- Email: [email protected]
Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing
G Model
JINJ-6393; No. of Pages 4 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Technical Note
Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing Hyoung-Keun Oh a,1,*, Suk-Kyu Choo a,1, Ji-Wan Kim b,1, Mark Lee c,1 a
Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, Republic of Korea Department of Orthopedic Surgery, Haewoundae Paik Hospital, Inje University, Republic of Korea c Department of Orthopedic Surgery, UC Davis Medical Center, CA, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 28 September 2015
Background: We present the surgical technique of separate vertical wiring for displaced inferior pole fractures of the patella combined with Krachow suture and report the surgical outcomes. Materials and methods: Between September 2007 to May 2012, 11 consecutive patients (mean age, 54.6 years) with inferior pole fractures of the patella (AO/OTA 34-A1) were retrospectively enrolled in this study. Through longitudinal incision, all patients underwent open reduction and internal fixation by separate vertical wiring combined with Krackow suture. The range of motion, loss of fixation, and Bostman score were primary outcome measures. Results: The union time was 10 weeks after surgery on average (range: 8–12). No patient had nonunion, loss of reduction and wire breakage. There was no case of wound problem and irritation from the implant. At final follow-up, the average range of motion arc was 129.48 (range: 120–140). The mean Bostman score at last follow-up was 29.6 points (range: 28–30) and graded excellent in all cases. Conclusion: Separate vertical wiring combined with Krackow suture for inferior pole fractures of the patella is a useful technique that is easy to perform and can provide stable fixation with excellent results in knee function. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Patellar fracture Separate vertical wiring Krackow suture
Introduction The surgical goal of reconstruction of patella fractures is to reestablish the extensor mechanism while simultaneously restoring articular congruency. Tension-band wiring has been the most commonly used surgical technique for displaced transverse patellar fractures [1]. However, extra-articular fractures of the distal pole of the patella are difficult to fix and maintain reduction because of small fragment and comminution [2–5]. Various surgical techniques including partial patellectomy and reattachment of patellar tendon using transosseous suture [6] or suture anchor [2] and specific plate fixation [7] have been reported for this difficult fracture.
* Corresponding author at: Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 2240 Daehwa-dong, Ilsanseo-gu, Koyang-si, Republic of Korea. Tel.: +82 31 910 7968; fax: +82 31 910 7967. E-mail address: [email protected] (H.-K. Oh). 1 These authors have no relevant financial relationships to disclosure for this work.
We present the surgical technique of separate vertical wiring for displaced inferior pole fractures of the patella combined with Krachow suture and report our surgical outcomes. Materials and methods Between September 2007 to May 2012, 17 patients were treated with separate vertical wiring combined Krackow suture for displaced inferior pole fracture of patella. Among them, 4 patients who had concomitant ipsilateral femur or tibia fractures that could affect functional outcomes of knee joint and 2 patients treated separate vertical wiring only were excluded. All the patients gave informed consent prior to study inclusion. The study was authorized by the local ethics committee (IB-1411-048) and performed in accordance with the Ethical standards of the 1964 Declaration of Helsinki (revised in 2000). This retrospective study reviewed radiological and functional outcomes of 11 patients. There were five men and six women with an average age of 54.6 years (range: 23–74). All fractures occurred from simple falls to the ground. There were no open fractures in this study group. The time from injury to surgery averaged 6.4 days (range:
http://dx.doi.org/10.1016/j.injury.2015.09.026 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Oh H-K, et al. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.09.026
G Model
JINJ-6393; No. of Pages 4 H.-K. Oh et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
Fig. 1. Preoperative radiograph shows displaced inferior pole fracture of the patella and intraoperative photograph shows extra-articular location of the fracture with complete disruption of retinaculum.
