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CASE REPORT

Use of the Ilizarov Method to Reduce Quadriceps Lag in the Management of Neglected Non Union of a Patellar Fracture

Shabir Ahmed Dhar, Mohammed R Mir

Address for Correspondence

Shabir Ahmed Dhar
The Government Bone and Joint Surgery Hospital Barzallah
Srinagar Kashmir 190005.
E-Mail: shabirdhar@yahoo.co.in

 

Keywords: Patella, Ilizarov, Quadriceps lag

J.Orthopaedics 2007;4(1)e12

Introduction:

Patellar fractures account for 1% of all skeletal fractures.1 Due to the central role of the patella in ensuring continuity of the extensor mechanism, therefore salvage of the patella is indicated in all but the most severely comminuted fractures. The goal of all surgical procedures in the management of patellar fractures is to accurately reconstruct the extensor mechanism.Non Union of the fracture of the patella is rare with a reported incidence of 2.4%.2 Non union is well tolerated by patients with limited or decreased functional demands on the knee. This however is not true in cases with a large gap between the fragments. Reports about the management of such situations are even rarer.3

We report the case of an eight month old non union of a patellar fracture in a 60 year old male with a significant gap between the fragments. Preliminary application of the Ilizarov technique to bring the fragments together helped avoid possible complications during final surgery.

Case report:

A 60 year old male reported to the outdoor department of our hospital with inability to walk unaided. On eliciting the history, the patient revealed that he had sustained a trauma to the knee 8 months ago due to fall from a height. He had been unable to walk unaided since then and had started using a cane to move around one week after the trauma. The patients pain had subsided over a period of 3 weeks, by which time he had become habituated and reliant on the cane. Physical examination revealed a gap between two bony swellings on the anterior aspect of the knee. The patient was unable to extend the knee with a flexion deformity of 40 degrees. Radiographic examination revealed that the patella had fractured and the two pieces were separated by a gap of 7 centimeters.

Due to the age of the patient and the duration of the neglect, a patellectomy was planned. However it was not possible to bring the two fragments close enough clinically to go ahead with the surgery straight away. A significant quadriceps lag was apprehended. To overcome this potential complication two Steinmann pins were passed transversely through the two fragments of the patella. These were connected by a system of threaded rods and plates. The fragments were gradually brought together over a period of 10 days by applying compression across the Steinmann pins with the help of the threaded rods. The final status was maintained for one more week. After a total of 17 days a patellectomy was carried out. During the surgery the cartilage of the patella was found to be significantly degenerated with significant tears in the expansions. A heavy non absorbable suture was placed through the margins of the patellar and quadriceps tendons and through the medial and lateral capsular expansions in a purse string manner. The suture was pulled taut evaginating the tendons outside the joint. Supplemental interrupted sutures to reinforce the capsular repair and further appose the quadriceps and patellar tendon ends were added. Post operatively the patient was immobilized by a posterior splint for 3 weeks. Range of motion exercises were instituted at 3 weeks. On a followup at 9 months the patient has no quadriceps lag and a 135 degree flexion. Ther was a 2.5 centimeter quadriceps wasting.


                 Fig 1                                 Fig 2

Fig 1:  Showing the visible gap between the fracture fragments at the initiation of the application of the compression fixation.

Fig 2: Radiographs showing the large gap between the fracture fragments at the time of presentation.


                 Fig 3                                 Fig 4

Fig 3: Showing the approximation of the fracture fragments after ten days of gradual compression.

Fig 4: Approximation of the fragments is appreciable clinically as well.

Discussion:

