A clinical comparison study of three different methods for treatment of transverse patellar fractures

Complications following surgical treatment of patella fractures - a systematic review and proportional meta-analysis

PURPOSE

The aim of this systematic review and proportional meta-analysis was to identify complications of surgical treatment of patella fractures and to estimate their incidence. We extended existing knowledge on this topic by including several more recent and large-scale studies.

METHODS

This systematic review and meta-analysis were performed in accordance with the Cochrane Handbook for systematic reviews of interventions. After searching in PubMed, MEDLINE, EMBASE, Cochrane Library, and OpenGrey, all studies after 2000, with study populations > 100 patients, including only patients > 18 years and follow-up > 30 days, were included. Two independent authors assessed the literature search and extracted the data. The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. The meta-analysis was performed on complications pooled in infections, nonunion, symptomatic implant removal, and fixation failure.

RESULTS

The data on complications were available from 14 studies, including a pool of 5659 patients. The most common complication was symptomatic implant removal, affecting.

CONCLUSION

Surgically, treatment of patella fractures was associated with a high risk of complications. The most common complication was symptomatic implant removal, affecting 29.6% of patients. Other complications stated were fixation failure 5.2%, infections 3.1% and nonunion 1.7%.

Dorsal Hook Plating of Patella Fractures With Immediate Range of Motion Results in Reliable Fixation, Low Implant Removal Rates, and Satisfactory Clinical Outcomes

OBJECTIVES

To evaluate radiographic and clinical patient-reported outcomes following dorsal hook plating of displaced patella fractures with permittance of immediate postoperative active closed chain range of motion.

METHODS

DESIGN

Retrospective review of prospectively collected data.

SETTING

Urban academic level 1 trauma center.

PATIENT SELECTION CRITERIA

Adult patients with displaced patella fractures (OTA/AO 34C1-3) who underwent dorsal plating with immediate range of motion between 2018 and 2023.

OUTCOME MEASURES AND COMPARISONS

Numerical Rating Scale for Pain, Knee Outcome Score (KOS-ADL), Tegner-Lysholm score, radiographic union, and wound complications were collected.

RESULTS

Sixty-one patients were included (47 female) with an average age of 63 years (SD 14.7, range 22-86 years). The mean BMI was 24.2 (SD 3.6, range 16.6-33.3). There were 13 34-C2 and 48 34-C3 fractures. All but 2 patients (96.7%) achieved bony union after the index procedure. 89% (n = 54) of patients completed outcome surveys with at least 6-month follow-up. Six patients (9.8%) underwent removal of plate implant at a mean of 15.1 months postoperatively. The mean KOS-ADL score was 91.4, the mean Tegner-Lysholm score was 78.1, and the mean NRS was 2.7.

CONCLUSIONS

Dorsal hook plating offers secure fixation to allow early range of motion, reliable fixation with low nonunion and implant failure rates, low implant removal rates, and satisfactory patient-reported outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evolution in the Management of Patella Fractures

Patella fractures usually occur as a result of direct trauma to the anterior knee joint, indirect injury as a result of eccentric muscle contraction, or rapid knee flexion against a contracted quadriceps muscle. The patella functions as part of the extensor mechanism of the knee, where large forces are transmitted, and its subcutaneous nature has made treatment of patella fractures a challenge. In this review article, we evaluate how the management of these fractures has evolved over time and the advantages associated with the various treatment techniques. There are few comparative studies looking at the different treatment types for fractures of the patella, with the goal of achieving a functional extensor mechanism with low rates of post-traumatic arthritis and metal-work irritation.

To plate, or not to plate? A systematic review of functional outcomes and complications of plate fixation in patellar fractures

PURPOSE

Poor outcomes and high complication and reoperation rates have been reported with tension-band wiring (TBW) in the management of patellar fractures and particularly the comminuted ones. The purpose of this study was to investigate the functional outcomes and complication rates of patellar fractures managed with open reduction and internal fixation (ORIF) with a plate.

METHODS

MEDLINE, EMCare, CINAHL, AMED and HMIC were searched, and the PRISMA guidelines were followed. Two independent reviewers extracted the data from the included studies and assessed them for the risk of bias.

