Showing papers on "Patella fracture published in 2019"

Patellar complications after total knee arthroplasty.

Abstract: Patellar complications are a source of poor total knee arthroplasty (TKA) outcomes that can require re-operation or prosthetic revision. Complications can occur with or without patellar resurfacing. The objective of this work is to answer six questions. (1) Have risk factors been identified, and can they help to prevent patellar complications? Patellar complications are associated with valgus, obesity, lateral retinacular release, and a thin patella. Selecting a prosthetic trochlea that will ensure proper patellar tracking is important. Resurfacing is an option if patellar thickness is greater than 12mm. (2) What is the best management of patellar fracture? The answer depends on two factors: (a) is the extensor apparatus disrupted? and (b) is the patellar implant loose? When either factor is present, revision surgery is needed (extensor apparatus reconstruction, prosthetic implant removal). When neither factor is present, non-operative treatment is the rule. (3) What is the best management of patellar instability? Rotational malalignment should be sought. In the event of femoral and/or tibial rotational malalignment, revision surgery should be considered. If not performed, options consist of medial patello-femoral ligament reconstruction and/or medialization tibial tuberosity osteotomy. (4) What is the best management of patellar clunk syndrome? When physiotherapy fails, arthroscopic resection can be considered. Recurrence can be treated by open resection, despite the higher risk of complications with this method. (5) What is the best management of anterior knee pain? The patient should be evaluated for causes amenable to treatment (fracture, instability, clunk, osteonecrosis, bony impingement on the prosthetic trochlea). If patellar resurfacing was performed, loosening should be considered. Otherwise, secondary resurfacing is appropriate only after convincingly ruling out other causes of pain. A painstaking evaluation is mandatory before repeat surgery for anterior knee pain: surgery is not in order in the 10% to 15% of cases that have no identifiable explanation. (6) What can be done to treat patellar defects? Available options include re-implantation (with bone grafting, cement, a biconvex implant, or a metallic frame), bone grafting without re-implantation, patellar reconstruction, patellectomy (best avoided due to the resulting loss of strength), osteotomy, and extensor apparatus allograft reconstruction. LEVEL OF EVIDENCE: V, expert opinion.

Patellar complications following total knee arthroplasty: a review of the current literature

Abstract: Total knee arthroplasty is a common operation for treating patients with end-stage knee osteoarthritis and generally has a good outcome. There are several complications that may necessitate revision of the implants. Patella-related complications are difficult to treat, and their consequences impact the longevity of the implanted joint and functional outcomes. In this review, we explore the current literature on patellar complications in total knee arthroplasty and identify risk factors as well as strategies that can help in preventing these complications. We present pertinent findings relating to patellar complications. They can be classified into bony or soft tissue complications and include bone loss, aseptic loosening, periprosthetic fractures, patella fracture, patellar clunk syndrome, patellofemoral instability, extensor mechanism complications, maltracking, patella baja and malrotation. We conclude that patellar complications in total knee arthroplasty are common and have significant implications for the functional outcome of total knee arthroplasty. A high index of suspicion should be maintained in order to avoid them. Implant malpositioning and other forms of intraoperative technical error are the main cause of these complications, and therefore, primary prevention is crucial. When dealing with these established problems, a clear plan of action should be formulated in advance to allow appropriate management as well as anticipation of adverse outcomes.

Outcomes after locked plating of displaced patella fractures: a prospective case series

Abstract: Tension band wiring remains a common treatment for patella fractures, but complication rates are high, with unsatisfactory results. The purpose of this observation study was to evaluate clinical results and complication rates of a novel patella locking plate fixation. Twenty patients (mean age, 59.2 ± 18 years) with displaced patella fractures were prospectively enrolled. Range of motion, knee scores (Tegner, Lysholm, Kujala), complications, and revision surgeries were assessed six weeks, six months, 12 months, and 24 months after surgery. Results were compared to the situation before trauma in regards to the time of follow-up using a paired sample t test. According to the OTA classification, the fractures were classified as follows: one A1, four C1, six C2, and nine C3. Range of motion improved from 121° after six weeks to 140°, 141°, and 143° within the follow-up period. While the Tegner, Lysholm, and Kujala scores were 4.1/97/97, respectively, before trauma, they improved from 2.6/80/89 to 3.6/94/89, 3.7/95/94, and 4.1/97/97 within the follow-up period. Three patients had a complication (15%): one fracture dislocation, one reactive bursitis, and one renewed fracture. Four patients reported discomfort or anterior knee pain especially when kneeling on the implant. The patella locking plate is a safe and effective treatment for patella fractures, including comminuted fractures. Function can be restored within six months after surgery, and the complication rate is low. Nonetheless, the implant can cause discomfort or anterior knee pain especially when kneeling, which can necessitate an implant removal.

