Authors of section

Author

Denis Marcellin-Little

Executive Editor

Amy Kapatkin

General Editor

Noel Moens

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Tension band wiring

1. General considerations

The patella fracture is under tension and distracted apart by the the pull of the quadriceps muscle group. Acute patella fractures can be reduced. Chronic patella fractures may not be reducible.
The fixation method must resist the large tension forces constantly acting on the patella. Longitudinal K-wires and tension bands can be an effective method to counteract the tension on the patella.
Every effort should be made to reconstruct the patella. If reconstruction is not possible, a partial or complete patellectomy is performed.
Tension band wiring

2. Preparation and approach

The patient is positioned in dorsal recumbency. The pelvic limb is extended.
Dog in dorsal recumbency
A sagittal or parasagittal skin incision is made over the patella.
Sagittal or parasagittal skin incision
A lateral parapatellar or medial parapatellar dissection is performed along the patellar ligament and patella proximally to the quadriceps muscle.

The direction of the approach is based on the location of the comminution.
Lateral parapatellar dissection

3. Reduction

The fragments are reduced and evaluated for reconstruction based on their size and shape.
Reduction of patella fragments
Non-reconstructible fragments are removed using forceps.
Non-reconstructible fragments removal
The two main fragments are clamped with pointed reduction forceps. The smaller fragment is reduced in the proximal or distal part of the patella based on what achieves maximal stability.
Reduction of the first two fragments
The fixation of small fragments often relies on one or two K-wires. Bone screws in lag fashion are used for larger fragments.
The direction of K-wires or lag screws should be as perpendicular as possible to each fracture line. Additional information on lag screw fixation is available here. This process is repeated with additional fragments, until the patella has two main fragments. The size of the patella and the fragments may limit the possibility of applying the fixation.
Patellar fragments fixation

The two main fragments are anatomically reduced and stabilized using small pointed reduction forceps.

Note: Attention should be paid to preserve the patellar ligament fibers.
Main fragments reduction and stabilization

4. Fixation

A hole is drilled transversally in the extra-articular portion of the patella.
A hole is drilled transversally in the extra-articular portion of the patella
Orthopedic wire is pre-placed in the hole. As a guideline, the dimensions of the wire for a German shepherd breed is 18 gauge (1.25 mm).
Smaller wires are used in medium and small breeds. For example, 20 gauge wire (1.0 mm) is used in a border collie, and a 22 gauge wire (0.8 mm) is used in a miniature poodle.
Orthopedic wire pre-placement

Two K-wires are introduced from the proximal or distal aspect of the patella, based on fracture configuration. K-wires are placed:

  • From the smaller to the larger fragment
  • At the medial and lateral edges of the patellar ligament
  • Cranial to the articular surface

The K-wires are directed along the long axis of the patella, making sure to avoid the articular surface.

Note: If the patella is large enough and the fracture configuration allows, the tension band may be substituted with a lag screw.
K-wires placement
The K-wires are placed using a power drill, at low speed (less than 300 rpm), using irrigation to minimize heat generation.
As a guideline, the dimension of the K-wire for a German shepherd is 0.062'' (1.55 mm). Smaller K-wires are used in medium and small breeds. For example, 0.045'' (1.15 mm) is used in a border collie, and a 0.032'' (0.8 mm) is used in a miniature poodle.
K-wires insertion
In small dogs and cats, placing two K-wires may not be feasible due to the small patellar size and a single K-wire may be sufficient.
Single K-wire in small animal patella

A second orthopedic wire is slid under the K-wires. This wire should be placed in close contact with the K-wires and remain cranial to the articular surface.

Note: Be sure the K-wire is placed in close contact to the patella.
Second orthopedic wire insertion
The two wires are tightened using two twists, in a figure of 8 pattern.
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The excess length of the twist is trimmed. Care must be taken to avoid interference between the remaining twists and the articular surface.
The excess length of the twist is trimmed
The K-wires are cut and bent on the near end away from the articular surface. Far ends may also be bent, if accessible.
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Note: The end of the K-wires should not interfere with the patellar ligament or the trochlear ridges.
Risk of interference of the K-wires

Alternative: single orthopedic wire as tension band

A single longer piece of orthopedic wire can be used to create the tension band.
The wire is threaded through the patella; one end is wrapped cranial to the patella under the K-wires and twisted onto the other end of the wire.

Note: This technique may cause uneven tension and displacement of the fragment. The benefit of having one twist knot is minimized tissues interference.

Single orthopedic wire as tension band
The excess length of the twist is trimmed.
The excess length of the twist is trimmed.
The articular surface is evaluated to make sure that it is anatomically reduced.
Articular surface evaluation
The K-wires are cut and bent on the near end, away from the articular surface. Far ends may also be bent, if accessible.
K-wires are cut and bent on the near end
The end of the K-wires should not interfere with the patellar ligament.
The end of the K-wires should not interfere with the patellar ligament.

5. Closure

The stifle joint is sutured using monofilament absorbable suture material. The wound is closed in layers.
Closure of the stifle joint

6. Aftercare

General considerations

Limb disuse after the repair of a patellar fracture is unusual. Most dogs start weight bearing within 3 days of surgery.

The focus of physical rehabilitation is to:

  • Avoid loss of stifle joint motion, particularly loss of extension
  • Avoid excessive stress on the surgical repair during the healing period
  • Promote low-impact weight bearing pelvic limb exercise

The stifle joint is protected and partially immobilized if deemed necessary for approximately 14 days.

Cryotherapy and passive range of motion are indicated but not possible if immobilization is used.

Activity is limited to leash walks until bone healing is radiographically evident.

Phase 1: 1-3 days after surgery

The aim is to reduce the edema, inflammation and pain using cryotherapy anti-inflammatory and analgesic medications.

Gentle passive range of motion of the hip and stifle joint can be initiated to promote mobility and joint health.

Phase 2: 4-14 days after surgery

The aim is to resolve the hematoma, edema, control pain and prevent muscle contracture.

Anti-inflammatory and analgesic medications may still be needed.

If the dog is not starting to use the limb within a few days after surgery, re-evaluation is recommended.

Phase 3: 14 days-8 weeks after surgery

Rehabilitation therapy is continued.

10-14 days after surgery the sutures are removed.

Radiographic assessment is performed every 4-8 weeks until bone healing is confirmed.

Implant removal

If the implants interfere with soft tissues, they should be removed after the fracture is healed.