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The treatment of fractures of the patella
THE TREATMENT OF FRACTURES OF THE PATELLA* J.
ALBERT
Professor of CIinicaI Orthopedic ST.
A
KEY,
Surgery, Washington LOUIS,
of the pateIIa usualIy invoIves an interruption of the extensor apparatus of the knee. The objects of treatment are (I) to restore the compIete and powerfu1 extension of the knee and (2) to preserve or restore the norma range of ffexion without Ieaving some irreguIarity of the articular surface which wiI1 tend to irritate the joint and Iead to the deveIopment of a progressive arthritis after function is resumed. In addition to the above, the treatment shouId be so planned that the patient is subjected to as IittIe risk as possibIe, that his Ioss of time from work is as short as possibIe, and that he is as comfortabIe as possibIe during his convaIescence. That the idea1 method of treatment has not yet been evoIved is evident from the Iarge number described in the Iiterature and at present used by various surgeons. It may be assumed that each of the methods now in use has been found to be satisfactory to some surgeons but not to aI1. In this paper I shaI1 mention brieffy a number of the methods in genera1 use and shaI1 describe the methods which I prefer and state why I prefer them. In considering the treatment of a recent simpIe fracture of the pateIIa the first decision required is whether or not an open operation is indicated. This decision is based upon the position of the fragments as determined by the physica examination and the roentgenogram, it being assumed that a competent surgeon and adequate faciIities for aseptic surgery are avaiIabIe. The operation appears quite simpIe, but may easiIy go wrong and rigid asepsis is necessary because the superficia1 position of the bone and its reIativeIy poor bIood suppIy seem to render it Iiable to infection. ShouId infection occur the knee joint is of Surgery, Washington
University
SchooI of Medicine
MISSOURI
FRACTURE
* From the Department
M.D.
usuaIIy invoIved and the surgeon faces a surgica1 catastrophe of considerabIe magnitude. ConsequentIy, operative fixation of a fracture of the pateIIa is reserved for those instances in which the fracture consists of, or incIudes, a compIete transverse Iesion with the fragments separated for $6 inch or more. Experience has shown that such fractures do not tend to unite by bone under conservative treatment and that it matters not whether the fracture is simpIe transverse, mildIy cornminuted, or steIIate in type. Not onIy do these fractures not unite by bone, but when there is separation of the fragments the IateraI aponeurosis of the knee on either side of the pateIIa is torn and the contraction of the quadriceps tends to puI1 the proxima1 fragment of the pateHa upward and the separation tends to increase with time. This resuIts in a weak and reIativeIy unstabIe extremity. TREATMENT
OF
IN WHICH ARE
SIMPLE THE
NOT
FRACTURES
FRAGMENTS
SEPARATED
We wiI1 first consider the treatment of simpIe fractures without separation of the fragments. These may be either simpIe transverse or cornminuted, as the number and the direction of the fracture Iines apparentIy make IittIe or no difference in the heaIing, unIess the fragments are separated. As a matter of fact, an extensiveIy comminuted fracture of the pateIIa without separation of the fragments may be expected to unite more promptIy than wiI1 a simpIe transverse fracture with a separation of ?& inch, because these comminuted fractures are the resuIt of direct vioIence and as a rule the IateraI aponeurosis is not torn. University 166
School of Medicine, St. Louis, Missouri.
NEW SERIES Var. XLlV,
No. I
Key-Fracture
In fractures in which it has been decided not to operate it is advisabIe to aspirate the knee joint and appIy a pressure dressing for from twenty-four to forty-eight hours, having the patient remain in bed either with or without a posterior splint. A very efficient form of pressure dressing is one made of a roII of absorbent cotton wrapped around the knee. Over this either a gauze or an eIastic bandage is appIied tightIy. This will tend to prevent further accumuIation of bIood in the joint. After the excess fluid has been removed and before the pressure dressing is appIied, an attempt shouId be made to mould the fragments by IateraI and vertica1 digita pressure if the roentgenogram has shown sIight dispIacement. Any irreguIarity of the articuIar surface is corrected by pressing the pateIIa downward against the condyIes of the femur. If at the end of from twenty-four to forty-eight hours there is excess fluid in the joint this shouId be aspirated a second time. In aspirating the knee usuaIIy no IocaI anesthesia is necessary. An area Iateral or mesia1 to the superior border of the pateIIa is painted with strong tincture of iodine. With a quick stab the needIe is pIunged into the knee joint, aiming at a point directIy beneath the upper portion of the pateIIa. In a hypersensitive or nervous patient the area may be infiItrated with novocaine if desired. As much bIood as can be removed is then aspirated, the needie withdrawn, and a piece of steriIe gauze pIaced over the puncture wound. I do not beIieve that it is necessary, or even advisabIe, to shave the Ieg or for the surgeon to scrub his hands or use rubber gIoves. There is no need for the surgeon’s hands to come in contact with the aspirating needIe at any time during the procedure. After the excess bIood in the joint has been removed, a pIaster of Paris cast is appIied with the knee in a position of extension. This cast is preferably of the skin-tight waIking pIaster type with a smaI1 piece of feIt over the pateIIa and a thin Iayer of cotton around the knee joint
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in order to provide for the smaI1 amount of movement which occurs at the knee. However, if one prefers, the ordinary padded pIaster of Paris cast may be used. It shouId extend from the toes up to the groin, as it is necessary that it incIude as much of the thigh as possibIe. One shouId plan on Ieaving the cast on about six weeks. Various types of adhesive dressings have been used beneath the pIaster in an attempt to bring the pateIIar fragments together. The usua1 method is to pIace obJique cross strips above and beIow; those above tend to puI1 the proxima1 fragment downward and those beIow tend to puI1 the dista1 fragment upward. These strips often irritate the skin beneath the cast and I do not beIieve they are very effective in hoIding the fragments together. ConsequentIy, I no Ionger use them. At the end of from four to eight weeks, depending on the fracture and the age of the patient, the pIaster cast is removed and the patient may begin to bend the knee. It wiI1 be found that a reIativeIy smaI1 amount of movement wiI1 be permitted. However, the knee shouId not be forced. The patient may appIy hot wet compresses or dry heat to the knee two or three times daiIy and shouId exercise the quadriceps and begin to waIk. At first crutches are used and then a cane; as the power in the Ieg returns the support is abandoned. For at Ieast four weeks after the remova of the cast the patient is cautioned not to put his weight on the leg with the knee in a position of flexion, but to waIk with the knee straight, because not onIy is the union not firm, but extensive atrophy has occurred in the pateIIa and it can be refractured with reIativeIy sIight force. (Fig. I.) Union shouId be quite firm at the end of eight weeks and bony union is usualIy present at the end of tweIve weeks. However, it may not be demonstrabIe in the x-ray for severa months. The exercises to restore the power in the quadriceps must be kept up over a period of severa months. If union occurs a practicaIIy norma knee may
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be expected in from four to six months and the patient may be expected to return to occupations not invoIving heavy Iifting or running within about three months.
of PateIIa fragments by wires, pins or cIamps have been advised and used. I do not beIieve that any subcutaneous method shouId be used, because contro1 of asepsis thus
FIG. I. Above, simpIe fracture of the pateIIa without dispIacement. BeIow, same case two months Iater after re*movaI of the cast. Note union, but marked atrophy of the bone.
