Updated: 9/18/2018

Patella Fracture ORIF with Tension Band

Preoperative Patient Care

A

Basic Preop Evaluation & Management

1

Obtain focused history and performs focused exam

  • Evaluate ability to straight leg raise
  • aspirate hemarthrosis and inject local anesthetic if patient unable to perform due to pain
  • Document distal neurovascular status
  • Assess for concomitant and associated orthopaedic injuries

2

Obtain and interpret basic imaging studies including radiographs and CT scan (if indicated)

  • Radiographs views of knee
  • AP view
  • position patient supine with knee extended and leg IR 3-5°
  • aim beam 1.5cm distal to apex of patella
  • true AP view should have symmetrical femoral and tibial condyles, fibular head bisected by the tibia, and visualization of intercondylar eminence in intercondylar fossa
  • lateral view
  • best view to see transverse fractures
  • position patient supine with knee extended
  • aim beam 2.5cm distal to medial epicondyle
  • true lateral view should have superimposition of posterior aspect of femoral condyles, superimposition of fibular head and tibia, open patellofemoral and tibiofemoral joints, and no visualization of adductor tubercle
  • tangential view
  • best view to see vertical fractures
  • position patient supine with knee flexed 90°
  • aim beam to point inferosuperior and 10-20° cephalad
  • true tangential view should have visualization of femoral condyles and trochlear groove, no superimposition of patella and femur, and open patellofemoral joint
  • Radiographic findings
  • fracture displacement
  • degree of fracture displacement correlates with degree of retinacular disruption
  • patella alta
  • Insall-Salvati ratio <1
  • indicates disruption of patellar tendon
  • patella baja
  • Insall-Salvati ratio >1
  • indicates disruption of quads tendon
  • CT scan of knee
  • obtain if suspicion for patellar stress fracture, nonunion, or malunion

3

Prescribe nonoperative management if indicated

  • Indications
  • intact extensor mechanism (patient able to perform straight leg raise)
  • nondisplaced or minimally displaced fractures (<2mm step-off or <3mm displacement)
  • vertical fracture patterns
  • Early active ROM with hinged knee brace
  • early WBAT in full extension
  • progress in flexion after 2-3 weeks

4

Make informed decision to proceed with operative treatment

  • Describe accepted indications and contraindications for surgical intervention
  • Indications
  • extensor mechanism failure (inability to perform straight leg raise)
  • open fractures
  • fracture articular displacement >2mm
  • displaced patella fracture >3mm
  • patella sleeve fractures in children
B

Advanced Preop Evaluation & Management

1

Perform detailed history and physical exam

  • History
  • identify risk factors for infection and other complications
  • Physical Exam
  • evaluate for stability of knee in all planes

2

Interpret advanced imaging studies

  • See above

3

Explain benefits and alternatives to patient so they can make informed decision

  • Understand need for consultation for flap coverage

4

Explain risks of surgery in patients with Diabetes

  • Know risks of infection and nonunion based on patient risk factors
C

Preoperative History & Physical

1

Perform focused orthopaedic exam

  • Assess ability to straight leg raise
  • aspirate hemarthrosis and inject local anesthetic if patient unable to perform due to pain
  • Evaluate for soft tissue compromise/open fracture
  • perform saline load test
  • Check neurovascular status

2

Obtain and interpret basic imaging studies including radiographs and CT scan (if indicated)

  • See above

3

Perform operative consent

  • Describe complications of surgery including
  • neurovascular injury
  • infection
  • nonunion
  • infection
  • symptomatic implants
  • weakness
  • stiffness

Operative Techniques

E

Preoperative Plan

1

Template fracture reductions

  • Obtain order of reduction for fracture fragments
  • Determine order of reduction for fracture fragments

2

Template instrumentation

  • Template size and type of instrumentation

3

Execute surgical walkthrough

  • Describe key steps of the operation verbally to attending prior to beginning of case
  • Describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • Curettes
  • Periarticular clamps
  • K wires
  • Cerclage wires

2

Room setup and equipment

  • Radiolucent flat top table
  • C-arm fluoroscopy

3

Patient positioning

  • Place patient supine
  • Place bump under ipsilateral hip
  • Place tourniquet high on the thigh
G

Superficial Dissection

1

Mark out and make the incision

  • Make a midline longitudinal incision centered over the patella

2

Expose the patellar bursa

  • Identify the patellar bursa
  • Open the patellar bursa
H

Fracture Preparation

1

Clear the fracture site

  • Identify and clear hematoma from the fracture site using curettes and irrigation
  • Identify and remove loose bodies or devitalized fragments

2

Identify and tag the retinacular tissue

  • Follow the fracture line to identify the retinacular tissue
  • Identify the superior and inferior leaves of the retinaculum and tag them for later repair
I

