treatment of communited patellar fractures

1. PERCUTANEOUS TREATMENT OF
COMMINUTED PATELLAR FRACTURE: FOCUS
ON THE PYRFORD TECHNIQUE
Five minutes talk by: Lalisa Marga, OSR
[ Notes stated in complete to convey the full messages
because the presentation is not face to face]
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2. MASTEWAL ASCHALEW, F/37, 068538
HOUSEWIFE, A.A
 FDA /01 day
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3. 3
5.86 mm

4. INTRODUCTION
 Comminuted patellar fractures usually occur with
direct trauma.
 Traditional open reduction with AO tension band
principles has gained great popularity, but it also
results in some postoperative complications, such
as infection and prolonged rehabilitation.
 With the development of the minimally invasive
surgical approach, minimally invasive surgery is
the current trend to treat the patellar fractures.
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5. INTRODUCTION…
 To fix comminuted patellar fractures
percutaneously, Pyrford techniques are recently
developed options as a prototype minimally
invasive surgery. (For both small and larger fracture
fragments)
 Percutaneous cerclage wiring for treatment of
displaced patella fractures ( especially for a highly
comminuted ones) is also described on a very
limited number of cases.
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6. PYRFORD TECHNIQUE
 Indications:
 Fractures in which fragments in the upper and lower
pole of the patella are relatively intact.
 Articular surface displacement no more than 2.5 cm.
 Anterior knee soft tissue contusion not suitable for open
reduction and internal fixation.
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7. PYRFORD TECHNIQUE…
 Relative contraindications:
 Upper pole avulsion fractures
 Difficult closed reduction (soft tissue suspected to
be embedded in the fracture)
 Fracture in which articular surface fracture
fragments are dissociated in the articular cavity
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8.  28 patients with comminuted
patellar fractures , 2017
 Percutaneous Pyrford used
technique to fx fractures
Results: The mean operation time was 72.3 ± 31.9 minutes. Intraoperative
fluoroscopy was 7.6 ± 2.4 times. All patients were followed up for a mean period of
34.4 months (13 to 53 months). Radiographic evidence of solid fracture union was
observed in all cases in a mean time period of 13.7 ± 2.6 weeks. Only one case of
broken steel wire was encountered, but the fracture had already been united. There
were no other complications, such as broken K-wire, fracture displacement, wound
infection or non-union.
Conclusion: Surgical treatment of the comminuted patellar fractures by the
percutaneous Pyrford technique achieved satisfactory clinical outcomes and knee
function in the selected patients. Its advantage is small incision, simple operation,
anatomical reduction, fixation stability, and achieves early mobilization.
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9. PYRFORD TECHNIQUE : THE STEPS TO FIX
FRACTURE WITH SMALL FRACTURE FRAGMENTS
 Aspirate the hematoma in the articular cavity using a needle.
 Make longitudinal incision of about 0.5-1 cm at the superolateral
aspect of the patella. And three other puncture points over the
other corners of the patella.
 Pass a circumferential cerclage wire in a pursestring fashion
close to the bone using wire passer(puncture passer) through the
puncture wounds.
 Pass a second wire through the quadriceps tendon, looping
anteriorly across the patella and through the patellar tendon to
act as a tension band using the puncture wounds as entry points.
 Apply closed manipulative reduction. Confirm the reduction by
fluoroscopy and then tighten the tension band wire and the
cerclage wire.
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10. PYRFORD TECHNIQUE…
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11. PYRFORD TECHNIQUE…
 NB:- If the close manipulative reduction is not
successful, the fracture reduction can be assisted
percutaneously using a Kirschner wire (K-wire) or a
Weber clamp.
 Finally, the small incisions are sutured and closed.
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12. PYRFORD TECHNIQUE : THE STEPS TO FIX FRACTURE
WITH LARGER FRACTURE FRAGMENTS
 Apply close manipulative reduction and confirm the reduction by
fluoroscopy.
 Apply the cerclage wire as described for fracture with smaller
fragments percutaneously.
 Flex the knee at 30°, and confirm the entry point of the K-wires.
The entry points are located in the middle-outer 1/3 and middle-
inner 1/3 of the superior or inferior patella.
 Next, two longitudinal incisions of about 0.5-1 cm are made at the
entry point( needs another two longitudinal incisions) and two 2-
mm K-wires are passed percutaneously to fix the fracture
fragments. The K-wire is best located at the middle-posterior 1/3
of the patella on the sagittal plane.
 Ultimately tighten the wire and twist the K-wires, knotted and
shortened. Finally, suture and close the small incisions.
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14. PYRFORD TECHNIQUE…
 Postoperative management:
 The isometric contraction exercise of the
quadriceps is allowed one day after the surgery.
 The knee flexion and extension are performed at 2-
3 days postoperatively. The active flexion could
reach above 90° at 4-5 days postoperatively.
 Allow the patient to gradually walk with stitches
after the knee active extension is powerful enough
in 7 days.
 Stitches are removed in 2~3 weeks.
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15. ADVANTAGES
 Significantly reduce the damage to the local blood supply
 Good healing rate
 Allow early functional exercise and rehabilitation, which can
result in good knee joint function
 Reduce the iatrogenic adhesion formation of the joint and
muscular injury
 Reduce infection rate
 Smaller scars and less interference with soft tissue which can
result in lower postoperative pain
 Much easier removal of the implants
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16. PERCUTANEOUS CERCLAGE WIRING
 The method includes soft tissue approximation in the
wiring.
 It may be especially suitable for comminuted fractures for
which classic tension band wiring techniques cannot be
used.
 The procedure is performed atraumatically by manipulating
peripatellar soft tissues together with the fracture fragments
in order to obtain optimal restoration of continuity of the
extensor mechanism.
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17.  Five patients included, 2014
 Percutaneous cerclage wiring done
for all
Results: The mean duration of follow-up was 11.2 months
(4–21 months). No limitation of extension was noted in any
patient with average flexion at 141º (120–160º). Excluding
the AO type A case, which was an inferior pole
fracture, bone union was achieved in the other four cases.
Conclusion: Although this procedure is not simple, it may
be superior to classic fixation techniques for highly
comminuted fractures with minimal displacement.
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18. PERCUTANEOUS CERCLAGE WIRING TECHNIQUE…
 Ten millimetre and 5-mm medio-lateral skin incisions are
made at the superior and inferior margins of the patella,
respectively.
 Cable passer is inserted into the patellar tendon through
the skin incision at the inferior margin, followed by the
passage of the cable.
 The cable is then passed around the patella including the soft
tissues, penetrating through the quadriceps femoris tendon
proximally, and then passed along the superior margin of the patella.
 The cable wiring is applied in each of the superficial and deep layers.
On realignment of the patellofemoral joint,
congruency of the patella to the knee joint is confirmed by
bending and extending it under flouroscopy.
 Tension is applied using a cable tensioner to lock the sleeve.
 The small incisions are sutured and closed.
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20. SUMMARY
 Treatment of comminuted patellar fracture by the
percutaneous Pyrford technique is feasible and
achieves satisfactory clinical outcomes.
 Although the minimally invasive techniques are applied
for comminuted fractures, it should be noted that
percutaneous TBW or screws for mildly displaced
simple transverse patellar fractures also achieves
excellent results.
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21. Percutaneous TBW for simple transverse patellar fracture
Percutaneous screw fixation for simple transverse patellar fracture
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22. Thank you !
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