Patellar Fracture Surgery Performed Autonomously by Residents, Yields Similar Short-Term Outcomes to Surgery Performed by Fellowship-Trained Surgeons.

BACKGROUND: Open reduction and internal fixation are the gold-standard treatment for displaced patellar fractures. The current literature remains inconclusive on the relationship between resident participation in the operating room and optimal patient outcomes. We hypothesize that surgeries performed solely by residents, without attending supervision, can provide similar outcomes to those performed by fellowship-trained orthopedic surgeons, providing new insights into the relationship between resident autonomy and surgical outcomes in the field of orthopedic trauma. METHODS: A tertiary trauma center cohort was retrospectively reviewed for all surgically treated patellar fractures between 2015 and 2020. The cohort was divided into 2 groups: patients operated by residents and patients operated by orthopedic trauma specialists. Demographics, surgical parameters, and radiographs were compared between the groups to evaluate complications and reoperation rates, radiographic outcomes (such as hardware failure, or loss of reduction), and clinical outcomes (including residual pain, painful hardware, decreased range of motion, and infections). RESULTS: A total of 129 patellar fractures were included in the study. Demographics and ASA were similar between the groups. There were no significant differences in complications (p = 0.900) or reoperation rates (p = 0.817), with an average follow-up time of 8 months (SD ± 5.3). Residents had significantly longer surgery duration (p =0.002). However, the overall length of stay was shorter in the resident group (p < 0.001). CONCLUSION: The study shows patellar fracture surgery performed by adequately trained residents can provide similar outcomes to those performed by fellowship-trained orthopaedic trauma surgeons. These findings highlight the significance of surgical autonomy in residency and its role in contemporary surgical education.

"Pediatric Patella fractures - A Systematic review".

Background: Patella fractures in the pediatric age group often have a dilemma in their ease of diagnosis and treatment required. Indications for conservative management or surgical intervention in the pediatric population during growth phase are not clearly defined. The current systematic review aims to provide a consensus on the morphological types, treatment options, indications, the outcomes expected and complications and their management. Methods: The review was conducted as per the PRISMA guidelines. Inclusion criteria were (a).Articles published in English, (b) Age <18 years, (c) Patellar fractures including osteochondral fractures. Exclusion criteria includes articles with incomplete data, case reports, biomechanical studies, case series with sample size <2, biomechanical studies, reviews, letter to the editor, or editorials and Non-English language. Results: The review search yielded a total of 18 articles. A total of 288 patients with patellar fractures were included in the review. The average age ranged from 9.6 years to 16 years. The follow-up period ranged from 3 months to 20 years. In total, 49 individuals underwent immobilization with cast or brace application, 4 with spica cast application and 48 with cylindrical cast in extension. Overall, 83 patients in 13 studies underwent surgical fixation most of which underwent wiring. Conclusion: Pediatric patella fracture/dislocations or Osteochondral fractures (OCF) although being a rare event, may be associated with a child with knee injury and swelling. Conservative management in terms of casting and immobilization may be an alternative but surgical intervention should be the primary mode of treatment in such cases.

Multi-planar fixation of displaced, multi-fragmentary patella fractures in elderly patients with anterior locking plates and cerclage wires: preliminary results.

PURPOSE: The purpose of this study was to evaluate the outcomes of displaced, multi-fragmentary patella fractures in elderly patients treated with anterior plating and cerclage wires. PATIENTS AND METHODS: Between 2018 and 2020, patients aged at least 60 years old undergoing anterior plating and circumferential wiring for displaced, multi-fragmentary patella fractures with a minimum of 12 months follow-up were included. Fragments were reduced and circumferentially stabilized by loop wires, followed by multi-planar fixation with an anterior locking plate and multi-directional screws. Postoperative outcomes were evaluated with the Böstman scores and range of motion. Patients were also asked about symptomatic hardware as well as satisfaction with postoperative outcomes. RESULTS: Sixteen patients with an average age of 71.8 ± 9.3 years old were followed up for an average follow-up was 25.1 ± 8.2 months. At the latest follow-up, the average Böstman scores were 27.2 ± 3.4, and active knee flexion was 123 ± 14°. Two patients complained pinpoint implant irritation and underwent implant removal. Another underwent implant removal due to cultural reasons. Fifteen patients were satisfied with the operative outcomes, and one was unsatisfied due to intermittent patellofemoral pain. Cerclage wire breakage was noted in nine patients on postoperative radiographs, but none elicited pinpoint pain. No wound complications, infections, nonunion or loss of reduction were observed. CONCLUSIONS: Anterior locking plates and cerclage wires in tandem provide reliable multi-planar fixation for displaced, multi-fragmentary patellar fractures in elderly patients and resulted in favorable clinical outcomes.

