MULTIPLANAR FIXATION OF PATELLA

FRACTURE USING A LOW PROFILE MESH

PLATE

BY -: DR RISHAB DUBEY
JR-1, ORTHOPAEDICS
 INTRODUCTION
PATELLA FRACTURES ARE RARE ORTHOPAEDIC INJURIES
ACCOUNTING FOR APPROXIMATELY 1% OF ALL FRACTURES. THESE
INJURIES WERE EITHER TREATED NONOPERATIVELY OR WITH
PARTIAL OR TOTALLY PATELLECTOMY. TENSION BAND CONSTRUCTS
ARE COMMONLY USED IN THE OPERATIVE FIXATION OF PATELLA
FRACTURES. THEORETICALLY, THE TENSION BAND TECHNIQUE
ALLOWS FOR TRANSLATION OF TENSION FORCES INTO
COMPRESSIVE FORCES AT THE FRACTURE SITE, BUT THIS HAS
FAILED TO BE PROVEN BIOMECHANICALLY. KNEE PAIN, CONSTRUCT
FAILURE, AND FUNCTIONAL LIMITATION WITH TENSION BAND
FIXATION HAVE ALL BEEN REPORTED IN THE LITERATURE.
• PLATING CONSTRUCTS HAVE DEMONSTRATED PROMISE IN IMPROVING FIXATION
STRENGTH AND CLINICAL OUTCOMES IN PATIENTS WITH PATELLA FRACTURE.
SEVERAL BIOMECHANICAL STUDIES HAVE SHOWN AN ADVANTAGE TO FIXATION
OF PATELLA FRACTURES WITH PLATING CONSTRUCTS VERSUS TENSION BAND
FIXA- TION.
• AT OUR INSTITUTION, OPERATIVE PATELLA FRACTURES ARE ROUTINELY
TREATED WITH FIXATION USING OUR NOVEL CAGE PLATE CONSTRUCT THAT
SPANS HALF OF THE PATELLA CIRCUMFERENCE LATERALLY AND PROVIDES
MULTIPLANAR FIXATION THAT IS BICORTICAL FROM LATERAL TO MEDIAL AND
FROM INFERIOR TO SUPERIOR, AND UNICORTICAL FROM ANTERIOR TO
POSTERIOR. IN THIS REPORT, WE DESCRIBE OUR TECHNIQUE OF CAGE PLATE
FIXATION OF PATELLA FRACTURES AND PRESENT THE CLINICAL OUTCOMES OF
OUR STUDY COHORT.
• THE PATIENT IS POSITIONED SUPINE ON A RADIOLUCENT OPERATING TABLE, WITH A
BUMP PLACED UNDER THE IPSILATERAL HIP. A NON-STERILE TOURNIQUET IS PLACED
AS PROXIMAL AS POSSIBLE ON THE OPERATIVE EXTREMITY. IF THE TOURNIQUET IS
USED, REDUCTION OF COMMINUTED FRACTURES MAY BE MORE DIFFICULT BECAUSE
OF SHORTENING OF THE QUADRICEPS.
• NEXT, THE KNEE IS PLACED INTO APPROXIMATELY 20–30 DEGREES OF FLEXION, AND
A 15-CM LONGITUDINAL INCISION IS MADE FROM THE TIBIAL TUBERCLE TO A POINT
APPROXIMATELY 3 FINGER BREADTHS ABOVE THE SUPERIOR POLE OF THE PATELLA.
OF NOTE, THE LONGITUDINAL SKIN INCISION IS PURPOSEFULLY PLACED ALONG THE
LATERAL BORDER OF THE PATELLA, TO MINIMIZE THE SIZE OF THE LATERAL SOFT
TISSUE FLAP FOR THE LATERAL PARAPATELLAR ARTHROTOMY.
• ONCE THE EXTENSOR MECHANISM AND RETINACULUM ARE IDENTIFIED, A
LATERAL PARAPATELLAR ARTHROTOMY IS CREATED.
• THE LATERAL PARAPATELLAR ARTHROTOMY IS USED TO AVOID THE
PREDOMINANT VASCULARITY TO THE PATELLA COMING IN INFEROMEDIALLY
AND TO ALLOW FOR INVERSION OF THE PATELLA TO DIRECTLY VISUALIZE THE
ARTICULAR SURFACE REDUCTION AND FIXATION.
• AFTER INVERSION OF THE PATELLA, THE FRACTURE HEMATOMA IS EVACUATED
USING SMALL ANGLED CURETTES, IRRIGATION, AND SUCTION, AND THE
FRACTURE ENDS ARE EXPOSED. REDUCTION OF THE OSTEOCHONDRAL