TREATMENT THE
OF SIMPLE
PATELLA OF THE
WITH
FRACTURES
OF
SEPARATION
FRAGMENTS
In these fractures operative reduction and fixation of the fragments and operative suture of the IateraI aponeurosis is advised. This operation has been done for many years. That there is no method which is universaIIy satisfactory is evidenced by the fact that there are a muItitude of methods in use and by the fact that many subcutaneous methods of manipuIating the
becomes more diffIcuIt and contro1 of the fragments is Iess exact. The first question to decide is-When shouId one operate? A considerable number, and perhaps the majority, of surgeons beIieve that the operation shouId be postponed for a week to ten days, or even Ionger. The reasons given are: (I) that one shouId wait unti1 a11 tendency to hemorrhage in the joint has ceased; (2) that one shouId wait unti1 a reaction has occurred in the knee joint which wiI1 render it Iess IiabIe to infection; and (3) that one shouId
NEW SERIESVOL. XLIV, No. I
Key-Fracture
wait unti1 a smaI1 amount of caIIus is thrown out from the surface of the broken bone, as it is thought that this wiII tend to hasten union. I do not beIieve that any of the above reasons is vaIid. We controI the hemorrhage at the time of the operation, we do not create an artifIcia1 reaction in a cIean knee before operating upon it,and in other fractures we do not wait for beginning caIIus before reducing the fragments. The onIy reasons for not operating immediateIy are shock to the patient, which prohibits any surgica1 procedure beyond those necessary for saving Iife, and damage to the skin over the patella, which makes it impossibIe to contro1 asepsis. OrdinariIy, with abrasions or lacerations of the skin, if the patient is seen within a few hours of the injury, it is possibIe by the use of strong antiseptics and by pIacing the incision away from the injured area to perform the operation without undue danger of infection. On the other hand, if the patient is seen twenty-four hours or more after the injury when the superficia1 abrasions or Iacerations have become infected, then it is extremeIy unwise to operate unti1 the skin wounds have heaIed, and even then the skin incision shouId be placed as far away as possibIe from the recentIy infected area. ConsequentIy, if the condition of the skin and the general condition of the patient permit, I believe that the pateIla should be operated upon as soon after the injury as it is convenient to do so, preferably immediateIy. Before the operation the extremity from the mid thigh to the middIe of the Ieg is shaved, scrubbed with soap and water, washed with alcohol and ether, and painted with strong tincture of iodine or one of the newer skin antiseptics. A tourniquet is not used and the patient is pIaced on the operating tabIe with a smaI1 sand bag under the affected knee. The next question is-What anesthetic shouId be used? This depends entireIy upon the choice of the surgeon and upon the condition of the patient. As the bone is superficia1, IocaI anesthesia can be used
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American Journal of Surgery
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with entire satisfaction. I have empIoyed in about haIf of the patients I per cent novocaine in the skin and $5 per cent in the deeper tissues. The novocaine soIution contains three drops of adrenaIin to the ounce, for this not onIy tends to contro1 the hemorrhage, but tends aIso to counteract the toxic effect of the novocaine. The injection is made aIong the Iine of the proposed skin incision. The subcutaneous tissues under the skin incision are infihrated with 45 per cent novocaine and about IO C.C. of novocaine is injected we11 away on each side above the IateraI margins of the skin incision opposite the tear in the aponeurosis. If preferred, a genera1 anesthetic may be used. A number of different types of incisions may be used. Most surgeons prefer either a verticaI incision or a u-shaped incision which is convex downward. I prefer the u incision with a rather short Aap, the bottom of the u being just beIow the distal end of the patella. With this incision the suture Iine in the skin does not Iie over the fracture. The incision is carried down through the subcutaneous tissue to the IateraI aponeurosis and the upper portion of the pateIIar Iigament. The ffap, in&ding the subcutaneous tissues, is dissected upward and retracted after skin towe1.s have been appIied. This exposes the break in the bone and the tear in the aponeurosis, and through the break in the bone the knee joint is opened. The blood in the joint is evacuated and wiped out with gauze sponges. Any Ioose fragments of bone in the joint are removed. Likewise, Ioose fragments of bone which are compIeteIy detached or so nearly detached that their circuIation is markedIy impaired are removed. If the fracture is a simpIe transverse one it wiII not be necessary to remove any Ioose fragments or to revise the edges of the fracture. However, if a cornminuted fracture is present it may be advisabIe to remove a considerabIe portion of the bone and if this is done it may be necessary to revise the ends of the fragments which
170
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Journal
of Surgery
Key-Fracture
remain in order to obtain as accurate a coaptation of the fracture Iine as possibIe. This can be done with rongeur forceps or
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APRIL, 1939
heId together. The various procedures advocated wiI1 be discussed beIow. We use stainIess stee1 wire of the ffexibIe type and
FIG. 2. Simple comminuted fracture of the patelIa after fixation by encircIing staintess steeI wire.
bone cutting forceps. It wiI1 be found that the aponeurosis on either side of the pateIIa is torn for a variabIe distance outward, the Iength of the tear varying directIy with the degree of the separation of the fragments. This tear may be quite cIean cut, but is usuaIIy rather irreguIar, with frayed margins. Likewise, the thin aponeurosis extending over the superficia1 surface of the bone is torn, usuaIIy in an irreguIar manner. Some fringes of fibrous tissue tend to hang down into the space between the fragments. These fringes are excised because it is not possibIe to suture them suffIcientIy firmIy to be of vaIue in hoIding the fragments together. It is now necessary to coapt the fragments and hoId them together unti1 union has occurred or one may excise either a11or part of the pateIIa. There is a considerabIe difference of opinion as to how and with what materiaIs the fragments shouId be
of a strength sufficient to hoId the fragment firmly together (20 or 22 gauge in a fresh fracture). This wire may be pIaced through or around the fragments or through the Iarger and around the smaIIer fragment, depending upon the size and shape of the fragments. It wiI1 be noted that the dista1 fragment tends to be tiIted in such a manner that the fractured surface tiIts forward whiIe the proxima1 fragment, which is usuaIIy the Iarger, is drawn directIy upward. ConsequentIy, in most instances a hoIe is driIIed transverseIy through the Iarger (proxima1) fragment and the wire is passed through it. The hoIe is made as cIose to the anterior surface of the pateIIa as possibIe, because it is very important that the wire shouId not enter the knee joint, and aIso because it is important that it tend to puI1 the superficia1 or anterior margins of the fracture Iine together as this assures an
NEW SERIES VOL. XLIV. No. I
Key-Fracture
accurate coaptation of the articuIar surface. Then the wire is brought down through the IateraI aponeurosis cIose to the
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and the Iower up by sharp toothed retractors pIaced in the proxima1 and dista1 ends of each, respectiveIy, so that the fractured
FIG. 3. A bitateral fracture of the patella wired with soft iron wire. No trouble with the wire after seven years. Both knees apparentIy normaI.
margins of the pateIIa, and passed either through another transverse driI1 hoIe in the dista1 fragment or, if this fragment is quite smaI1 and cornminuted, through the patelIar Iigament just beIow this fragment. The two fragments are then accurateIy approximated, the upper being puIIed down
surfaces are pressed together. Then the wire is puIIed taut, twisted together and cut off. The twisted end is bent downward and inward and buried in the tissues aIongside the Iower poIe of the pateIIa. The IateraI aponeurosis is now sutured with mattress sutures of D siIk. It is to be noted
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American JournaI of Surgery
Key-Fracture
that th Le pateIIa is first wired firmIy tois sutured gethc :r before the aponeurosis This is done for two reasons: (I) because
of PateIIa
APRIL, ,939
fers, however, and if the fragments have been secureIy wired together, no immobiIization is necessary. An eIastic bandage
FIG. 4. Compound comminuted fracture of the pateIIa debrided and wired after remova of about haIf of the bone. UneventfuI recovery. Marked atrophy of Iower fragment and questionabIe union in the x-ray.