Metal vs non-metal fixation methods for patellar fractures: A systematic review and meta-analysis of clinical and radiographic outcomes.

Introduction: This paper aims to systematically review and meta-analyse the available evidence regarding the clinical and radiographic outcomes of non-metal fixation methods in treating patellar fractures compared to a control metal fixation group, in the hopes of bringing insight into their effectiveness. Methods: Two investigators systematically reviewed studies across 9 English or Mandarin electronic databases - Cochrane Library, EMBASE, Google Scholar, Medline, PubMed, Scopus, Web of Science, CNKI and Wanfang Data, in adherence to PRISMA guidelines. The inclusion criteria for study selection were: English or Mandarin comparative studies that evaluated clinical (Patient Reported Outcome Measures, incidence of reoperations and postoperative complications) or radiographic (time to union and incidence of secondary loss of reduction) outcomes of metal and non-metal fixation methods for patellar fractures. From an initial pool of 1269 studies, 19 studies involving 1612 patients were included in the meta-analysis after full-text evaluation and accounting for exclusion criteria. Results: Clinically, the reduction in reoperations (OR = 0.22, 95% CI [0.10, 0.51], P = 0.0003), direct (OR = 0.17, 95% CI [0.08, 0.33], P < 0.00001) and indirect (OR = 0.50, 95% CI [0.27, 0.93], P = 0.03) implant-related postoperative complications were significantly in favor of non-metal fixation. Radiographically, the decrease in time to union (SMD = -0.79, 95% CI [-1.11, -0.47], P < 0.00001) in the non-metal group compared to the metal group was also significant. The remaining results were comparable. Conclusion: This meta-analysis suggests that non-metallic internal fixation had similar if not superior outcomes to their metallic counterparts, with fewer implant-related complications and improved postoperative recovery. Given the higher re-operation rates associated with metallic fixation, non-metallic methods may be preferable from economic and safety perspectives. Nevertheless, more homogenous studies with standardised fracture configurations and treatment modalities are needed before declaring non-metallic fixation as the gold standard for patellar fractures.

Fixation of patella fractures with metallic implants is associated with a significantly higher risk of complications and re-operations than non-metallic implants: a systematic review and meta-analysis.

PURPOSE: The use of metallic implants for the treatment of patella fractures often involves complications related to the hardware. As a result, there has been a considerable focus on the use of non-metallic implants. The aim of this study was to determine the differences in clinical outcomes, including the rates of complications and re-operations following the surgical management of patellar fractures with metallic versus non-metallic implants. METHODS: The systematic review was conducted in accordance with PRISMA guidelines. Two investigators independently applied the search strategy to PubMed, SCOPUS, Google Scholar, and Cochrane databases, limited to publications between 1st January 2000 to 30st September 2021. The search strategy identified studies in which there was a comparison between the clinical outcome of the metallic and non-metallic fixation. Meta-analysis was conducted according to the Cochrane Collaboration and Quality of Reporting of Meta-Analysis (QUORUM) guidelines. RESULTS: A total of 19 studies were selected for the systematic review and seven studies for the meta-analysis. Two hundred ninety-sixt patients formed the pooled study population for the meta-analysis. The outcomes evaluated in the meta-analysis were range of motion (ROM), complications, and re-operation rates. There was no significant difference between groups regarding ROM, but the risk ratio (RR) of re-operation (RR 0.19, 95% CI [0.09-0.41]) and complications (RR 0.30, 95% CI [0.17-0.55]) was significantly in favor of fixation with non-metallic implants. CONCLUSION: The use of non-metallic implants for fixation of patella fractures was associated with significantly lower risk of complications and re-operations than fixation with metallic implants, without any difference between groups with respect to the final range of motion or functional outcome measures.

Epidemiology, classification and treatment of patella fractures: an observational study of 3194 fractures from the Swedish Fracture Register.

BACKGROUND: Basic epidemiological data on patella fractures derived from large nationwide and multicenter studies are scarce. This observational register study describes patient epidemiology, fracture classification and treatment of patella fractures in adults in a Swedish population. METHODS: We conducted an observational study on data derived from the Swedish Fracture Register (SFR) on all patella fractures classified as non-periprosthetic and non-pathological, registered between 2014 and 2018 in individuals aged ≥ 18years. Epidemiological data on sex, age, side, seasonal variation, trauma mechanism, fracture classification (according to AO/OTA), and treatment were analyzed. RESULTS: 3194 patella fractures were analyzed, occurring at a median age of 67 (range 19-100) years. 64% of all patients were female. Most fractures were caused by low-energy trauma, with 70% due to falling from a standing height. 1796 (56%) of the fractures were transverse compared to 845 (26%) vertical fractures. Most fractures (N=2148, 67%) were treated non-operatively. Operative treatment consisted mainly of Tension Band Wiring (TBW) performed in 774 (24%) patients. CONCLUSIONS: Patella fractures mainly occur in elderly women (> 65 years), commonly caused by low-energy trauma. The main treatment is non-operative (67%), except for transverse (AO/OTA C3) fractures. TBW remains the most used operative treatment of choice. These results may help health care providers, researchers and clinicians better understand the panorama of patella fractures in Sweden.

