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 Table of Contents  
ORIGINAL ARTICLE
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 73-77

Modified tension band wiring of transverse patella fractures through cannulated cancellous screws: An analysis of functional outcomes and complications


Department of Orthopaedics, SDMCMSH, SDM University, Dharwad, Karnataka, India

Date of Submission12-Jul-2022
Date of Decision29-Oct-2022
Date of Acceptance10-Nov-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Abhishek Gumaste
Department of Orthopaedics, SDMCMSH, SDM University, Sattur, Dharwad - 580 009, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_58_22

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  Abstract 


Introduction: The management of transverse patella fractures with modified tension band wiring using Kirschner wires, though routinely used is associated with complications such as implant loosening, wire migration, and infection. We hypothesized that using cannulated cancellous screws with tension band wiring through the screws will overcome these complications. Objective: The objective was to assess the functional and radiological outcomes following patellar fracture fixation with modified tension band wiring through cannulated cancellous screws. Materials and Methods: Twenty-four patients with transverse patella fractures fixed with modified tension band wiring through cannulated cancellous screws were included in this retrospective study. Surgical technique involved a vertical incision over the knee, reduction of the fracture initial fixation with Kirschner wires, replaced with cannulated cancellous screws. A stainless steel wire was passed through the lumen of the screws, and tension band was applied. Follow-up at 3, 6, and 12 months was done to assess the radiological union. Functional outcome was assessed with the Bostman scoring. Results: The study included 13 male and 11 female patients with an average age of 39.6 years, with 8 three-part and 16 two-part fractures. The average follow-up was 14 months, and the average time to union was 8.5 weeks. Twelve patients had an excellent, 11 patients a good, and one patient an unsatisfactory functional outcome as per the Bostman score. No infection or implant loosening was observed. Conclusion: The technique of patella fracture fixation with modified tension band through cannulated cancellous screws offers an enhanced stability, minimizing the complications such as implant migration, prominent implant, and refracture. As such, we recommend this technique in all transverse patella fractures.

Keywords: Bostman score, modified tension band wire, transverse patella fracture


How to cite this article:
Gumaste A, Baindoor P, Jeevannavar S, Shenoy K, Gurudev R. Modified tension band wiring of transverse patella fractures through cannulated cancellous screws: An analysis of functional outcomes and complications. J Orthop Dis Traumatol 2023;6:73-7

How to cite this URL:
Gumaste A, Baindoor P, Jeevannavar S, Shenoy K, Gurudev R. Modified tension band wiring of transverse patella fractures through cannulated cancellous screws: An analysis of functional outcomes and complications. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:73-7. Available from: https://jodt.org/text.asp?2023/6/1/73/365286




  Introduction Top


With an incidence of 13.1 per 100,000, fractures of the patella are a common occurrence.[1] A vital component of the extensor mechanism of the knee, patella, increases the quadriceps lever arm, initiating and maintaining the knee extension.[2] Thereby, restoring patellar integrity is essential for optimal functioning of the extensor mechanism as well as to prevent patellofemoral arthritis.

Modified tension band wiring, whereby fracture reduction is held by parallel Kirschner wires and compression provided by a tension band wire construct, is the most routinely employed technique of fixation of transverse patella fractures.[3],[4] Although satisfactory outcomes have been reported with this technique,[2],[3] a host of complications that includes implant migration, implant breakage, infection, irritation of the overlying skin, and soft tissues, have been widely observed.[5],[6]

Several biomechanical and clinical studies[7],[8] have recommended using a screw system with tension band that overcomes the above limitations. However, there is a paucity of clinical studies in the Indian settings regarding the same.

We hypothesized that replacing Kirschner wires with cannulated screws and passing the tension band construct through the screws enhance the fracture stability while minimizing the complications. The purpose of this retrospective study was performed to assess the radiological and functional outcomes following the fixation of two- and three-part transverse fractures of patella with modified tension band wiring through cannulated cancellous screws.


