Knee > Fractured Kneecap > Treatments

    Open Reduction and Internal Fixation

Preparing for Surgery

If your fractured kneecap cannot be treated non-operatively, you may have to undergo surgery to have the broken pieces of your kneecap placed back into the best possible position under direct visualization and held in place with metal wires, pins, and/or screws. This is known as open reduction internal fixation (ORIF). If some of the broken pieces are too small to be fixed, they are removed. If part of or the entire kneecap is so severely fractured that it cannot be repaired, it may be partially or totally removed. The decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in giving you the best possibility of a healthy recovery. Most insurance companies require a second opinion before agreeing to reimburse a patient for a surgical procedure. Getting a second opinion from a surgeon who is as qualified as the surgeon who gave the initial diagnosis is advisable in any case.

   Prior to your return home from the hospital, make sure you have received any equipment you will need when you get home from the hospital. This may include a knee brace, crutches, walker, ice packs or coolers, or a continuous passive motion (CPM) machine. You should receive prescriptions for any of these from your doctor when your surgery is scheduled.

   Understand the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   Any physical problems or changes in your overall health, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any medication you are taking.

   Discontinue the use of any anti-inflammatory medicine, especially aspirin, a week prior to surgery, to prevent excessive bleeding during the procedure.

   To reduce the risk of infection, improve healing, and decrease complications, try to quit smoking or decrease the amount you smoke. In general, smokers have a higher overall infection and complication rate.

   If possible, practice walking with your crutches in case you need to use them after surgery.

   Make sure the orthopedist performing the surgery is board-certified, which can be determined by calling the American Board of Orthopaedic Surgery at 919-929-7103.

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If you are not admitted directly to the hospital from the emergency room for your surgery, you will be allowed to go home and schedule your fractured kneecap surgery at a more convenient time over the next few days. Prior to surgery, you may be instructed to go to the hospital for pre-admission testing a few days before surgery. A nurse will review your medical history and provide you with all the preoperative instructions you need.You will be asked about your past medical history, given a complete physical exam and undergo the appropriate routine blood and urine tests and diagnostic studies (e.g. X-rays and electrocardiogram). If you are taking any medications, you will receive instructions about which medications to take and the appropriate dosing prior to your surgery. At most medical centers, you will go to "patient admissions" to check in for your surgery. There may be separate areas for ambulatory outpatients (patients who go home the same day after surgery) and for overnight inpatient surgery check-in. Be sure to ask your doctor or one of his assistants about this. After you have checked in to the hospital, you will go to a holding area where the final preparations are made. The mandatory paperwork is completed and your knee area may be shaved (this is not always necessary). You will be asked to change into a hospital gown and, if necessary, to remove all of your jewelry, watches, dentures, and glasses. You will have the opportunity to speak with your orthopedic surgeon or one of his assistants, and meet the anesthesiologist or anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Unless requested, most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   If your surgery is going to be an outpatient procedure, arrange for someone to drive you home when you are released, as the anesthetic and pain medications may make you drowsy.

   If your surgery is going to be an inpatient overnight stay procedure, pack a bag for yourself that contains toiletries, underwear, personal phone numbers you may need, and any other items you would like to have during your hospital stay.

   Wear a loose pair of pants or other clothing that will fit comfortably over your knee bandage when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

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In an open reduction-internal fixation (ORIF) surgery, which usually lasts approximately two hours, the skin is opened and the broken bones are put back together by the surgeon.

   General anesthesia is typically used for surgery, though in some cases a spinal or epidural anesthetic is used. You can expect to be given a sedative in the operating room before the anesthesiologist administers the anesthesia to put you to sleep.

   One linear incision is made over the front of the kneecap to expose the fractured kneecap. The fractured pieces are examined, placed back into the best possible position, and held together and metal wires, pins, and/or screws. If some of the broken pieces are too small to be fixed, they will be removed. If part of or the entire kneecap is so severely fractured that it cannot be repaired, it may be partially or totally removed.

   After your fractured kneecap is repaired, your incision is closed, a sterile dressing is placed over the wound, and a knee immobilizer or cast is placed to restrict knee movement. You will then be taken to the recovery room.

   The wires or screws remain in place unless they are irritating. This is not uncommon, especially in thin patients. If this is the case, the irritating metal wires, pins, and/or screws will be removed after your fractured kneecap has fully healed.

After surgery to repair your fractured kneecap, you will be transported to the recovery room where you will be closely observed for one to two hours while the immediate effects of the anesthesia wear off. After surgery, you will experience some pain. Adequate pain medications will be prescribed for you. You will be given oral, IV (intravenous), or intramuscular pain medications when you ask for them. In some cases, you will be given an IV patient-controlled analgesia (PCA) device, which delivers pain medications in safe amounts when you push a button. Your knee will be bandaged and may have ice on it. There will likely be pain, and you can expect to be given pain medication as needed. Be sure to ask for medication as soon as you feel pain coming on, because pain medication works best on pain that is building rather than on pain that is already present. The nurses will not give you more than your doctor has prescribed and what is considered to be safe. You should try to move your hips, feet, and ankles while you are in the recovery room to improve circulation. Your temperature, blood pressure, and heartbeat will be monitored by a nurse, who, with the assistance of the doctor, will determine when you are ready to leave the hospital or, if necessary, be admitted for an overnight stay. You may be able to bear some weight on your leg, but you will probably have to use crutches or a walker while a cast or knee immobilizer is on your leg. Older patients may heal more slowly, and their physicians may recommend they remain in a cast or knee immobilizer and continue using crutches, a walker, or a cane for a longer period of time.

