A Novel Surgical Technique for Patellar Fracture: Application of Extra-articular Arthroscopy With Hanger-Lifting Procedure

Abstract

We describe a novel operative technique for patellar fracture. The patient is placed in the supine position for setup of both an image intensifier and arthroscopy. After routine intra-articular inspection with an arthroscope, an extra-articular space including the prepatellar bursa is developed. The space is created with a lifting hanger applied from a portal wherein an arthroscope can then afford both intra- and extra-articular observation of the articular and bony surface of the patella. By use of an image intensifier, the fracture can be treated and fixed in percutaneous fashion with the aid of an arthroscope. This new technique offers surgeons a magnified view of the patella, both intra- and extra-articularly, through a minimally invasive procedure. Although it includes inherent risks and limitations, this new application of arthroscopy would certainly help surgeons to treat patellar fracture.

Fig 1

Operational field during surgery in a left knee. The patient's head is to the right, and the foot is to the left. The hanger (A) lifts up the anterior skin of the patella, affording the operator a view from outside the patella. In this situation the operator is trying to hold the fractured patella with a reduction clamp under an extra-articular arthroscopic view.

Fig 2

Case 1: An 83-year-old man. (A, D) Preoperative and postoperative radiographs of patellar transverse fracture. The fracture was reduced and fixed with 3 cannulated screws and surgical wires in a tension-band wiring fashion. (B, E) Preoperative and postoperative views of extra-articular dry arthroscopy. The gap that existed between the patellar fragments (B) has been reduced and fixed with wires (E). (C, F) Preoperative and postoperative views from inside joint through water. (C) Only the proximal fragment and blood clot had been seen from the AL portal before the reduction. (F) Acceptable reduction was confirmed postoperatively.

Fig 3

Case 2: An 85-year-old woman. (A, C) Preoperative and postoperative radiographs of patellar transverse fracture. Although the length of the K-wires is not long enough, sufficient repositioning could be acquired. (B, D) Preoperative and postoperative views from outside joint. The gap that existed preoperatively has become much smaller after reduction. The wires for tension-band wiring are also seen. The arrowheads indicate the hanger lifting the anterior skin.