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INTRODUCTION:
The increasing participation of young people in sports has led to a higher incidence of patellar dislocations, which are often associated with injury to the medial patellofemoral ligament. When these injuries are isolated, the first episode can usually be managed conservatively. However, when accompanied by flake-type osteochondral fractures, surgical treatment is required.
Several fixation techniques have been described depending on the size of the fragment, ranging from resection and microfractures to fixation with metallic or bioabsorbable screws. This paper describes a technique published by Siebenlist et al., which uses confluent bone tunnels to pass double- or triple-loaded absorbable sutures. This method allows secure fixation of the fragment while distributing pressure evenly, providing a cost-effective solution.
TECHNIQUE DESCRIPTION:
A diagnostic arthroscopy is performed to identify the lesion and retrieve the fragment, which can also be done through an open approach. A central longitudinal incision is then made, followed by the creation of medial and lateral flaps. The continuity of the patellar tendon is evaluated and, if necessary, reconstructed.
A medial parapatellar approach is carried out after dissecting the vastus medialis obliquus (VMO), which is isolated and later repaired. The patella is manipulated using a 1.8 mm Kirschner wire as a joystick and everted. The bed and fragment are curetted; the fragment often needs to be reshaped due to osmotic hydration.
Temporary fixation of the fragment is achieved using 1.2 mm Kirschner wires, after which confluent tunnels are drilled at the lesion margins toward the anterior patellar cortex. Double- or triple-stranded Vycril 1-0 sutures are passed through the tunnels, forming a parachute configuration. The sutures are crossed over the fragment to ensure stable fixation and tied on the anterior cortex.
Finally, the joint capsule is closed, and formal reconstruction of the medial patellofemoral ligament is performed—or, as described here, advancement of the vastus medialis obliquus can be done instead. This avoids drilling additional tunnels in the patella, thus reducing the risk of fracture secondary to the osteochondral defect.
RESULTS:
This technique provides a stable, simple, and cost-effective reduction suitable for any flake-type lesion configuration. Studies have demonstrated excellent clinical and radiologic outcomes, with significant improvements in pain and knee function scores, rapid fragment integration, and restoration of the articular surface.
REFERENCES.
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Ehmann, Y. J., Zuche, L., Schmitt, A., et al. (2022). Excellent clinical and radiological outcomes after both open flake refixation and autologous chondrocyte implantation following acute patella dislocation and concomitant flake fractures. *Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, 30*(10), 3334-3342. https://doi.org/10.1007/s00167-022-06899-3
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Mittal, R., Digge, V. K., & Nayak, T. (2023). Chronic osteochondral fractures of the patella managed with open reduction and internal fixation yields excellent knee function. *The Journal of Knee Surgery, 36*(8), 894-899. https://doi.org/10.1055/s-0042-1744222
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Astur, D. C., Arliani, G. G., Binz, M., et al. (2014). Autologous osteochondral transplantation for treating patellar chondral injuries: Evaluation, treatment, and outcomes of a two-year follow-up study. *The Journal of Bone and Joint Surgery: American Volume, 96*(10), 816-823. https://doi.org/10.2106/JBJS.M.00312
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Scanlon, J. P., Raymond, A. C., Aujla, R. S., et al. (2023). Combined quadriceps medial patellofemoral ligament reconstruction and osteochondral fixation offers good patient-reported outcomes and low rates of recurrent instability for osteochondral defects secondary to acute patella dislocation. *Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, 31*(9), 4007-4015. https://doi.org/10.1007/s00167-023-07430-y
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Mehl, J., Vieider, R. P., & Siebenlist, S. (2024). Osteoarticular open flake fracture refixation: The “parachute” technique. Arthroscopy Techniques, 13(1), 102805. https://doi.org/10.1016/j.eats.2023.08.010
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Felus, J., Kowalczyk, B., Starmach, M., & Wyrobek, L. (2022). Osteochondral fractures in acute patellar dislocations in adolescents: Midterm results of surgical treatment. Orthopaedic Journal of Sports Medicine, 10, Article 23259671221107608. https://doi.org/10.1177/23259671221107608
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“Flake-Type” Patellar Luxation Fracture. Fixation Using the “Parachute” Technique.