Kirschner Wire Placement and Fracture Reduction

1

Place K wires

  • Place 2 K wires in the proximal fracture fragment
  • K wires can be placed antegrade (through the superior aspect of the patella) or retrograde (through the fracture sie)
  • on the coronal view, K wires should be placed parallel to each other and divide the patella longitudinally into thirds
  • on the sagittal view, K wires should be placed approximately 5mm below the anterior surface of the patella

2

Advance K wires to the fracture site

  • Deliver the K wires until they are flush with fracture line

3

Reduce the fracture

  • Place the knee in a slightly flexed position
  • Reduce the fracture using a patellar reduction clamp or a large Weber clamp
  • Reduce any depressed articular fragments with a freer elevator

4

Check the reduction

  • Confirm the reduction by palpating the articular surface with a freer elevator
  • if any small articular fragments without attached subchondral bone are found, they should be removed
J

Kirschner Wire Advancement

1

Advance the K wires

  • Advance the K wires through the opposite side of the fracture fragment, from proximal to distal

2

Check K wire placement using the c-arm

  • Obtain a lateral x-ray to ensure that K wire placement and fracture reduction are appropriate
  • K wires should be placed approximately 5mm below the anterior surface of the patella
K

Cerclage Wire Placement

1

Orient the cerclage wires

  • Pass a 1.0 mm thick cerclage wire just deep to the K wires
  • this should abut the superior pole of the patella
  • be sure to not leave any soft tissue between the superior pole and the tension band

2

Place angiocath

  • Pass a 16-gauge angiocath through the quadriceps mechanism

3

Advance the cerlage wire

  • Advance the wire through the catheter to assist in placement of the wire
  • Pass the cerclage wire distally in a similar fashion
  • ensure that the wire abuts the distal pole of the patella

4

Loop the cerclage wire

  • Loop the wire around the anterior aspect of the patella
  • Another option is to crisscross the wires in a figure 8 fashion
  • Verify that the K wires have captured the cerclage wires

5

Secure the cerclage wire

  • For even tensioning, use the two loop tensioning technique
  • Gently twist the cerclage wire at both limbs using a large needle driver
  • lift the loop to tension the wire and then twist
  • alternate between the two ends to provide equal tension
  • Continue to sequentially tighten the wires until the desired amount of compression is visualized and palpated at the fracture site
L

Wire Contouring

1

Trim and bury the cerclage wires

  • Clip the ends of the cerclage wire twists
  • Bend the free end of the twists so that they are facing bone and tamp down

2

Trim and bury the K wires

  • Clip the ends of the K wires
  • Bend the ends of the K wire 180° posteriorly to form a hook and tamp down
M

Soft Tissue Repair

1

Check the soft tissues

  • Identify retinacular tears

2

Repair the soft tissues

  • Repair the retinacular defect with absorbable braided suture
  • this is critical in restoring the extensor mechanism
N

Wound Closure

1

Irrigation, hemostasis, and drain

  • Copiously irrigate the wound
  • irrigate until backflow is clear
  • Cauterize peripheral bleeding vessels

2

Deep closure

  • Arthrotomy closure using figure of 8 nonabsorbable suture

3

Superficial closure

  • Subcutaneous closure with 2-0 vicryl
  • Skin closure with 3-0 vicryl and suture or staples

4

Dressings

  • Place a well-padded sterile dressing
  • Place a knee immobilizer

Postoperative Patient Care

O

Perioperative Inpatient Management & Discharge

1

Write comprehensive admission orders

  • Advance diet as tolerated
  • Pain control
  • Inpatient physical therapy
  • Prescribe appropriate DVT prophylaxis
  • Wound management
  • remove dressings on POD2
  • Foley out when ambulating
  • Check appropriate labs
  • Antibiotics

2

Check radiographs in postop

  • Check placement of implants

3

Initiate physical therapy on POD1

  • Immediate weightbearing as tolerated in a knee immobilizer or locked hinge brace

4

Appropriate medical management and medical consultation

5

Discharges patient appropriately

  • Pain meds
  • DVT prophylaxis
  • Outpatient physical therapy
  • Schedule 2 week follow-up
P

Basic Postoperative Care of the Patient without Complications

1

Postop: 2-3 week postoperative visit

  • Continue physical therapy and range of motion exercises
  • Discontinue DVT prophylaxis
  • Wound check
  • Repeat radiographs of knee
  • Remove staples/sutures
  • Diagnose and manage early complications
  • Place locked hinge knee brace in flexion 0 to 60° for 2 weeks, then place in full flexion for 2 weeks

2

Postop: ~6 week postoperative visit

  • Start full weightbearing out of the brace if radiographic signs of healing are present
  • Diagnose and manage of late complications

3

Postop: 1 year postoperative visit

Q

Advanced Postoperative Care of Patient with Simple Complications (does not require revision)

R

Postop Care of Patient with Major Complications (requires revision surgery)

1

Develops unique, complex post-operative management plans

 

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