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Due to the functional importance of the patella, accurate reduction and rigid fixation of patellar fractures are required. Tension band wiring has long been the standard treatment of these fractures, but there are several problems associated with this technique, e.g. loosening of the wires, fracture dislocation and poor outcome. Another possibility in the treatment of transverse patellar fractures is screw fixation. Although this technique ensures stable osteosynthesis, anatomical reduction is often problematic, especially in comminuted fractures. A good option in the treatment of (comminuted) patellar fractures is the newly designed locking patella plate, which combines anatomical reduction and stable osteosynthesis. In biomechanical tests the plate provided a more stable fixation of the patellar fracture and showed higher mechanical strength compared to classic tension band wiring. The first clinical applications achieved optimal fracture reduction. No complications have occurred to date following the use of the plate. Thus the patella plate represents a good option in the treatment of patellar fractures.     

前侧入路直视关节面复位内固定治疗粉碎性髌骨骨折

目的总结前侧入路直视关节面复位内固定治疗粉碎性髌骨骨折的疗效。方法采用前侧入路直视关节面复位内固定手术治疗31例粉碎性髌骨骨折患者。结果31例均获得随访,时间6~26个月。均未发生骨折再移位、内固定松动及断裂、感染等并发症。骨折愈合时间8~12周。结论前侧入路直视关节面复位内固定治疗粉碎性髌骨骨折恢复快、并发症少。     

髌骨全切术后膝关节功能的随访

目的探讨髌骨骨折后行髌骨全部切除术对膝关节功能的影响。方法 1995年9月至2007年3月,对107例粉碎性髌骨骨折患者行髌骨全部切除术。其中男69例,年龄33~75岁,平均53岁;女38例,年龄55~76岁,平均68岁。结果术后对患者进行2~14年的随访,按照术后残余痛、膝关节活动度、工作及日常生活情况,髌骨近端10cm萎缩程度以及Bostman临床疗效评分表评价膝关节功能,优28例,良59例,差20例,患者满意率达81.31%。结论髌骨全部切除术对严重粉碎性髌骨骨折且关节面毁损患者是一种有价值的手术方法 。     

微创张力带固定治疗横断型髌骨骨折

目的探讨微创张力带固定治疗横断型髌骨骨折的适应征和临床效果。方法回顾性分析1997年6月～2005年6月间应用微创张力带法治疗横断型髌骨骨折(闭合性或污染较轻的开放性骨折)38例,其中经皮穿刺克氏针钢丝张力带固定26例,经皮穿刺空心钉张力带固定12例。对骨折复位程度、关节活动度及膝关节功能进行分析。结果所有手术操作顺利。所有患者获6个月～6．5年(平均32个月)的随访。骨折愈合时间6～12周,平均7．7周；无内固定失败及创伤性关节炎等并发症发生。临床效果评定采用胥少汀式髌骨张力带固定术后评价标准,骨折复位程度：优21例,良11例,中6例,优良率为84．2%。全部病例膝关节活动度均在正常范围内,膝关节功能评价均为优良,其中优34例,良4例。结论微创张力带固定治疗横断型髌骨骨折临床效果优良。该技术主要适用于闭合性横断型髌骨骨折和创口较小且污染较轻的髌骨骨折,对于骨折块不超过3个且位置尚可的粉碎骨折也可酌情使用。     

Patellafrakturen

Fractures of the patella account for approximately 0.5% to 1.5% of all skeletal injuries. The diagnosis is made by means of the mechanism of injury, physical and radiological findings. The kind of treatment of patella fractures depends on the type of fracture, the size of the fragments, the integrity of the extensor mechanism and the congruity of the articular surface. Independent of the kind of treatment an early rehabilitation is recommended. Modified tension band wiring is the most commonly used surgical treatment for patella fractures and can be used for almost every type of fracture. Due the superior stability in biomechanical studies two parallel cannulated lag screws combined with a tension band wiring are the treatment of choice for horizontally displaced two-part fractures. In comminuted fractures a partial or total patellectomy may be necessary. However, since the loss of quadriceps muscle power and the poor outcome total patellectomy should be considered as a salvage procedure.     

