Short Communication - (2022) Volume 12, Issue 8
Early mobilization may result in loss of fracture reduction and immobilization failure in Inferior Pole Fracture of the Patella (IPFP), which features small, comminuted fracture blocks that are challenging to immobilize. To accomplish strict immobilization with early functional activity is thus a challenge of treatment. Here, tension-free external immobilization is proposed as a novel therapeutic approach.
Inferior Pole Fracture of The Patella (IPFP)
Patellar fractures, frequent intra-articular fractures, make up around 1% of all systemic fractures. The patellar inferior pole fracture is a unique form of patellar fracture that occurs in the distal quarter of the patella or the point where the patellar tendon attaches. The patella is primarily made of cancellous bone, which has no articular surface coverage and is unrelated to the patellofemoral joint. IPFP makes up 9.3%-22.4% of patellar fractures and is classified as an extra-articular fracture.
Due to IPFP's small and comminuted fracture blocks, which are challenging to stabilize, and its propensity for displacement due to patellar tendon traction, conservative treatment is frequently ineffective and must be supplemented with surgery. Currently, two surgical procedures are the main treatments for IPFP. The first technique involves removing the inferior patellar pole and repairing and reconstructing the patellar ligament; however, this shortens the ligament, causes patellar lowering, and puts more pressure on the patellofemoral joint surface, leading to complications like restricted knee flexion and anterior patellar pain. Aiming to preserve the patella's anatomical integrity, the second method involves reduction and immobilization with steel wires, steel plates, and sutures. However, it has limited stability when immobilizing smaller IPFPs, and early mobilization may result in the loss of fracture reduction and immobilization failure. Therefore, the clinical challenge of how to effectively immobilize the knee while still regaining knee function with early rehabilitation activity persists [1].
Inclusion criteria: Imaging-detected unilateral IPFP; age 18; normal bone mineral density; and a follow-up period of 12 months.
Exclusion criteria: Pathological fractures, fractures of the femur, tibia, or fibula on the affected side, injuries to the popliteal blood vessels or nerves, additional acute or chronic conditions that affect knee function, multiple injuries, or surgical intolerance brought on by underlying illnesses.
The study included six men and five women with an average age range from 18 years-53 years. In five cases, automobile accidents led to IPFP, while in six cases, falls did. All of the cases included closed unilateral injuries, including four to the left knee and seven to the right. From injury until surgery, it took 3 days-7 days.
Surgical techniques
A sterile tourniquet was applied to the root of the thigh on the afflicted side and inflated after general anaesthesia in the supine position, standard cleaning, and draping. To reveal the IPFP terminus, an anterior median longitudinal incision of the patella was done. The fracture ends were managed while being seen clearly. Olive-tipped needles or Kirschner wires with a blocking head were used for fracture immobilization and reduction if the avulsion fracture blocks were large. For suture immobilization, one-gauge absorbable sutures were utilized. The waist segment of the patella was crossed-inserted percutaneously with two 1.5 mm Kirschner wires, and the Kirschner wires and the 1/2 ring were secured with needle-passing bolts. One 4.0 mm threaded needle was inserted vertically in front of the tibia on this plane, one 2.0 mm Kirschner wire was inserted horizontally through the tibia beneath the tibial tubercle, and the Kirschner wire, threaded needle, and 2/3 ring were joined and fixed with needle-passing bolts and threaded needle pads.
The distal end of the two 2/3 rings was bridged and secured with threaded needles, needle-passing bolts, and threaded needle pads. One 4.0 mm threaded needle was placed vertically in front of the tibia around 12 cm distant. The joint hinge was then modified to allow for excellent knee motion and no tension on the suture at the fracture end before the devices at the fracture's two ends were attached. The surgical wound was then closed once the tourniquet was removed, the incision was cleaned, and the bleeding had stopped [2].
Postoperative care and follow-up
We administered antibiotics to prevent infection and nonsteroidal anti-inflammatory medications to treat pain within 24 hours of surgery. After surgery, the knee could be passively manipulated on the bed. One day after surgery, the patients were urged to exercise their knees actively. Two days later, they strengthened their knee function and began to walk on crutches while bearing some weight, and one week later, they were able to bear full weight without using crutches.
Within 3 days following surgery, once per month until the removal of external immobilization devices and fracture healing, and then once every 6 months, the anteroposterior and lateral X-rays of the knee on the affected side were examined. The length of the procedure, intraoperative blood loss, hospital stay, and surgical complications were noted. During the follow-up, the fracture healing process, the removal of the external immobilization device, and postoperative complications were noted. The knee's range of motion was measured before surgery, one month after surgery, and at the most recent follow-up. The affected knee's function was evaluated using the Böstman score during the most recent follow-up, and the range of motion of the affected and unaffected knees was compared [3].
Small, highly comminuted fracture blocks present in IPFP are difficult to immobilize. There is no universally accepted method for treating IPFP, and each method has advantages and disadvantages. Resection or reduction of fracture blocks is a common component of therapies. According to the majority of experts, reduction of fracture blocks can most effectively restore the patella's normal anatomical structure, whereas resection of fracture blocks will lead to patellar defects, dislocation of the patellofemoral joint, high patellar tendon tension, and challenges with tendon-bone healing.