after the pateIIa is wired the aponeurosis can be sutured more easiIy and without undue tension; and (2) because the accurate apposition of the patelIar fragments, which is important if one is to prevent postoperative arthritis of the knee, can be performed more readiIy before the aponeurosis is sutured. The mattress sutures take smaI1 bites in the aponeurosis on either side; usuaIIy about four such sutures are pIaced on each side of the pateIIa. The subcutaneous tissues are then closed with fine siIk and the skin is sutured with silk. PostoperativeIy the knee may be immobiIized or not, depending upon the choice of the surgeon and upon the security with which the fragments of the pateIIa have been fixed by the wire. The patient is more comfortabIe if it is immobiIized in a cyIinder pIaster cast for about ten days, at the end of which time the cast is taken off, the sutures are removed and an elastic bandage is appIied. The patient is encouraged to exercise the knee. If one pre-
is appIied over the dry dressing and the patient may begin to move the knee within three or four days after the operation. The sutures are removed at the usua1 time and the patient may be up on crutches at the end of two weeks. He is encouraged to exercise the knee, but is advised not to put his weight upon the extremity with the knee flexed. At the end of eight weeks union shouId be firm and aImost norma motion in the knee shouId be present. The patient may begin Iight work within about four weeks, but shouId use a cane for at Ieast eight weeks after the operation. The stainIess stee1 wire is used because the fragments can be fixed more firmIy with wire than with any absorbabIe materia1 or with siIk. The stainIess stee1 wire can be toIerated indefiniteIy by the tissues and has not, in my experience, caused troubIe. There has not even been a great dea1 of difEcuIty with the wire in the two instances which I have seen in which postoperative infection of the wound occurred. The exact
Key-Fracture
NEYY SERIES VOL. XLIV, No. I
mainner of pIacing the wire depends upon the 2 form and size of the fragments found In some instances the at the operation.
A
of PateIIa
American Journal of Surgery
1173
to a11 intents and purposes normaI. ? ‘he patient is now over 60 years of age and Ieads a very active Iife.
B
FIG. 5. A, simpIe fracture of the patelIa wired. FolIowed by postoperative infection. Wire Ieft in until patella had united. B, same case after remova of the wire. StabIe painless knee with about 70 degrees of movement six months after injury.
wire is pIaced through both fragments, in some instances through one fragment and around the other, and in other instances around both fragments. (Figs. 2, 3, 4 and 3.) When one or both fragments are encircIed with wire, this is pIaced through or just beneath the aponeurosis and care is taken that the wire does not Iie in the joint cavity at any point. This is accompIished by threading the wire on a Iarge curved needIe, the point of which is brought out through the superficia1 fibers of the aponeurosis as often as is necessary to maintain the superficia1 position of the wire. Before fIexibIe stainIess stee1 wire was obtainabIe I used soft iron wire (stove pipe wire) and found that even this type of wire is toIerated by the tissues over many years without diffIcuIty. The biIatera1 fracture iIIustrated in Figures 4 and 5 was fixed with soft iron wire in 1932 and has caused no difficuIty up to this time, the knees being
My objection to the use of fascia, chromic catgut, kangaroo tendon or siIk for the fixation of bone fragments is that none of these can be reIied upon to fix the fragments together as firmIy as does wire. A further objection to the use of fascia is that it unnecessariIy compIicates the procedure. Likewise, I beIieve that there is more danger of postoperative infection after the use of fascia or heavy absorbabIe sutures, such as chromic catgut or kangaroo tendon, than there is after the use of a slender inert stainIess stee1 wire. If wire were not avaiIable, I wouId choose heavy braided siIk or Iinen and encircIe both fragments, because there is a tendency for siIk to be cut by the edge of the bone when it is passed through a drill hoIe and tied under tension. The objection which many men have to Ieaving non-absorbabIe materia1, such as wire or metal screws or pIates, in bone wiI1, I beIieve, disappear as the use of stainIess
I74
American Journd
of Surgery
Key-Fracture
steeI becomes more generaI. Other forms of fixation, such as screws or bone grafts are Iess effective and render the operation
of PateIIa
APRIL, 1939
cence and maintains a better function in the knee. It is probabIe that in an instance such as
FIG. 7. Avulsion of patelIar ligament sutured with heavy braided sitk. UneventfuI recovery. FIG. 6. OId fracture of the patelIa. Lengthening of quadriceps and excision of ends of fragments necessary before wiring.
much more diffIcuIt. ObviousIy, anything that can be done to simpIify the operation and the postoperative care shouId be encouraged. EspeciaIIy to be condemned is the method of suturing onIy the IateraI aponeurosis and not wiring or tying the bone fragments together. This procedure demands proIonged immobiIization and invites nonunion. I beIieve that the importance of suturing the aponeurosis has been overemphasized. It is good surgery to suture the aponeurosis after the fragments have been wired together, but it is more important to coapt the bone fragments and hoId them together unti1 union has occurred. The question of excision of the Iower fragment as advocated by Thomson1 and BIodgett and FairchiId,2 or of excision of the entire pateIIa as advocated by Brooke,3 Tippett,4 and BIodgett and FairchiId2 is one which may be given thought. Thomson excises the Iesser of the two fragments, usuaIIy the Iower, and fixes the pateIIar Iigament or quadriceps tendon to the remaining fragment, thus eIiminating the necessity of union by bone. He beIieves that this procedure shortens the convaIes-
that iIIustrated in Figure 4 it wouId have been wise to excise the Iower fragment and suture the pateIIar Iigament to the upper fragment with siIk, because, whiIe cIinicaIIy there was union, the x-ray did not show union five months after the accident. The patient, being a compensation case, cIaimed that the fragments were not united. His doctors cIaimed that it wouId be necessary to remove the wire and the Iower fragment, aIthough there was no cIinica1 indication for the remova of either and the knee was apparentIy norma with the exception of weakness from quadriceps atrophy. It is thus evident that the presence of wire in the tissues is sIightIy objectionabIe in compensation cases. However, I do not beIieve that this objection is of sufficient importance to bar its use when its other advantages are considered. This particuIar case was a severe compound cornminuted fracture with fragments of a broken emery whee1 in the tissues. Concerning the question of the remova of the entire pateIIa, I have not performed this operation for fracture of the pateIIa, aIthough I have done it for ankyIosis of the pateIIa to the femur. However, the resuIts and the experimenta observations of Brooke3 are very convincing and I see no reason why it shouId not be done, espe-
NEW SERIES VOL. XLIV,
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Key-Fracture
ciaIIy in severeIy cornminuted fractures with separation of the fragments. On the other hand, it is quite a radica1 procedure and I do not beIieve that it wiI1 be generaIIy adopted as a treatment for uncompIicated fractures of the pateIIa. COMPOUND
FRACTURES
OF THE
PATELLA
A compound fracture of the pateIIa is simiIar to a compound fracture of any other bone pIus an opening into the knee joint and if it is seen earIy (within six to ten hours after the accident) it shouId be thoroughIy debrided and sutured. The debridement is carried out according to standard principIes, excising the skin edges, removing a11 foreign matter and Ioose fragments of bone and then washing out the wound and washing out the knee joint with a Iarge amount of warm normal saIt solution. Any devitalized tissue is excised. The fragments of the pateIIa are then fixed with stainless stee1 wire just as described above for a simpIe fracture and theaponeurosis is sutured, either with siIk or chromic catgut, according to the preference of the surgeon. The skin and subcutaneous tissues are sutured in one Iayer with interrupted siIkworm gut sutures and a smaI1 rubber drain is inserted on either side. This drain may be placed down to the capsuIe or may extend into the knee joint, depending upon whether one beIieves that he has performed an adequate debridement suffIcientIy soon after the injury to be reasonably sure that the knee wiI1 not become infected. This drain is removed at the end of forty-eight hours and the fracture is treated as a simpIe fracture. (Fig. 4.) After suture of the pateIIa for a compound fracture the knee is immobiIized in a weII-padded pIaster cast which extends from the toes to the groin and vaseIine gauze is pIaced over the suture line to permit drainage, the skin being sutured rather Ioosely. The knee is immobiIized in a cast because I beIieve that this is an important factor in the prevention of infection. SuIfaniIamide in doses of 15 gr. every four hours shouId aIso be given as a
