e-ISSN: 2722-3558 Sriwijaya Journal of Surgery [SJS] https://sriwijayasurgery.
Neglected Transverse Patella Fracture in a Geriatric Patient Following Traditional Bone-Setting: Successful Surgical Salvage with Combined Tension Band Wire and Circumferential Cerclage Construct Restu Adi Wardana1*.
Ramco Abtiza2 1General Practitioner.
Pringsewu Regional General Hospital.
Pringsewu.
Indonesia 2Orthopedic Surgeon.
Pringsewu Regional General Hospital.
Pringsewu.
Indonesia
ARTICLE
ABSTRACT
INFO
Keywords:
Cerclage Extensor mechanism Neglected fracture Patellar fracture Tension band wiring *Corresponding author:
Restu Adi Wardana E-mail address:
restuadiwardana5@gmail.
All authors have reviewed and approved the Anal version of the manuscript.
https://doi.
org/10.
37275/sjs.
Introduction: Patellar fractures constitute about 1% of all skeletal injuries and disproportionately affect elderly women because of osteoporosis and lowenergy falls.
Displaced transverse fractures disrupt the knee extensor mechanism and, if unaddressed, predispose to non-union and permanent In many low- and middle-income settings, initial referral to traditional bone-setters remains common and frequently delays definitive Case presentation: A 66-year-old woman presented one month after a simple fall with a displaced transverse fracture of the left patella and KellgrenAeLawrence grade II osteoarthritis of the same knee.
Prior care was limited to traditional bone-setting without improvement.
On admission, she had a palpable patellar gap and an inability to actively extend the knee.
Radiographs confirmed displacement of 10 mm.
Single-stage open reduction and internal fixation with a modified tension band wire construct reinforced by circumferential cerclage was performed.
Active-assisted flexion began on postoperative day 14.
by four weeks, she had 30A of pain-free flexion, full active extension, and primary wound healing, and was discharged for structured outpatient physiotherapy.
Conclusion: A combined tension band wire plus circumferential cerclage construct provided reliable fixation and an encouraging early functional result despite a one-month delay and prior bone-setter manipulation.
Prompt referral and structured rehabilitation remain pivotal for minimising non-union, hardware failure, and long-term disability in geriatric patellar fractures.
Introduction latter pattern is driven by an aging population and the Fractures of the patella account for approximately parallel epidemic of osteoporosis, and is strongly 1% of all skeletal injuries encountered in everyday skewed toward women.
4-6 In elderly patients, the orthopedic practice and constitute one of the classic combination of diminished bone quality, pre-existing injuries that threaten the knee extensor mechanism.
degenerative joint disease, slower protective reflexes.
The peak incidence historically falls within the third to and reduced neuromuscular coordination conspires to fifth decades of life, during which direct blows to the produce displaced and comminuted fracture patterns anterior knee and high-energy decelerations are the after trivial falls.
1,4,7
The patella is a sesamoid bone embedded within epidemiologic surveys have documented a rising the extensor mechanism of the knee, and its structural secondary peak in patients older than sixty years, in whom low-energy mechanical falls predominate.
3,4 The quadriceps force across the joint for the maintenance of active knee extension.
7,8 Transverse tertiary care after weeks of unsuccessful traditional fractures represent the most common morphology treatment, therefore represent a distinct clinical and, when displaced by more than 2Ae3 mm or population whose management requires a tailored accompanied by articular step-off exceeding 2 mm, approach that balances fracture reduction, soft-tissue invariably disrupt extensor continuity and mandate preservation, and the realistic rehabilitation potential operative stabilization.
non-operative management is of an aged musculoskeletal system.
16,21,22
for minimally displaced fractures with 1,3,8,9,10 Despite the abundance of literature addressing Numerous acute patellar fractures, there remains a paucity of surgical techniques have been described, including data specifically describing the surgical management modified tension band wiring using parallel Kirschner and early outcomes of neglected, displaced transverse wires, tension band wiring through patellar fractures in elderly patients referred after screws, circumferential cerclage, fixed-angle plating, and, for highly comminuted fractures, partial or total published case reports describe acute fractures or 7,8,11,12,13 non-union presentations exceeding six months, while Among these, modified tension band wiring remains the subset of patients who present at an intermediate the standard of care because it converts the tensile interval .
pproximately four to six weeks after injur.
forces generated by quadriceps contraction into with a displaced but not yet fully consolidated fibrous compressive forces at the fracture site during active non-union scientific interest of such cases lies in the question of whether conventional one-stage fixation techniquesAi patellectomy with quadriceps 7,8,11 Nonetheless, bone-setting.