  Materials and Methods Top


A retrospective study was undertaken in our tertiary care center. All patients with patella fractures that were treated surgically for 5 years from January 2016 to January 2021 were assessed. We included patients with two-part and three-part transverse patella fractures that were fixed with modified tension band wiring through cannulated cancellous screws.

Patients who underwent patella fracture fixation with other techniques such as modified tension band wiring with Kirschner wires, encirclage, and cannulated screw fixation without tension band were excluded. Open patella fractures, fractures with ipsilateral femur or tibia fractures, and those with neuromuscular disorders were also excluded from the study.

Surgical technique

After a written, informed consent was taken, under spinal anesthesia, with the patient in the supine position, a vertical incision was taken centering over the knee. Our surgical technique was similar to the one described by Berg[9] Fracture site was cleared of hematoma and fracture fragments were brought in alignment aided by the knee extension using a bolster at the ankle. The fragments were held together with a patella clamp. The reduction was confirmed under fluoroscopy. Two Kirschner wires were drilled in parallel, from the distal pole to the proximal fragment [Figure 1]. Wires were then replaced with 4-mm cannulated cancellous screws (merill surgicals, 4-mm cannulated cancellous screws) taking care that the distal tip of screws was within the bone and not penetrating into the soft tissue [Figure 2]. A tension band was applied using 16-gauge stainless steel wire, passing the wire through the screws in a figure-of-eight fashion, starting and ending the figure-of-eight at the superolateral end of the screw. An additional tension band was applied with Ethibond 2–0 over the construct, [Figure 3] in a figure-of-eight manner, with the ends of Ethibond passed underneath the patellar tendon and quadriceps tendon at either end.
Figure 1: Initial reduction and fixation with Kirschner wires

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Figure 2: Kirschner wires replaced with cannulated cancellous screws

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Figure 3: Intraoperative final construct with an additional tension band with Ethilon 2-0

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In a three-part fracture, two smaller fragments were reduced first; then, this complex was reduced to the larger fragment. Retinacular tears were repaired with Vicryl No 1, and the wound was closed in layers.

The nonweight-bearing mobilization with knee brace and static quadriceps exercises were begun in the immediate postoperative period. At 2 weeks, after suture removal, the knee range of motion exercises was started with a partial weight bearing. Regular follow-ups were done at 3 months, 6 months, and 1 year. Patients were assessed for the radiological union [Figure 4] and [Figure 5], knee range of motion, and potential complications if any. The Bostman scoring for the functional assessment was done at 6 months and at further follow-ups.
Figure 4: Preoperative X-ray – three-part fracture

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Figure 5: Postoperative X-ray of the same patient

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  Results Top


Between January 2016 and January 2021, we had 67 patients with patella fractures presenting to our tertiary care center. Twenty-four patients fit into our inclusion criteria and were included in the study. There were 13 males and 11 females with the average age being 39.6 years, with an age range of 21–69 years [Table 1]. All patients presented within 24 h of trauma and were operated within 24 h of presentation. Sixteen patients had two-part fracture, and eight had a three-part patella fracture. The average follow-up was 14 months, and the average time for union was 8.5 weeks.
Table 1: Patient demographics, fracture pattern, and time to union

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In the functional assessment, according to the Bostman scoring, 12 patients had an excellent outcome, 11 good, and one patient had an unsatisfactory outcome [Table 2].
Table 2: Bostman functional scoring

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One patient had knee stiffness. There were no cases of infection, implant migration, prominent implant, or refracture.


  Discussion Top


Modified tension band wiring with Kirschner wires has been the gold-standard technique of the fixation of transverse patella fractures.[3],[4] The modified tension band wire provides compression by converting tensile forces into compression forces at the fracture site.[10] However, the Kirschner wires in the construct while maintaining the fracture reduction, do not provide any additional mechanical advantage in the form of fracture compression, which is being done by the tension band wire alone. As such, the addition of screws to the tension band has shown to provide compression, reduce fracture separation, and resist tensile stresses during the terminal extension.[7] Thereby, replacing the Kirschner wires seems to provide an additional stability to the fracture.