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American
Journal
of Surgery
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prophyIactic against infection in severe compound fractures. If there should be evidence of infection, as indicated by a rise in temperature, a rise in the puIse or an unusua1 amount of pain in the wound, the cast shouId be bivaIved and the wound inspected immediateIy. Sufficient skin sutures shouId be removed to determine whether or not the infection is in the superficia1 tissues or in the knee joint. If the infection is deep, the joint shouId be opened freeIy and a large wet dressing applied, at the same time maintaining immobiiization. I have not found that the presence of the wire was a detrimenta factor in the earIy days of an infected wound and beIieve that its immobiIizing effect is a distinct benefit. In such wounds, however, it is usua1 to remove the wire after the infection has quieted down, but before it has healed. In very severe fuIminating infections it is advisabIe to remove the wire, separate the fragments, remove a11 Ioose fragments and, if necessary, remove the pateIIa. However, this has not yet been necessary in my experience. If the infection is found to be due to a streptococcus or to a gas baciIIus a massive dose of SuIfaniIamide (90 gr.) shouId be given immediateIy and shouId be foIIowed by 15 gr. every four hours. This is continued until the patient’s temperature has dropped to a satisfactory IeveI and the infection has subsided, or unti1 it is necessary to stop the drug because of an idiosyncrasy. In addition to the chemotherapy the wound shouId be treated surgicaIIy as described above. Throughout the process of the treatment of the knee for an infection due to a compound fracture of the pateIIa or due to a postoperative infection of a pateIIa which has been sutured, the knee shouId be kept in a straight position and no attempt shouId be made to move it until the infection has subsided and the deeper tissues have heaIed. UsuaIIy it wiI1 be found that this wiI1 resuIt in a IocaIization of the infection in the front of the knee joint. After the
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Key-Fracture
infection has subsided and the wounds have healed there will be a slow, but progressive return of function and in most instances the range of movement will increase over a period of months (Fig. 5), although occasionally bony ankylosis at the knee may occur. OLD
FRACTURES
OF
THE
PATELLA
In old fractures of the patella the fragments are usually widely separated and the proximal fragment is maintained in its abnormal position by contracture of the quadriceps muscle. In addition to the above, the ends of the fragments are sealed over by scar tissue. Likewise, there is a thin layer of scar tissue bridging the space left by the tear in the lateral aponeurosis on either side of the patella. In treating such a lesion it is necessary to excise the scar tissue between the torn ends of the aponeurosis and to excise the ends of each fragment in order that fresh bleeding bone may be exposed and opposed. After this has been done it will usually be found that it is not possible to pull the two fragments together. Not only is the proximal fragment displaced and held up on the thigh, but the distal fragment is displaced downward. In order to coapt the two freshened bone surfaces it will usually be necessary to lengthen the quadriceps tendon. This can be done by the z method or by the tendon plastic method of Bennett in which a long tongue of the quadriceps tendon is cut free and slipped downward and then sutured at a lower level by suturing the muscle fibers to it on either side. However, in performing this operation it is to be noted that lengthening of the central tendon itself will not permit downward displacement of the patella, nor will it permit ffexion in a knee which has become fixed in extension by contractures. The real fixation of the patella upward on the femur is not due to the quadriceps tendon, but is due to the shortening of the tissues on either side of the upper pole of the patella which bind it to the femur just above the condyles. These are largely portions of the vastus internus
of Patella and externus, and these fibers must be cut across, opening the quadriceps bursa of the knee joint and freeing the upper pole of the patella on either side. Then the upper fragment can be pulled downward, swinging by a pedicle of tissue on either side and carrymg with it the freed quadriceps tendon above. This will leave a dead space or gap I to 2 inches wide in the quadriceps muscle on either side at the upper pole of the patella. I have usually left the space open, but occasionally I have partly obliterated it by transplantation of muscle fibers. It apparently takes care of itself and has not caused any trouble, except worry, until the danger of infection is over. After the quadriceps apparatus has been lengthened to such a degree that the upper fragment can be brought downward, the two fragments are held together with sharp toothed retractors and are lixed with a wire loop, just as though one were dealing with a fresh simple fracture. Then the aponeurosis on either side is sutured with silk and the wound is closed in the usual manner. For this operation a long anterior incision is used, the incision curving inward around the mesial aspect of the patella, extending down to the tibia1 tubercle and as far upward on the thigh as is necessary. After the operation it is advisable to immobilize the extremity in a plaster of Paris cast with as much flexion as can be obtained without undue tension on the fragments. The immobilization is continued for from two to four weeks, depending upon the postoperative course. (Fig. 6.) TREATMENT QUADRICEPS
OF
AVULSION
TENDON
PATELLAR
OR
OF OF
THE THE
LIGAMENT
In these instances the tear is usually close to the upper or lower pole of the a small patella and not infrequently amount of bone is torn off with the tendon. It is not practicable to fix the tendon to the bone with wire because the wire pulls through the vertical tendon fibers and becomes loose and when the wire becomes loose it acts as an irritant. Consequently,
NEW SERIESVOL.XLIV, No.
I
Key-Fracture
for these injuries I use heavy braided siIk sutures, weaving the silk into the tendon and Ieaving four strands of silk projecting from the torn end of the tendon. Then two drilI hoIes are made in the pateIIa, passing verticaIIy upward or downward through the bone, keeping we11 away from the articuIar surface. The heavy siIk is passed through these driI1 hoIes and tied hrmIy at the opposite poIe of the bone. The torn aponeurosis is sutured with siIk in the usual manner and the subcutaneous tissues and skin are cIosed with siIk. PostoperativeIy the knee is immobiIized in a pIaster of Paris cast for four weeks. It is not feIt that the siIk is strong enough to permit free use of the knee before this time, nor is it feIt that the union between the torn tendon and the bone wiI1 be sufhcientIy strong to permit freedom of the knee without danger that the sutures may be torn loose. At the end of this time the cast is removed and the patient is encouraged to begin exercising the knee and to bear weight upon it with the knee in the straight position. He may waIk with crutches or with a cane, but is cautioned against putting his weight on the flexed knee. A very strong and usefu1 knee may be expected within eight to tweIve weeks and
of PateIIa
American Journal of Surgery
a practicaIIy norma months. (Fig. 7.)
knee within about
I77
six
SUMMARY
Simple fractures of the pateIIa without separation of the fragments are treated by immobiIization in a pIaster of Paris cast. If the fragments are separated they are reduced by open operation and tied together. A Ioop of stainIess stee1 wire is preferred to any other type of suture. The tear in the Iateral aponeurosis is sutured with D siIk. AvuIsions of the quadriceps tendon or of the pateIIar Iigament are repaired by heavy siIk which is passed through two driI1 holes in the pateha and tied at the opposite poIe of the bone. The management of compound fractures, of infected fractures and of old fractures of the pateha is described. KEFERENCES I. THOMSON, J. E. M. Comminuted fractures of the patella. J. Bone ti Joint Surg., 17: 431, 1935. 2. BLODCETT, W. E., and FAIRCHILD, R. D. Fractures of the pateIla. j. A. M. A., 10612121, 1936. 3. BROOKE, R. Treatment of fractured patelIa by excision. A study of morphology and function. Brit. J. Surg., 24: 733, 1936-1937. 4. TIPPETT, G. 0. Treatment of fractures of the patella by excision. Brit. M. J., I: 383 (Feb. rg) 1938.
