Management of displaced transverse fractures of the patella using tension band wiring with or without circumferential cerclage wiring: A comparative study

Background: Transverse fractures of body of the patella are by far the most common fractures of this bone. Surgical fixation is the recommended treatment in displaced fractures with extensor lag. Although, tension band wiring (TBW) technique is the gold standard for these fractures, few surgeons recommend augmentation with circumferential cerclage wiring to improve the strength of the fixation. We compared the results of the internal fixation of displaced transverse fractures of the patella using TBW and circumferential cerclage wiring with those treated with TBW alone. Methods: We treated 54 displaced transverse fractures of the patella at our institution. We segregated the patients into two groups: Group 1 (n=23) included fractures treated with tension band wiring (TBW) along with augmented circumferential cerclage wiring while as Group 2 (n=31) included fractures treated by TBW alone. Outcome was studied, graded and compared on the basis of knee pain, knee stiffness, quadriceps wasting, loss of flexion and loss of extension. Results: 73.90% patients among group 1 and 70.96% among group 2 showed excellent to good results (P value < 0.1). Fixation failure and need for revision surgery among group 1 and group 2 was found to be 8.69% and 9.67%, respectively (P value < 0.6). Infections and non union occurred among 4.34% patients in group 1 whereas in group 2 it was 6.45% of the patients who encountered the same (P value < 0.6). Conclusions: The use of circumferential cerclage wiring along with tension band wiring for displaced transverse fractures of patella seems to have no added advantage over fixation with tension band wiring alone. Keywords: Patella fracture, Tension band wiring, cerclage wiring

Supplementary Technique for Unstable Clavicle Shaft Fractures: Interfragmentary Wiring and Temporary Axial K-Wire Pinning

BACKGROUND: Treatment of unstable clavicle fractures remains a challenge for orthopedic surgeons, but the evolution of treatment strategies has allowed for reliable results with minimal complications. Although several surgical options exist, open reduction with plating remains the treatment of choice for clavicle fractures. The purpose of this study is to determine an easy way to achieve successful preplating reduction while minimizing surrounding soft tissue damage during treatment of midshaft fractures of the clavicle. METHODS: A retrospective study included all consecutive adult patients operated on by a single surgeon for acute displaced clavicular midshaft fracture between January 2010 and October 2014. Hybrid technique with interfragmentary cerclage wiring, temporary axial K-wire pinning, or their combination was used in all patients. The demographic data and clinical outcomes, including operation time, union time, restoration of anatomy, shoulder functional score, and complications were evaluated. RESULTS: There were 54 male and 19 female patients, with an average age of 39.3 years (range, 18 to 77 years) for males and 58.3 years (range, 39 to 77 years) for females. They were followed up for 24 months (range, 12 to 44 months). All patients had reliable bone union after surgery using interfragmentary cerclage wiring and temporary axial K-wire fixation; fracture union was obtained at an average of 11.7 weeks (range, 8 to 21 weeks) postoperatively. Additionally, there was no postoperative loss of fracture reduction or plate loosening. At the final follow-up, all patients had regained excellent functional outcomes. CONCLUSIONS: The cognizant effort to achieve anatomic reduction without surrounding soft tissue insult before definitive plating allows excellent radiologic and functional outcomes. Interfragmentary cerclage wiring and temporary axial K-wire pinning can overcome difficulties associated with unstable clavicle fractures to allow proper fracture reduction. In this article, we introduce a concise technique for achieving the desired outcomes reliably and efficiently when treating unstable clavicle midshaft fractures.

Subtrochanteric Fracture: Emphasis on Surgical Techniques in Nailing / 대한정형외과학회잡지

Intramedullary nailing is considered the most biomechanically advantageous therapeutic modality in the treatment of subtrochanteric femoral fractures. Many technical pitfalls and difficulties in nailing are well known. Reduction of the proximal fragment in a flexed, abducted, and externally rotated position should be performed before nailing of subtrochanteric fractures in order to avoid malalignment and nonunion. In this review, various reduction techniques to control the proximal fragment which are useful in nailing will be discussed.

