Case Report
Non union patella with quadriceps contracture –
A case report
Rohan A. Bhimani*, Sanjay N. Patil**
*
**
Resident, Professor and HOD, Department of Orthopaedics, Bharati Hospital, Pune – 411043 Maharashtra, INDIA.
Email: [email protected], [email protected]
Abstract
Introduction: Non union patella with quadriceps contracture is an unusual orthopaedic finding. Very few cases have
recorded in the past have been recorded with similar findings. We record a case of 45 year male with non union patella
with quadriceps contracture secondary to trauma. Case Report: A 45 year male with post traumatic non union patella
with quadriceps contracture since 6months presented in the O.P.D. with complaints of defect in right knee with restriction
of movements. The roentogram of right knee confirmed our findings. He underwent Quadricepsplasty with Tension Band
Wiring for the patella followed by rigorous physiotherapy to achieve current level of knee flexion of 110 degrees.
Conclusion: Thus we conclude that quadricepsplasty with tension band wiring is one the good modalities of treatment
for a non union patella associated with quadriceps contracture.
Keywords: Non- union patella; Quadricepsplasty; Fracture Patella;Tension Band Wiring; Patellectomy.
*
Address for Correspondence:
Dr. Rohan A. Bhimani, Resident, Department of Orthopaedics, Bharati Hospital, Pune – 411043 Maharashtra, INDIA.
Email: [email protected]
Received Date: 18/08/2015 Revised Date: 10/12/2015
Accepted Date: 04/10/2016
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INTRODUCTION
Fractures of the patella contribute almost1% of all
skeletal injuries1. The anterior subcutaneous location of
the patella makes it vulnerable to direct trauma.
Transverse pattern fracture patella is a common form of
presentation in clinical practice. Delayed presentation of
displaced fracture of patella is not an uncommon
presentation in practice. Majority of the times when such
cases present in O.P.D., the fragments are grossly
displaced. In addition there are soft tissues contractures
like quadriceps, retinaculum, and internal ligaments of the
knee joint. There is associated knee joint stiffness and
extensor lag in these patients. The major hurdle is to bring
the fracture fragments together and restore the extensor
mechanism either by bone to bone or bone to tendon
union. It is necessary that length of the contracted tissues
be achieved so that further flexion of the knee is possible.
There are three different schools of thoughts which give
management for such fracture presentation. One is to go
for conservative management with knee ROM exercises.
Other option is to go for one staged procedure in which
the proximal fragment is mobilized and fixed with the
lower fragment using V-Y/ Z plasty and achieving
fractional lengthening. The third option is preoperative
traction to the proximal fragment by skeletal traction
using pins or Ilizarov method to approximate the
fragments and the procedure is done in two stages. We
have used one staged procedure in this case and the
results are encouraging.
CASE REPORT
A 45 year male came to the O.P.D. with complaints of
instability and defect in his left knee since 6 months.
Patient gave history of trauma due to fall as he was under
alcohol influence while walking 6 months back. The
patient had not taken treatment for 6 months because of
financial constraints and ignorance. On examination,
emptiness was present in left knee with intercondylar
articulation surface of tibia and femur visible. A swelling
was seen in anterior aspect of left distal third thigh, which
on palpation was the superior part of the patella. The
lower pole of patella was palpable just above the left
tibial tuberosity (Figure 1). The radiograph confirmed
superior fragment of patella lying in the distal third aspect
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of thigh and lower fragment close to tibial tuberosity
(Figure 2). Patient was then operated by anterior approach
where quadricepsplasty and tension band wiring for
patella was done after bringing the superior fragment
down (Figure 3). Another tension band wire was passed
through neutralization hole made just posterior to tibial
tuberosity and the retinaculum was then repaired.
During Post – Op Period
Figure 1: Cinical picture of the patients
affected patella ragment present in
distal third of thigh
Patient was made to do dynamic quadriceps strengthening
exercises and active straight leg raising. After suture
removal continuous passive motion for his knee was
started. On discharge passive knee ROM was 5 degrees of
extension lag to 40 degrees was present. After 6 weeks
post operative follow up patient had 5 to 90 degree
passive knee ROM. At 3 months follow up patient had
knee passive ROM of0 to 110 degrees (Figure 4).
