PROCEDURE 27 Operative Treatment of Fractures of the Patella
Operative treatment of displaced patella fractures is the standard of care due to the increased incidence of nonunion and loss of extensor mechanism strength associated with nonoperative treatment and prolonged knee immobilization (Chen et al., 1998).
Several studies have found that biodegradable materials or strong sutures yield similar clinical and biomechanical results when compared to traditional wire tension band techniques (Bostman et al., 1983; Hung et al., 1985; Jakobsen et al., 1985).
Examination/Imaging
PHYSICAL EXAMINATION
Open knee wounds should be examined thoroughly to determine if they communicate with the fracture site or the knee joint.
Surgical Anatomy
The patella is a subcutaneous bone with minimal soft tissue covering. It is the largest sesamoid bone of the body and lies within the fascia lata and the fibers of the quadriceps tendon.
The patella is served by both extraosseous and intraosseous vascular systems.• The primary blood supply to the patella is from branches of the geniculate anastomotic system around the knee (Fig. 2A).
The patella is surrounded and anchored by a strong retinaculum derived from the deep fibers of the tensor fascia lata in combination with fibers from the vastus medialis, vastus lateralis, iliotibial tract, and patellofemoral ligaments (Fig. 3).
The patellar tendon originates at the apex of the patella and inserts onto the tibial tubercle, blending with the patellar retinaculum and the iliotibial tract fibers (see Fig. 3).
Positioning
The procedure is performed with the patient in the supine position on a radiolucent table with a tourniquet on the proximal thigh (Fig. 4A and 4B).
The leg must be free draped to allow easy flexion/extension of the knee throughout the surgery (Fig. 4C).
Portals/Exposures
Medial and lateral full-thickness flaps are developed and exposure of both retinacula is obtained (Fig. 5B).
