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Lasse Bayer - Hillerød - april 2015

PatellafrakturerOverlæge Lasse Bayer

Ortopædkirurgisk afdeling, Traumesektionen

NOH Hillerød

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.

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.

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

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 or different types of

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.

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...

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.

TABLE 1

TABLE 1 . Randomization scheme for testing the three

techniques of fracture fixation using nine pairs (eighteen

knees) of cadaveric lower extremities

FIG. 2

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.

FIG. 3

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).

FIG. 4

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.

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

• 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 påmere 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

læderet

Retinaculum

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