RESULTS

Plating of patellar fractures is associated with satisfactory range of movement (ROM) and postoperative function and low pain levels. We found a 10.44% complication rate and a low reoperation rate. Reoperations were mainly performed for metalwork removal.

CONCLUSION

ORIF with plating of patellar fractures is a safe alternative in the management of patellar fractures and may be associated with a lower complication and reoperation rate compared to TBW. Future randomized prospective studies are needed to validated the results of the present systematic review.

Pin and Wire System Fixation for the Treatment of Comminuted Patella Fractures

We describe the wiring technique and evaluate the radiographic and clinical outcomes of treatment with a pin and wire system (PWS) for comminuted patella fractures. From June 2013 to October 2018, 33 patients with comminuted patella fractures were treated using a PWS. Open reduction and internal fixation was performed with multiple pins and a wire. All patients were allowed full weight bearing without a brace. Radiographs were obtained to evaluate bone union, implant breakage, back-out of pins, and intra-articular gaps and step-off. Clinical outcomes and postoperative complications were assessed at final follow-up examination. All fractures were united. Thirteen cable wires in 13 patients were partially broken without displacement of fracture at an average of 7.4 months (range, 1-19 months) postoperatively. The average preoperative, postoperative, and final follow-up intra-articular gap and step-off were 11.7 mm, 0.5 mm, and 0.03 mm and 6.6 mm, 0.4 mm, and 0.2 mm, respectively. The average postoperative pin displacement was 0.1 mm (range, 0-0.8 mm). Deep infection was not observed after the surgery. The implant removal rate was 21% (7 of 33). Among these, the symptomatic implant removal rate was 9% (3 of 33). Additionally, 3 of 7 patients with implant removal had broken wires. The average flexion and extension of knee joints were 139.7° (range, 120°-150°) and -0.9° (range, -10° to 0°), respectively. A PWS prevents back-out of the pins and reduces intra-articular gaps and step-off distances to acceptable levels, even if the cable wire is partially broken. Therefore, a PWS is a good treatment option for comminuted patella fractures. [Orthopedics. 2023;46(5):291-296.].

Plate osteosynthesis in patellar fractures: a systematic review and meta-analysis

INTRODUCTION

To perform a systematic review and assess the indications, outcomes, complications, and union rates associated with plate osteosynthesis in patellar fractures compared to tension band wiring.

METHODS

The systematic search was conducted for articles in PubMed, Embase Biomedical, Cochrane central, and LILACS databases (date of inception to July 30, 2020). Articles were included if they were randomized control trials, cohort studies, case-control studies, and case series (with more than five cases), which focused on the clinical outcomes of patients with plate osteosynthesis as a treatment for fracture of the patella and had a minimum follow-up of 3 months. All studies were assessed according to their level of evidence, the number of patients, age of patients, fracture patterns described, complications of treatment, and results summarized. Meta-analysis could only be done for two parameters (complications and reoperations) due to the paucity of data and heterogeneity of studies' limited statistical analysis. The data are presented as a review table with the key points summarized.

RESULTS

Twenty studies (seven prospective and 13 retrospective articles) identified 533 patients with 534 fractures who had undergone plate osteosynthesis for fracture of the patella. The most common fracture treated with plate osteosynthesis was 34C.

CONCLUSION

Basket plate was most commonly used for inferior pole fractures, while mesh plates were for intra-articular patella fractures. Overall plating was associated with better clinical outcomes, fewer complication rates, and high union rates compared to tension band wiring for patella fractures.

Patellar Fracture Fixation With Cannulated Compression Screws and FiberTape Cerclage

Transverse patella fractures with loss of knee extensor mechanism function are a common orthopaedic injury requiring operative fixation. Current accepted surgical options for noncomminuted transverse fractures include open reduction with tension band wiring. Although these procedures result in good clinical outcomes and fracture healing, symptomatic hardware from the historically used metal implants is very common. The purpose of this Technical Note is to describe a technique for treatment of transverse patellar fractures using cannulated compression screws with tensioned high-resistance suture tape functioning as the tension band. This technique provides effective, reproducible fracture fixation while minimizing symptomatic hardware, failure, and reoperation.