16,21
Many consistently report hardware-related complications, wire migration, and symptomatic implants that circumferential cerclageAican still achieve stable occasionally demand reoperation.
The When an acute displaced patellar fracture is not mitigate the excess morbidity attributable to the delay.
promptly recognized and stabilized, the inherent The novelty of the present report is therefore threefold:
biological and biomechanical environment of the .
it documents successful single-stage fixation using patella becomes increasingly hostile to union.
Because a composite tension band and cerclage construct in a the patella is surrounded by synovial fluid and patient with a one-month-delayed, traditional bone- subjected to repetitive shear forces generated by setter-treated displaced transverse patellar fracture quadriceps contraction, interfragmentary motion, and occurring in the setting of pre-existing grade II persistent distraction rapidly predisposes to fibrous .
it illustrates a pragmatic and non-union.
3,15,16 Quadriceps shortening, peripatellar resource-sensitive approach directly transferable to secondary-level hospitals in Indonesia and similar progressive knee stiffness compound the surgical difficulty of any subsequent intervention.
16,17 In middle-income .
disadvantages are often amplified by cultural and messaging with surgical practice to reduce the burden logistical factors: traditional bone-setters remain a of delayed presentations.
The aim of this case report is popular first point of contact for musculoskeletal accordingly to describe the clinical presentation, radiographic findings, operative technique, and six- week functional outcome of a 66-year-old woman with manipulative practices, and a higher rate of malunion, a neglected displaced transverse patella fracture who non-union, and Patients who reach was successfully managed by a combined tension band wire and circumferential cerclage construct, and The patientAos past medical history was significant to situate these findings within the contemporary well-controlled literature on geriatric patellar fracture care.
amlodipine 5 mg daily and for a postmenopausal status of approximately fifteen years without prior Case Presentation hormone replacement therapy or bone mineral density Written informed consent for surgical treatment She denied prior fragility fractures, and for the anonymised publication of this case, chronic corticosteroid use, active malignancy, or including clinical and radiographic details, was inflammatory arthritis.
She was a lifelong non-smoker, obtained from the patient.
The institutional ethics did not consume alcohol, and described herself as committee of Pringsewu Regional General Hospital independent in activities of daily living prior to the waived formal ethical review in line with institutional injury, performing household work, gardening, and policy for single-case reports.
Consent for publication occasional light farming.
There was no relevant family was obtained from the patient.
history of metabolic bone disease or of recurrent Table 1 presents the demographic, anthropometric, and clinical characteristics of the patient at the time On presentation, she was ambulating with bilateral of her initial orthopedic evaluation.
A 66-year-old axillary crutches and weight-bearing exclusively on female of Javanese descent, domiciled in a rural area the contralateral right lower limb.
She denied fever, of Pringsewu Regency.
Lampung Province.
Indonesia, presented to the outpatient orthopedic department of Focused examination of the left knee Pringsewu Regional General Hospital thirty days after revealed moderate suprapatellar and peripatellar sustaining a mechanical fall in her own yard.
swelling with faint residual ecchymosis along the According to the accompanying family members, she medial aspect of the knee.
The overlying skin was had lost her balance while carrying a basin of water intact, without laceration, sinus, or evidence of prior and had fallen forward onto her left knee on a relatively surgical incision.
mild superficial abrasions consistent flat, unpaved ground surface.
She did not lose with repeated manual massage were noted laterally.
consciousness, and there was no secondary trauma well-defined transverse palpable gap of approximately Immediately after the fall, she developed 10 mm was appreciated across the body of the patella, severe anterior knee pain, rapid swelling, and inability tender to palpation.
Knee range of motion was to straighten the knee against gravity.
Rather than markedly limited by both pain and loss of extensor seeking formal medical attention, the patient and her continuity: passive flexion was tolerated to 60 degrees, family sought care from a locally renowned traditional but the patient was unable to perform a straight leg bone-setter raise or initiate active terminal extension.
She could manipulations and applied herbal preparations and sustain only a partial .
pproximately 20A) active arc of circumferential bindings over the anterior knee for the flexion in the seated position.
Patellofemoral crepitus following four weeks.
During this period, her pain and was present on careful passive motion, consistent with functional disability persisted, and, contrary to the pre-existing expectations conveyed by the practitioner, there was cruciate ligament testing was unremarkable within the no restoration of active knee extension.