Management of a Gap Non-union Patella Fracture Using Encirclage Wire and Tension Band Wiring with Quadriceps V-Y Plasty in an Elderly Patient: A Rare Case Report and Review of Literature.

Introduction: The management of gap non-union patella fractures continues to be a challenge in orthopedics. The incidence of these cases ranges between 2.7% and 12.5%. The quadriceps muscle attached to the proximal fractured fragment pulls it proximally leading to the gap at fracture site. If the gap is too large, there won't be any fibrous union resulting in failure of quadriceps mechanism and extension lag. The primary aim is to bring the fracture fragments together and restore the extensor mechanism. Most of the surgeons prefer single-stage procedure, in which mobilization of the proximal fragment, followed by fixing with the lower fragment is done using V-Y plasty or x lengthening with or without pie Crusting. Others use of pre-operative traction to the proximal fragment using pins or ilizarov method. In our case, we used single-stage procedure whose results were encouraging. Case Report: A 60-year-old male patient presented with pain in the left knee with difficulty in walking since 3 months. The patient had road traffic accident 3 months back and sustained trauma to left knee. On clinical examination, there was palpable gap of more than 5 cm between the fracture fragments, anterior surface of femur and condyles was palpated through fracture site and knee range of motion was between 30° and 90° of flexion, and X-ray suggests of patella fracture. Midline 15 cm longitudinal incision was taken. The insertion of the quadriceps tendon over proximal pole of patella was exposed and pie crusting was done on medial and lateral side and V-Y plasty was done. SS wire was used to hold the reduction of the fragments by encirclage wiring and anterior tension band wiring done. Retinaculum was repaired and wound closed in layers. Postoperatively, long rigid knee brace was given for 2 weeks and walking with partial weight-bearing started. After suture removal at 2 weeks, full weight-bearing initiated. At 3 weeks, knee range of motion started and continued till 8 weeks. At 3 months post-operative, the patient is able to do flexion up to 90° and no extension lag is present. Conclusion: Adequate quadriceps mobilization during the surgery along with pie crusting and V-Y plasty with TBW and encirclage combined gives good functional outcome in patella gap non-unions.

Cannulated screws with sutures for treatment of transverse patellar fractures / 中华创伤骨科杂志

Objective:To evaluate the clinical efficacy of cannulated screws with sutures in the treatment of patellar transverse fractures.Methods:A retrospective analysis was performed of the data of 70 patients with patellar transverse fracture who had been admitted to Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital from January 2017 to March 2021. According to the construction methods for the tension band, the patients were divided into 3 groups. In group A of 21 cases subjected to fixation with cannulated screws with sutures (Fiber-Tape), there were 8 males and 13 females with a median age of 55.0 (48.0, 65.0) years; in group B of 32 cases subjected to fixation with Kirschner wire tension band, there were 15 males and 17 females with a median age of 52.5 (41.5, 63.0) years; in group C of 17 cases subjected to fixation with Cable-Pin system, there were 5 males and 12 females with a median age of 55.0 (37.0, 65.0) years. The 3 groups were compared in terms of complications, secondary surgery (removal of internal fixation), operation time, intraoperative blood loss and knee function rated by the Lysholm and B?stman scores at the last follow-up.Results:There were no significant differences in the preoperative general data between the 3 groups, showing they were comparable ( P > 0.05). There was no significant difference in the operation time, intraoperative blood transfusion or follow-up time among the 3 groups ( P > 0.05). The incidence of soft tissue irritation [4.8% (1/21)] and the secondary operation rate [4.8% (1/21)] in group A were significantly lower than those in group B [43.8% (14/32) and 37.5% (12/32)] and group C [41.2% (7/17) and 35.3% (6/17)] ( P < 0.05), but there was no statistically significant difference between group B and group C ( P > 0.05). In groups A, B and C, respectively, the Lysholm knee score was 84.0 (69.0, 88.0), 89.0 (71.5, 95.0) and 82.0 (63.0, 90.0), and the B?stman knee score 26.0 (23.0, 28.0), 26.5 (24.0, 27.5) and 26.0 (22.0, 28.0), showing no significant difference ( P > 0.05). There was no significant difference either in the incidence of other complications among the 3 groups ( P > 0.05). Conclusion:In the treatment of patellar transverse fractures, compared with the Kirschner wire tension band and Cable-Pin system, cannulated screws with sutures (Fiber-Tape) may lead to a lower incidence of soft tissue irritation and a lower rate of secondary surgery, but no significant differences in operation time, intraoperative blood loss, other complications or postoperative functional scores.

