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Stress fracture patella following patella tendon repair
Injury Extra (2004) 35, 13—16
CASE REPORT
Stress fracture patella following patella tendon repair B.I. Singha,*, S. Sinhaa, S. Singha, R. Shrivastavaa, V.I. Mandaliab a
Department of Trauma & Orthopaedics, William Harvey Hospital, Kennington Road, Ashford TN24 0LZ, UK b Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK Accepted 5 November 2003
KEYWORDS Patella fractures; Stress fractures; Patella tendon repair; Suture material
Summary Introduction: Patella fractures account for less than 1% of injuries treated by orthopaedic surgeon. Stress fractures or iatrogenic fractures are rare. Patella fracture following repair of avulsed patellar tendon is not yet been reported in literature. Case Report: A fit 28-year-old gentleman sustained an injury to his right knee while playing football. He underwent an exploration and primary repair of his avulsed tendon. A technique employing transosseous suture material through patella was used. Eight weeks following the primary injury, he twisted his knee while walking and sustained a fracture patella. On table he was found to have comminuted fracture of patella, with vertical and transverse split at the point of suture exit. This was treated with circlage wiring and tension band wiring loop. Discussion: Patella tendon ruptures are uncommon. Avulsion from the distal pole of patella is treated with transosseous repair using non-absorbable sutures (e.g.: Ethibond) along with circlage wiring to protect the repair. The reasons for this fracture and methods to reduce this complication are discussed. ß 2003 Elsevier Ltd. All rights reserved.
Introduction
Case report
Patella fractures account for <1% of injuries treated by orthopaedic surgeon. Stress fractures or iatrogenic fractures are rare and are commonly seen following total knee replacement surgery and rarely in high impact sports like basketball. Patella fracture following repair of avulsed patellar tendon is not yet been reported in literature.
A fit 28-year-old gentleman sustained an injury to his right knee while playing football. He was unable to bear any weight on the leg and could not continue playing following the fall. He was brought to Accident & Emergency Department where he was diagnosed to have a rupture of patella tendon (Fig. 1). He underwent an exploration and primary repair of his avulsed tendon. The tendon was found to be avulsed from its attachment to the distal pole of patella. A technique employing transosseous suture material through patella was used. Three tunnels were made from the distal pole to patella exiting through the mid portion on the anterior aspect, using a 2.5 mm drill bit. EthibondÕ Excel
*Corresponding author. Present address: The Anchorage, 8A Tovil Green, Maidstone ME15 6RJ, KENT, UK. Tel.: þ44-1622-752640; mobile: þ44-7876-494044; fax: þ44-1227-864141. E-mail address: [email protected] (B.I. Singh).
1572–3461/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.11.015
14
B.I. Singh et al.
Figure 1
Following first injury, causing avulsion of patella tendon from distal pole of patella.
(Polybutylate Coated Polyester–—EthiconÕ Limited) No. 2 was used as the primary anchoring device. Care was taken for adequate saggital plane alignment and the sutures were tightened with the knee in 458 flexion. The repair was supplemented with continuous suturing of the remainder of tendon with the periosteum of patella using a No. 2—0 VicrylÕ. The repair was protected by a loop of stainless steel wire around the patella, patella tendon and anchored just distal to the tibial tubercle with a single screw. The leg was immobilised in a plaster for 8 weeks following which supervised mobilisation was started and placed in range of motion brace. The circlage wire was removed 2 weeks later. The patient progressed to 458 knee flexion by 4 weeks
Figure 2
following removal of the plaster. At 6 weeks, following the removal of the plaster the patient presented to the Accident & Emergency Department. He had sustained a twisting injury to his knee whilst walking, unable to walk. He was found to have a swollen knee and was unable to do an active straight leg raise. Clinically, there was suspicion of a fracture patella, which was confirmed on plain radiographs (Fig. 2). This showed a transverse fracture through the distal half of the patella. A decision to treat this fracture surgically was taken after discussion with the patient.At second surgery, a comminuted fracture of the distal half of patella was found. There was a transverse line through the middle of patella. The distal half was found to have
Second injury leading to fracture patella. At surgery fracture through suture holes was found.