Growing concern and a deteriorating ability to ambulate examination was normal with intact dorsalis pedis and prompted a family member to bring her to the hospital, posterior tibial pulses, normal capillary refill, and at which point a formal orthopedic assessment was preserved sensation in all cutaneous distributions of the lower limb.
As shown in Table 1, her body mass Collateral index was 26.
3 kg/mA, her calculated American Society of Anesthesiologists physical status was II, and the injury was classified according to the AO/OTA 34-C1 .
imple Table 1.
Demographic and clinical characteristics of the patient at initial orthopedic evaluation.
Characteristic Value / Description Age 66 years Gender Female Body mass index 3 kg/mA .
Ethnicity/domicile Javanese.
rural Pringsewu Regency.
Lampung.
Indonesia Occupation/function Homemaker.
independent in activities of daily living before injury Mechanism of injury Low-energy mechanical fall in own yard onto left knee Interval from injury to orthopedic 30 days* Prior care Traditional bone-setter with repeated manipulation, herbal no improvement Chief complaint Pain and inability to actively extend the left knee Relevant comorbidities Essential hypertension .
mlodipine 5 mg dail.
15 years.
no known osteoporosis diagnosis Smoking/alcohol Never smoked.
no alcohol use Physical examination Palpable 10-mm transverse gap.
unable to perform active straightleg raise.
extension lag.
skin intact with minor lateral abrasions Range of motion Active flexion 0Ae20A.
passive flexion 0Ae60A .
ain-limite.
A Distal neurovascular status Dorsalis pedis / posterior tibial pulses 2 , intact sensation and motor function below the knee AO/OTA classification 34-C1 .
imple articular, transverse, displace.
ASA physical status * Interval between the initial fall and formal orthopedic presentation.
A Range of motion measured using a handheld goniometer with the patient supine.
Laboratory evaluation performed on the day of soft-tissue admission was undertaken to complete preoperative prolonged bone-setter manipulations.
Renal function Table 2 summarizes the complete was preserved .
lood urea nitrogen 14 mg/dL, laboratory panel along with reference ranges and 9 mg/dL), and liver enzymes as well as Hemoglobin was 12.
4 g/dL, consistent electrolytes were unremarkable.
Serum with mild age-related anemia and without evidence of phosphate, and alkaline phosphatase values were active bleeding.
leukocyte count .
8 y 10A/AAL) and within reference ranges, yet 25-hydroxyvitamin D differential were within normal limits, and serum C- reactive protein .
2 mg/L) was not elevated, arguing ng/mL.
South-East Asian postmenopausal women.
Coagulation indices (PT 12.
cholecalciferol 1,000 IU once daily and elemental s, aPTT 32 s.
INR 1.
and fasting blood glucose .
calcium 1,000 mg daily were initiated from admission, mg/dL) were reassuring for elective surgery.
Because of her postmenopausal status and the suspected assessment was planned after discharge.
Table 2.
Laboratory examination and imaging results with reference ranges.
Parameter Patient value Reference range Interpretation Hemoglobin 4 g/dL 0Ae16.
0 g/dL Low-normal.
age-related mild White blood cell count 8 y 10A/AAL 0Ae10.
0 y 10A/AAL Normal.
no leukocytosis Platelet count 245 y 10A/AAL 150Ae400 y 10A/AAL Normal C-reactive protein 2 mg/L < 5 mg/L Not elevated.
no systemic infection Blood urea nitrogen 14 mg/dL 7Ae20 mg/dL Normal Serum creatinine 9 mg/dL 6Ae1.
1 mg/dL Normal Fasting blood glucose 96 mg/dL 70Ae99 mg/dL Normal Serum calcium 2 mg/dL 6Ae10.
3 mg/dL Normal Serum phosphate 6 mg/dL 5Ae4.
5 mg/dL Normal Alkaline phosphatase 84 U/L 30Ae120 U/L Normal 25-OH vitamin D 21 ng/mL** Ou 30 ng/mL Insufficiency Prothrombin time / INR 8 s / 1.
11Ae13 s / 0.
9Ae1.
Normal aPTT 25Ae35 s Normal AP / lateral / Merchant Transverse fracture mid-body patella, 10 mm displacement, 3 mm articular stepoff Ai Displaced transverse fracture with early fibrous interposition Knee KellgrenAeLawrence 0AeIV Mild pre-existing osteoarthritis Ultrasonography of the extensor mechanism Quadriceps and patellar tendon interposition at the fracture line Ai Extensor mechanism failure is limited to the patellar body ** Abnormal values are shown in bold red.