Comparing 3 Different Techniques of Patella Fracture Fixation and Their Complications.

Abstract: Introduction:Patella fractures managed by fixation with metal implants often cause local soft tissue irritation and necessitate implant removal. An alternative is to utilize suture-based fixation m...

Medial Quadriceps Tendon Femoral Ligament Reconstruction Technique and Surgical Anatomy.

Abstract: Medial patellofemoral ligament reconstruction risks patellar fracture with the osseous violation necessary for patellar attachment. Anatomic studies identify an entire medial patellofemoral complex of structures responsible for medial restraint to patellar lateral instability. One specific component of this complex is the medial quadriceps tendon femoral ligament (MQTFL). This note presents the technique, pearls and pitfalls, and critical surgical anatomy necessary for successful MQTFL reconstruction-a treatment strategy for patellar instability with no increased risk for patellar fracture. An autograft hamstring tendon or allograft tendon is fixed to the anatomically identified femoral origin and passed deep to the vastus medialis obliquus to then weave around the distal medial quadriceps tendon. This simulates the native anatomic interdigitation of the MQTFL with the quadriceps tendon and provides a stable restraint to prevent lateral patellar subluxation or dislocation.

Where should Kirschner wires be placed when fixing patella fracture with modified tension-band wiring? A finite element analysis

Abstract: The position of Kirschner wires (K-wires) has an influence on the outcome of modified tension-band wiring (MTBW) in fixing patella fractures. However, the instruction for K-wires positioning is not clear enough. This study tried to clarify the effect of K-wires positioning and provide evidence for a more definite instruction. The sagittal position (SP) suitable for placing K-wires was evenly divided into SP 1–5 from anterior to posterior, and the finite element models of midpatella transverse fractures fixed by the figure-of-eight or figure-of-zero MTBW were built up at each SP. Separating displacement of the fracture, stress of the fracture, and stress of the internal fixations were measured at 45° knee flexion by using finite element analysis. The separating displacement of the fracture was smaller at SP 3–5 (23% smaller than SP 1–2). From SP 1 to 5, the compression of the fracture surfaces increased (R = 0.99, P = 0.001); the improper stress area of the fracture surfaces decreased (R = − 0.96, P = 0.01), and so was the stress of K-wires (R = − 0.93, P = 0.02). However, the stress of stainless steel wires showed a stable trend. The SP of K-wires plays a role in the function of MTBW in the surgical management of transverse patella fracture. At 45° knee flexion, posteriorly placed (close to the articular surface) K-wires enable optimal stability and stress for the fracture, which provides basis for the positioning of K-wires in clinical practice.

Miniplate Augmented Tension-Band Wiring for Comminuted Patella Fractures.

Abstract: The aim of this study was to introduce various applications of miniplate augmented tension-band wiring (TBW) for comminuted patella fractures and to evaluate the clinical outcomes. Comminuted articular patella fractures were managed with anterior cortical miniplate fixation with a TBW technique from January 2014 to January 2016. The primary end point was radiographic union. Secondary end points were complications related to the procedure. Functional outcomes including range of motion were also evaluated. Thirty patients were followed up for a mean of 20 months (range, 12-28) postoperatively. The primary union rate was 96% (29 of 30 patients). Mean time to union was 3.2 months. One patient required additional surgery because of acute postoperative infection. Twenty-five patients recovered a full range of motion relative to the contralateral limb. The mean Bostman score at the last follow-up was 28.6 points (range, 26-30). In conclusion, miniplate augmented TBW is a versatile and useful technique for comminuted patella fracture fixation.