Application of fracture mapping in knee injuries / 中华创伤骨科杂志

Fracture mapping, also known as mapping of fracture lines, is a technique of drawing fracture lines based on 3D reconstruction of radiological images. Fracture mapping can be used to describe fracture morphology, calculate fracture line angle and fragment area, improve clinical practice, propose a new classification system, clarify a fracture mechanism, and establish a model of bone fracture. At present, fracture mapping has become a powerful tool for study of morphology and clinical decision in orthopaedics. Reviewing the development of fracture mapping techniques, this paper addresses their clinical application in knee injuries, tibial plateau fracture, distal femur fracture and patellar fracture in particular. In addition, considering the trend of fracture mapping techniques and the morphology-related studies at present, we offer suggestions concerning improvement of techniques and morphology studies in knee injuries.

Three-dimensional fracture mapping of multi-fragmentary patella fractures (AO/OTA 34C3).

BACKGROUND: Multi-fragmentary patella fractures (MFPFs) are common patella fracture type. Low-profile plate fixation seems to be promising advancement in the treatment of such difficult fractures. There is no systematic morphologic study specifically for MFPFs to provide objective reference for the improvement of future implants and biomechanical models. This study aimed to delineate and quantify the location and spatial frequency of fracture lines, comminution zones, and coronal plane fragments in MFPFs using three-dimensional (3D) CT mapping technique. METHODS: A total of 187 MFPFs were retrospectively reviewed and analyzed. Fractures were digitally reconstructed from CT data, and fracture lines, comminution zones, and coronal fragments were graphically overlaid onto a 3D patella template. Fracture characteristics were summarized qualitatively based on the fracture maps and quantitatively on the counts and volume of each fragment. Furthermore, according to the classic fracture patterns concerning MFPFs, subgroup analysis was conducted. RESULTS: On average, we observed 7 fragments in each fracture, 3 of which were <1 cm3. Most fractures (81.2%) had coronal fragments on the anterior and/or posterior patella surfaces. We identified three classic patella fracture patterns: transverse with comminution, stellate, and "displaced comminuted" in 104, 54, and 29 knees, respectively. 3D maps demonstrated distinct distribution fracture patterns of fracture lines, comminution zones, and coronal fragments. CONCLUSIONS: Supero-medial corner of the patella was seldomly involved, and might be used as the cornerstone for fixation. Coronal fragments were common on both anterior and posterior patella surfaces, justifying the application of anterior plate osteosynthesis characterized by multi-planar fixation. Comminution areas mainly concentrated in the lower half of the patella, potentially suitable for an implant in combination with sutures or circumferential cerclage wiring. The described 3D features of MFPFs could provide reference for the design of future implants and biomechanical models.

Comparison of minimally invasive percutaneous fixation and open reduction internal fixation for patella fractures: a meta-analysis.

BACKGROUND: Open reduction internal fixation (ORIF) has long been the conventional procedure for managing displaced patella fracture. This surgical approach has certain drawbacks, which might affect clinical outcomes and patient prognosis. Minimally invasive percutaneous fixation (MIPF) was proposed to overcome these disadvantages. Few in-depth investigations have been performed to determine the superiority of MIPF over ORIF. The aim of this study was to compare the efficacies of MIPF and ORIF for patella fractures. METHODS: The PubMed, Cochrane Library, Embase, and Scopus databases were searched for relevant studies from November 26 to December 17, 2020. Non-English publications and pediatric orthopedic articles were excluded. Statistical analysis was performed using Review Manager, version 5.4, with mean differences (MDs), standardized mean differences (SMDs), odds ratios (ORs), and respective 95% confidence intervals (CIs) calculated using a random effects model. The primary outcomes were the pain score, knee range of motion, and joint functionality. The secondary outcomes were the surgical time, complications, and implant removal rate. RESULTS: Six articles with a total of 304 patients were included in the meta-analysis. Pooled analysis revealed that patients with MIPF had a significantly reduced pain score (MD = - 1.30, 95% CI = - 1.77 to -0.82; p < 0.00001) and increased knee extension angles (MD = 0.72, 95% CI = 0.18 to 1.25; p = 0.009) at 3-month follow-up. Furthermore, knee flexion angles (MD = 8.96, 95% CI = 5.81 to 12.1; p < 0.00001) and joint functionality (SMD = 0.54, 95% CI = 0.21 to 0.86; p = 0.001) had statistically improved at 2 years. However, no difference was observed between MIPF and ORIF with regard to the surgical time. The risk of complications (OR = 0.10, 95% CI = 0.05 to 0.18; p < 0.00001) and implant removal rate (OR = 0.20, 95% CI = 0.07 to 0.57; p = 0.003) were significantly lower with MIPF than with ORIF. CONCLUSIONS: MIPF is more favorable than ORIF in terms of the pain score, knee range of motion, joint functionality, complications, and implant removal rate. Thus, it can be adopted as an alternative to ORIF.

