findings were evaluated by experienced orthopedic surgeons, and radiographic outcomes were assessed for K-wire migration, implant breakage, and loss of reduction. Logistic regression analysis was performed to identify radiographic factors associated with postoperative complications.

RESULTS

Implant migration occurred in 44 cases (19.6%), with bending of a single K-wire end identified as a significant risk factor (OR: 12.90; 95% CI: 4.99-33.30; P < 0.001). Implant breakage occurred in 43 cases (19.2%), with a large patella-tension band ratio (OR: 291.0; 95% CI: 19.60-4330; P < 0.001) and a wide distance between K-wires (OR: 1.15; 95% CI: 1.060-1.250; P = 0.001) identified as significant risk factors. Loss of reduction occurred in 5 cases (2.0%), but no significant risk factors were identified.

CONCLUSION

This study highlights the importance of bending both ends of the K-wires and proper placement of the tension band and K-wires in reducing postoperative complications in patellar fractures treated with TBW. Further research is needed to better understand the risk factors associated with loss of reduction.

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.

Biomechanical comparison of different screw-included angles in crossing screw fixation for transverse patellar fracture in level walking: a quasi-dynamic finite element study

BACKGROUND

A minimally invasive technique with various screw configurations without open surgery is currently used for the fixation of transverse patellar fractures. Percutaneous crossing screw configuration has been reported to have a good bone union rate in patellar fractures. However, the difference in mechanical stability of the fractured patella between different screw-included angles has not been fully investigated. Hence, this study aims to compare the mechanical stability of parallel and crossing screw fixations with different screw-included angles for the fixation of transverse patellar fractures during level walking.

METHODS

A finite element knee model containing a patella with a transverse fracture is created. Two headless compression screws with different angles (0°, 30°, 60°, and 90°) are used to fix the fracture. The loading conditions of the knee joint during level walking are used to compare the stability of the fractured patella with different fixation screw configurations.

RESULTS

The results indicate that the maximum fracture gap opening distance increased with an increase in the included angle. Two parallel screws yield the smallest gap distance among all screw configurations. The maximum gap opening distances at the anterior leading edge of the fractured patella with two parallel screws and two screws having an included angle of 90° are 0.73 mm and 1.31 mm, respectively, at 15% walking cycle.

CONCLUSIONS

Based on these results, the superior performance of two parallel screws over crossing screw fixations in the fixation of transverse patellar fractures is established. Furthermore, the smaller the angle between the crossing screws, the better is the stability of the fractured patella.

Iliac Crest Allograft with Plate Osteosynthesis for a Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Donor-Site Fracture: A Case Report

CASE

A 20-year-old man sustained a comminuted bone-patellar tendon-bone donor-site fracture 17 days after a contralateral anterior cruciate ligament revision reconstruction. Successful fixation was achieved by using a tricortical iliac crest allograft bone plug with mesh plate osteosynthesis. At 6 months of follow-up, the patient had full range of motion without pain.

CONCLUSION

Patellar fractures after bone-patellar tendon-bone harvest may be treated successfully with mesh plate osteosynthesis and a tricortical iliac crest allograft bone plug. This unique fixation option addresses bone loss and restores the extensor mechanism while avoiding autograft donor site morbidity.

The clinical outcome of the reduction of the patellar inferior pole fracture with wire cerclage through a generated bone hole, in combination with patellar concentrator: a retrospective comparative study

OBJECTIVE

The patellar inferior pole fracture is typically comminuted. Hence, achieving firm fixation and early activity is highly challenging. In this article, we employed the method of wire cerclage through a generated bone hole to reduce the fracture. Our objective was to compare the clinical efficacy of patellar concentrator alone with a combination of cerclage and patellar concentrator in the treatment of patellar inferior pole fracture.

METHODS

We conducted a retrospective review of patients with patellar inferior pole fractures, who underwent patellar concentrator fixation only (the control group) or cerclage combined with patellar concentrator fixation (the experimental group), performed by a single surgeon, between July 2015 and October 2019. Our analysis included surgical indexes like7 aspects (fracture gap after operation, operation time, intra-operative blood loss, intra-operative number of C-arm fluoroscopies conducted, Insall-Salvati ratio calculated immediately after operation, initial range of motion on the 7th day after operation, and fracture healing time), as well as the Bostman score and complications recorded on 1-, 3-, 6-, and 12-month follow up post operation.

