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Preoperative Patient Care
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
 

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