Stress fracture patella following patella tendon repair
15
Figure 3 Final follow up, fracture united well and ROM 0—90.
splits in the saggital plane at two places, leaving the distal portion in three pieces. The fracture was found to correspond to the exit point of the tunnels, made for primary anchoring. The fracture was reduced and fixed using a figure of eight tension band wiring as well as a circlage wire as it was not possible to use the standard tension band wiring technique (Fig. 3). The leg was further immobilised for a period of 6 weeks, following which he underwent supervised mobilisation. At 8 weeks, following the second surgery the patient had regained 0—908 knee flexion. He complained of prominent wires but was able to walk independently. The fracture has united satisfactorily.
Discussion Fracture of the patella constitutes only about 1% of all skeletal injuries, resulting from a combination of direct and indirect forces. Stress fractures are uncommon and are seen as a complication following total knee replacement surgery3 and more recently following reconstruction of the ruptured anterior cruciate ligament (ACL) with the use of bone patella tendon graft.7 There are no previous case reports of fracture patella following repair for ruptured patella tendon. Patella tendon ruptures are uncommon. Mid substance ruptures are easier to repair as compared to avulsion injuries. Avulsion from the distal pole of patella is treated with transosseous repair using non-absorbable sutures (e.g. Ethibond) along with some sort of circlage wiring to protect the repair.1,2,4—6 The reason for employing non-absorb-
able sutures is to give enough strength to the repair while the tendon heals and regains attachment to the patella. There are various possible explanations why the fracture occurred. Firstly, the use of nonabsorbable material may have led to persistence of the drill holes for a longer period of time, leaving a potential area of weakness. Secondly, immobilisation for 8 weeks2 may have caused a certain amount of disuse osteopenia and, finally, the exit of the tunnels on the anterior surface would have caused a stress riser effect. Our patient had achieved a knee flexion of 458 and after removal of the circlage wire, caused the stress to concentrate over the drill holes leading to a fracture. The availability of better absorbable synthetic sutures, which are absorbed slowly may provide alternative to non-absorbable sutures. Polydioxanone (PDSÕ) and Polyglactin 910 (VicrylÕ) are two synthetic absorbable suture materials, which retain enough tensile strength to be able to provide strength to the repair, while healing takes place. PDS, retains approximately 50% of its original strength at 6 weeks and makes an ideal substitute. There is minimal absorption until 90 days and is complete around 180—210 days. There is minimal inflammatory reaction in tissues and is eventually replaced with an in-growth of fibrous connective tissue. After a repair, the leg is immobilised for 3—4 weeks,1 during which time the absorbable sutures maintains enough strength to facilitate mobilisation. Use of range of motion brace and supervised physiotherapy earlier would have prevented disuse osteopenia. Finally, we believe and recommend that the tunnels should exit at the superior pole of patella and not anteriorly.
16
We also think use of synthetic absorbable suture materials may be safe and help prevent this type of complication and is a safe option.
References 1. Campbell’s operative orthopaedics: repair of fresh rupture of patella tendon. Chapter 32. 2. Enad JG, Loomis LL. Primary patellar tendon repair and early mobilisation–—results in an active-duty population. J South Orthop Assoc 2001;10(1):17—23.
B.I. Singh et al.
3. Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthopaed 1985;192:13—22. 4. Ong BC, Sherman O. Acute patellar tendon rupture: a new surgical technique. Arthroscopy 2000;16(8):869—70. 5. Ravalin RV, Mazzocca AD, Grady-Benson JC, Nissen CW, Adams DJ. Biomechanical comparison of patellar tendon repairs in a cadaver modal: an evaluation of gap formation at the repair site with cyclic loading. Am J Sports Med 2002;30(4):469—73. 6. Shelbourne KD, Darmelio MP, Klootwyk TE. Patellar tendon rupture repair using Dall—Miles cable. Am J Knee Surg 2001; 14(1):20—1. 7. Stein DA, Hunt SA, Rosen JE, Sherman OH. The incidence and outcome of patella fractures after anterior cruciate ligament reconstruction. Arthroscopy 2002;18(6):578—83.
