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Abstract
Introduction
Nonunion patella with quadriceps contracture is an unusual orthopaedic finding. Very
few cases have been recorded in the past with this complication. We present a case
of a 40-year-old male with nonunion patella with quadriceps contracture secondary
to trauma
. Case Report. A 40-year-old male with posttraumatic nonunion patella with quadriceps contracture
since 6 months presented with complaints of defect in the left knee with restriction
of movements. X-ray of the left knee confirmed our findings. He underwent quadricepsplasty
with double-tension band wiring for the patella followed by rigorous physiotherapy
to achieve the current level of the knee flexion of 110 degrees.
Conclusion
We conclude that quadricepsplasty with tension band wiring and neutralization wire
is one of the good modalities of treatment for a nonunion patella associated with
quadriceps contracture.
Fractures of the patella account for about 1% of all skeletal injuries and can lead to profound impairment due to its crucial function in the extensor mechanism of the knee. Diagnosis is based on the injury mechanism, physical examination and radiological findings. While the clinical diagnosis is often distinct, there are numerous treatment options available. The type of treatment as well as the optimum timing of surgical intervention depends on the underlying fracture type, the associated soft tissue damage, patient factors (i.e. age, bone quality, activity level and compliance) and the stability of the extensor mechanism. Regardless of the treatment method an early rehabilitation is recommended in order to avoid contractures of the knee joint capsule and cartilage degeneration. For non-displaced and dislocated non-comminuted transverse patellar fractures (2-part) modified anterior tension band wiring is the treatment of choice and can be combined – due to its biomechanical superiority – with cannulated screw fixation. In severe comminuted fractures, open reduction and fixation with small fragment screws or new angular stable plates for anatomic restoration of the retropatellar surface and extension mechanism results in best outcome. Additional circular cerclage wiring using either typical metal cerclage wires or resorbable PDS/non-resorbable FiberWires increases fixation stability and decreases risk for re-dislocation. Distal avulsion fractures should be fixed with small fragment screws and should be protected by a transtibial McLaughlin cerclage. Partial or complete patellectomy should be regarded only as a very rare salvage operation due to its severe functional impairment.
To review our experience with nonoperative versus operative management of patients with patellar delayed union or nonunion. Retrospective study with an average follow-up of 64 months (range 5-135) after definitive treatment. All patients were reviewed and evaluated at a large multi-specialty clinic. The series represents twenty patients who all presented to our institution with a diagnosis of patellar nonunion irrespective of their initial treatment. This included twelve males and eight females with an average age of 38 (range 12-76) years. Initial treatment of the original fracture was nonoperative in 12 and operative in eight. All fractures progressed to symptomatic nonunion at an average of 34 months from original injury (range 4-109). Definitive treatment of the nonunion was nonoperative in seven patients and operative in 13. Nonoperative management consisted of observation, activity modification, physical therapy, and local pain relief measures. Operative management included open reduction and internal fixation, partial patellectomy, or patellectomy. The internal fixation consisted of tension band wiring, Bunnell wiring, cerclage wiring, or screw fixation. MAIN OUTCOME OR MEASURES: Patients were reviewed for radiographic analysis as well as Knee Society knee and function scores. Definitive treatment was nonoperative in seven patients. Their mean Knee Society knee and function scores at the time of presentation with nonunion were 72 and 78, respectively, with an average knee range of motion of 127 degrees. The nonunions of thirteen patients were treated operatively. Knee Society knee and function scores at the time of presentation with nonunion averaged 82 and 80, respectively, with an average knee range of motion of 112 degrees. Patients who had operative management or elective nonoperative management performed better than those who refused operative management. Patients treated surgically had an average Knee Society score of 94, a function score of 93, and an average knee range of motion of 109 degrees. Those treated nonoperatively had an average knee score of 83, a function score of 75, and an average range of motion of 120.0 degrees. In the nonoperative group, all seven patients had persistent radiographic nonunion. Only one of thirteen patients treated operatively had persistent radiographic nonunion. Our findings suggest that patients with minimally symptomatic delayed union or nonunion of the patella can be successfully treated nonoperatively with the knowledge that the fracture will not unite. Operative management of symptomatic patients can be expected to achieve union and increase function of the knee.
Background: Nonunion of patella is an uncommon entity prevalent more commonly in developing countries. Many of them have a functional knee joint and only those with a wide gap and failed extensor mechanism need surgery. We report an analysis of nonunion of fracture patella treated by 3 surgical method. Materials and Methods: 35 patients of nonunion/delayed union of patella with significant gap and failure of quadriceps mechanism, underwent three different methods surgically: 1) V–Y plasty and tension band wiring (n=10); 2) patellar traction followed by tension band wiring without V–Y plasty (n=15); and 3) patellar traction followed by partial or total patellectomy (n=10). We compared the results of the treatment in terms of Knee Society Score (KSS), Melbourne patella score, time of union, pain, range of movement, quadriceps power, and ability to do daily activities and complications encountered. Results: The 15 cases of patellar traction followed by tension band wiring showed the best results in terms of time to return to normal activities and complications encountered. Cases with patellectomy showed the next best results but they had a longer period of rehabilitation with ultimately lesser patient satisfaction. V–Y plasty gave the worst results both in complication rate and function return. Conclusion: Preoperative patellar traction followed by tension band wiring is a good procedure giving better results than either patellectomy or V–Y plasty.
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