Early Outcomes After Surgical Management of Geriatric Patella Fractures.

OBJECTIVES: To report the incidence and risk factors for prolonged hospitalization, discharge to a facility, and postoperative complications in geriatric patients who underwent surgery for patella fracture. DESIGN: Retrospective database review. SETTING: The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) collects data from 600 hospitals across the United States. PATIENTS/PARTICIPANTS: NSQIP patients over 65 years of age with patella fractures. INTERVENTION: Surgical fixation of patella fracture including extensor mechanism repair. MAIN OUTCOME MEASUREMENTS: Prolonged hospitalization, discharge to a facility, and 30-day post-operative complications. RESULTS: 1721 patients were included in the study. The average age was 74.9 years. 358 (20.8%) patients were male. 122 (7.1%) patients had a length of stay greater than 7 days. Factors associated with prolonged length of stay include pre-existing renal failure, need for emergent surgery, and time to surgery greater than 24 hours from admission. 640 patients (37.2%) of patients were discharged to a facility after surgery. Discharge to facility was associated with age >77 years, obesity, anemia, thrombocytopenia, pre-operative SIRS, and CCI > 0.5. Admission from home decreased the odds of discharge to a facility. The most common postoperative complications in this population were unplanned readmission (3.4%), unplanned reoperation (2.7%), surgical site infection (1.1%), mortality (1.0%), venous thromboembolism (0.8%), and wound dehiscence (0.2%). Complication rates increased with anemia and ASA class IV-V. CONCLUSIONS: Geriatric patients undergoing operative intervention for patella fractures are at high risk for prolonged hospitalization, discharge to facility, unplanned readmission or reoperation, and surgical site complications in the first 30 days following surgery. This study highlights modifiable and non-modifiable risk factors associated with adverse events. Early recognition of these factors can allow for close monitoring and multidisciplinary intervention in the perioperative period to improve outcomes. LEVEL OF EVIDENCE: Prognostic level III.

A precise navigation device for fixation of patella fractures with modified K-wire tension band:a comparative retrospective study.

BACKGROUND: Traditionally, the technique of modified tension band wires (MTBW) has been the most commonly used surgical procedure. The purpose of this study is to design a precise navigation device that can obtain a standard position of K-wires for (MTBW) and to compare the precise MTBW (P-MTBW) by a navigation device with the conventional MTBW (C-MTBW) by hands in a retrospective study. METHODS: The device was designed by solidworks2012 software (USA), which could provide a precise guidance for obtaining parallel K-wires. Besides, it could set the distance between two K-wires and the level of K-wires below patellar anterior surface. From June 2014 to August 2018, a total of 112 patients were employed in this retrospective study. The patients were divided into P-MTBW group and C-MTBW group according to the surgical technique with or without the precise navigation device. We needed to record and analyze the operation time and the number of fluoroscopy, postoperative internal fixation imaging, knee function and complications. RESULTS: There were 54 patients in P-MTBW group and 58 patients in C-MTBW group. There were statistically significant differences (P < 0.001) in the operation time between P-MTBW group (39.5 ± 4.7; range, 32-49 min) and C-MTBW group (53.7 ± 6.8; range, 42-71 min). The number of intraoperative fluoroscopy was significantly less (P < 0.001) in P-MTBW group (4.2 ± 1.4) versus that of C-MTBW group (8.3 ± 2.7). According to Iowa knee score, there was no significant difference (P = 0.268 at 1 year) in function between the two groups. According to our own evaluation criteria for MTBW, anyone in the P-MTBW group was excellent and 26 patients were excellent, 20 patients were good, and 2 patients were fair in the C-MTBW group. CONCLUSION: The navigation device can reduce operation time and intraoperative fluoroscopy frequency. P-MTBW fixation is an accurate and effective surgical procedure for patella fractures.

Incidence and risk factors for deep venous thrombosis of lower extremity after surgical treatment of isolated patella fractures.