Patella rings for treatment of patellar fracture

To evaluate a new fixation technique for patellar fracture using patella rings. A total of 75 patients (average age of 51.3 years) with comminuted or transverse patellar fractures were treated by fixation with patella rings. The Böstman scores at the time of bone union and at 12 months postoperatively were recorded, as was the degree of pain on a visual analogue scale (VAS), the range of motion of the knee at 12 months postoperatively, and any signs of postoperative complications. The average Böstman scores for patients in the transverse fracture group were 25.2 and 29.4 at 3 and 12 months postoperatively, respectively, while the scores for patients in the comminuted fracture group were 27.6 and 28.7, at the same time points. Böstman scores were graded as excellent and good in more than 90 % for patients with either a transverse or comminuted fracture. At the time of 12 months after surgery, the VAS score for patients with comminuted fractures was 0.38, whereas the score for patients in the transverse fracture group was 0.35. No statistically significant difference was found in the range of motion between the affected and uninjured knee at 12 months after surgery for patients in both groups (P > 0.05). This new fixation technique using a patella ring resulted in good outcomes for both transverse fracture and comminuted fracture and is beneficial for patients wishing to commence early functional activity.     

Outcome of open comminuted tibial plateau fractures treated using an external fixator

Background The purpose of this study was to evaluate the outcome of open severe comminuted tibial plateau fractures treated with minimal internal fixation and circular external fixation frames. Methods Fifteen open comminuted tibial plateau fractures were involved in this retrospective study. In eight knees, the fracture was reduced through an extended open traumatic wound. In seven patients, another limited incision over the major fracture line or area of comminution was performed to assist in reducing the articular reduction. Simultaneous bone grafting, soft tissue reconstruction, and stabilization of the fracture using a circular external fixator were carried out. Results The patients were followed for an average of 32 months (range 24–54 months). The average time to union of the fractures and frame removal was 22.8 weeks (range 16–44 weeks). The quality of the reduction of the joint surface was rated as anatomical in four patients, good in five patients, fair in three patients, and poor in three patients. Four patients experienced loss of articular reduction. The Knee Society Clinical Rating scores indicated that three knees were excellent, seven were good, one was fair, and four were poor. Complications included one case of septic arthritis, one of osteomyelitis, one of malunion, and four with loss of reduction. Conclusions This technique provided acceptable results for open severe comminuted fractures of the tibial plateau without comminuted posterior wall fractures. The most significant disadvantage of the technique is insufficient anatomical reduction and loss of reduction in comminuted posterior wall fractures in the coronal plane. This technique should be combined with a minimally invasive internal fixation method to prevent loss of reduction in open severe comminuted and irreducible tibial plateau fractures.     

Olecranon fractures: treatment options

Fractures of the olecranon process of the ulna typically occur as a result of a motor-vehicle or motorcycle accident, a fall, or assault. Nondisplaced fractures can be treated with a short period of immobilization followed by gradually increasing range of motion. Open reduction and internal fixation is the standard treatment for displaced intra-articular fractures. Stable internal fixation with figure-of-eight tension-band wire fixation for simple transverse fractures allows early motion to minimize stiffness. Use of two knots produces symmetric tension at the fracture site and provides more rigid fixation than a single knot. Care should be taken to ensure that the tension-band wire and the proximal ends of the Kirschner wires are positioned deep to the triceps fibers to prevent wire migration. If the anterior cortex is engaged, overpenetration of the wires into the soft tissues should be avoided. Plate fixation is appropriate for severely comminuted fractures, distal fractures involving the coronoid process, oblique fractures distal to the midpoint of the trochlear notch, Monteggia fracture-dislocations of the elbow, and nonunions. For comminuted fractures and nonunions, a dorsally applied limited-contact dynamic-compression plate with supplemental bone graft should be utilized to support comminuted depressed articular fragments. A one-third tubular hook-plate can be used for fractures with a small proximal fragment for which additional fixation of the olecranon tip is desired. Fragment excision and triceps advancement is appropriate in selected cases in which open reduction seems unlikely to be successful, such as in osteoporotic elderly patients with severely comminuted fractures.     