FRAGMENTS IS ACCOMPLISHED USING A COMBINATION OF POINTED REDUCTION
CLAMPS AND 2.0-MM THREADED KIRSCHNER WIRES TO JOYSTICK AND HOLD THE
FRACTURE FRAGMENTS REDUCED.
• AT THIS STAGE, A SYNTHES 2.4-MM MESH PLATE IS CUT TO SIZE AND
CONTOURED TO FIT AROUND THE LATERAL RIM OF THE REDUCED PATELLA AND
• THE CAGE PLATE IS FASHIONED TO ACHIEVE FIXATION OF EACH MAJOR
FRACTURE FRAGMENT WITHOUT ENCROACHMENT ON THE TENDINOUS
INSERTIONS ON THE SUPERIOR AND INFERIOR POLE OF THE PATELLA.
• EMPHASIS IS PLACED ON POSITIONING THE SUPERIOR LIMB UNDER THE
QUADRICEPS TENDON DIRECTLY ON THE BONEY EDGE OF THE SUPERIOR
PATELLA AND THE INFERIOR LIMB UNDER THE PATELLA TENDON ON THE
NONARTICULATING DISTAL POLE OF THE PATELLA.
• AFTER PLATE PLACEMENT AROUND THE PATELLA, THE PLATE IS TRANSFIXED TO
THE PATELLA USING A COMBINATION OF 2.4-MM AND 2.7- MM COMPRESSION
SCREWS TO ACHIEVE STABLE COMPRESSION AND ABSOLUTE STABILITY OF THE
MAJOR FRACTURE FRAGMENTS.
• LOCKING SCREWS ARE PLACED IN AN ANTEROPOSTERIOR FASHION THROUGH
THE COMMINUTED, MORE OSTEOPOROTIC DISTAL POLE WHILE COMPRESION
SCREWS CAN BE USED THROUGH THE SUPERIOR LIMB INTO BETTER CORTICAL
BONE OF THE SUPERIOR POLE.
• TWO #5 FIBERWIRE SUTURES ARE THEN THREADED UNDER THE SUPERIOR AND
INFERIOR TRANS- VERSE LIMBS OF THE PLATE, AND THEN PASSED AS A
KRACKOW SUTURE THROUGH THE MEDIAL AND LATERAL ASPECTS OF THE
PATELLAR TENDON. THE SUTURES ARE TIED WITH THE KNEE HELD IN
EXTENSION, AND THE KNEE IS CYCLED THROUGH COMPLETE RANGE OF MOTION
(ROM)
 POSTOPERATIVE PROTOCOL
• POSTOPERATIVELY, PATIENTS ARE ALLOWED TO BEAR WEIGHT AS TOLERATED IN
A KNEE BRACE LOCKED IN EXTENSION. STRAIGHT LEG RAISES AND ISOMETRIC
QUADRICEPS CONTRACTION ARE ALLOWED AT THE 2 WEEK POSTOPERATIVE
VISIT WHILE KNEE ROM EXERCISES ARE PROHIBITED.
• AT THE 4-WEEK VISIT, THE HINGED KNEE BRACE IS DISCONTINUED AND ACTIVE
AND PASSIVE ROM EXERCISES AS WELL AS NO RESISTANCE-STATIONARY BIKING
IS ALLOWED. A CHONDROMALACIA PATELLA–STRENGTHENING PROTOCOL,
INCLUDING QUADRICEPS, HAM- STRING, AND CALF RESISTANCE EXERCISES, IS
ADDED TO THE THERAPY REGIMEN AT THE 2-MONTH VISIT. PATIENTS ARE
ADDITIONALLY EVALUATED AT 3, 6, AND 12 MONTHS POSTOPERATIVELY.
 CLINICAL SERIES
• 9 PATIENTS UNDERWENT OPEN REDUCTION AND INTERNAL FIXATION WITH OUR
NOVEL CAGE PLATE CONSTRUCT.
• MEAN PATIENT AGE WAS 65 YEARS (RANGE, 50–86) WITH ALL PATIENTS BEING
WOMEN. MEAN BODY MASS INDEX WAS 25.3.
• NO PATIENTS DEVELOPED AVASCULAR NECROSIS (AVN), POSTOPERATIVE
INFECTION, OR HAD WOUND COMPLICATIONS.
• PATIENTS HAD AN AVERAGE FOLLOW-UP OF 18 MONTHS (RANGE, 13–23).
• MEAN ROM WAS FULL EXTENSION TO 143 DEGREES OF FLEXION. MEAN TIME TO
UNION WAS 23 WEEKS WITH ALL PATIENTS ACHIEVING BONY UNION.
 DISCUSSION

