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Patella Fracture ORIF with Tension Band

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • document distal neurovascular status
  • concomitant and associated orthopaedic injuries

2

Interpret basic imaging studies

  • biplanar films of the knee

3

Prescribes nonoperative management

  • knee immobilizer

4

Make informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • continue physical therapy and range of motion exercises
  • discontinue DVT prophylaxis
  • wound check
  • repeat radiographs of femur
  • staples/sutures removed
  • diagnose and management of early complications
  • place locked hinge knee brace in flexion 0 to 60 degrees for 2 weeks, then place in full flexion for 2 weeks
  • postop: ~ 6 week postoperative visit
  • start full weightbearing out of the brace if radiographic signs of healing are present
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
B

Advanced Evaluation and Management

1

Prioritizes the needs of the polytrauma patient

  • works with consulting

2

Complex wound management and debridement

  • understanding need for consultation for flap coverage

3

Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection
C

Preoperative H & P

1

Performs focused orthopaedic exam

  • check the soft tissue
  • check neurovascular status

2

Appropriately orders basic imaging studies

  • order biplanar radiographs of the knee

3

Perform operative consent

  • describe complications of surgery including
  • neurovascular injury
  • infection
  • nonunion
  • infection
  • symptomatic implants

Operative Techniques

E

Preoperative Plan

1

Template fracture reductions

  • obtain order of reduction for fracture fragments

2

Template instrumentation

  • template size of instrumentation

3

Execute surgical walkthrough

  • resident can 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

  • 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 tourniquet high on the thigh
G

Superficial Dissection

1

Mark out and make the incision

  • make a longitudinal incision over the patella

2

Expose the patellar bursa

  • identify the patellar bursa
  • open the patellar bursa
H

Fracture Preparation

1

Clear the fracture site

  • usually a hematoma will be present
  • identify and clear the hematoma from the fracture site sing curettes and irrigation

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 kwires

  • place 2 kirschner wires that span the fracture
  • these Kwires should span the fracture in parallel

2

Advance K wires to the fracture site

  • deliver the k wires until they are flush with fracture line

3

Reduce the fracture

  • reduce the fracture with a patellar reduction clamp or a large Weber clamp
  • reduce any depressed articular fragments with a freer elevator

4

Check the reduction

  • check 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 discarded
J

Kirschner Wire Advancement

1

Advance the Kirschner wires

  • advance the K wire through the opposite side of the fracture fragment

2

Check the placement

  • take a lateral xray to ensure that Kwire placement and fracture reduction are appropriate
  • Ideally the K wire should placed approximately 5 mm below the anterior surface of the patella clip the K wire so that a 1 cm prominence will be presence below the inferior pole 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
  • for even tensioning, use the two loop tensioning technique
  • make a twist in the cerclage wire on the opposite side of the two free ends of the wire

5

Secure the cerclage wire

  • gently twist the free ends
  • sequentially tighten the two loops with a large needle driver
  • lift the loop to tension the wire and then twist
  • 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 the wires

  • clip the ends of the twists
  • bend the free end of the twists so that they are facing bone and tamp down
  • bend the superior portion of the K wire into a hook
  • cut excess wire

2

Rotate the wires

  • rotate and tamp down the superior portion of the K wire into the patella

3

Check the soft tissues

  • cut the inferior portion of the K wire to prevent irritation in the patellar tendon

4

Repair the soft tissues

  • repair the retinacular defect withabsorbable 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

Superficial closure

  • subcutaneous with 2-0 vicryl and skin closure with 3-0 vicryl and suture or staples

3

Dressings

  • place a well padded sterile dressing with padding over the leg from the malleoli ot the proximal thigh
  • place a knee immobilizer

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • pain control
  • prescribe appropriate DVT prophylaxis
  • wound management
  • remove dressings POD2
  • foley out when ambulating
  • check appropriate labs
  • antibiotics

2

Check radiographs in postop

  • check placement of implants

3

Initiate physical therapy on POD 1

  • immediate partial weightbearing in a knee immobilizer or locked hinge brace

4

Appropriate medical management and medical consultation

5

Discharges patient appropriately

  • pain meds
  • outpatient physical therapy
  • schedule 2 week follow up
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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