AP = anteroposterior.
INR = international normalized ratio.
aPTT = activated partial thromboplastin time.
Plain elevation and a well-visualized articular step-off of approximately 3 mm.
There was no comminution of projections, summarized together with other imaging either pole, the inferior pole was intact, and the findings in Table 2, demonstrated a single transverse femoropatellar joint demonstrated KellgrenAeLawrence fracture line traversing the mid-body of the patella with approximately 10 mm of superior fragment narrowing, mild subchondral sclerosis and small Merchant joint-space marginal osteophytesAifindings consistent with her preoperative counselling, including the orthopedic, symptomatic degenerative change.
The surrounding concluded that open reduction and internal fixation soft tissues were intact on imaging, and there was no offered the best opportunity for restoring extensor Ultrasonography of the knee confirmed intactness of suitable for early rehabilitation, and preventing the both the quadriceps tendon proximally and the transition of this partially organized fracture into an patellar tendon distally, with the fracture representing the sole anatomical lesion of the extensor mechanism.
consent, the patient was positioned supine on a Based on the integrated clinical and radiographic radiolucent table with a soft bolster beneath the evaluation, a definitive diagnosis of a neglected ipsilateral knee.
Spinal anesthesia using 12.
5 mg of displaced transverse fracture of the left patella (AO/OTA 34-C.
with background KellgrenAeLawrence supplemented with 25 AAg of intrathecal fentanyl.
grade II osteoarthritis was established.
single preoperative prophylactic intravenous dose of The non-union.
After cefazolin 2 g was given thirty minutes before incision.
management are outlined in Table 3.
Multidisciplinary Table 3.
Operative protocol and postoperative rehabilitation timeline.
Time point Intervention Key parameters Clinical response/finding Day of admission Pre-op workup.
long knee vitamin D3 1000 IU calcium 1000 mg Hb 12.
4 g/dL.
ASA II.
written informed consent Stable.
pain 7/10 at rest Operative day (Day .
Open reduction and internal fixation: 2y parallel K-wires figure-of-eight tension band wire circumferential Spinal anesthesia 12.
5 mg 5% 25 AAg cefazolin 2 g.
8mm K-wires.
0-mm cerclage wire Anatomical reduction.
stable through 0Ae90A estimated blood loss 120 operative time 85 Post-op days 1Ae3 Immobilizer in extension.
static isometric quadriceps ankle pumps.
enoxaparin 40 mg/d.
multimodal analgesia Paracetamol 1 g QID ketorolac 30 mg TID .
Ie celecoxib 200 mg BID Pain 5/10 Ie 3/10.
wound complication Post-op day 12 Suture removal.
Wound dry and intact Primary healing Post-op day 14 Initiation of active-assisted flexion to 30A under physiotherapist supervision Continued analgesia.
immobilizer during Flexion to 25A tolerated Post-op day 21 Progressive flexion.
training with crutches Partial weight-bearing Full active straight-leg no extension lag Post-op day 28 .
Discharge to outpatient bone-health Flexion 30A.
pain 2/10 rest, 3/10 motion Radiographs: reduction bridging callus anterior Week 6 .
elephone follow-u.
Continued outpatient fall-prevention Ambulating with a single cane indoors Adherent.
complications reported BID = twice daily.
QID = four times daily.
TID = three times daily.
A longitudinal anterior midline skin incision Postoperative approximately 10 cm in length was centered over the consisted of cefazolin 1 g every eight hours for 24 Subcutaneous tissues and the pre-patellar retinaculum were carefully dissected.
The fracture gap was filled with fibrous tissue and a partial fibrous placement of the tension band construct and cerclage callus, which was gently debrided using a small Early static isometric quadriceps exercises and curette while preserving as much periosteum and gentle ankle pumps were initiated on postoperative cortical surface as possible.
Both fragments were day 1 while the knee remained immobilized in inspected, and the retained cartilaginous surfaces Protected weight-bearing with crutches and were carefully rinsed.
Reduction was achieved by the knee immobilizer in place was permitted on gentle apposition under direct vision and confirmed by postoperative day 2 once the spinal anesthetic had fluoroscopy as well as by palpation of the restored fully resolved and the surgical wound was dry.
articular surface through a small medial parapatellar Two The clinical and rehabilitation timeline from the introduced in a longitudinal fashion, parallel to each review is summarised in Table 3, and the integrated other and to the patellar articular surface, from the clinical courseAiincluding the timeline, functional superior to the inferior pole.
