Management of a Gap Non-union Patella Fracture Using Encirclage Wire and Tension Band Wiring with Quadriceps V-Y Plasty in an Elderly Patient: A Rare Case Report and Review of Literature.

Abstract

The management of gap non-union patella fractures continues to be a challenge in orthopedics. The incidence of these cases ranges between 2.7% and 12.5%. The quadriceps muscle attached to the proximal fractured fragment pulls it proximally leading to the gap at fracture site. If the gap is too large, there won't be any fibrous union resulting in failure of quadriceps mechanism and extension lag. The primary aim is to bring the fracture fragments together and restore the extensor mechanism. Most of the surgeons prefer single-stage procedure, in which mobilization of the proximal fragment, followed by fixing with the lower fragment is done using V-Y plasty or x lengthening with or without pie Crusting. Others use of pre-operative traction to the proximal fragment using pins or ilizarov method. In our case, we used single-stage procedure whose results were encouraging. A 60-year-old male patient presented with pain in the left knee with difficulty in walking since 3 months. The patient had road traffic accident 3 months back and sustained trauma to left knee. On clinical examination, there was palpable gap of more than 5 cm between the fracture fragments, anterior surface of femur and condyles was palpated through fracture site and knee range of motion was between 30° and 90° of flexion, and X-ray suggests of patella fracture. Midline 15 cm longitudinal incision was taken. The insertion of the quadriceps tendon over proximal pole of patella was exposed and pie crusting was done on medial and lateral side and V-Y plasty was done. SS wire was used to hold the reduction of the fragments by encirclage wiring and anterior tension band wiring done. Retinaculum was repaired and wound closed in layers. Postoperatively, long rigid knee brace was given for 2 weeks and walking with partial weight-bearing started. After suture removal at 2 weeks, full weight-bearing initiated. At 3 weeks, knee range of motion started and continued till 8 weeks. At 3 months post-operative, the patient is able to do flexion up to 90° and no extension lag is present. Adequate quadriceps mobilization during the surgery along with pie crusting and V-Y plasty with TBW and encirclage combined gives good functional outcome in patella gap non-unions.