CASE REPORT
Stress fracture patella following patella tendon repair B.I. Singha,*, S. Sinhaa, S. Singha, R. Shrivastavaa, V.I. Mandaliab a
Department of Trauma & Orthopaedics, William Harvey Hospital, Kennington Road, Ashford TN24 0LZ, UK b Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK Accepted 5 November 2003
KEYWORDS Patella fractures; Stress fractures; Patella tendon repair; Suture material
Summary Introduction: Patella fractures account for less than 1% of injuries treated by orthopaedic surgeon. Stress fractures or iatrogenic fractures are rare. Patella fracture following repair of avulsed patellar tendon is not yet been reported in literature. Case Report: A fit 28-year-old gentleman sustained an injury to his right knee while playing football. He underwent an exploration and primary repair of his avulsed tendon. A technique employing transosseous suture material through patella was used. Eight weeks following the primary injury, he twisted his knee while walking and sustained a fracture patella. On table he was found to have comminuted fracture of patella, with vertical and transverse split at the point of suture exit. This was treated with circlage wiring and tension band wiring loop. Discussion: Patella tendon ruptures are uncommon. Avulsion from the distal pole of patella is treated with transosseous repair using non-absorbable sutures (e.g.: Ethibond) along with circlage wiring to protect the repair. The reasons for this fracture and methods to reduce this complication are discussed. ß 2003 Elsevier Ltd. All rights reserved.
Introduction
Case report
Patella fractures account for <1% of injuries treated by orthopaedic surgeon. Stress fractures or iatrogenic fractures are rare and are commonly seen following total knee replacement surgery and rarely in high impact sports like basketball. Patella fracture following repair of avulsed patellar tendon is not yet been reported in literature.
A fit 28-year-old gentleman sustained an injury to his right knee while playing football. He was unable to bear any weight on the leg and could not continue playing following the fall. He was brought to Accident & Emergency Department where he was diagnosed to have a rupture of patella tendon (Fig. 1). He underwent an exploration and primary repair of his avulsed tendon. The tendon was found to be avulsed from its attachment to the distal pole of patella. A technique employing transosseous suture material through patella was used. Three tunnels were made from the distal pole to patella exiting through the mid portion on the anterior aspect, using a 2.5 mm drill bit. EthibondÕ Excel
*Corresponding author. Present address: The Anchorage, 8A Tovil Green, Maidstone ME15 6RJ, KENT, UK. Tel.: þ44-1622-752640; mobile: þ44-7876-494044; fax: þ44-1227-864141. E-mail address: [email protected] (B.I. Singh).
1572–3461/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.11.015
14
B.I. Singh et al.
Figure 1
Following first injury, causing avulsion of patella tendon from distal pole of patella.
(Polybutylate Coated Polyester–—EthiconÕ Limited) No. 2 was used as the primary anchoring device. Care was taken for adequate saggital plane alignment and the sutures were tightened with the knee in 458 flexion. The repair was supplemented with continuous suturing of the remainder of tendon with the periosteum of patella using a No. 2—0 VicrylÕ. The repair was protected by a loop of stainless steel wire around the patella, patella tendon and anchored just distal to the tibial tubercle with a single screw. The leg was immobilised in a plaster for 8 weeks following which supervised mobilisation was started and placed in range of motion brace. The circlage wire was removed 2 weeks later. The patient progressed to 458 knee flexion by 4 weeks
Figure 2
following removal of the plaster. At 6 weeks, following the removal of the plaster the patient presented to the Accident & Emergency Department. He had sustained a twisting injury to his knee whilst walking, unable to walk. He was found to have a swollen knee and was unable to do an active straight leg raise. Clinically, there was suspicion of a fracture patella, which was confirmed on plain radiographs (Fig. 2). This showed a transverse fracture through the distal half of the patella. A decision to treat this fracture surgically was taken after discussion with the patient.At second surgery, a comminuted fracture of the distal half of patella was found. There was a transverse line through the middle of patella. The distal half was found to have
Second injury leading to fracture patella. At surgery fracture through suture holes was found.