3–11). Patient co-morbidities included just hypertension in two patients. All patients were ambulatory with no functional limitations before injury. All distal pole fractures occurred in extra-articular portion of distal pole and could be classified to 34-A1 according to AO/OTA classification. Average length of distal fragment was 11.2 mm (range: 7.3–14) and fracture gap was 7.5 mm (range: 4–10) both measured on lateral radiographs. Surveillance radiographs were taken monthly in the first 3 postoperative months. We evaluated the bony union through serial radiographs. Clinical outcomes were assessed by recording post-procedure complications, knee range of motion, and Bostman score [8] at last follow-up. Surgical techniques Patients were placed in the supine position on a radiolucent table and a pneumatic tourniquet was used in all cases. We performed a standard midline longitudinal incision extending from the upper end of patella to tibial tuberosity. Full thickness skin flaps were raised medially and laterally to expose the transversely ruptured retinaculum, fracture, and the patellar tendon (Fig. 1). Fracture fragments were identified and irrigated with saline to remove haematoma. In inferior pole fractures of patella, comminution is common and care is taken to preserve soft tissue attachment of patellar tendon to distal fragments. Secondary vertical fractures of the proximal fragment were anatomically reduced and held with K-wire fixation prior to vertical wiring. For separate vertical wiring, two or three 18-guage stainless wire
(1.2 mm in diameter) were used depending on fracture pattern. Drill holes were made using a 1.8 Kirschner-wire directed through the posterior margin of fractured surface of proximal fragment and directed to the antero-superior border of patella. Stainless wires were passed through drill holes utilizing an inside out technique (Fig. 2). For passing the wire through distal fragment, a 16-gauge needle was inserted through the inferior margin of distal fragment and through patellar tendon. Stainless wires were passed to distal fragment through the opening of 16 gauge needle (Fig. 3). Fracture was next reduced with pointed reduction forceps and separate vertical wires were tightened using standard technique (Fig. 4). To minimize skin irritation by protruded metal, we routinely place the knots at superior border of the patella. The reduction was verified with biplanar fluoroscopy. After completion of vertical wiring, a Krackow locking suture (#1 Ethibond1) was performed, interlocking running suture to each border of patellar tendon. The each free arm of suture were passed through 2 drill holes in the proximal fragment and tied over upper border of patella. Next, retinacular tears were repaired with #1 Vicryl1 without excessive tension. The joint stability was evaluated and the final stability of the fixation was checked in through a full range of knee motion. After insertion of suction drain, we performed a layered wound closure. For the postoperative management, long leg splint was applied for 2–3 days. After removal of suction drain, we applied a hinged knee brace and allowed full weight bearing without limiting knee flexion. Continuous passive motion and strengthening exercise of quadriceps were recommended in all patients postoperatively. Our goal of rehabilitation was to gain 908 of flexion within 2 weeks.
Fig. 2. Drill holes are made by 1.8 K-wire on posterior margin of fractured surface of proximal fragment directed to antero-superior border of patella for passing the stainless with an inside out manner.
Please cite this article in press as: Oh H-K, et al. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.09.026
G Model
JINJ-6393; No. of Pages 4 H.-K. Oh et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
3
Fig. 3. 16 gauge needle is inserted on inferior margin of distal fragment through patellar tendon and stainless wires are passed to distal fragment through the opening of 16 gauge needle.
Results The mean postoperative follow-up period was 13 months (range: 10–23). Fracture union defined as the loss of the fracture line and presence of bony trabecular continuity was achieved an average of 10 weeks after surgery (range: 8–12). No patient had nonunion, loss of reduction or wire breakage. There were no cases of wound complications or irritation from the implants. There were four cases of implant removal at 16th postoperative month (range: 10–23). The reason of implant removal was that they did not want to retain any metalic device in their body. At final follow-up, the average range of motion was 129.48 (range: 120–140). All patients regained full range of motion compared to contralateral knee. The mean Bostman score at last follow-up was 29.6 points (range: 28–30) and graded excellent in all cases. Discussion Open reduction and internal fixation is the preferred treatment for displaced patellar fractures to restore articular congruency and to maintain the extensor mechanism function. Among the various surgical techniques, tension-band wiring is the most commonly used method for transverse patellar fracture. This technique converts the anterior tension forces produced by the extensor mechanism and knee flexion into compression forces at the articular surface [1]. In order to compress the fracture site and to
