From the Guidelines
Tension band wiring for patellar fractures involves several key steps to achieve stable fixation and promote healing, with the most critical aspect being the application of the tension band principle to convert anterior tensile forces into compressive forces at the articular surface during knee flexion. The procedure typically starts with the patient positioned supine with the knee flexed 15-20 degrees over a bolster. After standard surgical preparation and draping, a midline longitudinal incision is made over the patella. The fracture site is exposed, and any hematoma is evacuated. Interposed soft tissue is removed, and the fracture fragments are reduced anatomically using reduction clamps.
- Key steps in the procedure include:
- Insertion of two parallel 1.6mm Kirschner wires from inferior to superior across the fracture site, approximately 5mm deep to the anterior surface of the patella.
- Passing an 18-gauge stainless steel wire in a figure-of-eight configuration around the K-wires and through the quadriceps and patellar tendons.
- Tightening the wire to compress the fracture site.
- Bending and cutting the K-wires, then impacting them into the bone to prevent soft tissue irritation.
- Repairing retinacular tears and closing the wound in layers.
The effectiveness of this technique is supported by the principle that it counteracts the pull of the quadriceps muscle, allowing for early mobilization, which is crucial for cartilage health and preventing stiffness while maintaining stable fixation during the healing process 1. Postoperatively, patients typically begin early controlled range of motion exercises in a hinged knee brace, with weight-bearing as tolerated. This approach is aimed at optimizing outcomes in terms of morbidity, mortality, and quality of life by promoting early recovery and minimizing complications.
From the Research
Step-by-Step Procedure for Fracture Patella Managed by Tension Band Wiring
- Preparation: The patient is prepared for surgery, and anesthesia is administered as necessary [(2,3,4,5,6)].
- Approach: A surgical approach is made to access the patella, and the fracture is reduced [(2,3,4,5,6)].
- Kirschner Wire Insertion: Kirschner wires are inserted into the patella, and the ends are bent to prevent migration 3.
- Tension Band Wiring: A tension band wire is passed around the Kirschner wires, and the fracture is secured [(2,3,4,5,6)].
- Tightening: The tension band wire is tightened to provide stability to the fracture [(2,3,4,5,6)].
- Closure: The surgical wound is closed, and the patient is immobilized as necessary [(2,3,4,5,6)].
Post-Operative Care
- Immobilization: The patient is immobilized for a period of time to allow for fracture healing [(2,4,6)].
- Rehabilitation: The patient undergoes rehabilitation to regain range of motion and strength [(2,3,4,5,6)].
- Follow-Up: The patient is followed up to monitor fracture healing and to remove hardware as necessary [(2,3,4,5,6)].
Complications and Considerations
- Loss of Reduction: There is a risk of loss of reduction, particularly in inferior patellar pole fractures 2.
- Implant Failure: There is a risk of implant failure, particularly in patients with osteoporotic bone 5.
- Skin Irritation: There is a risk of skin irritation from the hardware [(3,6)].
- Infection: There is a risk of infection, particularly in patients with poor wound healing 6.