A figure-of-eight 1.
0-mm recovery trajectory, and the fixation construct usedAi cerclage wire was then passed in front of the Kirschner is illustrated in Figure 1.
Active-assisted knee flexion, wires at their superior and inferior entry points using limited to 30A under physiotherapist supervision, an 18-gauge needle as a passer, tightened using two began on postoperative day 14.
The surgical wound parallel twists, and locked to create a tension band across the anterior cortex.
To further reinforce stability postoperative day 12.
By postoperative day 21, the in this osteoporotic bone and to counteract the chronic patient demonstrated active knee flexion to 25A, a symmetrical straight leg raise against gravity, and the day of injury through the six-week postoperative Kirschner 8-mm Immediate achieve circumferential compression.
The extensor moment of hospital discharge after a total inpatient retinaculum was repaired with interrupted absorbable stay of four weeks .
hich was prolonged by social and logistical factors rather than clinical need after the demonstrated stable fixation through 0Ae90A, and first five day.
, the patient had achieved 30A of active fluoroscopic images confirmed anatomical reduction flexion and 0A of extension.
Pain, measured on a with no articular step-off.
Subcutaneous closure and numerical rating scale, had decreased from 7/10 at running subcuticular skin approximation completed admission to 2/10 at rest and 3/10 with motion.
the procedure.
Total operative time was 85 minutes.
Radiographs at four weeks demonstrated no loss of estimated intraoperative blood loss was 120 mL, and reduction, no hardware migration, and early bridging there were no anesthetic or surgical complications.
callus at the anterior fracture line.
The patient was Postoperative placed around the equator of the patella, tightened to range-of-motion 0-mm cerclage wire was additionally four-week discharged on a structured outpatient physiotherapy immobilizer with the knee held in extension, limb protocol aimed at achieving 60A of flexion by week eight elevation, cryotherapy, subcutaneous enoxaparin 40 and 90A by week twelve, together with oral calciumAe mg daily for thromboprophylaxis, and scheduled vitamin D supplementation, advice on home fall multimodal analgesia comprising paracetamol 1 g four prevention, and a referral for bone mineral density times daily and ketorolac 30 mg three times daily for At the six-week telephone follow-up prior the first 48 hours, followed by oral celecoxib 200 mg to manuscript submission, the patient reported adherence to rehabilitation and was ambulating women to low-energy patellar fractures, the biological independently with a single cane inside her home.
and biomechanical consequences of one month of Discussion bone-setter manipulation, and the technical considerations that The present case illustrates several overlapping public-health relevance: the characteristic vulnerability of elderly render a combined modified tension band and circumferential cerclage construct a durable fixation option in osteoporotic patellar bone.
1,2,4,7,18,19,20
Figure 1.
Integrated clinical summary of the case.
(A) Clinical and rehabilitation timeline from the day of injury through the six-week follow-up, demarcating the neglected phase under traditional bone-setter care, the protected postoperative phase, and the active rehabilitation phase.
(B) Functional recovery trajectory showing the progression of active knee flexion .
and pain on the numerical rating scale .
from injury through projected 12-week (C) Schematic of the surgical construct used for fixation: two parallel longitudinal Kirschner wires, an anterior figure-of-eight tension band wire, and a supplementary circumferential cerclage providing reinforcement in osteoporotic bone.
Epidemiologic data consistently show that patellar registries from North America and Europe have fractures demonstrate a bimodal age distribution, with confirmed that the standardized incidence of patellar the elderly peak being dominated by women and by fractures rises steeply in women after the seventh low-energy mechanical falls.
1,4,23 Population-based postmenopausal This The pathophysiology of delayed patellar fracture mechanistically plausible: the patella is a sesamoid bone whose trabecular architecture depends on At the cellular level, fracture healing cyclical compressive loading, and the microstructural proceeds through well-described overlapping phases of haematoma, inflammation, soft callus, hard callus, osteoporosisAitrabecular susceptible to transverse cleavage fractures when excessive interfragmentary motion, inadequate blood subjected to rapid bending moments during a fall onto supply, or chronic micromotion redirects repair toward the flexed knee.
5,7 Our patient conforms to this fibrous rather than osseous union.
7,8,15 The patella is epidemiologic template.