Carpenter et al.[8] compared the biomechanical effectiveness of the three different modes of fixation, namely, modified tension band, cancellous screws alone, and screws with tension band through the screws. They found that fractures fixed with screws with tension band failed at relatively higher loads than those with tension band or screws alone. They concluded that screws with tension band through the screws provided a better mechanical strength to the fracture construct. In our study, this is evidenced by the fact that there was no case of refracture.

Several other studies further substantiate the biomechanical superiority of the construct.[11] Cekin et al.[12] concluded that the most efficient fixation was when lag screws were combined with tension band. Cramer et al.,[13] in their analysis of contemporary methods of fixation of patella fractures, found that a combination of screws and wires was biomechanically superior to the other methods.

Several other biomechanical studies[14],[15] further support our hypothesis that the addition of screws to the tension band construct leads to increased resistance to tensile stresses at varying degrees of the knee motion.

Shrestha et al.[7] in their comparative study, showed a comparable rate of union and better functional outcome with decreased rate of complications with tension band wiring with screws compared with modified tension band wiring with Kirschner wires. Berg[9] using a similar surgical technique showed that the screw tension band construct leads to lesser hardware problems while being efficient in osteoporotic fractures. Further studies by Tan et al.[16] reemphasize the better functional outcomes with screw construct and the need for hardware removal in the Kirschner wire group.

In our series, there was no case of hardware problem, infection, or refracture which further supports our hypothesis.

However, a majority of the published studies consider this modality only in two-part transverse fractures. We had eight patients with three-part fractures, wherein the above technique was employed with equivocal results. We added an additional tension band to the construct with Ethibond 2–0. This was to provide an additional stability to better resist the distraction forces.

Although several studies recommend encirclage as an adjunct,[17] the recent literature[18] finds no additional advantage with encirclage. Instead, adding a tension band construct with Ethibond 2–0 may enhance the stability as in our series, where there was no case of refracture reported.

The average time to union was 8.5 weeks, which is comparable to other studies in the literature.[19]

Hardware problems form the major concern when Kirschner wires are used in the construct. Implant migration, prominent implants, irritation of the skin, and overlying soft tissues due to prominent Kirschner wires are a major concern with Kirschner wire usage in the tension band.[20],[21] There was no case of implant-related complication in our study. The cannulated cancellous screws ended within the bone; there was no protrusion into the soft tissues. This made sure that the wires did not kink at the screw tips, ensuring the adequacy of the tension band construct. Functionally, 12 (50%) patients had an excellent outcome, and 11 had a good outcome. This is comparable to other studies that have used the same technique.[22]


  Conclusion Top


Patellar fracture fixation with cannulated cancellous screws and modified tension band construct combines the compression provided by the screws and dynamic tension band effect without the attendant complications associated with traditional Kirschner wires such as implant breakage, skin irritation, implant migration, and refracture. As such, with the dual advantage of enhanced stability and minimal complications, we recommend this technique in transverse two-part and three-part patella fractures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Larsen P, Court-Brown CM, Vedel JO, Vistrup S, Elsoe R. Incidence and epidemiology of patellar fractures. Orthopedics 2016;39:e1154-8.  Back to cited text no. 1
    
2.
Zhang Y, Xu Z, Zhong W, Liu F, Tang J. Efficacy of K-wire tension band fixation compared with other alternatives for patella fractures: A meta-analysis. J Orthop Surg Res 13, 226 (2018). doi: 10.1186/s13018-018-0919-6.  Back to cited text no. 2
    
3.
Siddaram N, Patil A. Prospective clinical study of patellar fractures treated by modified tension band wiring. Int J Biol Med Res 2014;5:3975-80.  Back to cited text no. 3
    
4.
Kota GR, Vamshi D. Patellar fractures treated by modified tension band wiring: A clinical study in a teaching hospitals. Ann Int Med Dent Res 2016;2:142-5.  Back to cited text no. 4
    
5.
John J, Wagner WW, Kuiper JH. Tension-band wiring of transverse fractures of patella. The effect of site of wire twists and orientation of stainless steel wire loop: A biomechanical investigation. Int Orthop 2007;31:703-7.  Back to cited text no. 5
    