Results of Tension Band Wiring and Additional Circumferential Wiring in Treatment of Comminuted Patella Fracture

PURPOSE: The purpose of this study is to evaluate the results of tension band wiring and additional circumferential wiring in treatment of comminuted patella fractures. MATERIALS AND METHODS: A retrospective study of 67 patients with follow-up period longer than six months who underwent tension band wiring and additional circumferential wiring for comminuted patellar fracture from January 2004 to December 2012 was conducted. Analysis was based on radiological evaluation of bony union and articular surface displacement, and clinically by evaluating the postoperative function of the knee joint using the Levack scoring system. RESULTS: Only one case out of 67 (1.5%) showed nonunion without metal breakage while good bone union was achieved in all other cases. Excluding the nonunion case, range of motion was 90 degrees minimum, 135 maximum, 129 on average. Average displacement was less than 2 mm, and 64 out of 67 cases showed satisfactory outcome with excellent functional score according to the Levack scoring system. CONCLUSION: Tension band wiring and additional circumferential wiring technique for treatment of comminuted patella fractures can be considered as an effective treatment for achievement of good bone union and restoration of normal knee function.

Separate Vertical Wiring for the Fixation of Comminuted Fractures of the Inferior Pole of the Patella

PURPOSE: Among patients over 50 years of age, separate vertical wiring alone may be insufficient for fixation of fractures of the inferior pole of the patella. Therefore, mechanical and clinical studies were performed in patients over the age of 50 to test the strength of augmentation of separate vertical wiring with cerclage wire (i.e., combined technique). MATERIALS AND METHODS: Multiple osteotomies were performed to create four-part fractures in the inferior poles of eight pairs of cadaveric patellae. One patella from each pair was fixed with the separate wiring technique, while the other patella was fixed with a combined technique. The ultimate load to failure and stiffness of the fixation were subsequently measured. In a clinical study of 21 patients (average age of 64 years), comminuted fractures of the inferior pole of the patellae were treated using the combined technique. Operative parameters were recorded from which post-operative outcomes were evaluated. RESULTS: For cadaveric patellae, whose mean age was 69 years, the mean ultimate loads to failure for the separate vertical wiring technique and the combined technique were 216.4+/-72.4 N and 324.9+/-50.6 N, respectively (p=0.012). The mean stiffness for the separate vertical wiring technique and the combined technique was 241.1+/-68.5 N/mm and 340.8+/-45.3 N/mm, respectively (p=0.012). In the clinical study, the mean clinical score at final follow-up was 28.1 points. CONCLUSION: Augmentation of separate vertical wiring with cerclage wire provides enough strength for protected early exercise of the knee joint and uneventful healing.

Bipolar Hemiarthroplasty Using Calcar Replacement Stem for Unstable Intertrochanteric Femoral Fracture in Elderly Patients / 대한고관절학회지

PURPOSE: The purpose of this study is to evaluate the results of bipolar hemiarthroplasty using calcar replacement stem for comminuted intertrochanteric fracture in elderly patients. MATERIALS AND METHODS: Between March 1998 and March 2008, the clinical records of 79 cases who were older than 75 years of age and underwent bipolar hemiarthroplaty, using calcar replacement stem with figure of eight and cerclage wiring, were reviewed. Their mean age was 82.4 years(75-92 years) and the mean follow-up period was 68 months(24-92 months). RESULTS: The mean postoperative Harris hip score was 82.1(62-92), and preoperative walking ability was recovered in 56 cases(71%). Bony ingrowth fixation was achieved in 70 cases(89%), and fibrous stable fixation was in 9 cases(11%). Stress shields were revealed in 21 cases(27%). Nonunion of trochanter was found in 3 cases(4%), and wire fixation breakages were in 3 cases after bony union. The mean duration of bony union was 16.3 weeks(12-38 weeks). Aseptic loosening was observed in 1 case and protrusio acetabuli were in 2 cases. CONCLUSION: The result of clinical and radiological evaluations of bipolar hemiarthroplasty, using calcar replacement stem with figure of eight and cerclage wiring, were satisfactory in elderly patients with comminuted intertrochanteric fracture.