obtain stable fixation by tension-band wiring, the fixation construct needs to withstand the tensile forces, and intact cortical buttress is required. Therefore, in many cases of severe comminution, tension band technique is not feasible and alternative fixation methods should be considered for stable fixation [1,5]. Inferior pole fractures of the patella account for 9.3–22.4% of all the patellar fractures [7] and are usually completely extraarticular. Therefore, the goal of surgical treatment of inferior pole fractures is restoration of extensor mechanism rather than anatomical articular reduction. In inferior pole fracture of the patella, comminution in fractured distal fragment is common and secure fixation to allow early motion is difficult to achieve. In our retrospective group, the average size of distal fragment on preoperative lateral radiograph was 11.2 mm and intraoperative findings revealed comminution all cases. Conventional wire fixation with K-wires or screws is typically ineffective for stable fixation of small comminuted distal fragments. Partial patellectomy and tendon reattachment via suture and transosseous tunnel [3] or suture anchor [2] has been reported for the treatment of inferior pole fracture. For the site of reattachment of the patellar tendon, some surgeons recommended near the articular surface [3] while others advocating near the anterior cortex [9]. Regardless of the site of reattachment of patellar tendon, it is important to protect the repair because of the powerful forces generated by the quadriceps mechanism. Kastelec and Veselko [6] reported 14 patients of inferior pole fracture of the patella treated
Fig. 4. After completion of vertical wiring, Krackow suture using #1 Ethibond1 is performed as a method of an interlocking running suture to each border of patellar tendon and postoperative radiograph shows a well reduced distal fragment.
Please cite this article in press as: Oh H-K, et al. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.09.026
G Model
JINJ-6393; No. of Pages 4 4
H.-K. Oh et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
with pole resection and tendon reattachment. Even though good clinical results at last follow-up, they needed postoperative immobilization in a cast for average 6.5 weeks. Furthermore, the change of the length of patellar tendon after pole resection may disrupt the normal physiology of the patellofemoral joint and cause long term problems [3,9]. For the preservation of patellar bone, some new methods have been described. Matejcic et al. [7] reported the basket plate osteosynthesis for the treatment of severe comminuted fractures of the inferior pole of the patella. The basket plate has the shape of a basket with hooks and can be secured to the patellar body with superiorly directed screws. However, this specific plate is not available in all institution and the relative bulk of the plate over the anterior patella may cause metal irritation in flexed knee position. Separate vertical wiring technique for comminuted fractures of the distal patella introduced by Yang and Byun [4] showed higher fixation strength than tension-band wiring in the biomechanical study. They reported a 100% union rate and no wire breakage at an average follow-up of 22 months in 25 patients. However, there is still concern about the holding power of separate vertical wires for the comminuted small fragments especially in elderly. Song et al. [10] reported the biomechanical and clinical study of separate vertical wiring augmented with cerclage wire. The combined procedure showed better fixation results than separate vertical wiring alone, but they experienced 4 cases of cerclage wire breakage out of 21 cases. We modified separate vertical wiring technique by adding Krackow suture for patellar tendon to improve immediate stability of fixation. We believe that three separate wires might not be sufficient to allow early ROM and to maintain the reduction in case of comminuted distal fragments. The Krackow suture technique has been widely used for tendon repair and relatively familiar technique to orthopaedic surgeon [11,12]. The Krackow whip stitch is stronger than the Kessler, or Bunnell, stitches that are used for repairing smaller tendons [12]. Interlocking running suture on each side of patellar tendon can be tightened through bone tunnel of patellar body and provide additional stability even in comminuted small distal fragment. We routinely checked stability of the fixation through full range of motion after procedure. We could allow immediate motion without immobilization in all cases and there was no case of reduction loss of the fracture and wire
