Neglected Patellar Fracture Treated Using Ipsilateral Hamstring Autograft Augmentation: A Case Report

Abstract

Introduction: Inferior pole patellar fractures occur in relatively young patients after eccentric contraction of the quadriceps or direct trauma. Early diagnosis and adequate treatment lead to excellent outcomes and prevent tendon retraction and scarring. The aim of surgical treatment is to restore of extensor mechanism rather than anatomical articular reduction. We propose a cerclage wire technique using ipsilateral hamstring augmentation for the patellar tracking restoration. Case Description: A forty nine-year-old female, presented to our sport clinic with chief complaint of pain in the left knee and difficulty in walking and standing in long period of time following a direct trauma falling from the stairs to the knee one year back. Clinical examination revealed gap in the left knee cap and the patient could not able to straighten the knee actively. Plain radiographs of knee were taken in anteroposterior and lateral views show fracture of the inferior pole of the left patella. Magnetic resonance imaging (MRI) of the knee confirmed inferior pole patellar fracture with the proximal migration of patella with no other intraarticular injuries with partial tear of left patellar tendon. Patellar tendon reconstruction was planned using ipsilateral semitendinosus (ST) and Gracillis (G) autograft and ORIF cerclage wire augmentation. Follow-up was performed after one month post-operation. Patient was able to straighten the left knee and fully weight bearing mobilized without any pain. Range of motion was 0/100 compared to the contralateral knee. Muscle atrophy was not found. Xray was performed and shows callus formation with stable fixation. Conclusion: Neglected patellar fracture is a rare occurrence, the treatment of which is a difficult challenge for orthopaedic surgeons. Therefore, the goal of surgical treatment of inferior pole fractures is restoration of extensor mechanism rather than anatomical articular reduction. In inferior pole fracture of the patella, comminution in fractured distal fragment is common and secure fixation to allow early motion is difficult to achieve. The advantage of the described technique is the possibility of immediate weightbearing and early mobilization. A parallel could be drawn with the biological augment for patellar tendon repair, in which semitendinosus augmentation allows immediate postoperative mobilization with excellent functional results. This allows patients with early functional exercise and has a positive significance for the smooth recovery of the articular surface of the patella and recovery of knee extensor device function. Functional impairment of the extensor mechanism and postoperative complications triggers the quest for finding the ideal technique.