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.
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
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.
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.
the use of any anti-inflammatory medicine, especially
aspirin, a week prior to surgery, to prevent excessive
bleeding during the procedure.
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.
possible, practice walking with your crutches in case
you need to use them after surgery.
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.
to ask the doctor
to take to the hospital
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:
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
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
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
a loose pair of pants or other clothing that will fit
comfortably over your knee bandage when you leave the
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.
to take to the hospital
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.
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.
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.
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
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:
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.
your cast or knee immobilizer clean, dry, and intact.
Wrap it in a plastic shower bag whenever you may come
in contact with water.
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.
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.
some pain for ten to fourteen days after your initial
injury. If needed, take pain medication as instructed.
your toes as much as possible to help circulate blood.
you develop a rash or irritated skin around your cast,
call your physician.
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
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.
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.
to call the doctor after surgery
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.
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.
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.
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.
- 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.