Frakturen der Kniescheibe

Fractures of the patella account for 0.5–1.5% of all skeletal fractures. Common mechanisms of injury are a direct fall onto the knee and dashboard injuries. Standard antero-posterior, lateral and tangential plain radiographic views confirm the diagnosis. Patellar fractures are most commonly classified according to the pattern of fracture into transverse, vertical, and comminuted fractures. The goals of operative treatment are accurate reduction, rigid fixation and the possibility of early motion of the knee. Nonoperative treatment is only justified when there is no displacement of the fragments. Tension band wiring is currently the standard operative method, although some experimental data do not support the theoretical principles behind this technique. Other operative options are screw fixation, Kirschner wires or combinations of these methods. In one-third of cases good results are achieved, while in 5–36% poor results must be expected. The most common postoperative problems are painful retropatellar arthrosis nonunion and a limited range of motion. Patellectomy is an option that yields acceptable long-term results in the treatment of comminuted fractures.     

Open reduction and internal fixation of comminuted patellar fractures with headless compression screws and wiring technique

Background

Management of a displaced comminuted patellar fractures is challenging, and various surgical fixation methods have been suggested. However, issues of loss of reduction and breakage of fixatives have not yet been resolved. In the current study, we describe a new technique for exposure and stabilization of comminuted patellar fractures and evaluate the clinical and radiologic outcomes of this new treatment.

穿骨道线缆结合带尾孔克氏针治疗髌骨骨折

目的:探讨应用穿骨道线缆结合带尾孔克氏针治疗髌骨骨折的临床疗效.方法:自2012年5月至2013年7月,采用穿骨道线缆结合带尾孔克氏针内固定治疗34例髌骨骨折患者,均为闭合性骨折,其中男18例,女16例;年龄26～81岁,平均(46.0±3.0)岁;横形骨折12例,粉碎性骨折22例.观察患者的手术时间、术中出血量、术后膝关节首次锻炼时间及术后并发症情况,术后根据B(o)stman髌骨骨折疗效评分标准对其功能进行评价.结果:所有患者获得随访,时间12～26个月,平均(16.0±2.0)个月.所有患者伤口甲级愈合,骨折全部愈合.手术时间(54.2±10.4) min,术中出血量(56.0±8.5)ml,术后膝关节首次锻炼时间(4.6±1.3)d.术后无感染、退针、线缆松脱,无皮肤刺激等并发症发生.根据B(o)stman髌骨骨折疗效评分标准进行评价,总分29.06±1.67,其中优33例,良1例.结论:穿骨道线缆结合带尾孔克氏针系统内固定治疗髌骨骨折,特别是横形骨折,固定牢固可靠,可早期活动膝关节,并发症少.     

Langzeitergebnisse nach operativer Versorgung von Patellafrakturen

In a retrospective analysis of 70 patellar fractures the-long-term results after surgery were followed-up for periods of up to twelve years. Subjectively, excellent or satisfactory results were reported by 89% (n=62) of patients. Clinical evaluation in the Lysholm score showed excellent or good results in 74.2% (n=52) of cases. The results in the Lysholm score correlated well with the radiological evidence of arthrosis (p<0,014) and with the clinical signs of chondropathy (p<0,0005). Poor results (79.2 Lysholm points) were seen for comminuted fractures; however, the results for patients with distal transverse fractures were even lower (68.28 Lysholm points). Medial transverse fractures as well as distal patella pole ruptures were shown to have good prognostic results. In cases with comminuted fractures resection techniques are to be preferred to conservative procedures (p<0,015). As regards long-term results in our patient population, partial patellectomy showed no obvious advantages over total patellectomy. In cases with multi-fragment fractures with questionable possibilities for reduction, cases with extensive cartilage damage as well as cases with distal transverse fractures partial or full patellectomy is recommended as the therapy of choice.     

Arthroscopic-assisted surgical technique for treating patella fractures

The purpose of this study was to describe and report preliminary results of an arthroscopic-assisted surgical technique for the treatment of displaced transverse patella fractures with percutaneous internal fixation. We applied this technique in 5 patients who presented a displaced transverse patella fracture and were followed-up for an average of 18 months. Under an image-intensifier fluoroscope, the fracture was closely reduced with a percutaneously reduction clamp while the congruence of the articular surface was monitored arthroscopically. Two Kirschner wires were inserted perpendicular to the fracture line followed by 2 cannulated lag screws obtaining interfragmentary compression. By using a cannulated guide, 2 wires were threaded through both cannulated screws and percutaneously were crossed over the top of the patella creating a figure-8 pattern tension band. At final follow-up, radiographic consolidation was achieved in all patients obtaining full range of motion and returning to the activity level previous to the fracture. Arthroscopic internal fixation is a valid alternative for the treatment of intra-articular displaced and noncomminuted patella fractures. This technique allows healing of the fracture with low patient morbidity, a short hospitalization period, and an accelerated rehabilitation of the affected knee.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 6 (July-August), 2002: pp 671–675     

