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Patellafrakturer
Overlæge Lasse Bayer
Ortopædkirurgisk afdeling, Traumesektionen
NOH Hillerød
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
ORIF
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Tension Band princippet
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
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!
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
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 4.5millimeter screws. C: Cannulated four-millimeter screws
plus tension band.
Lasse Bayer - Hillerød - april 2015
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Lasse Bayer - Hillerød - april 2015
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.
Lasse Bayer - Hillerød - april 2015
2
Lasse Bayer - Hillerød - april 2015
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
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
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
Lasse Bayer - Hillerød - april 2015
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
Copyright
© 2015
conservative treatment
or different
typesThe
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.
Lasse Bayer - Hillerød - april 2015
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.
Lasse Bayer - Hillerød - april 2015
Nonoperativ / Konservativ
Behandling
•Knæhængselsbandage/Lang
cirkulær gips
•Bandageringstid 4-6 uger
•Vægtbæring tillades i hele
bandageringsperioden
•Passive bevægeøvelser
•Quadriceps belastes
tiltagende
Lasse Bayer - Hillerød - april 2015
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
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
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
Lasse Bayer - Hillerød - april 2015
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%.
Lasse Bayer - Hillerød - april 2015
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.
Lasse Bayer - Hillerød - april 2015
Lasse Bayer - Hillerød - april 2015
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
Lasse Bayer - Hillerød - april 2015
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.
Lasse Bayer - Hillerød - april 2015
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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.
Lasse Bayer - Hillerød - april 2015
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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.
Lasse Bayer - Hillerød - april 2015
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.
Lasse Bayer - Hillerød - april 2015
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.
Lasse Bayer - Hillerød - april 2015
Anatomy
• Kroppens største
“sesamoide” knogle
• Tyk bruskbeklædt
ledflade
• Ledfladen delt I medial
og lateral “facet”.
• Den distale pol er
“nonarticular”.
Lasse Bayer - Hillerød - april 2015
Anatomy
• Patellas Retinaculum
• Longitudinale tendinøse
fibre
• Patellofemorale
ligamenter
• Blodforsyning
• Fra flere sider
Lasse Bayer - Hillerød - april 2015
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!
Lasse Bayer - Hillerød - april 2015
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.
Lasse Bayer - Hillerød - april 2015
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?
Lasse Bayer - Hillerød - april 2015
Procedure
Longitudinal
Incision
Oprens
frakturspalte
n
læderet
Retinaculum
Lasse Bayer - Hillerød - april 2015