Comparison between tension band and cerclage with X-Plate and lag screws in treatment of comminuted patellar fractures

BACKGROUND

Comminuted patellar fractures are not rare, and the ideal treatment method remains controversial. The present study was conducted to evaluate effects and compare complications of two different methods used to treat comminuted patellar fractures.

METHODS

From March 2010 to August 2016, 102 cases of 34-C2 or 34-C3 comminuted patellar fractures were treated at our hospital, wherein patients received two different treatments: titanium cable tension band with cerclage method (group A) and intrafragmentary screws with X-shaped plating technique (group B). At follow-ups, articular step-off, range of motion (ROM), Lysholm scores, time of union, and complications were recorded and analyzed. Radiographic and clinical data as well as rate of complications were statistically analyzed.

RESULTS

In total, 87 patients were included in the final analysis (n = 47 in group A and n = 40 in group B). No significant differences were noted in terms of cost of implant, age, gender, rate of 34-C3 fractures, rate of layered inferior pole fractures, postoperative articular step-off and union time. At 2-year follow-up, average Lysholm scores, ROM and rate of complications were (89.0 ± 4.5), (122°±12°) and (27.7%) in group A and (90.2 ± 3.9), (124°±11°) and (17.5%) in group B, respectively, with no significant differences (p > 0.05). The mean time of surgery in group B was shorter than that in group A with significant difference (p < 0.05).

CONCLUSIONS

Treatment using the intrafragmentary screws and plate method for amenable comminuted patellar fractures achieved similar complication rate and favorable functional outcomes at the 2-year follow-up, which was comparable to the titanium cable tension band with cerclage method. Thus, the intrafragmentary screws and plate method is effective, safe and convenient for 34-C2/C3 comminuted patellar fractures, especially appropriate for patients with layered fragments.

Patella Fractures: Approach to Treatment

Patellar fracture morphology varies based on the mechanism of injury. Most fractures are either a result of direct impact or through an indirect eccentric extensor contraction injury. Each fracture pattern requires appropriate preoperative planning and individualization of the fixation method. Displaced fractures affect the extension apparatus, and often require surgical fixation. Surgical treatment is recommended in fractures with any of the following features: articular step-off > 2 mm, > 3 mm of fracture displacement, open fractures, and displaced fractures affecting the extensor mechanism. Meticulous handling of the soft-tissue envelope is of the utmost importance, given the patella's tenuous blood supply and limited soft-tissue envelope. Incongruent articular surface can result in detrimental long-term effects; therefore, surgical treatment is directed toward anatomic reduction and fixation. The evolution of patellar fracture fixation continues to maximize options to balance rigid fixation with low-profile fixation constructs. Improving functional outcomes, minimizing soft-tissue irritation, and limiting postoperative complications are possible by using the therapeutic principles of rigid anatomical fixation and meticulous soft-tissue handling.

Interventions for treating fractures of the patella in adults

BACKGROUND

Fractures of the patella (kneecap) account for around 1% of all human fractures. The treatment of these fractures can be surgical or conservative (such as immobilisation with a cast or brace). There are many different surgical and conservative interventions for treating fractures of the patella in adults. This is an update of a Cochrane Review first published in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of interventions (surgical and conservative) for treating fractures of the patella in adults.

SEARCH METHODS

We searched CENTRAL (2020, Issue 1), MEDLINE, Embase, LILACS, trial registers and references lists of articles to January 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that evaluated any surgical or conservative intervention for treating adults with fractures of the patella. The primary outcomes were patient-rated knee function, knee pain and major adverse outcomes.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected eligible trials, assessed risk of bias and cross-checked data extraction. Where appropriate, we pooled results of comparable trials.

