Functional outcome and economic burden of operative management of patellar fractures: the pivotal role of onerous implants

Patellar Fracture Surgery Performed Autonomously by Residents, Yields Similar Short-Term Outcomes to Surgery Performed by Fellowship-Trained Surgeons

BACKGROUND

Open reduction and internal fixation are the gold-standard treatment for displaced patellar fractures. The current literature remains inconclusive on the relationship between resident participation in the operating room and optimal patient outcomes. We hypothesize that surgeries performed solely by residents, without attending supervision, can provide similar outcomes to those performed by fellowship-trained orthopedic surgeons, providing new insights into the relationship between resident autonomy and surgical outcomes in the field of orthopedic trauma.

METHODS

A tertiary trauma center cohort was retrospectively reviewed for all surgically treated patellar fractures between 2015 and 2020. The cohort was divided into 2 groups: patients operated by residents and patients operated by orthopedic trauma specialists. Demographics, surgical parameters, and radiographs were compared between the groups to evaluate complications and reoperation rates, radiographic outcomes (such as hardware failure, or loss of reduction), and clinical outcomes (including residual pain, painful hardware, decreased range of motion, and infections).

RESULTS

A total of 129 patellar fractures were included in the study. Demographics and ASA were similar between the groups. There were no significant differences in complications (p = 0.900) or reoperation rates (p = 0.817), with an average follow-up time of 8 months (SD ± 5.3). Residents had significantly longer surgery duration (p =0.002). However, the overall length of stay was shorter in the resident group (p < 0.001).

CONCLUSION

The study shows patellar fracture surgery performed by adequately trained residents can provide similar outcomes to those performed by fellowship-trained orthopaedic trauma surgeons. These findings highlight the significance of surgical autonomy in residency and its role in contemporary surgical education.

Surgical debridement and continuous irrigation for early surgical site infection caused by Staphylococcus aureus with a closed patella fracture surgery: A case report

INTRODUCTION

Management of postoperative surgical site infection (SSI) is a huge challenge to orthopedic surgeons, and significantly impacts patients and their families due to long treatment cycles and associated discomfort experiences.

PRESENTATION OF CASE

A 68-year-old woman without a medical history of any comorbidities, diabetes, hypertension, allergies, or tuberculosis, was admitted to our hospital complaining of right knee pain following a fall. X-ray and CT scans revealed a closed right patella fracture. The patient underwent open reduction and internal fixation with tension band wiring and circle wire. Preoperative assessment showed normal nutritional status. Prophylactic cefazolin sodium pentahydrate was administered 30 min preoperatively and maintained for 24 h post-operation to prevent infection. The patient was discharged 3 days after the operation. However, the wound exhibited signs of infection: redness, swelling, and the presence of secretions. Outpatient dressings and oral antibiotics were prescribed but failed to control the infection, leading to rehospitalization. Surgical debridement and continuous articular irrigation were implemented to address the infection. Secretion cultures were taken to identify the causative bacteria. Levofloxacin and Rifampicin were used according to drug sensitivity tests. However, the patient experienced severe knee swelling and an iodine irritative reaction subsequently. Anti-allergic treatment and normal saline dressings were applied to alleviate swelling, pain, and skin irritation. MRI results indicated arthroedema and possible infection necessitating further surgical debridement, the patient rejected additional surgery and requested discharge. Levofloxacin and Rifampicin were used for a month to control the infection after discharge, accompanied by regular rehabilitation exercises. Fortunately, the infection was successfully managed, and knee function was satisfactorily restored.

DISCUSSION

SSI after patella fracture surgery can lead to a worse quality of life, serious economic burden, and psychological distress. Therefore, effective treatment methods for managing postoperative SSIs are very important.

CONCLUSION

Sufficient surgical debridement is vital to remove infection tissue of early SSI caused by Staphylococcus aureus with a closed patella fracture surgery. Continuous articular irrigation and sensitive antibiotics help control infection, and active rehabilitation training improves knee function recovery.

Metal vs non-metal fixation methods for patellar fractures: A systematic review and meta-analysis of clinical and radiographic outcomes

Introduction

This paper aims to systematically review and meta-analyse the available evidence regarding the clinical and radiographic outcomes of non-metal fixation methods in treating patellar fractures compared to a control metal fixation group, in the hopes of bringing insight into their effectiveness.

Methods

Two investigators systematically reviewed studies across 9 English or Mandarin electronic databases - Cochrane Library, EMBASE, Google Scholar, Medline, PubMed, Scopus, Web of Science, CNKI and Wanfang Data, in adherence to PRISMA guidelines. The inclusion criteria for study selection were: English or Mandarin comparative studies that evaluated clinical (Patient Reported Outcome Measures, incidence of reoperations and postoperative complications) or radiographic (time to union and incidence of secondary loss of reduction) outcomes of metal and non-metal fixation methods for patellar fractures. From an initial pool of 1269 studies, 19 studies involving 1612 patients were included in the meta-analysis after full-text evaluation and accounting for exclusion criteria.

Results

Clinically, the reduction in reoperations (OR = 0.22, 95% CI [0.10, 0.51], P = 0.0003), direct (OR = 0.17, 95% CI [0.08, 0.33], P < 0.00001) and indirect (OR = 0.50, 95% CI [0.27, 0.93], P = 0.03) implant-related postoperative complications were significantly in favor of non-metal fixation. Radiographically, the decrease in time to union (SMD = -0.79, 95% CI [-1.11, -0.47], P < 0.00001) in the non-metal group compared to the metal group was also significant. The remaining results were comparable.