breakage. There was no significant change of the length of patellar tendon compared to contralateral knee and no case of limitation of ROM. The limitations of this study are retrospective design and small total case numbers. We believe that separate vertical wiring combined with Krackow suture for inferior pole fractures of the patella is a useful technique that is easy to perform and can provide stable fixation with excellent functional results in distal pole patella fractures. Conflict of interest statement No conflict of interest. References [1] Melvin JS, Mehta S. Patellar fractures in adults. J Am Acad Orthop Surg 2011;19(April (4)):198–207. [2] Anand A, Kumar M, Kodikal G. Role of suture anchors in management of fractures of inferior pole of patella. Indian J Orthop 2010;44(July (3)):333–5. [3] Saltzman CL, Goulet JA, McClellan RT, Schneider LA, Matthews LS. Results of treatment of displaced patellar fractures by partial patellectomy. J Bone Joint Surg Am 1990;72(9):1279–85. [4] Yang KH, Byun YS. Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella. J Bone Joint Surg Br 2003;85: 1155–60. [5] Chang SM, Ji XL. Open reduction and internal fixation of displaced patella inferior pole fractures with anterior tension band wiring through cannulated screws. J Orthop Trauma 2011;25(June (6)):366–70. [6] Kastelec M, Veselko M. Inferior patellar pole avulsion fractures: osteosynthesis compared with pole resection. J Bone Joint Surg Am 2004;86(4):696–701. [7] Matejcic A, Puljiz Z, Elabjer E, Bekavac-Beslin M, Ledinsky M. Multifragment fracture of the patellar apex: basket plate osteosynthesis compared with partial patellectomy. ArchOrthop Trauma Surg 2008;128:403–8. [8] Bostman O, Kiviluoto O, Nirhamo J. Comminuted displaced fractures of the patella. Injury 1981;13:196–202. [9] Marder RA, Swanson TV, Sharkey NA, Duwelius PJ. Effects of partial patellectomy and reattachment of thepatellar tendon on patellofemoral contact areas and pressures. J Bone Joint Surg Am 1993;75(1):35–45. [10] Song HK, Yoo JH, Byun YS, Yang KH. Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella. Yonsei Med J 2014;55(May (3)):785–91. [11] Heitman DE, Ng K, Crivello KM, Gallina J. Biomechanical comparison of the Achillon tendon repair system and the Krackow locking loop technique. Foot Ankle Int 2011;32(September (9)):879–87. [12] Krushinski EM, Parks BG, Hinton RY. Gap formation in transpatellar patellar tendon repair: pretensioning Krackow sutures versus standard repair in a cadaver model. Am J Sports Med 2010;38(January (1)):171–5.
Please cite this article in press as: Oh H-K, et al. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.09.026
JINJ-6393; No. of Pages 4 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Technical Note
Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing Hyoung-Keun Oh a,1,*, Suk-Kyu Choo a,1, Ji-Wan Kim b,1, Mark Lee c,1 a
Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, Republic of Korea Department of Orthopedic Surgery, Haewoundae Paik Hospital, Inje University, Republic of Korea c Department of Orthopedic Surgery, UC Davis Medical Center, CA, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 28 September 2015
Background: We present the surgical technique of separate vertical wiring for displaced inferior pole fractures of the patella combined with Krachow suture and report the surgical outcomes. Materials and methods: Between September 2007 to May 2012, 11 consecutive patients (mean age, 54.6 years) with inferior pole fractures of the patella (AO/OTA 34-A1) were retrospectively enrolled in this study. Through longitudinal incision, all patients underwent open reduction and internal fixation by separate vertical wiring combined with Krackow suture. The range of motion, loss of fixation, and Bostman score were primary outcome measures. Results: The union time was 10 weeks after surgery on average (range: 8–12). No patient had nonunion, loss of reduction and wire breakage. There was no case of wound problem and irritation from the implant. At final follow-up, the average range of motion arc was 129.48 (range: 120–140). The mean Bostman score at last follow-up was 29.6 points (range: 28–30) and graded excellent in all cases. Conclusion: Separate vertical wiring combined with Krackow suture for inferior pole fractures of the patella is a useful technique that is easy to perform and can provide stable fixation with excellent results in knee function. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Patellar fracture Separate vertical wiring Krackow suture
Introduction The surgical goal of reconstruction of patella fractures is to reestablish the extensor mechanism while simultaneously restoring articular congruency. Tension-band wiring has been the most commonly used surgical technique for displaced transverse patellar fractures [1]. However, extra-articular fractures of the distal pole of the patella are difficult to fix and maintain reduction because of small fragment and comminution [2–5]. Various surgical techniques including partial patellectomy and reattachment of patellar tendon using transosseous suture [6] or suture anchor [2] and specific plate fixation [7] have been reported for this difficult fracture.