6.
Tian Y, Zhou F, Ji H, Zhang Z, Guo Y. Cannulated screw and cable are superior to modified tension band in the treatment of transverse patella fractures. Clin Orthop Relat Res 2011;469:3429-35.  Back to cited text no. 6
    
7.
Shrestha P, Chalise PK, Paudel SR. Comparave study of modified tension band wiring versus tension band through Parallel cannulated cancellous screws in patella fractures. BJHS 2019;410:777-78.  Back to cited text no. 7
    
8.
Carpenter JE, Kasman RA, Patel N, Lee ML, Goldstein SA. 1Biomechanical evaluation of current patella fracture fixation techniques.J Orthop Trauma 1997;11:351-6.  Back to cited text no. 8
    
9.
Berg EE. Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring through parallel cannulated compression screws. J Orthop Trauma 1997;11:573-6.  Back to cited text no. 9
    
10.
Maurice E Muller, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixaon: Techniques Recommended by the AO-ASIF Group. verlag - berlin- Heidelberg: Springer Science & Business Media; 1991.  Back to cited text no. 10
    
11.
Burvant JG, Thomas KA, Alexander R, Harris MB. Evaluation of methods of internal fixation of transverse patella fractures: A biomechanical study. J Orthop Trauma 1994;8:147-53.  Back to cited text no. 11
    
12.
Cekin T, Tükenmez M, Tezeren G. Comparison of three fixationmethods in transverse fractures of the patella in a calf model. Acta Orthop Traumatol Turc 2006;40:248-51.  Back to cited text no. 12
    
13.
Cramer KE, Moed BR. Patellar fractures: Contemporary approach to treatment. J Am Acad Orthop Surg 1997;5:323-31.  Back to cited text no. 13
    
14.
Dargel J, Gick S, Mader K, Koebke J, Pennig D. Biomechanical comparison of tension band and interfragmentary screw fixation with a new implant in transverse patella fractures. Injury 2010;41:156-60.  Back to cited text no. 14
    
15.
Zderic I, Stoffel K, Sommer C, Höntzsch D, Gueorguiev B. Biomechanical evaluation of the tension band wiring principle. A comparison between two different techniques for transverse patella fracture fixation. Injury 2017;48:1749-57.  Back to cited text no. 15
    
16.
Tan H, Dai P, Yuan Y. Clinical results of treatment using a modified K-wire tension band versus a cannulated screw tension band in transverse patella fractures: A strobe-compliant retrospective observational study. Medicine (Baltimore) 2016;95:e4992.  Back to cited text no. 16
    
17.
Curtis MJ. Internal fixation for fractures of the patella. A comparison of two methods. J Bone Joint Surg Br 1990;72:280-2.  Back to cited text no. 17
    
18.
Yang TY, Huang TW, Chuang PY, Huang KC. Treatment of displaced transverse fractures of the patella: Modified tension band wiring technique with or without augmented circumferential cerclage wire fixation. BMC Musculoskelet Disord 2018;19:167.  Back to cited text no. 18
    
19.
Malik M, Halwai MA. Open reduction and internal fixation of patellar fractures with tension band wiring through cannulated screws. J Knee Surg 2014;27:377-82.  Back to cited text no. 19
    
20.
Hoshino CM, Tran W, Tiberi JV, Black MH, Li BH, Gold SM, et al. Complications following tension-band fixation of patellar fractures with cannulated screws compared with Kirschner wires. J Bone Joint Surg Am 2013;95:653-9.  Back to cited text no. 20
    
21.
Wang CX, Tan L, Qi BC, Hou XF, Huang YL, Zhang HP, et al. A retrospective comparison of the modified tension band technique and the parallel titanium cannulated lag screw technique in transverse patella fracture. Chin J Traumatol 2014;17:208-13.  Back to cited text no. 21
    
22.
Khan I, Dar MY, Rashid S, Butt MF. Internal fixation of transverse patella fractures using cannulated cancellous screws with anterior tension band wiring. Malays Orthop J 2016;10:21-6.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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