The purpose of reporting this case is to highlight the possibility of the use of the Ilizarov method in preventing quadriceps lag in patients of non union of patellar fractures with large gaps between the fracture fragments. 2.4% of patellar fractures end in non union. 2 However non union is well tolerated by patients with limited or decreased functional demands on the knee. Non union of the patella with a large gap between the fragments is a management challenge. The normal tensile forces across a patella may reach 3000N and may increase to 6000N in atheletes.4 Daily activities generate patellofemoral compressive forces greater than three times the body weight, while forces generated with stair climbing and deep squatting may exceed seven times the body weight.5 These forces act on the proximal pole unopposed when the fracture is accompanied by tears in the medial and lateral expansions. Preservation of the medial and lateral expansions along with anterior fascia lata and sharpey,s fibers allows active extension of the knee after patellar fracture. Unrestricted application of these forces, as in our case, causes a progressive increase in the gap between the fragments and a contracture of the proximal quadriceps mechanism. In this situation the metabolism of hyaline cartilage is disturbed and synovial fluid functions are impaired. Hyaline cartilage degenerates and irreversible changes occur rapidly. Patella preservation whenever possible is seen as a preferable approach compared to other patellar resection techniques, since a significant loss of the extensor mechanism occurs when the patella is partially or totally excised.6 However in certain situations patellectomy is unavoidable. Advocates of patellectomy enumerate shorter immobilization, less complicated operative technique and an earlier return to work as its advantages.7,8 Patellectomy when indicated is best accomplished by shelling out the fragments. Continuity between the quadriceps and patellar tendons is provided either by imbrication or direct suture. The tightness of repair is assessed by obtaining at least 90 degrees of intraoperative knee flexion before strain on the repair becomes noticeable. Attaining a greater degree of flexion, before the repair shows tension effects may increase post operative extension lag. 9 Reports of non union of fractures of the patella are rare.3,10,11 Satku et al reported on the management of a large gap non union of the patella. They used surgical mobilization and tension band wiring.3 When shortening is such that apposing the ends of the tendons is impossible, the Stability is improved and a practical range of knee motion is regained. However full forceful extension may be difficult to restore.Codavilla tendon lengthening technique may be helpful, as described by Scuderi.12 Our case demonstrates that the application of the gradual compression to appose non union fragments of the patella with a large gap, facilitates reconstruction of the quadriceps tendon, eliminating quadriceps lag.

Reference:

  1. Eric EJ.. Fractures do joelho. In; Rockwood CAJ, Green DP, Bucholz RW. Fractures em adultos. 3rd ed. Philadelphia; Lippincott; 1991. p1729-44.

  2. Nummi J; Fracture of the patella; A clinical study of 707 patellar fractures. Ann. Chir. Gynaecol. Fenn., 60[Suppl 179]; 1-85, 1971.

  3. Satku K, Kumar VP. Surgical management of non union of neglected fractures of the patella. Injury 1991 Mar; 22[2]; 108-10.

  4. Hubert HH, Hayes WC, Stone JL, et al. force ratios in the quadriceps tendon and ligamentum patellae. J Orthop Res. 2; 49-54, 1984.

  5. Rorabeck CH, Bobechko WP. Acute dislocation of the patella with osteochondral fracture. A review of eighteen cases. JBJS 58 A; 237-240, 1976.

  6. Muller EJ, Wick M, Muhr G. Patellectomy after trauma; Is there a correlation between the timing and clinical outcome. Unfallchirurg 2003; 106; 1016-9.

  7. Brooke R. Fractured patella; An analysis of 54 cases treated by excision. Br Med J 1946; 1; 231-233.

  8. Levack B, Flannagan JP, Hobbs S. Results of surgical treatment of patellar fracture. JBJS 67B; 476-419, 1985.

  9. Eric E Johnson, Rockwood and Greenís Fractures in adults. 4th Ed V2 p1968. Lippincott Raven. Carriera DA, Fox JA, Freedman KB, Bach BR Jr. Displaced non union patellar fracture following use of a patellar tendon autograft for ACL reconstruction; case report. J Knee Surg 2005 Apr; 18[2] 131-4.

  10.  Espinosa Morales R, Escalante A. Gout presenting as a non union of a patellar fracture. J Rheumatol 1997 Jul; 24[7]; 1421-2.

  11. Scuderi C. Ruptures of the quadriceps tendon; Study of twenty tendon ruptures. Am J Surg 95; 626, 1958.

This is a peer reviewed paper 

Please cite as : Shabir Ahmed Dhar:Use of the Ilizarov Method to Reduce Quadriceps Lag in the Management of Neglected Non Union of a Patellar Fracture

J.Orthopaedics 2007;4(1)e12

URL: http://www.jortho.org/2007/4/1/e12

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