MAIN RESULTS

We included 11 small trials involving 564 adults (aged 16 to 76 years) with patella fractures. There were 340 men and 212 women; the gender of 12 participants was not reported. Seven trials were conducted in China and one each in Finland, Mexico, Pakistan and Turkey. All 11 trials compared different surgical interventions for patella fractures. All trials had design flaws, such as lack of assessor blinding, which put them at high risk of bias, potentially limiting the reliability of their findings. No trial reported on health-related quality of life, return to previous activity or cosmetic appearance. The trials tested one of seven comparisons. In the following, we report those of the main outcomes for which evidence was available for the three most important comparisons. Four trials (174 participants) compared percutaneous osteosynthesis versus open surgery. Very low-quality evidence means that we are uncertain of the findings of no clinically important difference between the two interventions in patient-rated knee function at 12 months (1 study, 50 participants) or in knee pain at intermediate-term follow-up at eight weeks to three months. Furthermore, very low-quality evidence means we are uncertain whether, compared with open surgery, percutaneous fixation surgery reduces the incidence of major adverse outcomes, such as loss of reduction and hardware complications, or results in better observer-rated knee function scores. Two trials (112 participants) compared cable pin system (open or percutaneous surgery) versus tension band technique. The very low-quality evidence means we are uncertain of the findings at one year in favour of the cable pin system of slightly better patient-rated knee function, fewer adverse events and slightly better observer-rated measures of knee function. There was very low-quality evidence of little clinically important between-group difference in knee pain at three months. Very low-quality evidence from two small trials (47 participants) means that we are uncertain of the findings of little difference between biodegradable versus metallic implants at two-year follow-up in the numbers of participants with occasional knee pain, incurring adverse events or with reduced knee motion. There was very low-quality and incomplete evidence from single trials for four other comparisons. This means we are uncertain of the results of one trial (28 participants) that compared patellectomy with advancement of vastus medialis obliquus surgery with simple patellectomy; of one quasi-RCT (56 participants) that compared a new intraoperative reduction technique compared with a standard technique; of one quasi-RCT (65 participants) that compared a modified tension band technique versus the conventional AO tension band wiring (TBW) technique; and of one trial (57 participants) that compared adjustable patella claws and absorbable suture versus Kirschner wire tension band.

AUTHORS' CONCLUSIONS

There is very limited evidence from nine RCTs and two quasi-RCTs on the relative effects of different surgical interventions for treating fractures of the patella in adults. There is no evidence from trials evaluating the relative effects of surgical versus conservative treatment or different types of conservative interventions. Given the very low-quality evidence, we are uncertain whether methods of percutaneous osteosynthesis give better results than conventional open surgery; whether cable pin system (open or percutaneous surgery) gives better results than the tension band technique; and whether biodegradable implants are better than metallic implants for displaced patellar fractures. Further randomised trials are needed, but, to optimise research effort, these should be preceded by research that aims to identify priority questions.

Minimally invasive osteosynthesis technique in the treatment of transverse patellar fractures in the elderly

BACKGROUND

This prospective study aims to describe our experience in the management of transverse patellar fractures in elderly patients with minimally invasive osteosynthesis technique (MIOT), at 12-months follow-up.

METHODS

Patients older than 60, with transverse patellar fracture, type 34-C1 according to the AO/OTA classification system, referred to our trauma centre, between January 2014 and December 2017 were prospectively recruited. All the patients were managed using MIOT surgical procedure and underwent a clinical and radiological follow-up at 2 weeks, 6 weeks and at 3, 6, 12 and 15 months postoperatively. The clinical evaluation was performed using the Lysholm Knee Scoring System (LKSS) and the Visual Analogue Scale (VAS) for pain. The hardware removal was planned at 12-months follow-up. The paired t-test was performed. The test was two-tailed with a confidence level of 5%.

RESULTS

61 patients were recruited. The mean VAS was significantly lower in MIOT group until the 3-months follow-up (p = 0.001). ROM in flexion and LKSS score were significantly better in MIOT-group at all follow-ups, whereas ROM in extension showed no differences, between the two groups, starting from the 6-months follow-up. In the open surgery group, a significantly higher rate of delayed wound healing (p = 0.014), broken wires (p = 0.001) and non-cosmetic scar (p = 0.0221) was observed.

CONCLUSIONS

This prospective study shows that MIOT is a safe option for treatment of patellar transverse fractures in elderly patients, since it reduces the intra-operative blood loss, shortens the operating time, and is endowed with lower rates of postoperative complications.