Patellafrakturer Overlæge Lasse Bayer Ortopædkirurgisk afdeling, Traumesektionen NOH Hillerød
ORIF
Tension Band princippet
Operativ Behandling Mål Bevar ekstensionskraften/evnen Genetabler leddets kongruens Setup Blodtomhed (Valgfrit?) Hvis anvendes så bøj evt knæet lidt før inflation! Adgang Longitudinal midtlinie incision OBS fremtidig kirurgi!
Biomechanical Evaluation of Current Patella Fracture Fixation Techniques. Carpenter, James; Kasman, Roberta; Patel, Niraj; Lee, Michael; Goldstein, Steven Journal of Orthopaedic Trauma. 11(5):351-356, July 1997. FIG. 1. Techniques of internal fixation studied. A: Modified tension band. B: Interfragmentary 4.5- millimeter screws. C: Cannulated four-millimeter screws plus tension band. 3
Comparison of Cannulated Screw With Tension Band Wiring Versus Compressive Cannulated Locking Bolt and Nut Device (CompresSURE) in Patella Fractures-A Cadaveric Biomechanical Study. Domby, Brian; Henderson, Eric; Nayak, Aniruddh; Erdogan, Murat; Gutierrez, Sergio; Santoni, Brandon; Sagi, H Journal of Orthopaedic Trauma. 26(12):678-683, December 2012. DOI: 10.1097/BOT.0b013e31826f5985 FIGURE 1. Lateral radiographs illustrating articular (top left) and nonarticular (top right) placement of the cannulated lag screws in the tension band constructs. Lateral (bottom left) and anterior-posterior (bottom right) radiographs of the CompresSURE device placed in the articular half of the patella. 2
Fig. 1 Bilateral fixed-angle patella-plate. View from the distal pole. Simon Thelen, Johannes Schneppendahl, Eva Jopen, Christian Eichler, J?rgen Koebke, Eckhard Sch?nau, Mohssen... Biomechanical cadaver testing of a fixed-angle plate in comparison to tension wiring and screw fixation in transverse patella fractures Injury Volume 43, Issue 8 2012 1290-1295 http://dx.doi.org/10.1016/j.injury.2012.04.020
Fig. 3 The four anterior tension band constructs tested included (A) a single stainless steel wire with two compression twists, (B) a single-strand FiberWire tied with a sliding knot, (C) a double-strand FiberWire tied with individual sliding kno... P.B. Wright, V. Kosmopoulos, R.E. Cot?, T.J. Tayag, A.D. Nana FiberWire? is superior in strength to stainless steel wire for tension band fixation of transverse patellar fractures Injury Volume 40, Issue 11 2009 1200-1203 http://dx.doi.org/10.1016/j.injury.2009.04.011
Authors conclusions There is very limited evidence from RCTs about the relative effects of different surgical interventions for treating fractures of the patella in adults. There is no evidence from RCTs evaluating the relative effects of surgical versus conservative treatment Copyright or different 2015 types The of Cochrane Collaboration conservative interventions. Based on very low quality evidence, biodegradable implants seem to be no better than metallic implants for displaced patellar fractures; patellectomy with vastus medialis obliquus advancement may give better results than simple patellectomy for comminuted patellar fractures; and two novel methods of percutaneous osteosynthesis may give better results than conventional open surgery. However, until conclusive evidence becomes available, treatment options must be chosen on an individual patient basis, carefully considering the relative benefits and harms of each intervention and patient preferences. Further randomised trials are needed, but in order to optimise research effort, these should be preceded by research that aims to identify priority questions.
Nonoperativ / Konservativ Behandling Minimalt eller u-dislocerede frakturer < 2mm step-off I ledfladen & < 3mm diastase med intakt ekstensor mekanisme (extensor retinaculum) Evt. intra-artikulær injection af lokal anæstesi for at teste ekstensionsevnen Minimalt dislocerede frakturer hos low demand patients (Comorbiditet & funktion). Patienter med væsentlig medicinsk comorbiditet.
Nonoperativ / Konservativ Behandling Knæhængselsbandage/Lang cirkulær gips Bandageringstid 4-6 uger Vægtbæring tillades i hele bandageringsperioden Passive bevægeøvelser Quadriceps belastes tiltagende
Konklusion Standardbehandling af tværfrakturer i patella (de fleste steder?) Tension band med k-tråde og cerclage Ombuk i begge ender? Kanyllerede skruer og cerclage er stærkere Sutur kan evt. bruges i stedet for stålwire Vinkelstabile skinner kan blive en mulighed i fremtiden Komminutte frakturer (og distale pol frakturer) er svære
Fig. 3 The four anterior tension band constructs tested included (A) a single stainless steel wire with two compression twists, (B) a single-strand FiberWire tied with a sliding knot, (C) a double-strand FiberWire tied with individual sliding kno... P.B. Wright, V. Kosmopoulos, R.E. Cot?, T.J. Tayag, A.D. Nana FiberWire? is superior in strength to stainless steel wire for tension band fixation of transverse patellar fractures Injury Volume 40, Issue 11 2009 1200-1203 http://dx.doi.org/10.1016/j.injury.2009.04.011
Total Patellectomy Indikeret ved yderligere displaceret komminut fraktur hvor rekonstruktion er umulig. Evt komminut fraktur i kombination med stor åben skade. Medfører ekstensionsdefekt på op til 30 og et styrketab på ca.30%.