Hook plating in patella fractures.

Abstract: Purpose Tension band wiring is considered the standard treatment for patella fractures. However, it is limited for fractures with marginal involvement, comminution, and osteoporotic bone. Our experience indicates that these limitations can be overcome with the hook plate. We evaluated the radiographic and clinical outcomes in patients with patella fracture treated with hook plating. Methods We enrolled 30 patients who underwent hook plating for patella fracture at two institutions between 2013 and 2017. Fracture classification and surgical options were reviewed. Postoperative fracture gap and time to union as radiographic measurements, and complications, range of motion, and functional outcome with the Lysholm score as clinical outcomes, were evaluated retrospectively. Results Nine fractures were AO/OTA 34A1, three B1, one B2, two C1, nine C2, and six C3. All were closed fractures. There were 3 cases of revision, 4 with lateral or medial marginal fracture, 9 with isolated inferior pole fracture, and 14 with comminuted fracture. The average postoperative fracture gap was 0.4 (range, 0–2.0) mm, and bone union was achieved without additional intervention. The average time to union was 11.6 (range, 7–24) weeks. There were no complications, and no extension lag except in one case (10°). The average flexion was 138.5° (range, 110–145°). For functional outcomes, the average Lysholm score was 89.5 (range, 74–95), with 13 excellent, 14 good, 3 fair, and no poor cases. Conclusion This study suggests that hook plating can result in good bone union and restored knee function in marginal or comminuted fractures of the patella.

Changes in patellar fracture characteristics: A multicenter retrospective analysis of 1596 patellar fracture cases between 2003 and 2017.

Abstract: Purpose This study aimed to investigate the characteristics of patellar fracture and the changes in these characteristics over time in Korea. Methods A total of 1596 patients with patellar fractures who visited 5 university hospitals from 2003 to 2017 were included in the analysis. The demographic characteristics of the patients, including age, sex, body mass index, and fracture characteristics, including the fracture classification, injury mechanism, fixation method, and postoperative complication rate, were analyzed through a review of the medical records and plain radiographs. Results There were 988 (61.9%) male patients and 608 (38.1%) female patients. The mean age was 51.3 (range, 3–97) years for the study group, 47.6 (range, 8–94) years for male patients, and 57.3 (range, 3–97) years for female patients. Increasing trends in the proportion of patients aged ≥60 years and in the proportion of female patients were observed during the study period (p = 0.002 and p Conclusions Patellar fractures in the female and elderly populations are increasing. Moreover, elderly patients with patellar fractures had a higher postoperative complication rate and also a higher percentage of low-energy injury than younger patients. Therefore, patellar fractures in the elderly population should be considered fragility fractures, and further studies are warranted to suggest a specific treatment plan for fragility patellar fractures.

Influence of Patella Height on Total Knee Arthroplasty: Outcomes and Survival.

Abstract: Background The aim of this study is to assess clinical results of total knee arthroplasty (TKA) with pre-operative patella alta or patella baja, compared to TKA with pre-operative normal patellar height. Methods Patella height was measured using the Blackburne-Peel (BP) method in an initial, prospective cohort of 4103 TKAs performed at a single center. Three groups were defined: normal patella height (0.54 1.06), and patella baja (BP index ≤0.54). Pre-operative and post-operative clinical and radiological characteristics were collected and compared. All prostheses used a system of posterior stabilization by a third condyle. The primary outcome measure was the post-operative Knee Society Score. Statistical analysis was performed using Student’s t-test and chi-squared test, with P Results Two hundred twenty-three TKAs with pre-operative patella alta, 307 TKAs with pre-operative patella baja, and 2248 with pre-operative normal patella height, mean follow-up 39.3 months (range 24-239), were ultimately included. Post-operatively, there was no difference between the 3 groups in terms of Knee Society Score (knee and function scores). Patella baja statistically decreased the maximal flexion (118.2° vs 115.5°, P = .002) and increased the rate of patellar fracture (0.9% vs 2%, P = .05). Finally, survival rates were similar in the 3 groups with each above 91% (±2%) at 10 years. Conclusion Clinical and radiological results for TKAs with pre-operative patella alta and patella baja were comparable to TKAs with a normal pre-operative patellar height. Risk of post-operative patellar fracture increased for patients with pre-operative patella baja.