Figure 2: Roentogram showing fracture
of patella with superior f
Figure 3: intra-operative images of quadricepsplasty, reduction and fixation of patella
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Figure 4: Post operative x ray, suture line, current x ray and present knee range of movement
DISCUSSION
The purpose of reporting this case is to highlight the
possibility of the use of single staged procedure in which
the proximal fragment is mobilized and fixed with the
lower fragment using V-Y plasty and achieving fractional
lengthening preventing quadriceps lag in patients of non
union of patellar fractures with large gaps between the
fracture fragments. The rate of non union in patellar
fractures is about 2.4%. There are few cases reported in
management of such fractures. All cases of displaced
fracture of patella require operative treatment. Patient
generally lands up in gap non union because of patient’s
ignorance as he can walk full weight bearing. The normal
tensile force across a patella is around 3000N which
Authors
reporting
non union of
patella
Uvaraj NR et
al(2007)
Klassen et
al(1997)
Lachiewicz PF et
al(2008)
increase up to 6000N in athletes. Patellofemoral
compressive forces generated are greater than three times
the body weight during routine daily activities and may
exceed seven times the body weight while climbing stairs
and squatting. These forces only act on the proximal pole
if the fracture fragment is accompanied with tears in the
medial and lateral expansions. Integrity of the medial and
lateral expansions along with anterior fascia lata and
sharpies fibers allows active extension of the knee after
patellar fracture. Unopposed passage of these forces, as in
our case, allows a continuous increase in the gap between
the fragments leading to contracture of the proximal
quadriceps mechanism.
The available
support
ingliterature on such presentation is as follows:
Table 1: Various Studies Comparing Different Modalities of Treatment for Non Union Patella
Mean
Treatment for
Number cases
Number of cases
Mean
Duration of
quadriceps contracture
treated
reported
age
delay
( single staged or two
conservatively
staged)
3 (range 2—
22
43 years
No
6.5) months
20
7
38 years
34 months
Yes / single staged
1
-
67 years
2 years
Yes / single satged
Dhar et al(2007)
1
-
54 years
1 year
Yes / two stages
Total
44
The problem with two staged surgeries is that presence of
ilizarov or skeletal traction poses a mental trauma to the
patient along with surgical complications like bone
weakening, pin loosening, pin tract infection and prolong
duration of treatment. But two staged surgeries have been
reported with good results as shown in the table. We
Results ( in terms
of knee rom)
0 to 110 degrees
0 to 109 degrees
5 to 80 degrees of
flexion
0 to 135 degrees of
flexion
opted for one staged procedure i.e. proximal fragment is
mobilized and fixed with the lower fragment/patellar
tendon using V-Y/ Z plasty and achieving fractional
lengthening. Patellectomyis the most commonly practiced
management which is accompanied with problems like
long periods of rehabilitation and restricted range of
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motion. Patellectomy basically compromises the length of
lever arm of external apparatus mechanism, thereby
causing excessive stress on the knee joint during
extension which ultimately causes early degenerative
changes and is therefore a relative contraindication for
young individuals. The problem with osteosynthesis is the
quadriceps contracture which causes separation of the
fracture fragments. This was seen in our patient and
approximation of these two fragments is very difficult.
But we implied the technique of V-Y plasty, which is the
commonest practiced technique for such conditions and
we also tried this technique with very good results.
CONCLUSION
Thus we conclude that quadricepsplasty followed by
tension band wiring is a good surgical measure in
treatment of non union patella with quadriceps
contracture.
CLINICAL MESSAGE
Of many techniques available, we believe that
quadricepsplasty with tension band wiring is a superior
modality of treatment and should be used for patients
with such unusual presentation.
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Source of Support: None Declared
Conflict of Interest: None Declared
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