By utilizing steel plates, steel wires, and sutures for internal immobilization, fracture blocks are primarily preserved and decreased. The immobilization of smaller IPFPs is less successful using patellar concentrators, which are frequently employed in clinics and can concentrically aggregate the displaced patellar fracture blocks. The patellar ligament suffers significant structural and functional damage from basket plates, including shortening of the patellar ligament, destruction of the patellar ligament's blood supply, and internal immobilization irritation during knee flexion. Basket plates can effectively gather the fracture blocks and restore the knee extension function. Traditional steel wire or suture cerclage fails to produce synergy in immobilization due to scattered cohesiveness, leading to unstable immobilization, and fracture block dissociation and rotational displacement happen easily during knee flexion and extension. Knee stiffness and functional limitations are frequently brought on by postoperative auxiliary plaster immobilization. The patellar fracture blocks can be sutured with silk thread or suture anchors, but they don't offer enough support for early functional activity. In order to adequately immobilize the fracture blocks and counteract the stress of the anterior patellar ligament, tension bands with Kirschner wires or cannulated screws are used. This allows for early functional activity following surgery and produces favorable outcomes. Internal immobilization failure is caused by the fact that they perform poorly in the immobilization of IPFP and are prone to loosening after surgery. Right now, it's challenging to combine early functional exercise after IPFP decrease with strict immobilization [4].
We propose a new therapeutic approach called tension-free external immobilization in light of the challenges associated with treating IPFP and the limitations of the aforementioned surgical techniques. The external immobilization device consists of a joint hinge linking the patellar and tibial immobilization components, as well as the patellar and tibial immobilization parts. By modifying the joint hinge during surgery, this technique can accomplish stable immobilization in 3D space and provide excellent knee range of motion while the sutured fracture end is in a tension-free state. After receiving tension-free external immobilization in this study, all 11 patients experienced satisfactory fracture healing. Three times throughout the postoperative frame-carrying period, there was redness and swelling in the needle tract. In all three instances, this condition was resolved by symptomatic treatment one week after the external immobilization frame was removed. There were no additional surgical problems [5].
The benefits of the tension-free external immobilization are as follows, as may be observed from the technical attributes:
(1) Tension-free immobilization: The fracture end can be reduced and immobilized in a tension-free state by fixing the upper end to the patella's waist segment and the lower end to the tibia's upper segment. By modifying the joint hinge, it is possible to prevent fracture displacement or loss of immobilization due to high stress by maintaining the knee motion of the fracture end in a tension-free state.
(2) Early functional exercise: Through 3D-space immobilization, the external immobilization device ensures overall stability. The patient can move the knee on the bed right after surgery because there is no stress at the fracture end. The following day, the patient can walk with a walker or crutches, avoiding issues from immobility and joint stiffness.
(3) Small surgical trauma: Open reduction does not remove excessive periostea or soft tissues, and the Kirschner wires used to immobilize the patella are thin and placed far from the fracture end, which greatly facilitates fracture healing.
(4) Easy removal of the external immobilization device: After the fracture has healed, the external immobilization device can be removed in the outpatient clinic. The Kirschner wire is extracted through the opposite end to prevent doing the procedure again while under anaesthesia. First, the external immobilization ring and threaded needle are removed.
Precautions for surgery
(1) Excessive periosteum and soft tissues cannot be peeled off when the fracture end is sliced and exposed. The fractured end is stitched while the knee is extended and without any strain. Olive-tipped needles or Kirschner wires with a blocking head can be used to perform fracture immobilization and reduction if the avulsion fracture blocks are substantial.
(2) The waist segment of the patella, which is the most "hypertrophic" region of the patella, is typically used to immobilize the patellar end. On the cross-section of the waist, two Kirschner wires are percutaneously crossed and inserted in the medial upper-lateral lower and lateral upper-medial lower directions, respectively. The skin at the entry point should be tension-free, the two Kirschner wires should be on the same cross-section, and they shouldn't harm the articular surface.
(3) One 2.0 mm Kirschner wire is typically put below the tibial tubercle in the horizontal plane to immobilize the tibial end, and one threaded needle is introduced vertically in front of the tibia in the horizontal plane to fix the 1/2 ring.
(4) Installing the joint hinge requires that the patient's knee be in a straight position. The joint hinge should be placed on the lower sides of the patella at a height equal to that of the patella's middle axial plane. To guarantee that the knee joint's movement is consistent with the hinge's and that the fracture end is in a condition of tension-free movement, the relevant adjustments should be performed during the operation in accordance with the knee joint's movement [6].
An effective surgical treatment option for IPFP is tension-free external immobilization, which can facilitate early functional exercise with a positive clinical outcome. However, there are certain shortcomings in this approach. For instance, the patient may have inconvenience by the external immobilization device, particularly during the winter. Infection risk is increased by skin pinholes. The recovery of a patellar fracture can be accelerated by a tension-free state, although the proximal patellar tendon may become tenser as a result. Larger investigations are required because the sample size of this study was insufficient, and the evaluation of clinical efficacy may have been biased in some way.
Citation: Runkel M. Application of Tension-Free External Immobilization for the Treatment of Patellar Inferior Pole Fracture. Surg Curr Res. 2022, 12 (8), 001-002 .
Received: 03-Aug-2022, Manuscript No. SCR-22-19328; Editor assigned: 05-Aug-2022, Pre QC No. SCR-22-19328 (PQ); Reviewed: 16-Aug-2022, QC No. SCR-22-19328(Q); Revised: 18-Aug-2022, Manuscript No. SCR-22-19328 (R); Published: 23-Aug-2022, DOI: 1035248| 2161-1076.22.12(8).405
Copyright: ©2022 Runkel M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