Socioeconomic factors and individual lifestyles influencing the incidence of patella fractures: a national population-based survey in China

Abstract: We aimed to do a national survey on the population-based incidence of patella fractures and related risk factors fracture in China. All the data on patella fractures were available from the China National Fracture Survey (CNFS) between January and May in 2015. And in the CNFS, all eligible household members were selected from 24 urban cities and 24 rural counties of eight provinces of China, with stratified random sampling and the probability proportional to size method used. Questionnaire was sent to every participant for data collection and quality control was accomplished by our research team members. A total of 512,187 valid questionnaires were collected, and relevant data were abstracted. There were a total of 69 patients with 69 patella fractures that occurred in 2014, indicating that the incidence was 13.5 (95% CI, 10.3–16.7))/100,000 person-years. Slip, trip, or fall from standing height was the most common cause, leading to 69.6% (48/69) of patella factures, followed by traffic accidents (18.8%, 13/69). Home and road were the first two most common places, where 86.9% of the overall injuries occurred. Age of 45–64 and 65–74 years, alcohol consumption and previous history of fractures were identified as independent risk factors for patella fracture. Specific public health policies focusing on decreasing alcohol consumption should be implemented. Individuals aged 45–64 and 65–74 should pay more attention to bone mass density and prevention of falls, especially those with previous history of fracture.

Management of comminuted patellar fracture fixation using modified cerclage wiring

Abstract: Although there are several different kinds of fixation techniques for displaced comminuted patellar fracture, the treatment remains a challenge for orthopaedic surgeons. The purpose of this study is to evaluate the effectiveness and safety of a fixation technique for comminuted patellar fracture fixation using modified cerclage wiring. From February 2016 to April 2018, 38 cases of simple unilateral closed comminuted patellar fracture were treated by modified cerclage wiring. Among these cases, 16 patients were males and 22 were females, aged 23–68 years (average 40.4 ± 9.1 years). Comminuted patellar fractures were classified according to the AO/OTA classification: 10 cases were type 34-C2 (three fragments), 28 cases were type 34-C3 (more than three fragments). Postoperative complications including loosening of internal fixation, fragment re-displacement, nonunion, infection, breakage of internal fixation and traumatic osteoarthritis were assessed. The clinical results after operation were evaluated by the clinical grading scales of Bostman including range of movement, pain, work, atrophy, assistance in walking, effusion, giving way, and stair-climbing during follow-up. A total of 38 patients were followed up for 6–36 months (mean time 16.1 ± 5.8 months). The bone union radiographically occurred at approximately 2.5–3.5 months (mean time 2.92 ± 0.25 months). No postoperative complications, such as infection, dislocation, breakage of the implants, painful hardware, and post-traumatic osteoarthritis, were observed. According to the clinical grading scales of Bostman, satisfactory results were obtained, and the mean score at the final follow-up was 28.7 (range 20–30) points. Thirty-two patients (84.2%) with excellent results had a mean score of 29.5 ± 0.7 (range 28–30) points, and six patients (15.8%) with good results had a mean score of 24.5 ± 2.2 (range 20–27) points. The patients with excellent and good scores had active flexion of 130° (110–140). Modified cerclage wiring can effectively treat comminuted patellar fracture and offers a new strategy resulting in satisfactory results without obvious complications.

