Severe iatrogenic knee arthrosis caused by a delayed intra-articular migration of a broken k-wire. A potential destroying complication of patella tension band wiring
Stefano Carbone1, Valerio Arceri1, Gianfranco Canero2, Stefano Gumina1
1Sapienza University of Rome. Dept. of Orthopaedics and Traumatology. Rome , Italy
2Clinica San Feliciano, Dept. of Orthopaedics and Traumatology. Rome, Italy
Corresponding author: Stefano Carbone, Email: email@example.com
Citation: Carbone S, Arceri V, Canero G, Gumina S. Severe iatrogenic knee arthrosis caused by a delayed intra-articular migration of a broken k-wire. A potential destroying complication of patella tension band wiring. J Minim Invasive Orthop, 2014, 1(5): e5. doi:10.15383/jmio.5.
Competing interests: The authors have declared that no competing interests exist.
Conflict of interest: None
Copyright: 2014 By the Editorial Department of Journal of Minimally Invasive Orthopedics. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract: Patella fractures are relatively common injuries. Tension band wiring is often used to treat displaced patella fracture. Wire breakage and migration is a well-known complication of using a wire tension band construct. We report a case of intra-articular migration of a broken k-wire used for patella tension band wiring two years after fixation and noted six months after the last radiological examination. The broken wire was removed arthroscopically and remaining hardware via three mini-incision of the skin. The knee joint developed severe iatrogenic arthrosis. We would like to show that broken hardware can migrate also into the joint and that it can rapidly cause severe knee arthrosis, a detrimental complication rarely described in literature. Implant removal at fracture healing or close clinical and radiological examination after internal fixation are mandatory to avoid such complication.
Keywords: Patella fracture; Patella tension band wiring; Complication; K-wire migration; Iatrogenic arthrosis
Patellar fracturesare common injury caused by excessive tension through the extensor mechanism or a direct trauma. Treatment methods and fixation strategies changed over time and the best fixation method is still motive for discussion. Most of controversies derive from the sub-cutaneous and intra-articular localization of the patella, as well as from the patients’ desire of early active knee motion. Open reduction and internal fixation is the preferred treatment for most displaced patellar fractures, with the goal of restoring normal anatomy and a competent extensor mechanism.
After surgery, the most common complication is symptomatic hardware, often requiring removal.[1,2]Wire migration into the popliteal fossa and the right ventricle have been reported secondary to implant failure.[3,4]The migration of a broken k-wires into the knee joint is a potential destroying complication which has been rarely reported in literature.[5,6]We here report a case of a 38 year old man who sustained in 2011a closed comminuted patella fracture treated with a conventional tension band wiring, with a two-year post-operatory breakage of a k-wire and migration into the intercondylar notch of the knee, with secondary severe iatrogenic arthrosis.
A 38 year-old man was referred to our private practice ambulatory because of progressive pain on the right knee joint in the past 4 months, with severe limitation of daily activities. He sustained closed comminuted patellar fracture in March 2011 treated with open reduction and internal fixation using tension band wiring in another institution. Previously, in 2008, the patient had a bilateral distal shaft femoral fracture treated with nailing. He did not refer any additional trauma or any snap in the knee in the last months. Physical examination revealed: range of motion with full extension and 40° of maximum flexion; severe varus deviation andno swelling of the joint. The last follow-up radiographs (6 month earlier) showed rupture of the cerclage with no hardware mobilization.(Fig. 1a,b) Then, new two-plane radiographs were immediately taken. The last revealed k-wire rupture with migration into the intercondylar notch, varus deviation and severe arthrosis of the knee (Fig. 2a,b). A prompt arthroscopic removal of the k-wire with debridement of the joint and sub-quadricipital adherences ablation was performed. The broken k-wire was located in the intercondylar notch, with severe chondrolysis and synovitis, imbedded between the anterior and posterior cruciate ligament. Medial meniscus showed several lesions and important degeneration, treated with minimal meniscectomy. Perforations of the sub-chondral bone in the internal compartment were performed with the use of achondral pick . The remaining wires and the cerclage were removed via three mini-incision of the skin (Fig. 3). Post operatory x-ray was obtained. (Fig. 4) After surgery, range of motion was restored until 100° of flexion and pain quite completely disappeared, with a rapid improvement of knee function. The patient was informed about severe arthrosis of his joint with possible future total knee replacement. The patient gave informed consent to the operation and to the publication of the case, which was performed in line with the Declaration of Helsinki.
Figure 1. (Left) Antero-posterior and lateral (Right) view of the knee 6 month before hardware removal.
Figure 2. Antero-posterior (Left) and lateral (Right) view of the knee showing k-wire rupture and secondary severe femoro-tibial arthrosis.
Figure 3. Aesthetic aspect of the knee after surgery, with three mini-incision of the skin used for implant removal.
Figure 4. Post-operatory antero-posterior view of the knee.
Failure of hardware with pin migration is a well-known complication. Because thin, un-threated and tubular, k-wires have a strong tendency to migrate along the paths of least resistance. Theoretical routes of metal hardware migration include paths along myofascial planes and even into the circulation. After patellar fracture, pins are reported to migrate into the popliteal fossa,and to the heart. Only two cases of intra-articular migration of wires from patella to the knee joint have been documented in literature.[5,6] In one of the two cases, the wire migrated intra-articularly via a pseudarthrosis line. The authors postulated that in the absence of this fracture gap, it would be difficult, although not impossible, for the wire to find anintra-articularlyroute, as this would require the wire to pierce through a significant amount of soft tissues, such as the thick retinaculum, before entering the knee joint.Recently, attention was paid to modify patellar tension band wiring to minimize implant migration with locked tension band wiring using ring pins.The authors retrospectively reviewed 36 patients, with no fixation failure or pin migration.Another treatment option is cannulated screw instead of k-wires.  In our case, surgery was performed in another institution with a standard technique and complete healing of the fracture six months after surgery. The patient was referred to us after the breakage of the k-wire, with the last x-ray control performed six month earlier, with no sign of k-wire mobilization nor femoro-tibial arthrosis. The detrimental effects on knee cartilage of a loosened broken k-wire into the knee joint were never reported in literature. In less than six months, the patient developed severe femoro-tibialarthrosis with varus deviation and limping. Due to the intra-articular localization of the wire, we performed a standard knee arthroscopy for wire removal, debridement of the joint, ablation of retro-patellar and sub-quadricipital adherences, and for selective meniscectomy. In addition, perforations of the sub-chondral bone in the internal compartment were performed with the use of a chondral pick. To preserve vascularization of the skin for a possible future total knee replacement, we decided to removethe rest of hardware with a minimally invasive approach, through three mini-incision of the skin of less than 2.5 centimeters. The arthroscopic surgery associated to the minimally invasive approach for hardware removal permitted a very quick recovery in terms of pain and function few weeks after surgery. In fact, the patient got back to his daily activities in only one week post-operatory. Nevertheless, cartilage of the joint was badly damaged, with sub-chondral bone exposure in the medial compartment and in the intercondylar notch.
In conclusion, broken k-wire of patella tension band wiring can migrate into the joint with precocious detrimental iatrogenic effects on cartilage with femoro-tibial arthrosis. We recommend to remove hardware at fracture healing or, if not possible, to have close clinical and radiological follow-up. Since in this case report follow-ups were regularly done every six-months, any sudden change in symptoms or range of motion should be carefully evaluated. Patients and physicians should be aware of this rare destroying complication, because intra-articular localization of a broken k-wire can irremediably lead to severe femoro-tibialarthrosis in a very short time.
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