ALBERT
Professor of CIinicaI Orthopedic ST.
A
KEY,
Surgery, Washington LOUIS,
of the pateIIa usualIy invoIves an interruption of the extensor apparatus of the knee. The objects of treatment are (I) to restore the compIete and powerfu1 extension of the knee and (2) to preserve or restore the norma range of ffexion without Ieaving some irreguIarity of the articular surface which wiI1 tend to irritate the joint and Iead to the deveIopment of a progressive arthritis after function is resumed. In addition to the above, the treatment shouId be so planned that the patient is subjected to as IittIe risk as possibIe, that his Ioss of time from work is as short as possibIe, and that he is as comfortabIe as possibIe during his convaIescence. That the idea1 method of treatment has not yet been evoIved is evident from the Iarge number described in the Iiterature and at present used by various surgeons. It may be assumed that each of the methods now in use has been found to be satisfactory to some surgeons but not to aI1. In this paper I shaI1 mention brieffy a number of the methods in genera1 use and shaI1 describe the methods which I prefer and state why I prefer them. In considering the treatment of a recent simpIe fracture of the pateIIa the first decision required is whether or not an open operation is indicated. This decision is based upon the position of the fragments as determined by the physica examination and the roentgenogram, it being assumed that a competent surgeon and adequate faciIities for aseptic surgery are avaiIabIe. The operation appears quite simpIe, but may easiIy go wrong and rigid asepsis is necessary because the superficia1 position of the bone and its reIativeIy poor bIood suppIy seem to render it Iiable to infection. ShouId infection occur the knee joint is of Surgery, Washington
University
SchooI of Medicine
MISSOURI
FRACTURE
* From the Department
M.D.
usuaIIy invoIved and the surgeon faces a surgica1 catastrophe of considerabIe magnitude. ConsequentIy, operative fixation of a fracture of the pateIIa is reserved for those instances in which the fracture consists of, or incIudes, a compIete transverse Iesion with the fragments separated for $6 inch or more. Experience has shown that such fractures do not tend to unite by bone under conservative treatment and that it matters not whether the fracture is simpIe transverse, mildIy cornminuted, or steIIate in type. Not onIy do these fractures not unite by bone, but when there is separation of the fragments the IateraI aponeurosis of the knee on either side of the pateIIa is torn and the contraction of the quadriceps tends to puI1 the proxima1 fragment of the pateHa upward and the separation tends to increase with time. This resuIts in a weak and reIativeIy unstabIe extremity. TREATMENT
OF
IN WHICH ARE
SIMPLE THE
NOT
FRACTURES
FRAGMENTS
SEPARATED
We wiI1 first consider the treatment of simpIe fractures without separation of the fragments. These may be either simpIe transverse or cornminuted, as the number and the direction of the fracture Iines apparentIy make IittIe or no difference in the heaIing, unIess the fragments are separated. As a matter of fact, an extensiveIy comminuted fracture of the pateIIa without separation of the fragments may be expected to unite more promptIy than wiI1 a simpIe transverse fracture with a separation of ?& inch, because these comminuted fractures are the resuIt of direct vioIence and as a rule the IateraI aponeurosis is not torn. University 166
School of Medicine, St. Louis, Missouri.
NEW SERIES Var. XLlV,
No. I
Key-Fracture
In fractures in which it has been decided not to operate it is advisabIe to aspirate the knee joint and appIy a pressure dressing for from twenty-four to forty-eight hours, having the patient remain in bed either with or without a posterior splint. A very efficient form of pressure dressing is one made of a roII of absorbent cotton wrapped around the knee. Over this either a gauze or an eIastic bandage is appIied tightIy. This will tend to prevent further accumuIation of bIood in the joint. After the excess fluid has been removed and before the pressure dressing is appIied, an attempt shouId be made to mould the fragments by IateraI and vertica1 digita pressure if the roentgenogram has shown sIight dispIacement. Any irreguIarity of the articuIar surface is corrected by pressing the pateIIa downward against the condyIes of the femur. If at the end of from twenty-four to forty-eight hours there is excess fluid in the joint this shouId be aspirated a second time. In aspirating the knee usuaIIy no IocaI anesthesia is necessary. An area Iateral or mesia1 to the superior border of the pateIIa is painted with strong tincture of iodine. With a quick stab the needIe is pIunged into the knee joint, aiming at a point directIy beneath the upper portion of the pateIIa. In a hypersensitive or nervous patient the area may be infiItrated with novocaine if desired. As much bIood as can be removed is then aspirated, the needie withdrawn, and a piece of steriIe gauze pIaced over the puncture wound. I do not beIieve that it is necessary, or even advisabIe, to shave the Ieg or for the surgeon to scrub his hands or use rubber gIoves. There is no need for the surgeon’s hands to come in contact with the aspirating needIe at any time during the procedure. After the excess bIood in the joint has been removed, a pIaster of Paris cast is appIied with the knee in a position of extension. This cast is preferably of the skin-tight waIking pIaster type with a smaI1 piece of feIt over the pateIIa and a thin Iayer of cotton around the knee joint
of PateIIa
American JournaI of Surgery
I67
in order to provide for the smaI1 amount of movement which occurs at the knee. However, if one prefers, the ordinary padded pIaster of Paris cast may be used. It shouId extend from the toes up to the groin, as it is necessary that it incIude as much of the thigh as possibIe. One shouId plan on Ieaving the cast on about six weeks. Various types of adhesive dressings have been used beneath the pIaster in an attempt to bring the pateIIar fragments together. The usua1 method is to pIace obJique cross strips above and beIow; those above tend to puI1 the proxima1 fragment downward and those beIow tend to puI1 the dista1 fragment upward. These strips often irritate the skin beneath the cast and I do not beIieve they are very effective in hoIding the fragments together. ConsequentIy, I no Ionger use them. At the end of from four to eight weeks, depending on the fracture and the age of the patient, the pIaster cast is removed and the patient may begin to bend the knee. It wiI1 be found that a reIativeIy smaI1 amount of movement wiI1 be permitted. However, the knee shouId not be forced. The patient may appIy hot wet compresses or dry heat to the knee two or three times daiIy and shouId exercise the quadriceps and begin to waIk. At first crutches are used and then a cane; as the power in the Ieg returns the support is abandoned. For at Ieast four weeks after the remova of the cast the patient is cautioned not to put his weight on the leg with the knee in a position of flexion, but to waIk with the knee straight, because not onIy is the union not firm, but extensive atrophy has occurred in the pateIIa and it can be refractured with reIativeIy sIight force. (Fig. I.) Union shouId be quite firm at the end of eight weeks and bony union is usualIy present at the end of tweIve weeks. However, it may not be demonstrabIe in the x-ray for severa months. The exercises to restore the power in the quadriceps must be kept up over a period of severa months. If union occurs a practicaIIy norma knee may
168
Key-Fracture
American JournaI of Surgery
be expected in from four to six months and the patient may be expected to return to occupations not invoIving heavy Iifting or running within about three months.
of PateIIa fragments by wires, pins or cIamps have been advised and used. I do not beIieve that any subcutaneous method shouId be used, because contro1 of asepsis thus
FIG. I. Above, simpIe fracture of the pateIIa without dispIacement. BeIow, same case two months Iater after re*movaI of the cast. Note union, but marked atrophy of the bone.
