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Average 3.9 of 44 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 36-year-old female sustains a knee injury after falling from a ladder onto her flexed knee. A radiograph is shown in Figure A. Which of the following treatment options has been shown to have the best outcomes with this injury?
Long leg cast
Hinged knee brace use with functional rehabilitation protocol
Open reduction and internal fixation of patella
Distal patellar resection and allograft reconstruction
Placement of a cerclage wire from patella to proximal tibia
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The clinical presentation is consistent with and inferior pole patella fracture. Open reduction and internal fixation or excision with patellar tendon advancement is the most appropriate treatment of this injury pattern.
Whenever possible, salvage of the inferior pole through open reduction internal fixation is favored over simple excision and patellar tendon advancement, as this has been shown to be associated with improved outcomes. This is not always possible, however, and pole resection can be performed if the inferior comminution precludes fixation. Inferior outcomes of the partial distal patellectomy and patellar tendon advancement are (aside from the possible resulting patella baja) probably not directly related to the patellofemoral articulation. On the undersurface, the proximal 75% of the patella is covered with articular cartilage; however, the distal 25% is not, and does not articulate with the femoral trochlea.
Kastelec et al. performed a retrospective review of ORIF v. pole resection followed over 4.6 years postoperatively. There was a significant increase (better) in patellofemoral score with ORIF; significant differences in knee pain, tolerated activity levels, and ROM were also noted. Patella baja was frequently noted with pole resection and correlated with worse functional outcomes.
Matejcic et al. performed a retrospective review of ORIF v. pole resection followed over 5.3 years postoperatively. Results were excellent/good in 90.1% of the ORIF and only 73.1% of the pole resection patients. In addition, significant differences between the groups were noted with regard to knee pain, swelling, level activity, compression pain, range of motion, muscular atrophy, muscular strength, and final patellofemoral score (all better with ORIF).
Figure A is a lateral knee radiograph showing an inferior pole patella fracture.
Kastelec M, Veselko M
J Bone Joint Surg Am. 2004 Apr;86-A(4):696-701. PMID: 15069132 (Link to Abstract)
Kastelec, JBJS 2004
Matejcic A, Puljiz Z, Elabjer E, Bekavac-Beslin M, Ledinsky M
Arch Orthop Trauma Surg. 2008 Apr;128(4):403-8. PMID: 18270723 (Link to Abstract)
Matejcic, AOTS 2008
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Average 3.0 of 32 Ratings
A 43-year-old male suffers a knee injury and undergoes the operation seen in Figures A and B. At his one-year follow-up appointment, the patient notes pain in the peri-patellar region that is aggravated by palpation and kneeling. Range-of-motion is from -5 degrees to 130 degrees. A merchant view is performed which shows no significant degenerative changes of the patellofemoral joint. Which of the following treatments would most likely alleviate his pain?
Symptomatic treatment of his patellofemoral arthritis
Manipulation under anesthesia
Operative treatment of his non-union
Knee intrarticular corticosteroid injection
Removal of symptomatic hardware
Symptomatic hardware following surgical fixation of patella fractures is the most common complication, with ~18% of patients electing to undergo hardware removal.
Patella fractures are treated in a variety of ways. Non-displaced fractures with an intact extensor mechanism are typically treated non-operatively, displaced transverse fractures are typically treated with a tension-band construct, and severely comminuted fractures of the superior and inferior pole may be treated with partial patellectomy. When using the tension-band construct, either K-wires or cannulated screws may be used. Studies have shown decreased rates of symptomatic hardware when cannulated screws are used.
Melvin et al. reviewed patella fractures in adults. They cite the most common complication of operative fixation is symptomatic hardware, with literature reporting variable rates from 0-60%. This is increased in open fractures likely secondary to added insult to the soft tissues at the time of injury.
Eggink et al. looked at 60 patients who underwent tension-band wiring for patella fractures. Group 1 had their k-wires bent proximally and distally, while group 2 only had their k-wires bent proximally (see article for pictures). All failures (9) occurred in the group that had the k-wires bent proximally only.
Figures A and B show the post-operative films of a cannulated-screw tension band construct with a check-rein wire inserted in the tibial tubercle. Illustration A shows an example of a K-wire tension band construct used to treat a comminuted patella fracture.
Answer 1: Patellofemoral arthritis is a known complication following surgical fixation of patella fractures, but is less common than symptomatic implants.
Answer 2: Knee stiffness is a common complication following patella fractures, however the clinical symptoms in this patient are consistent with prominent hardware
Answer 3: Nonunion following patella fractures is a rare complication for closed injuries.
Answer 4: Intrarticular corticosteroid injection would not be indicated in this clinical scenario.
Melvin JS, Mehta S.
J Am Acad Orthop Surg. 2011 Apr;19(4):198-207. PMID: 21464213 (Link to Abstract)
Melvin, JAAOS 2011
Eggink KM, Jaarsma RL
Arch Orthop Trauma Surg. 2011 Mar;131(3):399-404. PMID: 21161252 (Link to Abstract)
Eggink, AOTS 2011
Average 3.0 of 13 Ratings
Partial patellectomy is the recommended treatment for which of the following injuries?
Vertical patella fractures
Severely comminuted inferior pole fracture
Stellate patella fracture
Chronic quadriceps tendon rupture
Partial patellectomy is a recommended treatment for a comminuted superior or inferior pole fracture measuring <50% of the patella's height that are not amenable to ORIF.
Comminuted patellar fractures are challenging to manage. Older studies show that in severely comminuted fractures, partial patellectomy is the recommended treatment. Newer studies are showing improved outcomes with ORIF. Therefore, if possible, proceed with ORIF. Unfortunately, when the comminution is severe, ORIF is often not possible and partial patellectomy is required.
The area can be excised and a technique of quadriceps tendon (superior pole) or patellar tendon (inferior pole) repair can then be undertaken.
Saltzman et al. reported maintenance of range of motion and strength (85% of the contralateral) with partial patellectomy at an average of 8.4 years follow up.
Marder et al. showed that change in patellofemoral forces is minimized by attaching the patellar tendon/quad tendon anteriorly on the remaining patella. Their study also showed that by resecting more of the inferior pole that contact stress increased as the size of the discarded portion of the patella increased.
Matejcic et al report, in a retrospective study of 71 patients that either had basket plate osteosynthesis v. partial patellectomy, that osteosynthesis by basket plate provides better clinical results. They recommend this technique if possible.
Saltzman CL, Goulet JA, McClellan RT, Schneider LA, Matthews LS.
J Bone Joint Surg Am. 1990 Oct;72(9):1279-85. PMID: 2229101 (Link to Abstract)
Saltzman, JBJS 1990
Marder RA, Swanson TV, Sharkey NA, Duwelius PJ.
J Bone Joint Surg Am. 1993 Jan;75(1):35-45. PMID: 8419389 (Link to Abstract)
Marder, JBJS 1993
Lazaro LE, Wellman DS, Klinger CE, Dyke JP, Pardee NC, Sculco PK, Berkes MB, Helfet DL, Lorich DG
J Bone Joint Surg Am. 2013 Oct;95(19):e1401-7. PMID: 24088975 (Link to Abstract)
Lazaro, JBJS 2013
Average 3.0 of 17 Ratings
Dear colleagues,in our Hospital (general hospital) any orthopaedic disease...
HPI - History of fall
How would you treat this patient?
HPI - s/p nonsyncopal fall at work earlier today. No prior knee pain or injuries.
How would you treat this injury?
HPI - fall from ladder
ideal treatment of patella with multiple fragment in different plane
HPI - fracture patella , motor vehicle accident, no dm or ht non alcoholic non smoker