* Corresponding author at: Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 2240 Daehwa-dong, Ilsanseo-gu, Koyang-si, Republic of Korea. Tel.: +82 31 910 7968; fax: +82 31 910 7967. E-mail address: [email protected] (H.-K. Oh). 1 These authors have no relevant financial relationships to disclosure for this work.
We present the surgical technique of separate vertical wiring for displaced inferior pole fractures of the patella combined with Krachow suture and report our surgical outcomes. Materials and methods Between September 2007 to May 2012, 17 patients were treated with separate vertical wiring combined Krackow suture for displaced inferior pole fracture of patella. Among them, 4 patients who had concomitant ipsilateral femur or tibia fractures that could affect functional outcomes of knee joint and 2 patients treated separate vertical wiring only were excluded. All the patients gave informed consent prior to study inclusion. The study was authorized by the local ethics committee (IB-1411-048) and performed in accordance with the Ethical standards of the 1964 Declaration of Helsinki (revised in 2000). This retrospective study reviewed radiological and functional outcomes of 11 patients. There were five men and six women with an average age of 54.6 years (range: 23–74). All fractures occurred from simple falls to the ground. There were no open fractures in this study group. The time from injury to surgery averaged 6.4 days (range:
http://dx.doi.org/10.1016/j.injury.2015.09.026 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Oh H-K, et al. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.09.026
G Model
JINJ-6393; No. of Pages 4 H.-K. Oh et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
Fig. 1. Preoperative radiograph shows displaced inferior pole fracture of the patella and intraoperative photograph shows extra-articular location of the fracture with complete disruption of retinaculum.
3–11). Patient co-morbidities included just hypertension in two patients. All patients were ambulatory with no functional limitations before injury. All distal pole fractures occurred in extra-articular portion of distal pole and could be classified to 34-A1 according to AO/OTA classification. Average length of distal fragment was 11.2 mm (range: 7.3–14) and fracture gap was 7.5 mm (range: 4–10) both measured on lateral radiographs. Surveillance radiographs were taken monthly in the first 3 postoperative months. We evaluated the bony union through serial radiographs. Clinical outcomes were assessed by recording post-procedure complications, knee range of motion, and Bostman score [8] at last follow-up. Surgical techniques Patients were placed in the supine position on a radiolucent table and a pneumatic tourniquet was used in all cases. We performed a standard midline longitudinal incision extending from the upper end of patella to tibial tuberosity. Full thickness skin flaps were raised medially and laterally to expose the transversely ruptured retinaculum, fracture, and the patellar tendon (Fig. 1). Fracture fragments were identified and irrigated with saline to remove haematoma. In inferior pole fractures of patella, comminution is common and care is taken to preserve soft tissue attachment of patellar tendon to distal fragments. Secondary vertical fractures of the proximal fragment were anatomically reduced and held with K-wire fixation prior to vertical wiring. For separate vertical wiring, two or three 18-guage stainless wire
(1.2 mm in diameter) were used depending on fracture pattern. Drill holes were made using a 1.8 Kirschner-wire directed through the posterior margin of fractured surface of proximal fragment and directed to the antero-superior border of patella. Stainless wires were passed through drill holes utilizing an inside out technique (Fig. 2). For passing the wire through distal fragment, a 16-gauge needle was inserted through the inferior margin of distal fragment and through patellar tendon. Stainless wires were passed to distal fragment through the opening of 16 gauge needle (Fig. 3). Fracture was next reduced with pointed reduction forceps and separate vertical wires were tightened using standard technique (Fig. 4). To minimize skin irritation by protruded metal, we routinely place the knots at superior border of the patella. The reduction was verified with biplanar fluoroscopy. After completion of vertical wiring, a Krackow locking suture (#1 Ethibond1) was performed, interlocking running suture to each border of patellar tendon. The each free arm of suture were passed through 2 drill holes in the proximal fragment and tied over upper border of patella. Next, retinacular tears were repaired with #1 Vicryl1 without excessive tension. The joint stability was evaluated and the final stability of the fixation was checked in through a full range of knee motion. After insertion of suction drain, we performed a layered wound closure. For the postoperative management, long leg splint was applied for 2–3 days. After removal of suction drain, we applied a hinged knee brace and allowed full weight bearing without limiting knee flexion. Continuous passive motion and strengthening exercise of quadriceps were recommended in all patients postoperatively. Our goal of rehabilitation was to gain 908 of flexion within 2 weeks.