Although formal dual-energy a unique environment for these biological processes X-ray absorptiometry had not been obtained prior to because it is almost entirely intra-articular on its deep the injury, her postmenopausal status, her vitamin D surface, continuously bathed in synovial fluid, and insufficiency, and the low-energy mechanism strongly subjected to high tensile and shear forces transmitted perforation, and loss of connectivityAirender the bone reinforcing the guideline recommendations to pursue bone mineral density testing and to initiate evidence- secondary bone healing by diluting haematoma and by fragility fracture in a postmenopausal woman.
scaphoid and femoral neck injuries.
7,15 When this stabilization, a delay that was in large part a manipulation that prevents soft callus from maturing, consequence of initial consultation with a traditional the probability of non-union rises sharply.
15,16,21 In bone-setter.
The practice of traditional bone-setting is our patient, the intraoperative finding of an organized deeply rooted in many African.
Asian, and Latin American communities and persists for a combination fragments, palpable as a firm membrane and excised of cultural, economic, and geographic reasons.
only with careful curettage, corresponded to an early Patients stage along this spectrum.
no sclerotic, atrophic, or practitioners as culturally congruent, more accessible, synovial pseudarthrosis was observed, which was less expensive, and less intimidating than formal congruent with the intermediate delay of four weeks.
hospital systems, particularly in rural districts.
Yet From a biomechanical perspective, the patella systematic reviews from Nigeria.
India, and Indonesia functions as the fulcrum of the knee extensor have repeatedly documented that traditional bone- mechanism, increasing the moment arm of the setting is associated with an elevated risk of malunion, quadriceps tendon and amplifying extension torque non-union, during locomotion.
7,8 A transverse fracture effectively soft-tissue biological milieu is compounded by repeated external provisional matrix, a phenomenon familiar from A central clinical feature of the present case is the one-month Synovial fluid is known to retard fractures specifically, with contracture of the extensor fragments, and any proximal migration of the superior fragmentAiobserved in our patient to the extent of 10 demonstrated in Table 4, our patientAos trajectory mmAiindicates total failure of the tension side of the mirrors several key features of previously reported extensor apparatus.
Restoration of extensor function series: a low-energy mechanism, several weeks of tight requires anatomical reduction and a fixation that can binding and manipulation, persistent extensor lag, convert the tensile forces of the quadriceps into and a displaced fracture line with early fibrous callus compressive forces at the fracture site during active at the time of formal presentation.
4,18,20,21,22
knee flexion, the classical biomechanical principle non-union.
syndrome, gangrene, and, in the context of patellar underlying 7,8,11 meticulously bent and buried the ends of both the Cadaveric and finite-element studies have quantified Kirschner wires and the cerclage loops within the the benefits of different fixation pretibial tendon tissue, and we did not leave any knots parallel Kirschner wires with an anterior figure-of- or ends lying in subcutaneous tissue, a strategy shown eight wire provide approximately 1.
2Ae1.
6 kN of resistance to interfragmentary distraction across an 12,14 We also counselled the patient and her average-sized family on the possibility of elective hardware removal cannulated screws and a tension band wire can once radiographic union and acceptable range of further augment stiffness and reduce fatigue failure motion are achieved, usually between six and twelve when healing is slow.
7,11,12 In severely osteoporotic months after surgery.
12,14
bone, however, the holding power of any single Modern alternatives to tension band wiring include cannulated screws with anterior tension band, fixed- circumferential cerclage has been reported to reduce angle locking plates .
nterior or wraparoun.
, and residual displacement and improve early range of small-fragment mini-plate constructs.
13,23,25 Plates motion without compromising the blood supply.
13,22,24
provide superior fatigue resistance for comminuted Our choice to combine a parallel-wire tension band patterns and can accommodate multiple locking with a superimposed circumferential cerclage was screws directed into small pole fragments, but they motivated by .
the intrinsically reduced bone mineral density expected in a 66-year-old postmenopausal dissection, higher implant profile and cost, and woman, .
the chronic shortening of the surrounding potential for symptomatic hardware over the anterior retinacular structures after a four-week delay, and .
13 In a resource-sensitive setting and for a active-assisted simple transverse fracture, modified TBW reinforced rehabilitation despite imperfect bone stock.
Published by cerclage offers an attractive trade-off among cost, case series using similar strategies have reported availability, biomechanical stability, and ability to be primary bone union rates of 8896%, a median time to radiographic union of 10Ae14 weeks, and functional secondary-level hospital, as was the case at our scores comparable to those of conventional TBW in The Cochrane review on interventions for younger populations.
