https://orcid.org/0000-0003-1854-309X
“To me there has never been a higher source of earthly honor or distinction than that connected with advances in science.” Isaac Newton.
Patellar fractures account for approximately 0.5–1.5% of all types of bone fractures.Citation1 The loss of knee extension turns these fractures into very limiting. Therefore, in case of a displacement greater than 2–3 mm and due to the incongruity caused, surgical treatment is advised.
The surgical repair allows for restoring anatomically, allowing for an early recovery, with total weight bearing in a short time and a knee range of motion that minimized the risk of arthrofibrosis.Citation2
Fractures among the inferior pole have an added problem, the difficulty of surgical repair due to the small amount of bone tissue available or the comminution of the fracture.Citation3
Once surgery is performed, these types of fractures present with two battlefields for the orthopedic surgeon.
First is the complication caused by the material used to synthesize the fracture. A multitude of surgical solutions have been described for patellar fractures. Currently, the most common treatment may be cerclage wiring and figure-of-eight reduction. Surgical steel, wire, are the most frequent materials used in most centers, due to their ease of use and access.Citation2–5
One step for the improvement of this critical point is the use of more resistant materials such as a titanium-made plate or even high-resistant sutures that avoid the removal. With all these variants, we will be able to observe better indexes of fracture consolidation, and fewer local complications and removal of material.Citation6 This fact reduces not only patients' problems, but also the hospital and medical costs.Citation2,Citation4,Citation5,Citation7,Citation8 The published study exposes a different way of reducing the pressure on the fracture site. Simply creating a focus of tension away from the fracture by a figure of eight suture reduces one of the biggest postoperative problems in these cases, which is the loss of reduction of the fracture.Citation8
The second major problem is the consequence over the articular cartilage, especially if the fracture has caused articular incongruences at the time of impact. In long term, osteoarthritis determines the joint's progress in terms of loss of range of motion and, above all, pain.
To improve the different degrees of chondropathy, there are several methods to improve the cartilage's biology, such as hyaluronic acid, platelet-rich plasma, or stem cells.Citation9
Therefore, when we face a patient with patellar fracture we are not only proposing bone reduction, restoring anatomy, or avoiding a bone step-off. We are not only thinking of early mobilization. We are not only avoiding stiffness. That is, when we propose a surgical treatment for these fractures, we are not only thinking of fracture consolidation, but also considering in mind the other big issue: avoid osteoarthritis.
Undoubtedly, the great long-term limitation of these lesions is the degree of injury that can occur at the moment of impact or the degeneration that may take place later. Experience tells us that an excellent surgery with an anatomic reduction will have good outcomes. But experience also tells us that an anatomic reduction does not exclude an osteoarthritic degeneration of the patellofemoral joint. Obviously, a normal patellofemoral axis and correct congruence will improve the long-term outcomes of the fracture. However, there are patients with a theoretical good prognosis at the beginning that may evolve poorly.
The anatomical restitution is very important to minimize the short- and long-term damages. The presented study seeks to generate a type of synthesis that not only recovers the anatomy, but also seeks greater stability without requiring new surgeries.Citation8
This is not a new concept, which was already published by the Cuscó team, using material that did not require removing with an excellent reduction.Citation2 However, in the case of the commented article, a concept is added. By generating a tension in the patellar tendon, we reduce the work of the fracture site and therefore reduce the forces that work on the fracture site, protecting our fixation system.Citation8
The main limitation to generate conclusions is that fractures have several variables that can produce a certain heterogeneity in the series described. Not only the traces of fracture, or the association of cartilaginous lesions will give us less consistent results, but the degree of osteopenia, osteoporosis, fragmentation of the fracture will condition us toward the surgery as well as the results. In the published study, we find another limitation of many studies. An insufficient design of the distribution of the groups and the lack of randomization generate studies of low average quality. A self-criticism to which we dedicate ourselves to surgery is that we tend to explain our usual work, but we do not stop to propose well-defined study designs thinking about the degrees of evidence. Conversely, when we have a long series, we tend to do level III or IV studies, which are many times more descriptive than inferential.Citation8
Therefore, when we face a patellar fracture, we do not restrict ourselves to restoring anatomy, but we must go further, think in biology with all the available resources and with whatever science progresses.
DECLARATION OF INTERESTS
Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
REFERENCES
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