• PLATE OSTEOSYNTHESIS OF PATELLA FRACTURES IS A RELATIVELY NEW CONCEPT

IN FRACTURE FIXATION.
• THE PURPOSE OF THIS TECHNIQUE WAS TO PROVIDE A MULTIPLANAR AND LOW-
PROFILE FIXATION CONSTRUCT FOR ANATOMIC REDUCTION UNDER DIRECT
VISUALIZATION OF COMPLEX ARTICULAR INJURIES WITH COMPRESSION PLATING
AND INTERFRAGMEN- TARY SCREW FIXATION WHILE MINIMIZING DISRUPTION TO
THE VASCULAR SUPPLY.
• THE PLATE APPLICATION TO THE LATERAL HALF CIRCUMFERENTIAL RIM OF THE
PATELLA ALONG WITH ITS 2 TRANSVERSE LIMBS PERMITS MULTIPLE OPTIONS FOR
MULTIPLE PLANES OF FIXATION, MAXIMIZING SCREW LENGTH AND FIXATION.
• USE A LATERAL AR- THROTOMY WITH INVERSION OF THE PATELLA TO DIRECTLY
VISUALIZE THE ARTICULAR SURFACE. WE HAVE FOUND THAT THIS EXPOSURE
SIG- NIFICANTLY REDUCES THE DIFFICULTY OF OBTAINING AN ANATOMIC
REDUCTION.
• KASTELEC AND VESELKO COMPARED THE CLINICAL OUTCOMES OF BASKET
PLATE FIXATION AND PARTIAL PATELLECTOMY AFTER INFERIOR PATELLAR POLE
FRACTURE. OF THEIR BASKET PLATE FIX- ATION COHORT, 9% OF PATIENTS
LACKED 15 DEGREES OF KNEE FLEXION AT FINAL FOLLOW UP AND 64% HAD THE
PLATE REMOVED AT AN AVERAGE OF 6 MONTHS POSTOPERATIVELY. NONE OF
THEIR 11 BASKET PLATE FIXATION PATIENTS DEVELOPED AVN OF THE PATELLA.
IN OUR STUDY, PATIENTS HAD A MEAN 143 DEGREES OF KNEE FLEXION AND 1
PATIENT UNDERWENT REMOVAL OF A SYMPTOMATIC IMPLANT.
• KASTELEC AND VESELKO DID NOTE THE POSSIBILITY OF PATELLAR AVN WITH
THE USE OF THE BASKET PLATE, AN INFERIOR PATELLAR POLE PLATE.
• USE OF OUR LATERALLY BASED CAGE PLATE MITIGATES THIS RISK BY AVOIDING
THE PREDOMINATE INFEROMEDIAL VESSEL, AFFORDING A VERY LOW RISK OF
INSULT TO THE PATELLAR BLOOD SUPPLY WHILE ALLOWING FOR DIRECT
ARTICULAR REDUCTION AND STABLE FIXATION.
• THE USE OF MULTIPLANAR FIXATION COMBINED WITH ADDI- TIONAL PATELLA
TENDON SUTURE REPAIR TO THE PLATE ALLOWS FOR THE IMPLEMENTATION OF
INTENSIVE POSTOPERATIVE PHYSICAL THERAPY.
• ANOTHER IMPORTANT ASPECT OF THIS CONSTRUCT IS THE ABILITY TO
EFFECTIVELY STABILIZE INFERIOR POLE COMMINUTION, WHICH IS SEEN IN 88%
OF PATELLA FRACTURES.
 CONCLUSION

• IN CONCLUSION, PATELLA FRACTURES ARE AMONG THE MOST CLINICALLY

CHALLENGING ORTHOPAEDIC INJURIES. THE TECHNIQUE DESCRIBED HERE
DEMONSTRATES GREAT CLINICAL PROMISE FOR TREATING DIFFICULT PATELLA
FRACTURE PATTERNS AND SERVES AS AN IMPROVEMENT OVER CURRENT
PATELLA FRACTURE FIXATION METHODS INCLUDING TENSION BAND FIXATION
AND BASKET PLATE FIXATION. WE RECOMMEND USE OF THIS SURGICAL
TECHNIQUE AND MESH PLATE CONSTRUCT TO ACHIEVE ANATOMIC ARTICULAR
REDUCTION AND MULTIPLANAR FIXATION OF PATELLA FRACTURES WHILE
MITIGATING THE RISK OF PATELLAR VASCULAR DISRUPTION.
•THANK
YOU