11,12,22,24 Our early functional outcomeAi30A of active flexion at four weeks and no loss of reduction at that time pointAifalls squarely implants remains sparse, and therefore individualized within these reported benchmarks, supporting the decision-making guided by surgeon experience, bone generalizability of a composite TBW-plus-cerclage quality, fracture morphology, and socio-economic approach to this specific clinical scenario.
context remains essential.
soft-tissue high-quality Symptomatic hardware is the most frequent long- Non-union, which is the dominant long-term term complication after patellar TBW, with reoperation complication of neglected patellar fractures, occurs in rates for implant removal approaching 2040% in published series.
12-14 This is particularly relevant in fractures but rises sharply when formal fixation is the elderly, in whom subcutaneous fat is thin and the 16,21 Transverse patterns and inferior pole anterior aspect of the knee is directly exposed to fractures are especially susceptible.
15,16,17,21 Harna pressure during kneeling and squattingAiactivities and colleagues described a series of non-union that, in the Indonesian setting, retain substantial freshening of the fracture ends, and repeat TBW 412.
supplemented by autologous iliac crest bone graft, achieving union in all cases at a mean of 14 weeks.
they emphasized the importance of early recognition integration of traditional practitioners into formal and of avoiding the clinical trap of traditional referral networks, and investment in accessible 16 Mankar and colleagues reported a primary-care orthopedic services to reduce the burden similar case in which quadriceps release was required of neglected fractures.
18-20 Within the Indonesian context specifically, qualitative research has identified underscoring that the window for straightforward several facilitators of traditional bone-setter use, single-stage fixation closes progressively with time.
including mistrust of surgical intervention, fear of In contrast, our patientAistill at four weeks after amputation, and the perception that hospital care is injuryAiretained sufficient soft-tissue length to allow unaffordable despite the existence of the national reduction without quadriceps lengthening, illustrating Jaminan Kesehatan Nasional insurance scheme.
19,20
the principle that even a one-month delay remains Surgeons working in districts with active bone-setter within the window amenable to single-stage fixation practice have a dual responsibility: first, to provide when adequate technique and reinforcement are culturally sensitive counselling that does not alienate As shown in Table 4, this positions the patients from future formal care, and second, to present case along a spectrum with Harna et al.
Mankar et al.
ix to twelve months of delay, requiring campaigns, for rural orthopedic outreach, and for adjunctive soft-tissue procedure.
at one end, and the targeted programmes addressing fragility fractures in work of Mulat et al.
and Li et al.
at the other end, where postmenopausal women.
The present case offers a early or novel modifications of the cerclage wire
16,17,21,22
the need Finally, several limitations of this report must be Rehabilitation strategy is the second determinant First, as a single-patient case report, of outcome.
The classical postoperative regimen after the generalizability of the outcomes is inherently TBW consists of 1Ae2 weeks of knee immobilization in larger prospective series are needed to confirm extension to allow wound healing, followed by the reproducibility of a one-month delayed TBW-plus- progressive active-assisted flexion and full weight- bearing with a brace.
8,11 Accelerated protocols have reported here .
ix week.
is short: patellar fractures been shown to produce superior early functional are known to require between twelve and twenty-four scores without compromising bone healing when weeks to achieve radiographic union, and longer fixation is stable.
11,22 In our patient, the rehabilitation observation will be required to confirm bone healing, programme was deliberately conservative during the functional recovery as measured by validated tools first two weeks to respect the biology of a recently such as the Lysholm.
KOOS, and Oxford Knee Score, cleared fibrous interposition, followed by graduated and the eventual need for implant removal.
Third, range-of-motion exercises.
The achievement of 30A of bone mineral density data were not available at the pain-free active flexion with no extension lag at four time of surgery, and retrospective classification of the weeks is reassuring and suggests that the composite fracture as a fragility fracture remains inferential.
fixation was sufficiently stable to permit meaningful Fourth, no direct head-to-head comparison with early mobilization despite the initial delay and the alternative fixation methods was possible in this osteoporotic bone stock.
11,12,22,24
clinical scenario.
Fifth, we did not perform pre- or Second, follow-up The public-health implications of our case extend intraoperative magnetic resonance imaging.
beyond the technical aspects of fixation.
In low- and not indicated for uncomplicated transverse fractures, middle-income countries, systematic reviews have information on the degree of fibrous interposition.
interposition is debrided, and fixation is reinforced to Despite these limitations, the present case contributes account for impaired bone quality.