Roles of the screw types, proximity and anterior band wiring in the surgical fixation of transverse patellar fractures: a finite element investigation

Abstract: Cannulated screws with an anterior wire are currently used for managing transverse patellar fracture. However, the addition of anterior wiring with various types of screws via open surgery to increase the mechanical stability is yet to be determined. Hence, this study aimed to compare the mechanical behaviors of a fractured patella fixed with various screws types and at various screw locations with and without the anterior wire. The present study hypothesized that using the anterior wire reduces the fracture gap formation. A finite element (FE) model containing a fractured patella fixed with various types of cannulated screws and anterior wiring was created in this study. Three types of screws, namely partial thread, full thread, and headless compression screws, and two screw depths, namely 5 and 10 mm away from the anterior surface of the patella, were included. The effect of the anterior wire was clarified by comparing the results of surgical fixation with and without the wire. Two magnitudes and two loading directions were used to simulate and examine the mechanical responses of the fractured patella with various fixation conditions during knee flexion/extension. Compared with partial thread and headless compression screws, the full thread screw increased the stability of the fractured patella by reducing fragment displacement, fracture gap formation, and contact pressure while increasing the contact area at the fracture site. Under 400-N in the direction 45°, the full thread screw with 5-mm placement reduced the gap formation by 86.7% (from 2.71 to 0.36 mm) and 55.6% (from 0. 81 to 0. 36 mm) compared with the partial thread screw with 10-mm placement, respectively without and with the anterior wire. The anterior wire along with the full thread screw is preferentially recommended for maintaining the surgical fixation of the fractured patella. Without the use of anterior wiring, the full thread screw with 5-mm placement may be considered as a less invasive alternative; however, simple screw fixation at a deeper placement (10 mm) is least recommended for the fixation of transverse patellar fracture.

Five-pointed star lattice sutures for fixation of patella transverse fractures: a clinical study

Abstract: Fixation of displaced patella fractures with metal implants may be associated with implant failure, post-operative pain, and high re-operation rate. This study reports preliminary clinical results of using five-pointed star lattice sutures for the management of patella transverse fractures. A five-pointed star lattice suture configuration was produced intraoperatively, and 25 patients with patella transverse fractures were treated with this newly designed sutures fixation. All patients were followed up until union of the fractures or until further surgical intervention. At a mean of 1.6 years (range 0.8–2.5 years) of follow-up, the notes and plain radiographs of the 25 patients were reviewed. Bostman score was used to evaluate the therapeutic effects. All 25 patients experienced union of the patella fractures, with excellent knee function in 19 patients and good in 6 patients evaluated with Bostman score. The newly designed five-pointed star lattice sutures fixation may be a feasible alternative to metal implants fixation in the management of patella transverse fracture. Level IV case series.

Combined Soft Tissue Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon-Femoral Ligament.

Abstract: Patellar dislocation is a major orthopaedic concern in pediatric and adult populations, with both conservative and surgical options available. Several surgical techniques of the combined or isolated reconstruction of the medial patellofemoral ligament are described in the literature using different grafts, locations, and types of fixations, providing different advantages and disadvantages. New recent developments in cadaveric dissection studies have unveiled the importance of structures that were neglected until recently, such as the medial quadriceps tendon–femoral ligament, which provides a connection between the medial femur and the quadriceps tendon component of the knee extensor mechanism. Hence, we present a surgical technique with combined reconstruction of the medial patellofemoral ligament and medial quadriceps tendon–femoral ligament without the use of hardware and with no need for patellar or femoral drilling (no physis compromise or risk of patellar fracture), which can be used concomitantly with other bony procedures.

Contourable craniofacial mesh plate osteosynthesis of patellar fractures: A new, low-profile fixation technique.

Abstract: Purpose Patellar fractures are challenging orthopaedic injuries that can be difficult to treat due to the complexity of fracture patterns, the high stresses at the patellofemoral joint, and subcutaneous location of the patella. Hardware prominence and need for hardware removal are two of the most common complications after surgical fixation of patellar fractures. There is an ever present need for low profile fixation constructs that are also biomechanically stable. Materials and methods We present an alternative technique of patella fixation with a low profile titanium mesh plate typically used in craniofacial skeletal trauma. Four patients at our institution underwent mesh plate fixation of patella fractures. Results All four patients had union without any post-operative complications. All four patients regained preoperative range of motion without residual pain or disability. Conclusions Mesh plate fixation of patellar fractures is an alternative to standard tension band technique, especially in comminuted fractures. The craniofacial mesh plate is very low profile, provides stable fixation that allows for early range of motion, and has the potential to reduce post-operative complications like hardware removal.