Fig. 2. Drill holes are made by 1.8 K-wire on posterior margin of fractured surface of proximal fragment directed to antero-superior border of patella for passing the stainless with an inside out manner.
Please cite this article in press as: Oh H-K, et al. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.09.026
G Model
JINJ-6393; No. of Pages 4 H.-K. Oh et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
3
Fig. 3. 16 gauge needle is inserted on inferior margin of distal fragment through patellar tendon and stainless wires are passed to distal fragment through the opening of 16 gauge needle.
Results The mean postoperative follow-up period was 13 months (range: 10–23). Fracture union defined as the loss of the fracture line and presence of bony trabecular continuity was achieved an average of 10 weeks after surgery (range: 8–12). No patient had nonunion, loss of reduction or wire breakage. There were no cases of wound complications or irritation from the implants. There were four cases of implant removal at 16th postoperative month (range: 10–23). The reason of implant removal was that they did not want to retain any metalic device in their body. At final follow-up, the average range of motion was 129.48 (range: 120–140). All patients regained full range of motion compared to contralateral knee. The mean Bostman score at last follow-up was 29.6 points (range: 28–30) and graded excellent in all cases. Discussion Open reduction and internal fixation is the preferred treatment for displaced patellar fractures to restore articular congruency and to maintain the extensor mechanism function. Among the various surgical techniques, tension-band wiring is the most commonly used method for transverse patellar fracture. This technique converts the anterior tension forces produced by the extensor mechanism and knee flexion into compression forces at the articular surface [1]. In order to compress the fracture site and to
obtain stable fixation by tension-band wiring, the fixation construct needs to withstand the tensile forces, and intact cortical buttress is required. Therefore, in many cases of severe comminution, tension band technique is not feasible and alternative fixation methods should be considered for stable fixation [1,5]. Inferior pole fractures of the patella account for 9.3–22.4% of all the patellar fractures [7] and are usually completely extraarticular. Therefore, the goal of surgical treatment of inferior pole fractures is restoration of extensor mechanism rather than anatomical articular reduction. In inferior pole fracture of the patella, comminution in fractured distal fragment is common and secure fixation to allow early motion is difficult to achieve. In our retrospective group, the average size of distal fragment on preoperative lateral radiograph was 11.2 mm and intraoperative findings revealed comminution all cases. Conventional wire fixation with K-wires or screws is typically ineffective for stable fixation of small comminuted distal fragments. Partial patellectomy and tendon reattachment via suture and transosseous tunnel [3] or suture anchor [2] has been reported for the treatment of inferior pole fracture. For the site of reattachment of the patellar tendon, some surgeons recommended near the articular surface [3] while others advocating near the anterior cortex [9]. Regardless of the site of reattachment of patellar tendon, it is important to protect the repair because of the powerful forces generated by the quadriceps mechanism. Kastelec and Veselko [6] reported 14 patients of inferior pole fracture of the patella treated
Fig. 4. After completion of vertical wiring, Krackow suture using #1 Ethibond1 is performed as a method of an interlocking running suture to each border of patellar tendon and postoperative radiograph shows a well reduced distal fragment.