Third, modified a pragmatic illustration of the fact that a neglected TBW with supplementary circumferential cerclage displaced transverse patellar fracture in an elderly constitutes a reproducible, low-cost, and effective patient can still be effectively salvaged at four weeks strategy in osteoporotic bone and within secondary- after injury with a well-executed composite fixation level surgical environments.
Fourth, early supervised strategy and structured rehabilitation.
rehabilitation is essential to optimize functional Clinical learning points can be summarized as outcomes and must be tailored to the patientAos social First, any elderly patient with an inability to environment and adherence potential.
Fifth, broader perform a straight leg raise after a low-energy fall to public-health interventions remain indispensable for the knee must undergo immediate radiographic evaluation, regardless of whether or not manipulation originating from traditional bone-setter referral, and has already been performed elsewhere.
Second, a displaced transverse patellar fracture at one month of constructively with traditional practitioners to improve delay remains amenable to single-stage ORIF provided the safety of the overall referral pathway.
Table 4.
Comparison of the present case with previously reported cases of displaced/neglected patellar fracture.
Study Year Patient profile Interval .
njury Ie Surgical technique Early functional Matthews et al.
Elderly .
ean 74 .
comminuted patella
< 2 weeks TBW and cannulated-screw
TBW
Union in most.
hardware removal Hsu et al.
Transverse patella fractures, mean age < 1 week Modified TBW Union 92%.
knee flexion Ou 120A in 83% Harna et Patellar non-union (Ou 6 month.
6Ae18 Re-fixation iliac crest bone graft Union at 14 weeks.
good extensor return Li et al.
Elderly patellar Acute (< 2 Novel modified cerclage wiring 94% union.
flexion 124A Hurkat & Desouza Displaced transverse patella fracture Acute Modified TBW .
ase Full extension at 6
flexion 100A
Mankar et
Non-union patella
fracture with > 12 months Quadriceps release TBW
Union and partial
extensor recovery Mulat et
Neglected patella
LMIC
6 months TBW
POP
Union with prolonged Present case A 66-y female.
transverse patella bone-setter delay 4 weeks TBW Flexion 30A at 4 weeks.
no loss of reduction.
early bridging callus A Systematic review.
A case series.
A the present case.
LMIC = low- and middle-income countries.
POP = plaster of Paris.
TBW = tension band wire.
Conclusion patients: a systematic review and case report.
Displaced transverse fractures of the patella in the Geriatr Orthop Surg Rehabil.
: 135Ae elderly are consequential injuries whose prognosis is determined by the timeliness of extensor-mechanism Gerhardt M.
Cooper C.
Willers J, et al.
restoration and by the stability of fixation in an Management osteoporotic skeletal environment.
The present report postmenopausal women: the 2012 position demonstrates that a neglected displaced transverse statement of the North American Menopause fracture presenting one month after injury following Society.
Menopause.
: 25Ae54.
prolonged traditional bone-setter manipulation can be Kanis JA.
Cooper C.
Rizzoli R, et al.
European managed effectively with single-stage open reduction guidance for the diagnosis and management and a modified tension band wire construct reinforced of osteoporosis in postmenopausal women.
by circumferential cerclage, achieving anatomical Osteoporos Int.
: 3Ae44.
reduction, pain control, and a meaningful early Gwinner C.
Myrdian S.
Schwabe P, et al.
functional gain within four weeks.
Key facilitators of Current concepts review: fractures of the this outcome were careful debridement of the fibrous GMS Interdiscip Plast Reconstr Surg interposition, reinforcement of fixation to compensate DGPW.
5: Doc01.
for reduced bone quality, a dedicated rehabilitation Archdeacon MT.
Surgical management of patellar fractures.
Orthop Clin osteoporosis management and fall prevention.
Our experience reinforces the broader message that early Kakazu North Am.
: 77Ae83.
Sayum Filho J.
Lenza M.
Tamaoki MJR, et al.
formal referral of any elderly patient with an acute Interventions for treating fractures of the knee injury remains indispensable, and that culturally patella in adults.
Cochrane Database Syst sensitive engagement with communities in which Rev.
: CD009651.
bone-setting Singer MS.
Halawa AM.
Adawy A.
Outcome of Further non-operative treatment of displaced patellar fractures with preserved extensor mechanism.
measures and longer follow-up are warranted to refine SICOT J.
7: 4.
the role of composite TBW-plus-cerclage constructs in Hsu KL.
Chang WL.
Yang CY, et al.
Factors the setting of delayed and osteoporotic patellar affecting the outcomes of modified tension band wiring techniques in transverse patellar Injury.
: 2800Ae6.
References