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Published Post 04/19/2019, 23:23 PM Dr. Buendía Saavedra Luis Alberto, Dr. Guillermo Redondo Aquino, Dr. Matus Jiménez Juan, Dr.Martínez Arredondo Hilario
Abstract: Knowing that there is little experience on the subject and type of surgery, on the osteosynthesis of the patella in a minimally invasive way, as well as the precise indications for the performance of this technique without affecting the standards of a joint fracture, a previous quasi-experimental study is carried out. clinical exercise in a cadaver specimen and applying it clinically in the HG La Villa in a period from March to June where two cases with patella fracture with a transverse line with a displacement of 3mm to 8mm were captured, demonstrating the viability of the sustained minimally invasive surgical technique; and what is reported in the literature, obtaining the international clinical and functional standards. Applying morphological criteria as surgical indication, the type of line and degree of displacement of the closed fracture of the patella. VAS pain scale: 0
Introduction: Open reduction and internal fixation applying a tension band, with various configurations, is still the gold standard. (1,2,3,4) Percutaneous surgery is a therapeutic option that has shown better results regarding postoperative pain, reduction in surgical time, improving the functional score at 2 years, reducing complications inherent to surgery. (5) If to this is added direct vision via arthroscopy, even better results have been achieved in the anatomical reduction of patellae with selected simple lines, not comminuted and a displacement of less than 8mm. (6,7) The best biomechanical and clinical result on the configuration of the tension band is obtained by attaching the wire to the bone and protecting the tendon from damaging materials. (7) Respecting the anterior circulation of the patella and the lower pole is important to favor the prompt consolidation of the fracture, reducing the risk of ischemic necrosis. (8)
The advancement of surgical techniques is aimed at repairing the damage, with the minimum possible intervention and with adequate biomechanical or superior results. The possibility of performing minimally invasive techniques in selected cases of patella fracture should be a stimulus to train in these techniques by offering a greater benefit to the patient by reducing the rate of infection, wound dehiscence, non-union, with the same standards in this type of surgery; Still in Mexico we do not have morbidity from treatments for this disease, so the side frequency and type of patella fractures in our country is also unknown.
Material and methods: since there is no extensive experience in performing percutaneous patellar surgeries; Minimally invasive procedures were performed on 5 knees of a human cadaver specimen, with a patella fracture with simple lines displaced less than 8mm. (I) under the same technique, it was percutaneously clamped with a field-type reduction forceps; hematoma is drained through the superior lateral portal 5mm (simulated); Controls are taken with AP and Lateral fluoroscope (simulated; the joint posterior to the fence is directly visualized), (II) 2mm kirchner nails are placed with a nail-passing guide and (III) wiring is started with a wire-pass guide, ( IV) Kirchner nails are bent into a cane; (V) they are pulled caudally and cut; Final fluoroscopic control is taken (visualized directly on the specimen). (VI) Satisfactory reduction of the fracture with an average surgical time of 25 min. With the parameters of stability in maximum flexion, stepping less than 2mm and diastasis less than 2mm.
Five possible cerclage configurations described. 5 were minimally invasive osteosynthesis of patellae, 2 at HG La Villa, 2 at HG Balbuena and one at HG Xoco; It comprised a period from March to June, capturing cases of patella with a transverse line with a displacement of 3mm to 8mm. Applying morphological criteria as surgical indication; type of line and degree of displacement of the closed fracture of the patella.
Surgical technique: In the usual operating room under the same aseptic technique, ischemia is placed and percutaneously clamped with a field-type reduction forceps; They take controls with AP and Lateral fluoroscope, corroborating the reduction, hematoma is drained through the superior lateral portal 5mm and surgical lavage with 9% saline solution; Then, 2mm kirchner nails are placed with a nail-passing guide and wiring is started with a wire-pass guide, kirchner nails are bent into a cane; they are traction caudally and cut; final fluoroscopic control is taken. Average surgical time 35min. Results. The anatomical reduction was achieved in all cases within the parameters of stability to maximum flexion, steps no greater than 2mm, diastasis no greater than 2mm.
Case 1: (photo 1) 17-year-old female with a bilateral transverse patella fracture and a 4mm displacement. a Right kneecap was lowered and fixed openly. b Left patella reduced and fixed minimally invasively; both with strap placement at "8". Clinical result at 8 weeks. Functional evaluation of the International Knee Society (IKS) 100/100 both knees. WOMAC = 1 (minimal pain evocation) there is no difference in both knees.
Photo 1📷Case 2: (Photo 2) 62-year-old male with left patella fracture, with 4mm displacement, Functional evaluation by the International Knee Society (IKS) 90/100 left at 8 weeks. WOMAC = 1 (minimal pain evocation) Patient wandering with cane support from the second postoperative day.
Discussion: In recent studies, minimally invasive surgery has shown its usefulness in the surgical treatment of patellar fractures in selected cases; the presentation of these cases using this technique exposes a feasible surgical resource, when performing the reduction of the fracture supported by x-rays, and basic instruments available in any trauma hospital.
One-year follow-up case 2
X-ray: consolidation of the grade III patella is observed one year after surgery.
The viability of closed reduction and internal fixation with dynamic tie is confirmed in selected cases of patellar bills, demonstrating an aesthetic benefit and reducing patella debris and therefore risks of infection, wound dehiscence, delayed consolidation, non-union , without diminishing the quality of the surgical and biomechanical result; Considering international criteria for pain and functional outcome, it is possible to add arthroscopic visualization in the initial lateral portal if the resource is available; guaranteeing joint alignment and functional result.
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