RESULTS

A total of 94 patients with patellar inferior pole fracture and a minimum 1-year follow up were recruited. Following operation, the control group had 33 (71.74%) patients with a fracture gap of 0-2 mm and 13 (28.26%) patients with a fracture gap greater than 2 mm (P = 0.002). Conversely, the experimental group had 46 (95.83%) patients with a fracture gap of 0-2 mm and 2 (4.17%) patients with a fracture gap greater than 2 mm (P = 0.002). Compared to the control group, the experimental group did not experience enhanced operation time or intra-operative blood loss (P = 0.811, P = 0.823). The Insall-Salvati ratio and initial range of motion in the experimental group were larger than the control group (P = 0.037, P = 0.000). Alternately, the number of intra-operative C-arm fluoroscopies conducted and fracture healing time of the experimental group were considerably less than the control group (P = 0.003, P = 0.000). Moreover, at 1-, 3-, 6-, and 12-month follow ups after operation, the Bostman scores of the experimental group were remarkably higher than the control group (P < 0.05). At 12 months post operation, 23 cases (50%) were classified as excellent, 22 cases (47.83%) were good, and 1 case (2.17%) was poor in the control group (P = 0.005). In the meantime, in the experimental group, 38 cases (79.17%) were deemed as excellent and 10 cases (20.83%) were good (P = 0.005). Lastly, complications were detected in 3 cases (6.52%; 1 case of internal fixation loss, 2 cases of hematoma) within the control group, and in 1 case(2.08%; marginal wound necrosis) within the experimental group. There was no wound infection, implant discomfort, or broken fixation in either group.

CONCLUSION

Managing the patellar inferior pole fracture with wire cerclage through a generated bone hole is both simple and effective. Moreover, an additional step of patellar concentrator fixation facilitates early functional exercise, with satisfactory clinical outcome.

Comparison of the Therapeutic Effects of Tension Band with Cannulated Screw and Tension Band with Kirschner Wire on Patella Fracture

Background

Patella fracture accounts for 1% of bone injury, of which anatomical reduction is of great significance to the recovery. Tension band with cannulated screw and Kirschner wire is commonly used methods for the treatment of displaced patella fracture. However, there is still some controversy on the clinical efficacy of the two treatment methods.

Objective

This study aimed at comparing the therapeutic effects of the cannulated screw and Kirschner wire tension bands on patella fracture and at providing more data basis for clinical selection of treatment methods for patella fracture.

Methods

Altogether, 146 patients with displaced patella fracture admitted to our hospital from March 2016 to February 2018 were selected and divided into two groups according to the different treatment methods. Among them, 71 patients received tension band with a cannulated screw (TBWCS group) and 75 patients received tension band with Kirschner wire (TBWKW group). Two groups of patients were compared in terms of surgical treatment effect after one year of treatment, complications within six months after the operation and operation-related indexes. The pain visual analogue scale (VAS) score, knee flexion degree, Lysholm score, and Bostman score were recorded at 1, 3, 6, and 12 months after operation, and the activity of daily living scale (ADL) score was evaluated at the last follow-up.

Results

During the operation of patella fracture patients, the intraoperative blood loss, hospitalization time, and knee flexion loss of patients in TBWCS group were less than those in the TBWKW group (P < 0.05), the starting time of postoperative functional exercise was earlier than that of patients in TBWKW group (P < 0.05), and the incidence rate of secondary operation was lower than that of patients in the TBWKW group (P < 0.05), but there was no statistical difference in the operation time, incision length, and postoperative fracture gap between the two groups. The results of curative effect analysis showed that the knee flexion, Lysholm score, and Bostman score of patients treated with tension band with cannulated screw were higher than those treated with Kirschner wire (P < 0.05), and VAS score was lower. Tension band with cannulated screw had a better curative effect on patella fracture (P < 0.05), lower complication rate (P < 0.05), and higher quality of life of patients (P < 0.05).

Conclusion

Tension band with cannulated screw has a good curative effect on patella fracture, low incidence of complications, early start of postoperative functional exercise, and high quality of life.