TREATMENT THE
OF SIMPLE
PATELLA OF THE
WITH
FRACTURES
OF
SEPARATION
FRAGMENTS
In these fractures operative reduction and fixation of the fragments and operative suture of the IateraI aponeurosis is advised. This operation has been done for many years. That there is no method which is universaIIy satisfactory is evidenced by the fact that there are a muItitude of methods in use and by the fact that many subcutaneous methods of manipuIating the
becomes more diffIcuIt and contro1 of the fragments is Iess exact. The first question to decide is-When shouId one operate? A considerable number, and perhaps the majority, of surgeons beIieve that the operation shouId be postponed for a week to ten days, or even Ionger. The reasons given are: (I) that one shouId wait unti1 a11 tendency to hemorrhage in the joint has ceased; (2) that one shouId wait unti1 a reaction has occurred in the knee joint which wiI1 render it Iess IiabIe to infection; and (3) that one shouId
NEW SERIESVOL. XLIV, No. I
Key-Fracture
wait unti1 a smaI1 amount of caIIus is thrown out from the surface of the broken bone, as it is thought that this wiII tend to hasten union. I do not beIieve that any of the above reasons is vaIid. We controI the hemorrhage at the time of the operation, we do not create an artifIcia1 reaction in a cIean knee before operating upon it,and in other fractures we do not wait for beginning caIIus before reducing the fragments. The onIy reasons for not operating immediateIy are shock to the patient, which prohibits any surgica1 procedure beyond those necessary for saving Iife, and damage to the skin over the patella, which makes it impossibIe to contro1 asepsis. OrdinariIy, with abrasions or lacerations of the skin, if the patient is seen within a few hours of the injury, it is possibIe by the use of strong antiseptics and by pIacing the incision away from the injured area to perform the operation without undue danger of infection. On the other hand, if the patient is seen twenty-four hours or more after the injury when the superficia1 abrasions or Iacerations have become infected, then it is extremeIy unwise to operate unti1 the skin wounds have heaIed, and even then the skin incision shouId be placed as far away as possibIe from the recentIy infected area. ConsequentIy, if the condition of the skin and the general condition of the patient permit, I believe that the pateIla should be operated upon as soon after the injury as it is convenient to do so, preferably immediateIy. Before the operation the extremity from the mid thigh to the middIe of the Ieg is shaved, scrubbed with soap and water, washed with alcohol and ether, and painted with strong tincture of iodine or one of the newer skin antiseptics. A tourniquet is not used and the patient is pIaced on the operating tabIe with a smaI1 sand bag under the affected knee. The next question is-What anesthetic shouId be used? This depends entireIy upon the choice of the surgeon and upon the condition of the patient. As the bone is superficia1, IocaI anesthesia can be used
of PateIIa
American Journal of Surgery
169
with entire satisfaction. I have empIoyed in about haIf of the patients I per cent novocaine in the skin and $5 per cent in the deeper tissues. The novocaine soIution contains three drops of adrenaIin to the ounce, for this not onIy tends to contro1 the hemorrhage, but tends aIso to counteract the toxic effect of the novocaine. The injection is made aIong the Iine of the proposed skin incision. The subcutaneous tissues under the skin incision are infihrated with 45 per cent novocaine and about IO C.C. of novocaine is injected we11 away on each side above the IateraI margins of the skin incision opposite the tear in the aponeurosis. If preferred, a genera1 anesthetic may be used. A number of different types of incisions may be used. Most surgeons prefer either a verticaI incision or a u-shaped incision which is convex downward. I prefer the u incision with a rather short Aap, the bottom of the u being just beIow the distal end of the patella. With this incision the suture Iine in the skin does not Iie over the fracture. The incision is carried down through the subcutaneous tissue to the IateraI aponeurosis and the upper portion of the pateIIar Iigament. The ffap, in&ding the subcutaneous tissues, is dissected upward and retracted after skin towe1.s have been appIied. This exposes the break in the bone and the tear in the aponeurosis, and through the break in the bone the knee joint is opened. The blood in the joint is evacuated and wiped out with gauze sponges. Any Ioose fragments of bone in the joint are removed. Likewise, Ioose fragments of bone which are compIeteIy detached or so nearly detached that their circuIation is markedIy impaired are removed. If the fracture is a simpIe transverse one it wiII not be necessary to remove any Ioose fragments or to revise the edges of the fracture. However, if a cornminuted fracture is present it may be advisabIe to remove a considerabIe portion of the bone and if this is done it may be necessary to revise the ends of the fragments which
170
American
Journal
of Surgery
Key-Fracture
remain in order to obtain as accurate a coaptation of the fracture Iine as possibIe. This can be done with rongeur forceps or
of PatelIa
APRIL, 1939
heId together. The various procedures advocated wiI1 be discussed beIow. We use stainIess stee1 wire of the ffexibIe type and
FIG. 2. Simple comminuted fracture of the patelIa after fixation by encircIing staintess steeI wire.
bone cutting forceps. It wiI1 be found that the aponeurosis on either side of the pateIIa is torn for a variabIe distance outward, the Iength of the tear varying directIy with the degree of the separation of the fragments. This tear may be quite cIean cut, but is usuaIIy rather irreguIar, with frayed margins. Likewise, the thin aponeurosis extending over the superficia1 surface of the bone is torn, usuaIIy in an irreguIar manner. Some fringes of fibrous tissue tend to hang down into the space between the fragments. These fringes are excised because it is not possibIe to suture them suffIcientIy firmIy to be of vaIue in hoIding the fragments together. It is now necessary to coapt the fragments and hoId them together unti1 union has occurred or one may excise either a11or part of the pateIIa. There is a considerabIe difference of opinion as to how and with what materiaIs the fragments shouId be
of a strength sufficient to hoId the fragment firmly together (20 or 22 gauge in a fresh fracture). This wire may be pIaced through or around the fragments or through the Iarger and around the smaIIer fragment, depending upon the size and shape of the fragments. It wiI1 be noted that the dista1 fragment tends to be tiIted in such a manner that the fractured surface tiIts forward whiIe the proxima1 fragment, which is usuaIIy the Iarger, is drawn directIy upward. ConsequentIy, in most instances a hoIe is driIIed transverseIy through the Iarger (proxima1) fragment and the wire is passed through it. The hoIe is made as cIose to the anterior surface of the pateIIa as possibIe, because it is very important that the wire shouId not enter the knee joint, and aIso because it is important that it tend to puI1 the superficia1 or anterior margins of the fracture Iine together as this assures an
NEW SERIES VOL. XLIV. No. I
Key-Fracture
accurate coaptation of the articuIar surface. Then the wire is brought down through the IateraI aponeurosis cIose to the
of Patella
American Journal of Surgery
171
and the Iower up by sharp toothed retractors pIaced in the proxima1 and dista1 ends of each, respectiveIy, so that the fractured
FIG. 3. A bitateral fracture of the patella wired with soft iron wire. No trouble with the wire after seven years. Both knees apparentIy normaI.
margins of the pateIIa, and passed either through another transverse driI1 hoIe in the dista1 fragment or, if this fragment is quite smaI1 and cornminuted, through the patelIar Iigament just beIow this fragment. The two fragments are then accurateIy approximated, the upper being puIIed down
surfaces are pressed together. Then the wire is puIIed taut, twisted together and cut off. The twisted end is bent downward and inward and buried in the tissues aIongside the Iower poIe of the pateIIa. The IateraI aponeurosis is now sutured with mattress sutures of D siIk. It is to be noted
172
American JournaI of Surgery
Key-Fracture
that th Le pateIIa is first wired firmIy tois sutured gethc :r before the aponeurosis This is done for two reasons: (I) because
of PateIIa
APRIL, ,939
fers, however, and if the fragments have been secureIy wired together, no immobiIization is necessary. An eIastic bandage
FIG. 4. Compound comminuted fracture of the pateIIa debrided and wired after remova of about haIf of the bone. UneventfuI recovery. Marked atrophy of Iower fragment and questionabIe union in the x-ray.
