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Patella fractures seminar mukul 11.06.2018
- 1. PATELLA FRACTURES Seminar Presentation: Dr Mukul Jain Guide: Dr Ramavtar Saini (Professor Orthopaedics) GMCH, Udaipur, Rajasthan 11.06.2018
- 2. Introduction • Largest sesamoid bone in body • Articular surface with large lateral facet and small medial facet • Attachments –Quadriceps Tendon - Patellar Ligament - Medial & Lateral Retinaculam
- 3. History • Until 19th century – nonoperative • 1940s – critical biomechanical function of patella highlighted • 1877 – first ORIF with wiring • 1950s – anterior tension band technique (muller)
- 4. • Current surgical treatment available 1.ORIF a.)TBW b.) cannulated screw tension band technique 2 Partial Patellectomy 3 Total Patellectomy
- 5. • Goals of surgical treatment are 1. Restoration of the functional integrity and strength of the extensor mechanism 2Maximizing articular congruity 3Preservation of patellar bone
- 6. Assessment Of patellar Fractures • Mechanism Of Injury A. Direct B. Indirect
- 7. • Signs and Symptoms H/o a.direct blow to patella b.fall from standing height c.forceful contraction of quadriceps on a partially flexed knee C/o anterior knee pain swelling difficulty ambulating after a fall
- 8. P/E: a.acute hemarthrosis b.tender, palpable defect c.Lacerations, abrasions(r/o compound # by SALINE LOAD TEST) • Note: the patient’s ability to extend the knee does not rule out a patella fracture, but rather it suggests that the continuity of the extensor mechanism is maintained via an intact retinacular sleeve.
- 9. Diagnostic Studies • Plain Radiographs- AP Lateral Tangential or axial views • bipartite or Tripartite Patella -may be mistaken for # patella -affects 8% of population -characteristic superolateral position -bilateral in 50% of cases
- 10. • Insall salvati Ratio (Assessment Of Patellar Height) Ratio of Height of Patella to length of patellar tendon a. Normal 1.02+/-0.13 b. Patella Alta <1 c. Patella Baja >1
- 11. • CT scan -Rarely required - imp. In evaluation of patellar stress fractures, nonunion, malunion • MRI (not routinely advised) -Used to evaluate Extensor mechanism injuries -normal xrays but is unable to straight leg raise -chondral injuries asso. with patellar dislocations -suspicion of osteochondral fractures
- 12. Classification Of patella Fractures • Non displaced -Transverse -Stellate -Vertical • Displaced -Transverse -Stellate -Pole -Osteochondral -Fractures after bone tendon bone harvest -Masqueraders
- 13. Non Operative Treatment Indications -<3mm of fragment dispacement or <2mm of articular incongruity -intact extensor machanism -severe medical comorbidity -severe osteopenia Relative contraindications • Extensor lag or incompetent extensor mechanism • >2 mm articular incongruity • >3 mm fracture displacement • Open fracture • Loose bone or chondral fragments
- 14. • Techniques -4 to 6 weeks of extension spinting or bracing -long leg cylindrical cast with proper moulding -SLR and isometric quadriceps exercises -ROM as soon as callus appears
- 15. Operative Treatment • Biomechanics of Tension Band The principle of tension band wire fixation : convert the tensile forces generated from the quadriceps complex at the anterior cortical surface of the patella into compressive forces at the articular surface. • A variety of internal fixation constructs have been performed till date. • Preoperative Planning: Simplifying the fracture pattern • Surgical approaches: Midline longitudinal extensile skin incision centered over patella
- 17. Surgical Steps Modified Anterior Tension Band • Anterior longitudinal midline incision • Avoid unnecessary undermining of tissue • Expose fracture and clear of debris • Assess degree of injury and define fracture pattern • Simplify fracture pattern with K-wires or screws when able • Reduce fracture • Place two 1.6-mm K-wires perpendicularly across fracture, • 5 mm below anterior cortical surface • Pass 18-gauge wire beneath patellar tendon posterior to K-wires • Cross limbs of wire over anterior patella • Pass wire through quadriceps tendon posterior to K- wires • Tighten wires by twisting both limbs of the wire simultaneously • Bend ends of K-wires 180 degrees posteriorly • Impact bent ends of K-wires into patella
- 18. Cannulated Screw Tension Band • Place two cannulated screw guidewires perpendicularly across fracture 5 mm below anterior cortical surface • Drill with cannulated drill over guidewires • Use depth gauge for screw lengths • Insert screws • Pass a single 18-gauge wire separately through each cannulated screw • Cross limbs of wire over anterior patella • Tighten wires by twisting both limbs of the wire simultaneously • Bend wire twists posteriorly into deep soft tissue
- 19. • Postoperative Care *Early Range Of Motion and protected weight bearing *CPM to reduce postop stiffness and improve articular cartilage healing
- 20. Partial Patellectomy • Indications -comminution of distal pole -dysvascular or free fragments • Contraindications -salvageable patella -tendon repair possible without removal of bony fragments
- 21. Steps • Anterior longitudinal midline incision • Expose fracture • Assess degree of injury and determine which fragments are salvageable • Remove nonviable patellar fragments • Reduce and internally fix retained fragments • Place grasping stitch in tendon • Reattach patellar or quadriceps tendon through three parallel drill holes • Secure suture over bone bridges in full extension • Assess strength of repair with controlled flexion • Consider adding cerclage wire from quadriceps tendon to tibial tubercle • Perform multilayer closure
- 22. Total Patellectomy Indications • Severely comminuted fractures unable to accept internal fixation or suture repair • Failed internal fixation • Patellar osteomyelitis Contraindications • Ability to retain any portion of the patella
- 23. Steps • Anterior longitudinal midline incision • Expose fracture • Assess degree of injury and determine if patellar salvage is possible • Remove patellar fragments • Imbricate redundant extensor mechanism tissue with heavy braided nonabsorbable suture • Check extensor mechanism tension at 90 degrees of flexion • Perform multilayer closure • Advance VMO
- 24. Thanks