Postoperativt regime Immobiliseres primært med knæ i extension. Succesiv oplåsning af skinnen. Tidlig range of motion Baseret på intraoperativ vurdering af osteosyntesens og knoglens kvalitet Aktiv fleksion og passiv ekstension Quadriceps styrke Begynder når der er radiologisk heling (Ca 6 uger). Regime modificeres til den enkelte patient afhængig af frakturen, osteosyntesen, osteoporose, comorbiditet mv.
Fig. 1 Schematics of the stainless steel three-point-bend model. P.B. Wright, V. Kosmopoulos, R.E. Cot?, T.J. Tayag, A.D. Nana FiberWire? is superior in strength to stainless steel wire for tension band fixation of transverse patellar fractures Injury Volume 40, Issue 11 2009 1200-1203 http://dx.doi.org/10.1016/j.injury.2009.04.011
TABLE 1 Biomechanical Evaluation of Current Patella Fracture Fixation Techniques. Carpenter, James; Kasman, Roberta; Patel, Niraj; Lee, Michael; Goldstein, Steven Journal of Orthopaedic Trauma. 11(5):351-356, July 1997. TABLE 1. Randomization scheme for testing the three techniques of fracture fixation using nine pairs (eighteen knees) of cadaveric lower extremities Lippincott-Raven Publishers. Published by Lippincott Williams & Wilkins, Inc. 2
FIG. 2 Biomechanical Evaluation of Current Patella Fracture Fixation Techniques. Carpenter, James; Kasman, Roberta; Patel, Niraj; Lee, Michael; Goldstein, Steven Journal of Orthopaedic Trauma. 11(5):351-356, July 1997. FIG. 2. Testing apparatus. Hydraulic cylinder applies load to quadriceps tendon, which is measured by the load cell. Tibia can move freely or be locked into place at any position from 0 to 90 degrees. Clip gauge measures displacement at the fracture site. Lippincott-Raven Publishers. Published by Lippincott Williams & Wilkins, Inc. 4
FIG. 3 Biomechanical Evaluation of Current Patella Fracture Fixation Techniques. Carpenter, James; Kasman, Roberta; Patel, Niraj; Lee, Michael; Goldstein, Steven Journal of Orthopaedic Trauma. 11(5):351-356, July 1997. FIG. 3. Displacement of fracture site with knee extension. Mean displacement measured at the fracture site (+/-standard deviation) as the knee is extended and flexed with zero to 300 newtons of force on the quadriceps tendon. Displacement for screws and tenstion band with screws were both statistically significantly lower than for modified tension band (p < 0.05). Lippincott-Raven Publishers. Published by Lippincott Williams & Wilkins, Inc. 5
FIG. 4 Biomechanical Evaluation of Current Patella Fracture Fixation Techniques. Carpenter, James; Kasman, Roberta; Patel, Niraj; Lee, Michael; Goldstein, Steven Journal of Orthopaedic Trauma. 11(5):351-356, July 1997. FIG. 4. Mean loads to failure at 45 degrees of flexion. With the knee locked at 45 degrees, the mean load (+/- standard deviation) required to displace the fracture more than three millimeters was measured. The difference between screws and tension band with screws was significant at p = 0.05. Other differences were not statistically significant. Lippincott-Raven Publishers. Published by Lippincott Williams & Wilkins, Inc. 6
Nonoperativ / Konservativ behandling Minimalt eller u-dislocerede frakturer < 2mm step-off I ledfladen & < 3mm diastase med intakt ekstensor mekanisme (extensor retinaculum) Kan benet løftes strakt fra lejet? Evt. intra-artikulær injection af lokal anæstesi for at teste ekstensionsevnen Minimalt dislocerede frakturer hos low demand patients (Comorbiditet & funktion). Patienter med væsentlig medicinsk comorbiditet.
Anatomy Kroppens største sesamoide knogle Tyk bruskbeklædt ledflade Ledfladen delt I medial og lateral facet. Den distale pol er nonarticular.
Anatomy Patellas Retinaculum Longitudinale tendinøse fibre Patellofemorale ligamenter Blodforsyning Fra flere sider
Biomekanik Patella bevæger sig ca 7 cm fra fleksion til fuld ekstension. Kun 13-38% af patellas ledflade er i kontakt med femur på et givent tidspunkt. Kongruens er essentiel!
Biomekanik Patella øger vægtarmen over knæet: Bidrager med at øge kraften op til 30%. Patella modstår kompressionskræfter på mere end 7 x kropsvægten under feks vægtløftning.
Examination Smerte, hævelse, kontusioner, sår og/eller hudafskrabninger. OBS: Kan være medbestemmende for timing af en eventuel operation! Palpabel defekt Kan pt løfte benet strakt fra lejet? Kontinuitetsbrist?
Procedure Longitudinal Incision Oprens frakturspalte n læderet Retinaculum