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      Patellar nonunions: Comparison of various surgical methods of treatment

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          Abstract

          Background:

          Nonunion of patella is an uncommon entity prevalent more commonly in developing countries. Many of them have a functional knee joint and only those with a wide gap and failed extensor mechanism need surgery. We report an analysis of nonunion of fracture patella treated by 3 surgical method.

          Materials and Methods:

          35 patients of nonunion/delayed union of patella with significant gap and failure of quadriceps mechanism, underwent three different methods surgically: 1) V–Y plasty and tension band wiring (n=10); 2) patellar traction followed by tension band wiring without V–Y plasty (n=15); and 3) patellar traction followed by partial or total patellectomy (n=10). We compared the results of the treatment in terms of Knee Society Score (KSS), Melbourne patella score, time of union, pain, range of movement, quadriceps power, and ability to do daily activities and complications encountered.

          Results:

          The 15 cases of patellar traction followed by tension band wiring showed the best results in terms of time to return to normal activities and complications encountered. Cases with patellectomy showed the next best results but they had a longer period of rehabilitation with ultimately lesser patient satisfaction. V–Y plasty gave the worst results both in complication rate and function return.

          Conclusion:

          Preoperative patellar traction followed by tension band wiring is a good procedure giving better results than either patellectomy or V–Y plasty.

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          Most cited references16

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          Biomechanical evaluation of current patella fracture fixation techniques.

          To compare the mechanical effectiveness of three different techniques for stabilization of transverse fractures of the patella. Cadaveric knees were used to model acute fractures of the patella. To test three treatment techniques in pairs of knees, specimen pairs were assigned randomly to a set of predetermined treatment pairs so as to provide equal numbers of paired and unpaired data sets. Results then were analyzed using a two-way analysis of variance. The treatment techniques used are widely applicable in the clinical setting for the treatment of transverse fractures of the patella. No specialized equipment or training is required for the general or subspecialized orthopaedic surgeon. None. Fractures were created in eighteen knees (nine pairs) and repaired by one of three techniques: (a) modified tension band (AO technique); (b) two parallel 4.5-millimeter interfragmentary lag screws; or (c) a new technique using four-millimeter cannulated lag screws with a tension band wired through the screws. In mechanical testing, the amount of interfragmentary separation in simulated knee extension and the maximum load to failure at 45 degrees of flexion were measured. Fractures stabilized with a modified tension band were found to displace significantly more than those fixed with screws alone or screws plus a tension band in simulated knee extensions (p < 0.05). The fractures fixed with the cannulated screws plus the tension band failed at higher loads (mean = 732 newtons) than those stabilized with screws alone (mean = 554 newtons, p = 0.06) or those with a modified tension band (mean = 395 newtons, p < 0.05). Combining interfragmentary screw fixation with the tension band principle appears to provide improved stability over the modified tension band or screws alone for transverse patella fractures. Cannulated screws allow for simple, reliable addition of a tension band to screw fixation.
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            Fractures of the patella.

            Patellar fractures usually occur from distraction and three-point bending of the patella as well as from direct blows. Surgical treatment is necessary for fractures that are displaced more than 2 mm and may include open reduction and internal fixation, partial patellectomy, or rarely, total patellectomy. We have presented a new technique for the stabilization of a simple transverse fracture that has provided superior results in laboratory tests. Postoperative complications can be minimized by good attention to wound care, accurate fracture reduction, secure fracture fixation and an early range of motion. Despite the surgeon's best efforts, however, post-traumatic osteoarthrosis can develop and may require additional treatment.
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              Mechanical function of the patella.

              H Kaufer (1971)
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                Author and article information

                Journal
                Indian J Orthop
                Indian J Orthop
                IJOrtho
                Indian Journal of Orthopaedics
                Medknow Publications & Media Pvt Ltd (India )
                0019-5413
                1998-3727
                May-Jun 2012
                : 46
                : 3
                : 304-311
                Affiliations
                [1]Department of Orthopaedics, Institute of Post Graduate Medical Education and Research, Kolkata, India
                Author notes
                Address for correspondence: Dr. Parag Garg, Room No. 219, Doors Quaters, SSKM Hospitals, 242 AJC Bose Road, Kolkata, India. E-mail: pgiluvu@ 123456gmail.com
                Article
                IJOrtho-46-304
                10.4103/0019-5413.96391
                3377141
                22719117
                1cb3b54a-3a5d-4bad-a217-aefd1516f377
                Copyright: © Indian Journal of Orthopaedics

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Original Article

                Orthopedics
                patellar traction,nonunion patella,v–y plasty,patellectomy
                Orthopedics
                patellar traction, nonunion patella, v–y plasty, patellectomy

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