A prospective observational study of 30 patients of avulsion fracture treated with tension band wiring followed up to 6 months

Abstract: Introduction: Wiring is the earliest forms of internal fixation. A loop of SS (Stainless steel- 316L) wire is passed around the fragments or through the drill holes and the ends are twisted together. It is used in Fractures of patella, olecranon and malleolus, greater trochanter of femur, greater tuberosity humerus, lateral end clavicle.In the present study, tension band wire technique was used which include use of 2 K wires and SS wire. The 2 K wires used, anchors to the TBW loop made by the SS wires and prevents tilting/rotation of fragments and holds the reduced fracture fragments in place till union.Aims and Objective: To study the technique of TBW and its principle as a modality of treatment. To clinically evaluate the results and efficacy of this principle and technique. We did prospective study of 30 patients of various fractures requiring K wire and TBW surgery for those fractures between October 2016 to October 2018.Results: We observed patella fracture is the most common constituting 33%, medial malleolus 30%, olecranon 17%, greater trochanter femur 7% and is followed by lateral one third clavicle, greater tubercle humerus, distal end ulna and non-union medial malleolus which is 3%. Superficial infection in 1(3.3%) case of medial malleolus fracture, joint stiffness in 3 (10%) cases (1 each of fracture patella, fracture olecranon, fracture bimalleolus), migration of K wire in 1(3.3%) case of fracture patella and osteoporosis in 1(3.3%) case of greater tuberosity humerus.Time for radiological union in weeks was 7.84, with 9 for fracture patella, 8 for medial malleolus, olecranon and distal end ulna, 6 for Greater Trochanter femur and 4 for lateral end clavicle and greater tuberosity humerus.Conclusion: TBW is a simple, inexpensive technique and effective means of fixing fracture based on biomechanical principle with minimum complication.

Extensor mechanism reconstruction with peroneus longus tendon autograft for neglected patellar fracture, report of 2 cases.

Abstract: Extensor mechanism deficiency in the knee may occur due to neglected patellar and quadriceps tendons rupture or may be caused by chronic fractures of the patella. Older patients can tolerate nonunion with impaired function including extension limitation or persistent muscle weakness. In young patients, performing rigid internal fixation with reoperation should be considered when a nonunion occurs. However, delayed and neglected nonunion in patella fractures require performing different surgical procedures. We report two cases, operated for a patella fracture, in whom nonunion occurred and accompanied by patellar migration and retraction of quadriceps tendon because of a fixation failure. We reconstructed the extensor mechanism with peroneus longus tendon autograft and, owing to this method, we achieved excellent functional results during a 2-year follow-up period.

Proof-of-concept prototype drill-guide for use in medial patello-femoral ligament (MPFL) reconstruction surgery.

Abstract: For surgical reconstruction of the medial patello-femoral ligament (MPFL) a variety of techniques are used for fixation of the graft to the medial border of the patella. The bone bridge or V-shaped tunnel technique utilises two tunnels drilled from the medial aspect of the patella that converge centrally creating a tunnel through which the graft is threaded. This technique has advantages: it avoids hardware (bone anchors) and their associated complications, creates a broad attachment of the ligament approximating normal anatomy and the tunnel does not breach the lateral cortex of the patella reducing the risk of patella fracture. In current practice the bony tunnels are created using freehand techniques. These rely on estimation of the patella centre by the surgeon and is subject to wide variation. Additionally this technique can be inefficient, inaccurate and time consuming. To address these disadvantages a new drill-guide device was developed. A prototype drill-guide was constructed using CAD and 3D printing methods. The device was designed to allow the surgeon to accurately and efficiently drill the required v-shaped bone tunnel. To assess the efficacy of the prototype drill guide, an experiment designed to assess a group of ten surgeons with an average of 4.2 years experience performing the task of creating a v-shaped bone tunnel using a free-hand technique and the drill-guide. To determine the accuracy of the tunnel placement, the angle between drill holes, distance from centre of the patella and the amount of over-drill were measured. Procedure duration was also compared. The results revealed that the prototype drill-guide created a more accurate bone bridge than the traditional free hand method. The root mean square error for the distance from centre was 0.50 mm vs 2.12 mm and the angle between tunnels was 2.6O vs 15.9O for the prototype and traditional methods respectively. There was a mean of 8.9 mm over-drill with the traditional method, which was negated when using the guide. Surgeons using the guide were approximately 25% faster than using the traditional free-hand technique. The prototype drill-guide improved the accuracy, reduced the variability, and reduced procedure duration compared to the traditional free-hand technique.