胫骨结节桥架治疗髌骨下极粉碎骨折18例

目的：观察胫骨结节桥架术治疗髌骨下极粉碎性骨折的疗效。方法：在髌骨上极与胫骨结节之间以1．2mm软钢丝“8”字桥架治疗髌骨下极粉碎性骨折18例，结果：其中17例获10－23个月随访，术后未出现钢丝断裂及骨折再移位，平均骨折愈合时间9周，功能恢复满意，结论：该方法是治疗髌骨下极粉碎性骨折有效实用的方法之一。     

Fractures of the base of the first metacarpal: current treatment options

Fractures of the thumb metacarpal occur most frequently at the base. These fractures can be subdivided into intra-articular and extra-articular types. Intra-articular fractures present treatment challenges because they have a tendency to displace due to deforming forces acting at the base of the thumb. An understanding of the anatomy, biomechanics, and fracture pattern will aid in deciding on the best treatment option for each fracture type. Surgical treatment is recommended for unstable fractures. Anatomic restoration of the articular surface in Bennett and Rolando fractures is not essential to obtain a good functional result. However, reduction should be 1 mm or less to reduce the risk of radiographic arthritis. Malunion of these fractures may result in long-term disability. Closed reduction and percutaneous Kirschner-wire fixation is generally the appropriate treatment for a Bennett fracture. Rolando fractures can be treated with either open reduction and internal fixation or external fixation, depending on the size of the fracture fragments. In the case of severely comminuted intra-articular fractures, articular impaction has been implicated as one of the causes of posttraumatic arthritis. It is difficult to restore the articular surface in these injuries. Therefore, external fixation can be considered when the fracture fragments are small and there is significant soft-tissue injury.     

A novel technique of patella fracture fixation facilitating early mobilization and reducing re-operation rates

Objective

Fractures of patella constitute 1% of all fractures. Various techniques have been described for internal fixation of patella fractures. Superiority of one technique over the other has long been debated. We reviewed a series of fifty-one patients with transverse or comminuted fractures of patella treated with a novel technique to assess if it had any advantages over the existing methods of fixation.

Design

Retrospective.

Setting

A tertiary care centre.

Patients & methods

Fifty-one patients with patella fracture OTA 34C, with a mean age of 39 years (range 18–61) were treated with technique of cerclage and two tension bands at our institute. Forty-eight patients completed the study.

Main outcome measurements

Range of Motion and evidence of radiological union were assessed at regular follow-ups.

Results

Forty-four out of forty-eight patients had gained up-to 90 degrees of active flexion at the end of 1 week. Two patients (4.2%) developed superficial infection. All fractures had united at the end of 12 weeks. Five patients (10.3%) underwent a second surgery; four (8.3%) due to implant related complications. Malunion or non-union was not noted in any of the cases.

Conclusion

The advantages of the described method are early mobilization, elimination of k-wire related complications, and ease of use in comminuted fracture pattern as well and a lower reoperation rates as compared to the available literature. We strongly recommend its use in cases of displaced comminuted/transverse fractures of patella as an alternate method of treatment.

Level of evidence

Level III.     

Metaphyseo-diaphyseal junction fracture of distal humerus in children

Six metaphyseo-diaphyseal junction fractures of distal humerus and 182 supracondylar fractures of humerus treated in our institute over a period of 5 years were retrospectively analyzed. Clinical data regarding child's age, neurovascular status, mechanism of injury, mode of treatment, and ultimate clinical outcome were collected for both these fractures and a comparison was made. Oblique (n=2), comminuted (n=3), and transverse types (n=1) of fracture patterns were identified at distal humeral metaphyseo-diaphyseal junction. The oblique and comminuted fractures were managed by closed reduction and plaster of Paris cast, whereas the only transverse fracture was treated by closed reduction and Kirschner wire fixation. In contrast, 125 patients of supracondylar fractures were treated by closed reduction and plaster of Paris cast and the remaining 57 fractures needed Kirschner wire fixation after closed reduction. Assessment by Flynn criteria after 1 year after of injury revealed better functional outcome in metaphyseo-diaphyseal junction fractures. Although transverse fractures are unstable and may require surgical fixation; oblique and comminuted fractures at the metaphyseo-diaphyseal junction of distal humerus can be managed conservatively.     