after the pateIIa is wired the aponeurosis can be sutured more easiIy and without undue tension; and (2) because the accurate apposition of the patelIar fragments, which is important if one is to prevent postoperative arthritis of the knee, can be performed more readiIy before the aponeurosis is sutured. The mattress sutures take smaI1 bites in the aponeurosis on either side; usuaIIy about four such sutures are pIaced on each side of the pateIIa. The subcutaneous tissues are then closed with fine siIk and the skin is sutured with silk. PostoperativeIy the knee may be immobiIized or not, depending upon the choice of the surgeon and upon the security with which the fragments of the pateIIa have been fixed by the wire. The patient is more comfortabIe if it is immobiIized in a cyIinder pIaster cast for about ten days, at the end of which time the cast is taken off, the sutures are removed and an elastic bandage is appIied. The patient is encouraged to exercise the knee. If one pre-
is appIied over the dry dressing and the patient may begin to move the knee within three or four days after the operation. The sutures are removed at the usua1 time and the patient may be up on crutches at the end of two weeks. He is encouraged to exercise the knee, but is advised not to put his weight upon the extremity with the knee flexed. At the end of eight weeks union shouId be firm and aImost norma motion in the knee shouId be present. The patient may begin Iight work within about four weeks, but shouId use a cane for at Ieast eight weeks after the operation. The stainIess stee1 wire is used because the fragments can be fixed more firmIy with wire than with any absorbabIe materia1 or with siIk. The stainIess stee1 wire can be toIerated indefiniteIy by the tissues and has not, in my experience, caused troubIe. There has not even been a great dea1 of difEcuIty with the wire in the two instances which I have seen in which postoperative infection of the wound occurred. The exact
Key-Fracture
NEYY SERIES VOL. XLIV, No. I
mainner of pIacing the wire depends upon the 2 form and size of the fragments found In some instances the at the operation.
A
of PateIIa
American Journal of Surgery
1173
to a11 intents and purposes normaI. ? ‘he patient is now over 60 years of age and Ieads a very active Iife.
B
FIG. 5. A, simpIe fracture of the patelIa wired. FolIowed by postoperative infection. Wire Ieft in until patella had united. B, same case after remova of the wire. StabIe painless knee with about 70 degrees of movement six months after injury.
wire is pIaced through both fragments, in some instances through one fragment and around the other, and in other instances around both fragments. (Figs. 2, 3, 4 and 3.) When one or both fragments are encircIed with wire, this is pIaced through or just beneath the aponeurosis and care is taken that the wire does not Iie in the joint cavity at any point. This is accompIished by threading the wire on a Iarge curved needIe, the point of which is brought out through the superficia1 fibers of the aponeurosis as often as is necessary to maintain the superficia1 position of the wire. Before fIexibIe stainIess stee1 wire was obtainabIe I used soft iron wire (stove pipe wire) and found that even this type of wire is toIerated by the tissues over many years without diffIcuIty. The biIatera1 fracture iIIustrated in Figures 4 and 5 was fixed with soft iron wire in 1932 and has caused no difficuIty up to this time, the knees being
My objection to the use of fascia, chromic catgut, kangaroo tendon or siIk for the fixation of bone fragments is that none of these can be reIied upon to fix the fragments together as firmIy as does wire. A further objection to the use of fascia is that it unnecessariIy compIicates the procedure. Likewise, I beIieve that there is more danger of postoperative infection after the use of fascia or heavy absorbabIe sutures, such as chromic catgut or kangaroo tendon, than there is after the use of a slender inert stainIess stee1 wire. If wire were not avaiIable, I wouId choose heavy braided siIk or Iinen and encircIe both fragments, because there is a tendency for siIk to be cut by the edge of the bone when it is passed through a drill hoIe and tied under tension. The objection which many men have to Ieaving non-absorbabIe materia1, such as wire or metal screws or pIates, in bone wiI1, I beIieve, disappear as the use of stainIess
I74
American Journd
of Surgery
Key-Fracture
steeI becomes more generaI. Other forms of fixation, such as screws or bone grafts are Iess effective and render the operation
of PateIIa
APRIL, 1939
cence and maintains a better function in the knee. It is probabIe that in an instance such as
FIG. 7. Avulsion of patelIar ligament sutured with heavy braided sitk. UneventfuI recovery. FIG. 6. OId fracture of the patelIa. Lengthening of quadriceps and excision of ends of fragments necessary before wiring.
much more diffIcuIt. ObviousIy, anything that can be done to simpIify the operation and the postoperative care shouId be encouraged. EspeciaIIy to be condemned is the method of suturing onIy the IateraI aponeurosis and not wiring or tying the bone fragments together. This procedure demands proIonged immobiIization and invites nonunion. I beIieve that the importance of suturing the aponeurosis has been overemphasized. It is good surgery to suture the aponeurosis after the fragments have been wired together, but it is more important to coapt the bone fragments and hoId them together unti1 union has occurred. The question of excision of the Iower fragment as advocated by Thomson1 and BIodgett and FairchiId,2 or of excision of the entire pateIIa as advocated by Brooke,3 Tippett,4 and BIodgett and FairchiId2 is one which may be given thought. Thomson excises the Iesser of the two fragments, usuaIIy the Iower, and fixes the pateIIar Iigament or quadriceps tendon to the remaining fragment, thus eIiminating the necessity of union by bone. He beIieves that this procedure shortens the convaIes-
that iIIustrated in Figure 4 it wouId have been wise to excise the Iower fragment and suture the pateIIar Iigament to the upper fragment with siIk, because, whiIe cIinicaIIy there was union, the x-ray did not show union five months after the accident. The patient, being a compensation case, cIaimed that the fragments were not united. His doctors cIaimed that it wouId be necessary to remove the wire and the Iower fragment, aIthough there was no cIinica1 indication for the remova of either and the knee was apparentIy norma with the exception of weakness from quadriceps atrophy. It is thus evident that the presence of wire in the tissues is sIightIy objectionabIe in compensation cases. However, I do not beIieve that this objection is of sufficient importance to bar its use when its other advantages are considered. This particuIar case was a severe compound cornminuted fracture with fragments of a broken emery whee1 in the tissues. Concerning the question of the remova of the entire pateIIa, I have not performed this operation for fracture of the pateIIa, aIthough I have done it for ankyIosis of the pateIIa to the femur. However, the resuIts and the experimenta observations of Brooke3 are very convincing and I see no reason why it shouId not be done, espe-
NEW SERIES VOL. XLIV,
No. I
Key-Fracture
ciaIIy in severeIy cornminuted fractures with separation of the fragments. On the other hand, it is quite a radica1 procedure and I do not beIieve that it wiI1 be generaIIy adopted as a treatment for uncompIicated fractures of the pateIIa. COMPOUND
FRACTURES
OF THE
PATELLA
A compound fracture of the pateIIa is simiIar to a compound fracture of any other bone pIus an opening into the knee joint and if it is seen earIy (within six to ten hours after the accident) it shouId be thoroughIy debrided and sutured. The debridement is carried out according to standard principIes, excising the skin edges, removing a11 foreign matter and Ioose fragments of bone and then washing out the wound and washing out the knee joint with a Iarge amount of warm normal saIt solution. Any devitalized tissue is excised. The fragments of the pateIIa are then fixed with stainless stee1 wire just as described above for a simpIe fracture and theaponeurosis is sutured, either with siIk or chromic catgut, according to the preference of the surgeon. The skin and subcutaneous tissues are sutured in one Iayer with interrupted siIkworm gut sutures and a smaI1 rubber drain is inserted on either side. This drain may be placed down to the capsuIe or may extend into the knee joint, depending upon whether one beIieves that he has performed an adequate debridement suffIcientIy soon after the injury to be reasonably sure that the knee wiI1 not become infected. This drain is removed at the end of forty-eight hours and the fracture is treated as a simpIe fracture. (Fig. 4.) After suture of the pateIIa for a compound fracture the knee is immobiIized in a weII-padded pIaster cast which extends from the toes to the groin and vaseIine gauze is pIaced over the suture line to permit drainage, the skin being sutured rather Ioosely. The knee is immobiIized in a cast because I beIieve that this is an important factor in the prevention of infection. SuIfaniIamide in doses of 15 gr. every four hours shouId aIso be given as a