Please cite this article in press as: Oh H-K, et al. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.09.026
G Model
JINJ-6393; No. of Pages 4 4
H.-K. Oh et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
with pole resection and tendon reattachment. Even though good clinical results at last follow-up, they needed postoperative immobilization in a cast for average 6.5 weeks. Furthermore, the change of the length of patellar tendon after pole resection may disrupt the normal physiology of the patellofemoral joint and cause long term problems [3,9]. For the preservation of patellar bone, some new methods have been described. Matejcic et al. [7] reported the basket plate osteosynthesis for the treatment of severe comminuted fractures of the inferior pole of the patella. The basket plate has the shape of a basket with hooks and can be secured to the patellar body with superiorly directed screws. However, this specific plate is not available in all institution and the relative bulk of the plate over the anterior patella may cause metal irritation in flexed knee position. Separate vertical wiring technique for comminuted fractures of the distal patella introduced by Yang and Byun [4] showed higher fixation strength than tension-band wiring in the biomechanical study. They reported a 100% union rate and no wire breakage at an average follow-up of 22 months in 25 patients. However, there is still concern about the holding power of separate vertical wires for the comminuted small fragments especially in elderly. Song et al. [10] reported the biomechanical and clinical study of separate vertical wiring augmented with cerclage wire. The combined procedure showed better fixation results than separate vertical wiring alone, but they experienced 4 cases of cerclage wire breakage out of 21 cases. We modified separate vertical wiring technique by adding Krackow suture for patellar tendon to improve immediate stability of fixation. We believe that three separate wires might not be sufficient to allow early ROM and to maintain the reduction in case of comminuted distal fragments. The Krackow suture technique has been widely used for tendon repair and relatively familiar technique to orthopaedic surgeon [11,12]. The Krackow whip stitch is stronger than the Kessler, or Bunnell, stitches that are used for repairing smaller tendons [12]. Interlocking running suture on each side of patellar tendon can be tightened through bone tunnel of patellar body and provide additional stability even in comminuted small distal fragment. We routinely checked stability of the fixation through full range of motion after procedure. We could allow immediate motion without immobilization in all cases and there was no case of reduction loss of the fracture and wire
breakage. There was no significant change of the length of patellar tendon compared to contralateral knee and no case of limitation of ROM. The limitations of this study are retrospective design and small total case numbers. We believe that separate vertical wiring combined with Krackow suture for inferior pole fractures of the patella is a useful technique that is easy to perform and can provide stable fixation with excellent functional results in distal pole patella fractures. Conflict of interest statement No conflict of interest. References [1] Melvin JS, Mehta S. Patellar fractures in adults. J Am Acad Orthop Surg 2011;19(April (4)):198–207. [2] Anand A, Kumar M, Kodikal G. Role of suture anchors in management of fractures of inferior pole of patella. Indian J Orthop 2010;44(July (3)):333–5. [3] Saltzman CL, Goulet JA, McClellan RT, Schneider LA, Matthews LS. Results of treatment of displaced patellar fractures by partial patellectomy. J Bone Joint Surg Am 1990;72(9):1279–85. [4] Yang KH, Byun YS. Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella. J Bone Joint Surg Br 2003;85: 1155–60. [5] Chang SM, Ji XL. Open reduction and internal fixation of displaced patella inferior pole fractures with anterior tension band wiring through cannulated screws. J Orthop Trauma 2011;25(June (6)):366–70. [6] Kastelec M, Veselko M. Inferior patellar pole avulsion fractures: osteosynthesis compared with pole resection. J Bone Joint Surg Am 2004;86(4):696–701. [7] Matejcic A, Puljiz Z, Elabjer E, Bekavac-Beslin M, Ledinsky M. Multifragment fracture of the patellar apex: basket plate osteosynthesis compared with partial patellectomy. ArchOrthop Trauma Surg 2008;128:403–8. [8] Bostman O, Kiviluoto O, Nirhamo J. Comminuted displaced fractures of the patella. Injury 1981;13:196–202. [9] Marder RA, Swanson TV, Sharkey NA, Duwelius PJ. Effects of partial patellectomy and reattachment of thepatellar tendon on patellofemoral contact areas and pressures. J Bone Joint Surg Am 1993;75(1):35–45. [10] Song HK, Yoo JH, Byun YS, Yang KH. Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella. Yonsei Med J 2014;55(May (3)):785–91. [11] Heitman DE, Ng K, Crivello KM, Gallina J. Biomechanical comparison of the Achillon tendon repair system and the Krackow locking loop technique. Foot Ankle Int 2011;32(September (9)):879–87. [12] Krushinski EM, Parks BG, Hinton RY. Gap formation in transpatellar patellar tendon repair: pretensioning Krackow sutures versus standard repair in a cadaver model. Am J Sports Med 2010;38(January (1)):171–5.
Please cite this article in press as: Oh H-K, et al. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.09.026