Outcome Analysis of Fixed Angle Locking Plate in Patella Fractures: A Single Centre Experience from North India

BackgroundTension band wiring supposedly is the most commonly used technique for displaced patella fractures, but is not effective in comminuted fractures and osteoporotic bones. It often leads to loosening of wires, dislocation of fracture, hardware problem and failure of osteosynthesis, resulting in knee stiffness and post-traumatic osteoarthritis. The aim of the study is to evaluate clinical outcome in patients with acute patella fractures (< 3 week) treated with unidirectional angle fixed low-profile titanium patella locking plate.Materials and methodsTwenty patients who presented with displaced patella fractures, aged between 18–70 years were included in the study. All fractures were reduced and fixed with unidirectional angle fixed stable low-profile titanium patella locking plate. Knee Range of motion and Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL) was used to evaluate the outcome.ResultsWe were able to achieve union in 19 out of 20 patients. One patient with comminuted patella fracture had failure of fixation, which was revised. Mean flexion at final follow-up was 124° (110°–130°) and none of the patients had extensor lag. The final radiograph revealed complete union in all patients.ConclusionThis technique offers an option of fixation in comminuted patella fracture and in osteoporotic individuals. It provides mechanical stability for fracture fixation resulting in anatomical reduction, good functional outcome, lower incidence of symptomatic implant or failure of osteosynthesis.     

镍钛形状记忆合金蟹爪式聚髌器的研制及生物力学研究

目的　研究一种治疗髌骨骨折的新的内固定方法。　方法　根据国人髌骨的统计数据 ,采用镍钛形状记忆合金制做蟹爪式聚髌器 ,并进行生物力学研究。　结果　对髌骨横行骨折 ,蟹爪式聚髌器的固定作用明显优于改良张力带钢丝固定 (P <0 .0 0 1) ;对髌骨粉碎性骨折 ,聚髌器的固定作用亦明显优于环形钢丝固定 (P <0 .0 0 1)。　结论　蟹爪式聚髌器设计符合髌骨的解剖和生物力学特点 ,其对髌骨骨折的固定强度可满足临床应用之需要。     

Open reduction and internal fixation of fractures of the radial head

BACKGROUND: The purpose of this retrospective study was to analyze the functional results following open reduction and internal fixation of fractures of the radial head and to determine which fracture patterns are most amenable to this treatment. METHODS: Fifty-six patients in whom an intra-articular fracture of the radial head had been treated with open reduction and internal fixation were evaluated at an average of forty-eight months after injury. Thirty patients had a Mason Type-2 (partial articular) fracture, and twenty-six had a Mason Type-3 (complete articular) fracture. Twenty-seven of the fifty-six fractures were associated with a fracture-dislocation of the forearm or elbow or an injury of the medial collateral ligament. Fifteen of the thirty Type-2 fractures were comminuted. Fourteen of the twenty-six Type-3 fractures consisted of more than three fragments, and twelve consisted of two or three fragments. The result at the final evaluation was judged to be unsatisfactory when there was early failure of fixation or nonunion requiring a second operation to excise the radial head, <100 degrees of forearm rotation, or a fair or poor rating according to the system of Broberg and Morrey. RESULTS: The result was unsatisfactory for four of the fifteen patients with a comminuted Mason Type-2 fracture of the radial head; all four fractures had been associated with a fracture-dislocation of the forearm or elbow, and all four patients recovered <100 degrees of forearm rotation. Thirteen of the fourteen patients with a Mason Type-3 comminuted fracture with more than three articular fragments had an unsatisfactory result. In contrast, all fifteen patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Of the twelve patients with a Type-3 fracture that split the radial head into two or three simple fragments, none had early failure, one had nonunion, and all had an arc of forearm rotation of > or =100 degrees. CONCLUSIONS: Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our data suggest that open reduction and internal fixation is best reserved for minimally comminuted fractures with three or fewer articular fragments. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair, especially with regard to restoration of forearm rotation.