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prophyIactic against infection in severe compound fractures. If there should be evidence of infection, as indicated by a rise in temperature, a rise in the puIse or an unusua1 amount of pain in the wound, the cast shouId be bivaIved and the wound inspected immediateIy. Sufficient skin sutures shouId be removed to determine whether or not the infection is in the superficia1 tissues or in the knee joint. If the infection is deep, the joint shouId be opened freeIy and a large wet dressing applied, at the same time maintaining immobiiization. I have not found that the presence of the wire was a detrimenta factor in the earIy days of an infected wound and beIieve that its immobiIizing effect is a distinct benefit. In such wounds, however, it is usua1 to remove the wire after the infection has quieted down, but before it has healed. In very severe fuIminating infections it is advisabIe to remove the wire, separate the fragments, remove a11 Ioose fragments and, if necessary, remove the pateIIa. However, this has not yet been necessary in my experience. If the infection is found to be due to a streptococcus or to a gas baciIIus a massive dose of SuIfaniIamide (90 gr.) shouId be given immediateIy and shouId be foIIowed by 15 gr. every four hours. This is continued until the patient’s temperature has dropped to a satisfactory IeveI and the infection has subsided, or unti1 it is necessary to stop the drug because of an idiosyncrasy. In addition to the chemotherapy the wound shouId be treated surgicaIIy as described above. Throughout the process of the treatment of the knee for an infection due to a compound fracture of the pateIIa or due to a postoperative infection of a pateIIa which has been sutured, the knee shouId be kept in a straight position and no attempt shouId be made to move it until the infection has subsided and the deeper tissues have heaIed. UsuaIIy it wiI1 be found that this wiI1 resuIt in a IocaIization of the infection in the front of the knee joint. After the
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Key-Fracture
infection has subsided and the wounds have healed there will be a slow, but progressive return of function and in most instances the range of movement will increase over a period of months (Fig. 5), although occasionally bony ankylosis at the knee may occur. OLD
FRACTURES
OF
THE
PATELLA
In old fractures of the patella the fragments are usually widely separated and the proximal fragment is maintained in its abnormal position by contracture of the quadriceps muscle. In addition to the above, the ends of the fragments are sealed over by scar tissue. Likewise, there is a thin layer of scar tissue bridging the space left by the tear in the lateral aponeurosis on either side of the patella. In treating such a lesion it is necessary to excise the scar tissue between the torn ends of the aponeurosis and to excise the ends of each fragment in order that fresh bleeding bone may be exposed and opposed. After this has been done it will usually be found that it is not possible to pull the two fragments together. Not only is the proximal fragment displaced and held up on the thigh, but the distal fragment is displaced downward. In order to coapt the two freshened bone surfaces it will usually be necessary to lengthen the quadriceps tendon. This can be done by the z method or by the tendon plastic method of Bennett in which a long tongue of the quadriceps tendon is cut free and slipped downward and then sutured at a lower level by suturing the muscle fibers to it on either side. However, in performing this operation it is to be noted that lengthening of the central tendon itself will not permit downward displacement of the patella, nor will it permit ffexion in a knee which has become fixed in extension by contractures. The real fixation of the patella upward on the femur is not due to the quadriceps tendon, but is due to the shortening of the tissues on either side of the upper pole of the patella which bind it to the femur just above the condyles. These are largely portions of the vastus internus
of Patella and externus, and these fibers must be cut across, opening the quadriceps bursa of the knee joint and freeing the upper pole of the patella on either side. Then the upper fragment can be pulled downward, swinging by a pedicle of tissue on either side and carrymg with it the freed quadriceps tendon above. This will leave a dead space or gap I to 2 inches wide in the quadriceps muscle on either side at the upper pole of the patella. I have usually left the space open, but occasionally I have partly obliterated it by transplantation of muscle fibers. It apparently takes care of itself and has not caused any trouble, except worry, until the danger of infection is over. After the quadriceps apparatus has been lengthened to such a degree that the upper fragment can be brought downward, the two fragments are held together with sharp toothed retractors and are lixed with a wire loop, just as though one were dealing with a fresh simple fracture. Then the aponeurosis on either side is sutured with silk and the wound is closed in the usual manner. For this operation a long anterior incision is used, the incision curving inward around the mesial aspect of the patella, extending down to the tibia1 tubercle and as far upward on the thigh as is necessary. After the operation it is advisable to immobilize the extremity in a plaster of Paris cast with as much flexion as can be obtained without undue tension on the fragments. The immobilization is continued for from two to four weeks, depending upon the postoperative course. (Fig. 6.) TREATMENT QUADRICEPS
OF
AVULSION
TENDON
PATELLAR
OR
OF OF
THE THE
LIGAMENT
In these instances the tear is usually close to the upper or lower pole of the a small patella and not infrequently amount of bone is torn off with the tendon. It is not practicable to fix the tendon to the bone with wire because the wire pulls through the vertical tendon fibers and becomes loose and when the wire becomes loose it acts as an irritant. Consequently,
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Key-Fracture
for these injuries I use heavy braided siIk sutures, weaving the silk into the tendon and Ieaving four strands of silk projecting from the torn end of the tendon. Then two drilI hoIes are made in the pateIIa, passing verticaIIy upward or downward through the bone, keeping we11 away from the articuIar surface. The heavy siIk is passed through these driI1 hoIes and tied hrmIy at the opposite poIe of the bone. The torn aponeurosis is sutured with siIk in the usual manner and the subcutaneous tissues and skin are cIosed with siIk. PostoperativeIy the knee is immobiIized in a pIaster of Paris cast for four weeks. It is not feIt that the siIk is strong enough to permit free use of the knee before this time, nor is it feIt that the union between the torn tendon and the bone wiI1 be sufhcientIy strong to permit freedom of the knee without danger that the sutures may be torn loose. At the end of this time the cast is removed and the patient is encouraged to begin exercising the knee and to bear weight upon it with the knee in the straight position. He may waIk with crutches or with a cane, but is cautioned against putting his weight on the flexed knee. A very strong and usefu1 knee may be expected within eight to tweIve weeks and
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a practicaIIy norma months. (Fig. 7.)
knee within about
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six
SUMMARY
Simple fractures of the pateIIa without separation of the fragments are treated by immobiIization in a pIaster of Paris cast. If the fragments are separated they are reduced by open operation and tied together. A Ioop of stainIess stee1 wire is preferred to any other type of suture. The tear in the Iateral aponeurosis is sutured with D siIk. AvuIsions of the quadriceps tendon or of the pateIIar Iigament are repaired by heavy siIk which is passed through two driI1 holes in the pateha and tied at the opposite poIe of the bone. The management of compound fractures, of infected fractures and of old fractures of the pateha is described. KEFERENCES I. THOMSON, J. E. M. Comminuted fractures of the patella. J. Bone ti Joint Surg., 17: 431, 1935. 2. BLODCETT, W. E., and FAIRCHILD, R. D. Fractures of the pateIla. j. A. M. A., 10612121, 1936. 3. BROOKE, R. Treatment of fractured patelIa by excision. A study of morphology and function. Brit. J. Surg., 24: 733, 1936-1937. 4. TIPPETT, G. 0. Treatment of fractures of the patella by excision. Brit. M. J., I: 383 (Feb. rg) 1938.