BACKGROUND: Limited information exists on the incidence of postoperative deep venous thromboembolism (DVT) in patients with isolated patella fractures. The objective of this study was to investigate the postoperative incidence and locations of deep venous thrombosis (DVT) of the lower extremity in patients who underwent isolated patella fractures and identify the associated risk factors. METHODS: Medical data of 716 hospitalized patients was collected. The patients had acute isolated patella fractures and were admitted at the 3rd Hospital of Hebei Medical University between January 1, 2016, and February 31, 2019. All patients met the inclusion criteria. Medical data was collected using the inpatient record system, which included the patient demographics, patient's bad hobbies, comorbidities, past medical history, fracture and surgery-related factors, hematological biomarkers, total hospital stay, and preoperative stay. Doppler examination was conducted for the diagnosis of DVT. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors. RESULTS: Among the 716 patients, DVT was confirmed in 29 cases, indicating an incidence of 4.1%. DVT involved bilateral limbs (injured and uninjured) in one patient (3.4%). DVT involved superficial femoral common vein in 1 case (3.4%), popliteal vein in 6 cases (20.7%), posterior tibial vein in 11 cases (37.9%), and peroneal vein in 11 cases (37.9%). The median of the interval between surgery and diagnosis of DVT was 4.0 days (range, 1.0-8.0 days). Six variables were identified to be independent risk factors for DVT which included age category (> 65 years old), OR, 4.44 (1.34-14.71); arrhythmia, OR, 4.41 (1.20-16.15); intra-operative blood loss, OR, 1.01 (1.00-1.02); preoperative stay (delay of each day), OR, 1.43 (1.15-1.78); surgical duration, OR, 1.04 (1.03-1.06); LDL-C (> 3.37 mmol/L), OR, 2.98 (1.14-7.76). CONCLUSION: Incidence of postoperative DVT in patients with isolated patella fractures is substantial. More attentions should be paid on postoperative DVT prophylaxis in patients with isolated patella fractures. Identification of associated risk factors can help clinicians recognize the risk population, assess the risk of DVT, and develop personalized prophylaxis strategies.

Treatment of patellar fractures using bioresorbable forged composites of raw particulate unsintered hydroxyapatite/poly-L-lactide cannulated screws and nonabsorbable sutures.

BACKGROUND: Forged composites of raw particulate unsintered hydroxyapatite/poly-L-lactide (F-u-HA/PLLA) implants are widely used in surgeries because they possess high mechanical strength, bioactivity, and radio-opacity. We previously reported that F-u-HA/PLLA implants were useful for treating lateral tibial condylar, lateral humeral condylar, and ankle fractures. The study aim was to investigate the efficacy of F-u-HA/PLLA cannulated screws and FiberLoop® for treating transverse patellar fractures. METHODS: From April 2013 to February 2019, 15 patients with transverse patellar fractures were treated with F-u-HA/PLLA cannulated screws and FiberLoop® as follows: Open reduction and internal fixation (ORIF) were performed with two F-u-HA/PLLA cannulated screws and a temporary fixation Kirshner wire (K-wire). Three No. 2 FiberLoops® were inserted into these two screw holes and the K-wire hole for temporary fixation. All patients were allowed to full weight-bearing gaits using a knee brace. Knee range of motion exercise was initiated on postoperative day 1. Knee flexion was restricted to ≤90° for 1 month postoperatively. Radiograph was performed to evaluate fracture healing, screw breakage, reduction loss, and screw radio-opacity. Clinical outcomes and postoperative complications were assessed. RESULTS: The average follow-up was 16.0 months. All fractures were successfully united. Screw breakage, reduction loss, osteolysis, and radiolucent zones around the screws were not observed at the final radiographic follow-up. All F-u-HA/PLLA screw shadows were observed during the follow-up. The average range of flexion and extension were 132.0° and -2.7°, respectively. No patients experienced deep infection episodes, late aseptic tissue reactions, or foreign body reactions postoperatively. No patients complained of pain at the final follow-up. All patients returned to their pre-injury work level and activities of daily living. CONCLUSION: Our results strongly suggest that ORIF with F-u-HA/PLLA screws and FiberLoop® could be an alternative treatment option for transverse patellar fractures.

[Aseptic nonunion of patella at the Centre Hospitalier Universitaire Bocar Sidy Sall de Kati about 25 cases]. / Pseudarthrose aseptique de la patella au Centre Hospitalier et Universitaire Bocar Sidy Sall (CHU-BSS) de Kati a propos de 25 cas.