Conclusion

This meta-analysis suggests that non-metallic internal fixation had similar if not superior outcomes to their metallic counterparts, with fewer implant-related complications and improved postoperative recovery. Given the higher re-operation rates associated with metallic fixation, non-metallic methods may be preferable from economic and safety perspectives. Nevertheless, more homogenous studies with standardised fracture configurations and treatment modalities are needed before declaring non-metallic fixation as the gold standard for patellar fractures.

A study of fracture lines distribution characteristics in complete articular fractures of the patella

Objective

The objective of this study was to unveil the characteristics of fracture lines distribution and explore its clinical significance of complete articular fractures of the patella.

Methods

A consecutive series of image data from 88 patients with complete articular patella fractures were retrospectively included. Three-dimensional reconstruction images of the patella fractures were created and collected. Subsequently, these reconstructed images were visually overlaid onto a standard anterior and posterior patella template. The fracture lines were then identified, traced onto the template, and utilized to generate patella fracture maps. Furthermore, the incidence rate of patella fracture lines involving the distal pole was analyzed.

Results

The maps depict the fracture lines of complete articular patella fractures. For simple and complex patella fractures, the primary fracture lines primarily converge within the Middle and Lower regions, exhibiting a transverse pattern. Conversely, the primary fracture lines in comminuted patella fractures are randomly dispersed across the patella. Examining the maps, approximately 63.6% (56/88) of complete articular patella fractures exhibited involvement of the distal pole in the anterior view, while 48.9% (43/88) displayed distal pole fractures in the posterior view. The incidence of distal pole injury increased progressively with the severity of patella fractures.

Conclusion

The patterns and distribution of fracture lines in cases of complete articular patella fractures are prominently illustrated on the constructed fracture maps. Familiarity with these common characteristics of complete articular patella fracture, especially with the distal pole injury, can aid surgeons in developing preoperative planning, executing surgical strategies effectively, and reducing inappropriate treatment.

Fracture-related infection of the patella: Treatment options and outcome

BACKGROUND

Fracture-related infection (FRI) after the operative management of patella fractures is a serious complication that can result in prolonged hospitalization, multiple revision procedures and permanent functional impairment. Till today, treatment modalities and outcome of FRI of the patella are not well described. Therefore, the main objective of this retrospective cohort study was to evaluate treatment options, functional outcome and healthcare costs related to FRI of the patella.

METHODS

This study evaluated 111 consecutive patients that were surgically treated for patella fractures, at the department of trauma surgery of the University Hospitals Leuven (Belgium), between January 2015 and April 2020. Patients were excluded if they (1) were younger than 18 years at the time of injury or (2) died during follow up. The minimal follow-up for all patients was 18 months.

RESULTS

During the 5-year study period, 107 patients with 108 patella fractures were included. A total of 10 patients were diagnosed with an FRI (9.3%). Four of these were treated with a DAIR approach and three patients underwent implant removal or exchange. Finally, three patients were treated with total patellectomy. Out of the 10 patients, two were diagnosed with a recurrence of infection. Overall, we observed substantial lower scores for all Knee Injury and Osteoarthritis Outcome Score subscales in the FRI group, compared to a reference population. Moreover, our study shows that direct hospital-related healthcare costs of FRI of the patella were nine times higher compared to non-FRI cases.

CONCLUSIONS

FRI of the patella is a challenging complication and recurrence of infection not uncommon. Although multiple treatment modalities exist, a multidisciplinary patient-specific approach is crucial. An early or delayed onset infection can be managed with a DAIR approach, but only when the construct is stable and the soft tissue coverage adequate. In patients with an FRI, implant removal is preferred when the fracture has healed. A total patellectomy can be used as a salvage procedure in complex cases with acceptable functional results. Overall, FRI of the patella leads to both a negative impact on the functional status of the patient and a ninefold increase in total healthcare costs.

Radiographic Outcomes Following the Suture Fixation of Mid-pole Patellar Fractures

Background

Mid-pole patellar fractures are typically fixed with metal implants in the conventional “11-8” tension band construct. However, this technique is fraught with numerous implant-related complications. The aim of this study is to evaluate the union rate following “all-suture” fixation of mid-pole patellar fractures.

Methods

We retrospectively evaluated a consecutive case series of patients with displaced mid-pole patella fractures treated with “all-suture” fixation in our institution. Fifteen cases were available for this study. The average age was 61.5 years. Clinical and radiological outcomes were evaluated. Union time, complications, and revision rate were recorded. The minimum follow-up was one year.

Results

There were eight males and seven females, with a mean age of 61.5 ± 13.3 years. Fourteen out of 15 cases (93.3%) achieved radiographic union at 12 weeks postoperatively. The average time to radiographic union was 8.0 ± 2.7 weeks. Five cases (33.3%) had an increase in the fracture gap (>2 mm) at around four to six weeks postoperatively. Four of these cases had an eventual union, whereas one patient had fibrous non-union. There was one case of superficial surgical site infection and one case of infected hematoma. None of the patients required revision surgery.

Conclusion

“All-suture” fixation of mid-pole transverse patellar fractures is a safe and viable alternative to the conventional “11-8” tension band constructs with metal implants, with good union time, rates, and added benefits of not requiring additional surgery for implant removal.

A Rare Case of Patella Fracture in Osteopetrosis: A Case Report

CASE

Fractures in patients with osteopetrosis pose unique technical challenges to the orthopaedic surgeon. We present a case of a 43-year-old man with osteopetrosis who underwent tension band wiring of a patella fracture. The intraoperative appearance of osteopetrotic bone, technical difficulties in passing wires through dense bone, and how this was overcome are presented.

CONCLUSIONS

A simple transverse fracture of the patella in a patient with osteopetrosis can be fixed successfully using a standard tension band construct.