A Basic Preop Evaluation & Management 1 Obtain focused history and performs focused exam Evaluate ability to straight leg raise aspirate hemarthrosis and inject local anesthetic if patient unable to perform due to pain Document distal neurovascular status Assess for concomitant and associated orthopaedic injuries 2 Obtain and interpret basic imaging studies including radiographs and CT scan (if indicated) Radiographs views of knee AP view position patient supine with knee extended and leg IR 3-5° aim beam 1.5cm distal to apex of patella true AP view should have symmetrical femoral and tibial condyles, fibular head bisected by the tibia, and visualization of intercondylar eminence in intercondylar fossa lateral view best view to see transverse fractures position patient supine with knee extended aim beam 2.5cm distal to medial epicondyle true lateral view should have superimposition of posterior aspect of femoral condyles, superimposition of fibular head and tibia, open patellofemoral and tibiofemoral joints, and no visualization of adductor tubercle tangential view best view to see vertical fractures position patient supine with knee flexed 90° aim beam to point inferosuperior and 10-20° cephalad true tangential view should have visualization of femoral condyles and trochlear groove, no superimposition of patella and femur, and open patellofemoral joint Radiographic findings fracture displacement degree of fracture displacement correlates with degree of retinacular disruption patella alta Insall-Salvati ratio >1 indicates disruption of patellar tendon patella baja Insall-Salvati ratio <1 indicates disruption of quads tendon CT scan of knee obtain if suspicion for patellar stress fracture, nonunion, or malunion 3 Prescribe nonoperative management if indicated Indications intact extensor mechanism (patient able to perform straight leg raise) nondisplaced or minimally displaced fractures (<2mm step-off or <3mm displacement) vertical fracture patterns Early active ROM with hinged knee brace early WBAT in full extension progress in flexion after 2-3 weeks 4 Make informed decision to proceed with operative treatment Describe accepted indications and contraindications for surgical intervention Indications extensor mechanism failure (inability to perform straight leg raise) open fractures fracture articular displacement >2mm displaced patella fracture >3mm patella sleeve fractures in children B Advanced Preop Evaluation & Management 1 Perform detailed history and physical exam History identify risk factors for infection and other complications Physical Exam evaluate for stability of knee in all planes 2 Interpret advanced imaging studies See above 3 Explain benefits and alternatives to patient so they can make informed decision Understand need for consultation for flap coverage 4 Explain risks of surgery in patients with Diabetes Know risks of infection and nonunion based on patient risk factors C Preoperative History & Physical 1 Perform focused orthopaedic exam Assess ability to straight leg raise aspirate hemarthrosis and inject local anesthetic if patient unable to perform due to pain Evaluate for soft tissue compromise/open fracture perform saline load test Check neurovascular status 2 Obtain and interpret basic imaging studies including radiographs and CT scan (if indicated) See above 3 Perform operative consent Describe complications of surgery including neurovascular injury infection nonunion infection symptomatic implants weakness stiffness
E Preoperative Plan 1 Template fracture reductions Obtain order of reduction for fracture fragments Determine order of reduction for fracture fragments 2 Template instrumentation Template size and type of instrumentation 3 Execute surgical walkthrough Describe key steps of the operation verbally to attending prior to beginning of case Describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Curettes Periarticular clamps K wires Cerclage wires 2 Room setup and equipment Radiolucent flat top table C-arm fluoroscopy 3 Patient positioning Place patient supine Place bump under ipsilateral hip Place tourniquet high on the thigh G Superficial Dissection 1 Mark out and make the incision Make a midline longitudinal incision centered over the patella 2 Expose the patellar bursa Identify the patellar bursa Open the patellar bursa H Fracture Preparation 1 Clear the fracture site Identify and clear hematoma from the fracture site using curettes and irrigation Identify and remove loose bodies or devitalized fragments 2 Identify and tag the retinacular tissue Follow the fracture line to identify the retinacular tissue Identify the superior and inferior leaves of the retinaculum and tag them for later repair I Kirschner Wire Placement and Fracture Reduction 1 Place K wires