Treatment of Patellar Lower Pole Fracture with Modified Titanium Cable Tension Band Plus Patellar Tibial Tunnel Steel “8” Reduction Band

Abstract: Purpose: To determine the efficacy of modified titanium tension band plus patellar tendon tunnel steel 8 "reduction band" versus titanium cable tension band fixation for the treatment of patellar lower pole fracture. Materials and Methods: 58 patients with lower patella fracture were enrolled in this study, including 30 patients treated with modified titanium cable tension band plus patellar tibial tunnel wire "8" tension band internal fixation (modified group), and 28 patients with titanium cable tension band fixation. All patients were followed up for 9∼15 months with an average of 11.6 months. Results: Knee flexion was significantly improved in the modified group than in the titanium cable tension band group (111.33 ± 13 degrees versus 98.21 ± 21.70 degrees, P = 0.004). The fracture healing time showed no significant difference. At the end of the follow-up, the improvement excellent rate was 93.33% in the modified group, and 82.14% in the titanium cable tension band group. Titanium cable tension band internal fixation loosening was found in 2 cases, including 1 case of treatment by two surgeries without loose internal fixation. Conclusions: The modified titanium cable tension band with "8" tension band fixation showed better efficacy for lower patella fractures than titanium cable tension band fixation.

Gap Non-union Patella Fractures: Case Report and Review of the Literature.

Abstract: Introduction Gap non-union patella fractures are rare but can be particularly challenging for the orthopedic surgeon. We report a case of a 12 cm gap non-union patella fracture in a patient with osteoporosis and its surgical management, functional outcome, and implications on clinical practice. Case report A 73-year-old fully independent female with a background of osteoporosis was referred to our outpatient knee clinic. She reported a fall from stairs following an initial soft-tissue injury to the left knee 6 months prior. She has had progressive decline in mobility since the injury and was restricted to a wheelchair when she was seen in clinic. On examination, she had significant wasting of the quadriceps on the left side. Her range of movement was from 40° extensor lag to 90° flexion actively. Passive movements of the knee were preserved. She was unable to straight leg raise. Plain radiographs revealed a 12 cm gap non-union of her left patella. The patient was managed operatively in a two-staged approach. The first stage involved application of ring fixator device to achieve gradual skeletal traction from 5 to 12 lbs over a period of 10 days. The second stage involved conventional tension band wiring. Conclusion At 1-year follow-up, the patient achieved full independent mobility. This case highlights the efficacy of a two-staged approach in the management of gap non-union patella fractures in patients with poor bone quality.

The modified anterior ellipsoidal cap titanium cable tension band for comminuted patellar fractures.

Abstract: Purpose:The purpose of this study was to assess the outcomes in a series of patients, who underwent cerclage and figure-of-eight tension band wiring using a single titanium cable for comminuted pat...

Long Term Follow-up of an Open Bicondylar Hoffa Fracture with a Disrupted Extensor Mechanism: A Case Report.

Abstract: This is the first report of a long-term follow-up of an open bicondylar Hoffa with patella fracture. It is interesting to note the radiological changes of osteoarthritis 15 years after global intra-articular injury of the distal femur. The good clinical outcome is possibly due to the integrity of the knee ligaments and reconstruction of the extensor mechanism in addition to stable anatomical reduction and fixation.

Implantless patellar fixation in medial patellofemoral ligament reconstruction.

