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2/1/2017 Patella Fractures- Treatment Options Disclosures SEFS 2017 Holly Pilson, MD Assistant Professor Objectives Patellar Anatomy- The Reverse Mullet Discuss unique patella anatomy Discuss challenges in patella imaging Discuss patella fracture patterns Discuss treatment options for various patella fracture patterns Patellar Anatomy Patellar Anatomy PARTY SIDE BUSINESS SIDE 1 2/1/2017 Patellar PatellarAnatomy Anatomy Patellar Imaging Patellar Imaging Patellar Imaging TRUE LATERAL LATERAL FACET Patellar Imaging MEDIAL FACET Patellar Imaging LATERAL FACET VIEW LATERAL FACET VIEW • Flat articular surface • Flat articular surface • Proximal beak • Proximal beak • Round dorsal surface • Round dorsal surface 2 2/1/2017 Patellar Imaging Patellar Imaging LATERAL FACET VIEW LATERAL FACET VIEW • Flat articular surface • Flat articular surface • Proximal beak • Proximal beak • Round dorsal surface • Round dorsal surface Patellar Imaging LATERAL FACET VIEW Patellar Imaging MEDIAL FACET VIEW • Flat articular surface • Pentagon • Proximal beak • Mild articular concavity • Round dorsal surface Patellar Imaging MEDIAL FACET VIEW Patellar Imaging MEDIAL FACET VIEW • Pentagon • Pentagon • Mild articular concavity • Mild articular concavity 3 2/1/2017 Patellar Imaging Patellar Imaging C-ARM This looks great! Patellar Imaging TRUE LATERAL Patellar Imaging LATERAL FACET TRUE LATERAL MEDIAL FACET MALREDUCED MEDIAL FACET Patella fractures – When to Fix? Consensus • Extensor mechanism disruption Debatable • > 2-3 mm articular step off • > 1-4 mm displacement LATERAL FACET MALREDUCED Patella fractures – Challenges • • • • • • Subcutaneous Soft tissue injury Small Cancellous Articular topography Imaging difficult/confusing 4 2/1/2017 Patella fractures – Treatment Options 1. Nonoperative 2. ORIF Cerclage wire Tension band wire Lag screws + tension band wire Tension band plating Lag screws Lag screws + neutralization plating Suture button Patella fractures – Treatment Goals • • • • Restore extensor mechanism Reduce articular incongruity Facilitate early knee mobilization Respect soft tissues 3. Partial patellectomy Approaches Extensive medial parapatellar Direct reduction Devascularization Patellar Fracture Patterns Anterior Indirect reduction Patellar Fracture Patterns Nonoperative Patellar Fracture Patterns Operative 5 2/1/2017 Patellar Fracture Patterns Patellar Fracture Patterns- Transverse Mostly Nonoperative, but Variable Suture button Tension band Lag screws + neutralization plating Lag screws + tension band Lag screws Patella Fractures – Tension Band Wire Inexpensive HW prominence Requirement: Cortical surface that can withstand compression Patella Fractures – Tension Band Wire Too long Patella Fractures – Tension Band Wire Too far Technical Points - Longitudinal K-wires close to articular surface - Longitudinal K-wires bent and rotated to capture tension band wire, cut short to minimize irritation - Tension band figure of 8 symmetric with knots tamped down, buried under quad tendon Tension Band Wire Problems Prominence Failure Technical Points - Longitudinal K-wires close to articular surface - Longitudinal K-wires bent and rotated to capture tension band wire, cut short to minimize irritation - Tension band figure of 8 symmetric with knots tamped down, buried under quad tendon Migration 6 2/1/2017 Patellar Fracture Patterns- Transverse Patella Fractures – Lag Screws + Tension Band Wire Biomechanically superior Suture button Tension band Lag screws + neutralization plating Lag screws + tension band Technical Points - Longitudinal screws close to articular surface - Screws antegrade vs retrograde- threads into larger/intact fragment - Screws stop short of cortex- screw tip may cut wire, want to tension bone, not screw Lag screws Patella Fractures – Lag Screws + Cable & Crimp More flexible More expensive Stronger Patella Fractures – Lag Screws + FiberTape® More flexible More expensive = Strength Less prominent Patella Fractures – Tension Band Material Patellar Fracture Patterns- Transverse Suture button Tension band Lag screws + neutralization plating Lag screws + tension band Lag screws 7 2/1/2017 Patella Fractures –Isolated Lag Screws • Literature scarce • Wang et al. – Shorter operative time – Lower loss of fixation – Lower rates symptomatic HW – Lower rates second surgery Patellar Fracture Patterns- Transverse Suture button Tension band Lag screws + neutralization plating Lag screws + tension band Lag screws Patella Fractures –Lag Screws + Neutralization Plate Patella Fractures –Lag Screws + Neutralization Plate *off label Synthes X-Plate *off label Patella Fractures –Lag Screws + Neutralization Plate Titanium mesh plate -easily contoured -multiple holes -Low profile Patellar Fracture Patterns- Transverse Suture button Tension band Lag screws + neutralization plating Lag screws + tension band Lag screws 8 2/1/2017 Patella Fractures –Suture Button Patella Fractures –Suture Button *off label *off label • No difference between TBW & Tightrope in fracture gapping and failure. • Possible lower risk of implant migration and soft tissue irritation Patella Fractures –Suture Button *off label McDonough VuMedi- “Patella Fracture Fixation using Minimal Hardware (7/2011) Patella Fractures– Patella Specific Implants • Zimmer Cable-Ready Pin System McDonough VuMedi- “Patella Fracture Fixation using Minimal Hardware (7/2011) Patella Fractures– Patella Specific Implants Complex Patellar Fracture Patterns *not available in US 9 2/1/2017 Complex Patellar Fracture Patterns Complex Patellar Fracture Patterns Complex Patellar Fracture Patterns Complex Patellar Fracture Patterns Cerclage wire Partial Patellectomy Complex Patellar Fracture Patterns Screws + Cerclage wire - Typically for severe, “non-reconstructable” inferior pole fractures Treat as patellar tendon repair – suture hole through remaining patella ANTERIOR attachment to prevent tilting Can augment with cerclage cable 10 2/1/2017 Complete Patellectomy • Partial patellectomy was only used when anatomic reduction could not be achieved • No statistical difference in ROM, functional outcomes, and complications Conclusion • • • • • • Historical Avoid if possible Only in unsalvageable cases Low patient satisfaction (6-25%) Extensor strength reduced by 50% Average 18 degrees loss of motion Thank You Patella anatomy- Reverse Mullet Patella imaging- Lateral & Medial facet views Patella fracture patterns Various treatment options exist Goals: • • • • Restore extensor mechanism Restore articular congruity Facilitate early knee mobilization Respect soft tissues 11