Place 2 K wires in the proximal fracture fragment K wires can be placed antegrade (through the superior aspect of the patella) or retrograde (through the fracture sie) on the coronal view, K wires should be placed parallel to each other and divide the patella longitudinally into thirds on the sagittal view, K wires should be placed approximately 5mm below the anterior surface of the patella 2 Advance K wires to the fracture site Deliver the K wires until they are flush with fracture line 3 Reduce the fracture Place the knee in a slightly flexed position Reduce the fracture using a patellar reduction clamp or a large Weber clamp Reduce any depressed articular fragments with a freer elevator 4 Check the reduction Confirm the reduction by palpating the articular surface with a freer elevator if any small articular fragments without attached subchondral bone are found, they should be removed J Kirschner Wire Advancement 1 Advance the K wires Advance the K wires through the opposite side of the fracture fragment, from proximal to distal 2 Check K wire placement using the c-arm Obtain a lateral x-ray to ensure that K wire placement and fracture reduction are appropriate K wires should be placed approximately 5mm below the anterior surface of the patella K Cerclage Wire Placement 1 Orient the cerclage wires Pass a 1.0 mm thick cerclage wire just deep to the K wires this should abut the superior pole of the patella be sure to not leave any soft tissue between the superior pole and the tension band 2 Place angiocath Pass a 16-gauge angiocath through the quadriceps mechanism 3 Advance the cerlage wire Advance the wire through the catheter to assist in placement of the wire Pass the cerclage wire distally in a similar fashion ensure that the wire abuts the distal pole of the patella 4 Loop the cerclage wire Loop the wire around the anterior aspect of the patella Another option is to crisscross the wires in a figure 8 fashion Verify that the K wires have captured the cerclage wires 5 Secure the cerclage wire For even tensioning, use the two loop tensioning technique Gently twist the cerclage wire at both limbs using a large needle driver lift the loop to tension the wire and then twist alternate between the two ends to provide equal tension Continue to sequentially tighten the wires until the desired amount of compression is visualized and palpated at the fracture site L Wire Contouring 1 Trim and bury the cerclage wires Clip the ends of the cerclage wire twists Bend the free end of the twists so that they are facing bone and tamp down 2 Trim and bury the K wires Clip the ends of the K wires Bend the ends of the K wire 180° posteriorly to form a hook and tamp down M Soft Tissue Repair 1 Check the soft tissues Identify retinacular tears 2 Repair the soft tissues Repair the retinacular defect with absorbable braided suture this is critical in restoring the extensor mechanism N Wound Closure 1 Irrigation, hemostasis, and drain Copiously irrigate the wound irrigate until backflow is clear Cauterize peripheral bleeding vessels 2 Deep closure Arthrotomy closure using figure of 8 nonabsorbable suture 3 Superficial closure Subcutaneous closure with 2-0 vicryl Skin closure with 3-0 vicryl and suture or staples 4 Dressings Place a well-padded sterile dressing Place a knee immobilizer
O Perioperative Inpatient Management & Discharge 1 Write comprehensive admission orders Advance diet as tolerated Pain control Inpatient physical therapy Prescribe appropriate DVT prophylaxis Wound management remove dressings on POD2 Foley out when ambulating Check appropriate labs Antibiotics 2 Check radiographs in postop Check placement of implants 3 Initiate physical therapy on POD1 Immediate weightbearing as tolerated in a knee immobilizer or locked hinge brace 4 Appropriate medical management and medical consultation 5 Discharges patient appropriately Pain meds DVT prophylaxis Outpatient physical therapy Schedule 2 week follow-up P Basic Postoperative Care of the Patient without Complications 1 Postop: 2-3 week postoperative visit Continue physical therapy and range of motion exercises Discontinue DVT prophylaxis Wound check Repeat radiographs of knee Remove staples/sutures Diagnose and manage early complications Place locked hinge knee brace in flexion 0 to 60° for 2 weeks, then place in full flexion for 2 weeks 2 Postop: ~6 week postoperative visit Start full weightbearing out of the brace if radiographic signs of healing are present Diagnose and manage of late complications 3 Postop: 1 year postoperative visit Q Advanced Postoperative Care of Patient with Simple Complications (does not require revision) R Postop Care of Patient with Major Complications (requires revision surgery) 1 Develops unique, complex post-operative management plans