Orthopaedics Beyond Implant Surgery

Today, we’re going to talk about Orthopaedics beyond the implant surgery. Here is one of the cases of comminuted fracture of patella, with partial bone loss. Patellectomy was performed. All that was needed was cerclage wire, of course with excellent surgical skillset.

Clinical History

• 27 year old male
• History of RTA
• Presented on the day of Injury
• Wound over right knee

Pre-operative Plan

• Encirclage wiring + figure of eight wiring + removal of small bony fragments
• Back up plan: total patellectomy

• Patellectomy is still considered as the last reserve in treatment of certain conditions including comminuted fractures, advanced chondromalacia or osteoarthritis, infections, and tumoral conditions.
• Problems associated with this procedure are:
  • Decrease in the moment arm of the extensor mechanism
  • Alteration of the forces acting on the tibiofemoral joint and instant center of motion
  • Limitation of range of motion
  • Anterior instability
  • Loss of protection of the trochlea from injury
  • Poor cosmesis

• Extensor mechanism may be repaired in a transverse or longitudinal fashion.
• Transverse repair only 15% of additional force was required to extend the knee after a transverse repair compared with 30% after a longitudinal repair.
• The main objection to a transverse repair is that complete flexion of the knee is limited because of the decrease in the length of the quadriceps-patellar tendon unit.
• An additional criticism is the longer period of immobilization that is needed to protect the tension on the suture line.(Transverse repair)

To Overcome Certain Challenges of Patellectomy

• Some parts of the quadriceps muscle are advanced over the site of the excised patella.
• These techniques provide relatively better cosmesis and better protection of the trochlea from injury.
• Anterior instability and lateral subluxation of the tendon also are avoided when these techniques are used.

Miyakawa technique of patellectomy

• In this technique, a strip of quadriceps tendon is pulled distally to fill the void that was left by the removal of the patella; the vastus medialis and lateralis then are advanced over the site of the excised patella.

Gunal technique- Patellectomy + vastus medialis obliquus advancement technique.

• In this technique, the defect is closed longitudinally and the vastus medialis obliquus is advanced distally and laterally and distal 1 cm and is plicated to increase the angle of insertion in the sagittal plane
• Patella is an important part of the exterior mechanism and should be preserved if possible; when patellectomy is indicated, it seems logical to combine patellectomy with reinforcement techniques.
• For reference