Abstract: Purpose The medial patellofemoral ligament (MPFL) acts as primary restraint to lateral patellar dislocation and its rupture has been reported in almost all cases of acute patellar dislocation. Various surgical techniques have been described for MPFL reconstruction, using many femoral and patellar fixation techniques and different grafts. This article details our technique for MPFL reconstruction using semitendinosus graft which avoids the use of implant at patellar end. Methods Twenty patients (8 males and 12 females) with complaints regarding acute and chronic lateral patellar instability were evaluated and treated by MPFL reconstruction procedure. The mean age of patients was 21 years (range 17-34 years). MPFL reconstruction was performed using semitendinosus graft passing through two parallel, obliquely directed tunnels created in patella. Fixation of graft was done with an interference screw only at the femoral end. Mean follow-up period after intervention was 26.4 months (range 23-30 months). Results were evaluated using Kujala score. Results All patients gained adequate patellar stability and full arc of motion. No incidence of patella fracture was noted. There were no postoperative complications related to procedure. There was no recurrence of instability in patella at final follow-up. Conclusion Passing the graft through the tunnels in patella without use of any implant has given excellent functional outcome and moreover has the advantages of less implant-related complications and cost-effectiveness.

Patellar Transskeletal Traction for the Treatment of Chronic Patellar Pseudoarthrosis

Abstract: Patellar fractures, which constitute approximately 1% of bone lesions, may lead to severe impairment of the extensor mechanism. When conservative or surgical treatment fails, the patella may develop pseudoarthrosis. Neglect or delayed treatment of this type of injury may lead to significant diastasis between the patellar fragments. There is no consensus regarding the best treatment for such cases. This study is aimed at describing a rare case of patellar pseudoarthrosis in a patient who underwent two-step surgical treatment comprising transskeletal patellar traction followed by osteosynthesis with a tension band. A 17-year-old male patient presented with a left patellar fracture that resulted from a fall from a standing height 8 years ago. He did not undergo any type of surgical treatment during that time, but the fracture was immobilized for only 2 weeks. The two-step surgical treatment with transskeletal patellar traction and patellar osteosynthesis was performed and provided satisfactory functional clinical results in this patient. This two-step surgical treatment can be performed in cases similar to ours with satisfactory results.

A Technique Utilizing GraftNet to Fill Graft Donor Sites in Bone-Patellar-Bone Anterior Cruciate Ligament Reconstruction

Abstract: Anterior knee pain and patella fracture are 2 potential complications of bone-patellar-bone autograft anterior cruciate ligament reconstruction. Techniques have been developed to minimize the risk of these complications, including filling the defects with autologous bone fragments and augmenting with biologic agents. We have developed a technique that uses a graft collection device to collect the autologous bone graft generated during surgery. This graft augments the larger bone graft derived from the bone plugs. This autologous augmentation provides a complete biologic strategy to potentially reduce the risk of anterior knee pain and potential patella fracture.

Non-Identical Bilateral Rupture of the Extensor Mechanism of the Knee in a Patient with Hyperlipidemia: A Case Study.

Abstract: Introduction Rupture of the extensor mechanism is a relatively common injury, most frequently occurring as a result of patella fracture, while ruptures of the quadriceps tendon and patellar ligament are less common. Extensor mechanisms of healthy knees are able to tolerate large forces before rupturing; therefore, complete ruptures without significant trauma are due to minor injury to an already degenerate or attenuated tendon. Hyperlipidemia has been linked as a cause of tendon degeneration due to the systemic biological effect that it has on tenocytes. Non-identical bilateral ruptures are rare. To the best of our knowledge, this is the only case report of bilateral ruptures involving the quadriceps tendon of one knee and patellar ligament of the contralateral knee simultaneously. Case Report A 42-year-old man presented to our department with bilateral traumatic rupture of the extensor mechanism of the knee. He had no medical history, was not taking any regular medications, and had no significant family history but a 15-year history of anterior knee pain. Both of his legs gave way on landing from a jump. Radiographs demonstrated a knee effusion with normal patella height on the left and a knee effusion with an elevated patella on the right. A diagnosis of quadriceps tendon rupture on the left and patellar ligament rupture on the right was made. Conclusion Hyperlipidemia has been associated with ruptures of the Achilles tendon but has not been reported in association with failure of the extensor mechanism of the knee. We suggest that all patients presenting with bilateral tendon ruptures, especially in the absence of systemic disease or corticosteroid therapy, are investigated for hyperlipidemia and treated accordingly.