Stress fracture patella following patella tendon repair
15
Figure 3 Final follow up, fracture united well and ROM 0—90.
splits in the saggital plane at two places, leaving the distal portion in three pieces. The fracture was found to correspond to the exit point of the tunnels, made for primary anchoring. The fracture was reduced and fixed using a figure of eight tension band wiring as well as a circlage wire as it was not possible to use the standard tension band wiring technique (Fig. 3). The leg was further immobilised for a period of 6 weeks, following which he underwent supervised mobilisation. At 8 weeks, following the second surgery the patient had regained 0—908 knee flexion. He complained of prominent wires but was able to walk independently. The fracture has united satisfactorily.
Discussion Fracture of the patella constitutes only about 1% of all skeletal injuries, resulting from a combination of direct and indirect forces. Stress fractures are uncommon and are seen as a complication following total knee replacement surgery3 and more recently following reconstruction of the ruptured anterior cruciate ligament (ACL) with the use of bone patella tendon graft.7 There are no previous case reports of fracture patella following repair for ruptured patella tendon. Patella tendon ruptures are uncommon. Mid substance ruptures are easier to repair as compared to avulsion injuries. Avulsion from the distal pole of patella is treated with transosseous repair using non-absorbable sutures (e.g. Ethibond) along with some sort of circlage wiring to protect the repair.1,2,4—6 The reason for employing non-absorb-
able sutures is to give enough strength to the repair while the tendon heals and regains attachment to the patella. There are various possible explanations why the fracture occurred. Firstly, the use of nonabsorbable material may have led to persistence of the drill holes for a longer period of time, leaving a potential area of weakness. Secondly, immobilisation for 8 weeks2 may have caused a certain amount of disuse osteopenia and, finally, the exit of the tunnels on the anterior surface would have caused a stress riser effect. Our patient had achieved a knee flexion of 458 and after removal of the circlage wire, caused the stress to concentrate over the drill holes leading to a fracture. The availability of better absorbable synthetic sutures, which are absorbed slowly may provide alternative to non-absorbable sutures. Polydioxanone (PDSÕ) and Polyglactin 910 (VicrylÕ) are two synthetic absorbable suture materials, which retain enough tensile strength to be able to provide strength to the repair, while healing takes place. PDS, retains approximately 50% of its original strength at 6 weeks and makes an ideal substitute. There is minimal absorption until 90 days and is complete around 180—210 days. There is minimal inflammatory reaction in tissues and is eventually replaced with an in-growth of fibrous connective tissue. After a repair, the leg is immobilised for 3—4 weeks,1 during which time the absorbable sutures maintains enough strength to facilitate mobilisation. Use of range of motion brace and supervised physiotherapy earlier would have prevented disuse osteopenia. Finally, we believe and recommend that the tunnels should exit at the superior pole of patella and not anteriorly.
16
We also think use of synthetic absorbable suture materials may be safe and help prevent this type of complication and is a safe option.
References 1. Campbell’s operative orthopaedics: repair of fresh rupture of patella tendon. Chapter 32. 2. Enad JG, Loomis LL. Primary patellar tendon repair and early mobilisation–—results in an active-duty population. J South Orthop Assoc 2001;10(1):17—23.
B.I. Singh et al.
3. Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthopaed 1985;192:13—22. 4. Ong BC, Sherman O. Acute patellar tendon rupture: a new surgical technique. Arthroscopy 2000;16(8):869—70. 5. Ravalin RV, Mazzocca AD, Grady-Benson JC, Nissen CW, Adams DJ. Biomechanical comparison of patellar tendon repairs in a cadaver modal: an evaluation of gap formation at the repair site with cyclic loading. Am J Sports Med 2002;30(4):469—73. 6. Shelbourne KD, Darmelio MP, Klootwyk TE. Patellar tendon rupture repair using Dall—Miles cable. Am J Knee Surg 2001; 14(1):20—1. 7. Stein DA, Hunt SA, Rosen JE, Sherman OH. The incidence and outcome of patella fractures after anterior cruciate ligament reconstruction. Arthroscopy 2002;18(6):578—83.