After surgery to repair a fractured kneecap, some patients remain in the hospital for one to two days. Depending on the severity of your fracture, the strength of your bone, the quality of your repair, and your surgeon's preference, you may be placed in a cylindrical, long leg extension cast or a knee immobilizer. If your knee is not immobilized, you may be started on range of motion exercises for your knee. This may be done using a continuous passive motion (CPM) machine. The CPM is placed on or attached to your bed and then your leg is placed in it. When turned on, it moves your leg through a continuous range of motion. After surgery, you will experience some pain. Adequate pain medications will be prescribed for you. You will be given oral, IV (intravenous), and/or intramuscular pain medications when you ask for them. In some cases, you will be given an IV patient-controlled analgesia (PCA) device, which allows pain medications in safe amounts when you push a button. Ice also helps control pain and swelling. You will probably be unable to drive a car, so be sure to have arranged a ride home.

If your fractured kneecap required a cast or knee immobilizer after surgery, here is what you can expect and how you can cope with the immobilization of your leg:

   The first concern is to monitor pain and swelling for the first 48 hours while wearing your cast. If your swelling decreases dramatically, the cast may become too loose. If swelling increases, circulation can be dangerously cut off. In both cases, you should contact your physician.

   Keep your cast or knee immobilizer clean, dry, and intact. Wrap it in a plastic shower bag whenever you may come in contact with water.

   Like most knee injuries, treat with R.I.C.E. (Rest, Ice, Compression, Elevation). You may or may not be able to put some weight on your leg, depending on your physician's recommendation. Wrap ice into a well-sealed plastic bag and drape it around the cast or knee immobilizer at knee level for as long as possible.

   Elevate the injured leg above heart level to help blood drain towards your body. It often helps to sleep with pillows or blankets under your ankles.

   Expect some pain for ten to fourteen days after your initial injury. If needed, take pain medication as instructed.

   Move your toes as much as possible to help circulate blood.

   If you develop a rash or irritated skin around your cast, call your physician.

   If you sudden increased pain, contact your physician as early as possible. In general, do not try to "grin and bear it" if pain does not go away within a few days.

   Expect your leg to be immobilized for about four to six weeks before you can begin range of motion and quadriceps strengthening exercises. However, straight leg raising, which exercises the thigh muscles (quadriceps), usually is recommended as soon as the acute pain associated with your injury allows it.

   To avoid complications, only your doctor, a physician assistant (PA), orthopedic nurse, or cast technician should remove the cast with a special vibrating cast saw. In most cases the cast is removed after four to six weeks.

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Once your cast has been removed or use of a knee immobilizer has been discontinued following surgery to repair a fractured kneecap (patella), your physician may recommend physical therapy to help you move about with the aid of crutches, a walker, or other assistive device to maintain and improve your overall conditioning. Though everyone's rehabilitation program is slightly different, rehabilitation for a fractured kneecap after cast removal or discontinuance of a knee immobilizer follows a general pattern. The rehabilitation focuses on strengthening the muscles around your knee and increasing the range of motion of the knee. Rehabilitation can begin about four to six weeks after the injury was treated. Range of motion is extremely important. Movement may be painful at first, but it is important to not allow the knee to stiffen. Rehab then progresses to resistive exercises - those involving weights - to keep the muscles around your knee strong. You should eventually be able to resume functional activities like stair climbing, single leg support, swimming, and driving. You will be able to begin more vigorous activities as your kneecap heals and your leg gets stronger.

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   Knee strengthening exercises: Kneecap (patella) injuries

Once your fractured kneecap has healed, building muscle strength around your knee can help you avoid further injury. Contact sports and activities increase your chances of re-injuring your kneecap. A kneepad can cushion the blow when playing contact sports. Another way to help prevent further knee injuries is to learn knee-sparing exercise techniques.

   Daily Living - the average person takes between 12,000 and 15,000 steps a day. Each step exerts a force between two and five times your body weight on your knees. After a knee injury, take it easy on your knees during the day whenever possible to save them for activities and exercise. Avoid stairs when there is an elevator, take the shortest path when walking, and consider wearing athletic shoes designed to absorb shock.

   Muscle Strengthening/Conditioning - activities themselves are not a substitute for conditioning. It is essential to adhere to the muscle strengthening program you learned in rehab throughout the remainder of your life. The best strengthening programs are low-impact and non-weight-bearing, like stationary bikes and certain weightlifting programs, so that the knees do not have to absorb shock.

   Recreation - your sport or activity of choice helps maintain mental and physical well-being, but it is not a conditioning program. Sports that require twisting and quick direction changes put great strain on your knee.