OBJECTIVE: The objective of Our study was to describe the epidemiological, clinical, therapeutic and prognostic aspects of Nonunion of patella fractures. PATIENTS METHODS: It was a retrospective study done concerning 25 patients treated fromJanuary 2005 to December 2015 in the orthopedic trauma service CHU Bocar Sidy SALL Kati. RESULTS: We gather together 25 cases of Nonunion of patella fractures disease among 28 caseswhich was about 89.28%. Our patients were divided into 20 men and 5 women, mean age was 36 years, ranging from ages 22 to 75 years. Posttraumatic period was 6-18 months. The initial fracture was neglected in 21 cases and treated in 4 cases. Physical examination revealed lameness in 92% of cases, atrophy of the quadriceps in 56% of cases, joint stiffness, 56% and an inter-fragmentary gap in 92% of patients. The radiographic data were consistent with pseudoarthrosis in all cases. The inter-fragmentary gap was 36 mm on average. The care of our patients was based on plugging and guy-wiring in 64 % of cases and strapping pre- and peri patella in 12% of cases. A partial patellectomy was practiced in 2 cases. A VY plasty of the quadriceps was recommended in 4 cases.The patients were reviewed after a mean of 10 months (8 months- 24 months). Functional outcomes analyzed using Bostman scores were excellent in 4 cases (16%), good in 18 cases (72%) and poor in 3 cases (12%). CONCLUSION: Nonunion of the patella is mostly due to the lack of treatment or wrong treatment leads. Treatment with plugging and guy-wiring seems the most appropriate method.

OBJECTIF: l'objectif de notre étude était décrireles aspects épidémiologiques, cliniques, thérapeutiques et pronostiques de la pseudarthrose de la patella. PATIENTS ET MÉTHODES: Il s'agissait d'une étude rétrospective concernant 25 patients colligés entre janvier 2005 et décembre 2015 dans le service d'orthopédie et de traumatologie du CHU Bocar Sidy SALL de Kati. RÉSULTATS: Nous avons colligé 25 cas de pseudarthrose aseptique de la patella sur 28 cas, soit 89,28%. Nos patients se répartissaient en 20 hommes et 5 femmes. L'âge moyen était de 36 ansavec des extrêmes de 22 et 75 ans. Ledélai post traumatique était de 6-18 mois. La fracture initiale était négligée dans 21 cas et traitée dans 4 cas. L'examen clinique retrouvait une boiterie dans 92%, une amyotrophie du quadriceps dans 56%, une raideur du genou dans 56%, et un vide inter-fragmentaire dans 92%. Les données radiographiques étaient compatibles avec la pseudarthrose de la patella dans tous les cas. L'écart inter-fragmentaire était de 36 mm en moyenne. La prise en charge de nos patients reposait sur l'embrochage-haubanage dans 64%, le cerclage péri-rotulien dans 12%, une patellectomie partielle dans 2 cas (8%) et une plastie du quadriceps en VY était préconisée dans 4 cas (16%). Les patients étaient revus après un recul moyen de 10 mois (8mois-24mois). Les issues fonctionnelles analysées selon le score de Bostman étaient excellentes dans 4 cas (16%), bonnes dans 18 cas (72%) et mauvaises dans 3 cas (12%). CONCLUSION: la pseudarthrose de la patella est surtout le fait de l'absence du traitement ou d'un traitement mal conduit. Le traitement par l'embrochage-haubanage semble la méthode la plus indiquée.

The application of the Nice knots as an auxiliary reduction technique in displaced comminuted patellar fractures.

PURPOSE: To evaluate intraoperative and early postoperative clinical outcomes using the Nice knot as an auxiliary reduction technique in displaced comminuted patellar fractures. METHODS: Thirty-nine patients with unilateral closed displaced comminuted patellar fractures received open reduction and internal fixation (ORIF), utilizing either Nice knot (the NK group, 24 patients) or traditional reduction (the TR group, 23 patients) techniques, were retrospectively reviewed in this study. Intra-operative surgical time and peri-operative hemoglobin were recorded. Post-operative clinical outcomes were measured using visual analgesic score, range of motion of the knee joint and the Böstman scales, and radiographic outcomes were used to evaluate fracture healing. Complications including infection, bone non-union, implant loosening, fragment displacement and painful hardware were also assessed. RESULTS: In-hospital records indicated significantly shorter surgical duration (32.6 min) in the NK group than in the TR group (63.9 min). Intraoperative blood loss was also significantly decreased in the NK group (64.7 ml) compared to the TR group (189.1 ml). Patients in the NK and TR groups were followed for mean of 12.9 months and 12.5 months respectively. The union rate was 100% (24/24) in the NK group and 91.3% (21/23) in the TR group. In the TR group, there were two non-unions, including one infected non-union. There was no difference in the visual analgesic score, the range of motion of the knee joint or the Böstman scale at last follow-up between the two groups. CONCLUSION: The sliding, self-stabilizing Nice knot was associated with reduced surgical time, decreased intraoperative blood loss, and satisfactory postoperative outcomes in the treatment of displaced patellar fractures. Future studies are needed to ensure the generalizability of these findings to additional patient populations at other institutions.

Venous thromboembolism rates remained unchanged in operative lower extremity orthopaedic trauma patients from 2008 to 2016.

