What is the step by step procedure for treating a fracture patella using the Krackow suturing technique?

Step by Step Procedure for Fracture Patella Repair Using Krackow Suturing Technique

The Krackow suture technique is the preferred method for patella fracture repair as it provides strong fixation with minimal soft tissue irritation and lower reoperation rates compared to metal fixation methods. 1

Pre-Operative Preparation

1. Patient Assessment:

   • Confirm patella fracture pattern (transverse, comminuted, or polar) through radiographic evaluation
   • Assess patient's age, functional status, and pre-existing conditions
   • Evaluate soft tissue condition around the fracture site

2. Pre-Operative Planning:

   • Prepare appropriate suture material (typically FiberWire or similar high-strength non-absorbable suture)
   • Ensure availability of necessary instruments (drill bits, needles, etc.)
   • Plan for antibiotic prophylaxis to be administered within one hour of skin incision 2
   • Prepare for active warming strategies to prevent intra-operative hypothermia 2

Surgical Procedure

Step 1: Patient Positioning and Approach

• Position patient supine on operating table with a bolster under the knee (30° flexion)
• Prepare and drape the knee in standard sterile fashion
• Make a midline longitudinal incision over the patella, extending from 2-3 cm above to 2-3 cm below the patella

Step 2: Fracture Exposure

• Develop full-thickness skin flaps
• Identify and protect the extensor retinaculum
• Evacuate hematoma and irrigate the fracture site
• Identify and remove small, non-viable bone fragments
• Expose the fracture surfaces completely

Step 3: Fracture Reduction

• Reduce the fracture fragments anatomically using reduction clamps
• Ensure articular congruity of the patella
• Temporarily hold the reduction with K-wires if necessary

Step 4: Krackow Suture Application

1. Use a high-strength non-absorbable suture (FiberWire #2 or #5)

2. Begin the Krackow stitch at the superior pole of the patella:

   • Insert the needle through the quadriceps tendon 1-2 cm above the superior pole
   • Pass the suture in a locking fashion along the medial and lateral borders of the quadriceps tendon
   • Continue the locking pattern distally across the fracture site
   • Create 3-4 locking loops on each side of the patella

3. For the inferior fragment:

   • Continue the locking pattern through the patellar tendon
   • Create 3-4 locking loops on each side of the inferior fragment
   • Exit the suture through the patellar tendon 1-2 cm below the inferior pole

4. For transverse fractures:

   • Apply the sutures in a figure-of-eight pattern around the patella
   • Ensure the sutures cross over the anterior surface of the patella

Step 5: Tension Application and Fixation

• Apply tension to the suture ends to compress the fracture site
• Ensure anatomic reduction is maintained during tensioning
• Tie the suture ends securely with multiple knots
• For additional stability in comminuted fractures:
  • Apply additional transverse sutures perpendicular to the main suture line
  • Consider adding circumferential sutures around the patella periphery

Step 6: Reinforcement (Optional)

• For highly unstable fractures, consider adding:
  • Additional transosseous sutures through drill holes in the patella
  • Perpendicular sutures to neutralize tensile forces

Step 7: Closure

• Repair the extensor retinaculum with absorbable sutures
• Close the subcutaneous tissue and skin in layers
• Apply sterile dressing and knee immobilizer or brace

Post-Operative Management

1. Immediate Care:

   • Continue antibiotic prophylaxis as per protocol
   • Administer appropriate pain management including regular paracetamol 2
   • Provide supplemental oxygen for at least 24 hours 2
   • Monitor for complications including compartment syndrome

2. Early Rehabilitation:

   • Begin isometric quadriceps exercises on day 1
   • Initiate early mobilization as tolerated
   • Maintain partial weight-bearing with assistive devices
   • Progress to an appropriate rehabilitation program including physical training and muscle strengthening 2

3. Follow-up Care:

   • Radiographic evaluation at 2,6, and 12 weeks post-surgery
   • Monitor for complications including:
     • Nonunion
     • Infection
     • Hardware irritation
     • Extensor mechanism insufficiency 3
   • Continue long-term balance training and fall prevention 2

Clinical Considerations and Pitfalls

• Advantages of Krackow Suturing:

  • Lower reoperation rate (15.4%) compared to metal fixation (43.9%) 1
  • Significantly less soft tissue irritation requiring implant removal 1
  • Avoids need for subsequent hardware removal surgery

• Common Pitfalls to Avoid:

  • Inadequate tension in the suture construct leading to loss of reduction
  • Over-tensioning causing patella baja (inferior displacement of patella)
  • Poor suture placement resulting in fragmentation of bone
  • Failure to repair the retinacular tears
  • Delayed mobilization leading to arthrofibrosis

• Special Considerations:

  • For elderly patients with poor bone quality, consider using larger suture material
  • Avoid hybrid fixation (combination of suture and metal) as it can lead to patella baja and higher rates of soft tissue irritation 1
  • Consider patient age as outcomes tend to be better in patients under 30 years 4

The Krackow suture technique represents an excellent option for patella fracture fixation with lower complication rates than traditional metal fixation methods, particularly for distal pole fractures of the patella 1.