BACKGROUND: Venous thromboembolism (VTE) is a serious complication that contributes to morbidity, mortality, and healthcare costs during the surgical care of patient with lower extremity fractures. Despite this, few recommendations on the topic exist and the literature on VTE incidence is incomplete. Therefore, this study will attempt to estimate annual incidence and trends in 30-day thrombotic events and mortality for the following fractures: (1) hip, (2) femur, (3) patella, (4) tibia and/or fibula, and (5) ankle. METHODS: We identified 120,521 operative lower extremity orthopaedic trauma patients from 2008 to 2016 using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. To evaluate the relationship between the year in which surgery was performed and comorbidities and demographic information bivariate analysis was performed. Bivariate analysis was also performed for the outcomes of interest and year in which the surgery was performed to assess for change. Additionally, bimodal multivariate logistic regression models for hip, femur, and ankle fractures were built, comparing the years 2009 to 2016 using 2008 as a baseline. RESULTS: Overall incidence for VTE over the study period was 1.7% for hip fractures, 2.4% for femur fractures, 0.9% for patella fractures, 1.1% in tibia and/or fibula fractures, and 0.6% in ankle fractures. Over the study period VTE incidence saw a significant decrease (p < 0.05) in hip and femur fractures, but not for patella, tibia and/or fibula, and ankle fractures. After adjusting for confounding factors with multivariate analysis, the change in hip and femur fractures was no longer significant, while no significant decrease was again found for ankle fractures (p > 0.05). CONCLUSION: Our study demonstrates that VTE rates have remained unchanged in operative lower extremity orthopaedic trauma from 2008 to 2016. This highlights the need for higher quality evidence on this important topic in orthopaedic trauma, including a reevaluation on the necessity of thromboprophylaxis guidelines. LEVEL OF EVIDENCE: III.

Hook plating in patella fractures.

PURPOSE: Tension band wiring is considered the standard treatment for patella fractures. However, it is limited for fractures with marginal involvement, comminution, and osteoporotic bone. Our experience indicates that these limitations can be overcome with the hook plate. We evaluated the radiographic and clinical outcomes in patients with patella fracture treated with hook plating. METHODS: We enrolled 30 patients who underwent hook plating for patella fracture at two institutions between 2013 and 2017. Fracture classification and surgical options were reviewed. Postoperative fracture gap and time to union as radiographic measurements, and complications, range of motion, and functional outcome with the Lysholm score as clinical outcomes, were evaluated retrospectively. RESULTS: Nine fractures were AO/OTA 34A1, three B1, one B2, two C1, nine C2, and six C3. All were closed fractures. There were 3 cases of revision, 4 with lateral or medial marginal fracture, 9 with isolated inferior pole fracture, and 14 with comminuted fracture. The average postoperative fracture gap was 0.4 (range, 0-2.0) mm, and bone union was achieved without additional intervention. The average time to union was 11.6 (range, 7-24) weeks. There were no complications, and no extension lag except in one case (10°). The average flexion was 138.5° (range, 110-145°). For functional outcomes, the average Lysholm score was 89.5 (range, 74-95), with 13 excellent, 14 good, 3 fair, and no poor cases. CONCLUSION: This study suggests that hook plating can result in good bone union and restored knee function in marginal or comminuted fractures of the patella.

Efficacy of K-wire tension band fixation compared with other alternatives for patella fractures: a meta-analysis.

BACKGROUND: To compare the efficacy and safety of K-wire tension band fixation (KTB) with other alternative approaches (cannulated screws, cable pin, and ring pin) for treatment of patella fractures by performing a meta-analysis. METHODS: PubMed and EMBASE databases were searched for all relevant studies. Standardized mean difference (SMD) or relative risk (RR) and their corresponding 95% confidence intervals (CIs) were calculated for continuous or dichotomous outcomes via either a fixed- or random-effect model using Stata 13.0 software. RESULTS: Nine literatures involving 949 patients (581 in the KTB group and 368 in the control group) were included. Pooled analysis showed there were no differences in the success rate, operative time, healing time, and number of infections between patients undergoing KTB and others. However, the incidence of complications (RR = 8.04, 95% CI = 4.45-14.53; p < 0.001) and VAS (SMD = 0.642, 95% CI = 0.22-1.06; p = 0.003) were lower, while flexion degree (SMD = - 0.70 95% CI = - 1.04-- 0.36; p < 0.001), Böstman joint function score (SMD = - 0.68, 95% CI = - 1.10-- 0.27; p = 0.001), Iowa knee score (RR = 0.88, 95% CI = 0.81-0.96; p = 0.004), and Lysholm score (SMD = - 0.71, 95% CI = - 1.10-- 0.32; p < 0.001) were significantly higher in patients undergoing alternative approaches than the KTB. Subgroup analysis also demonstrated the cannulated screw fixation was superior to KTB in reducing the incidence of complications. CONCLUSIONS: Alternative treatments may be effective for management of patella fractures and should be attempted to be popularized in clinic.