Cerclage Wiring in Internal Fixation of Displaced Acetabular Fractures

PURPOSE: To evaluate the usefulness of wire fixation in displaced acetabular fractures. MATERIALS AND METHODS: From January 2000 to December 2005, 19 cases of displaced acetabular fracture were treated with wire fixation. According to Letournel's classification there were 9 both column fracture, 5 transverse fracture, 3 anterior column with posterior hemitransverse and 2 T-type fracture. Only wire fixation in 13 cases and wire with plate or wire with screw fixation in 6 cases. RESULTS: We evaluate the accuracy of reduction by Matta' criteria, anatomical reduction in 12 cases, incomplete reduction in 4 cases, poor reduction in 2 cases and surgical secondary congruence in 1 case. The clinical results showed excellent in 12 cases, good in 4 cases, fair in 2 cases and poor in 1 case. The radiological results showed excellent in 10 cases, good in 4 cases, fair in 3 cases and poor in 2 cases. There were 4 cases of complication; wound infection in 1case, post-traumatic arthritis in 1 case and heterotopic ossification in 2 cases. CONCLUSION: The cerclage wiring is a preferable method in internal fixation of displaced acetabular fractures that can facilitate reduction and achieve stable fixation.

Trochanteric Management for Unstable Intertrochanteric Femoral Fracture in the Elderly Patients

PURPOSE: To evaluate the results after fixation with figure of eight and cerclage wiring for comminuted trochanteric fracture. Because comminution of the femoral trochanteric fracture in elderly patients is severer in the operating field than x-ray findings, so the fixation is more difficult. MATERIALS AND METHODS: Between March 1998 and March 2004, the clinical records on twenty-eight patients more than 70 years old who underwent the bipolar hemiarthroplaty using calcar replacement type of femoral stem and followed more than 24 months were reviewed. Figure of eight and cerclage wiring was used for the comminuted trochanteric fracture of the femoral intertrochanteric fracture. The mean age was 80.4 (70~103) years. 19 cases were female, 9 cases were male. Mean follow-up period was 58 (24~92) months. We evaluated the results by modified Harris hip score, walking ability, activity of daily living, radiologic findings and union of the fracture. RESULTS: The mean duration of bony union was 12 weeks. The mean postoperative modified Harris hip score was 82.3. Preoperative walking ability was recovered in 23 cases (82%). Also basic activity of daily living was recovered in 22 cases (79%). Nonunion of trochanter was found in only one case by radiologic evaluation but clinical correlation was not significant. CONCLUSION: We consider fixation with figure of eight and cerclage wiring for unstable intertrochanteric fracture of femur in the elderly patient is more appropriate in terms of convenience of fixation, duration of union, early ambulation and cost effectiveness.

Treatment of Comminuted Femoral Shaft Fracture by Interlocking Intramedullary Nailing: Comparision of results between open reduction with cerclage wiring and closed reduction

PURPOSE: To compare of results between open interlocking intramedullary nailing combined with cerclage wiring and closed interlocking intramedullary nailing in treatment of femoral shaft comminuted fracture, we reviewed retrospectively 62 femoral shaft fractures. MATERIALS AND METHODS: We reviewed retrospectively 62 femoral shaft comminuted fractures, who had been followed up for a minimum one year including Winquist-Hansen classification II, III, IV from January 1996 to December 2002. The group I include the patients who treated with closed interlocking intramedullary nailing. The group II include the patients who treated with open interlocking intramedullary nailing combined with cerclage wiring. RESULTS: The average bone union time was 18.6 weeks in group I, 27.6 weeks in group II. The complication included 3 delayed unions, 1 nonunion and shortening of more than two centimeters in 1 patents in group I. In group II, The complication included 2 infections, 7 delayed unions and 3 nonunions. CONCLUSION: We can use open interlocking intramedullary nailing with cerclage wiring in some femur shaft comminuted fractures, but there are many problems and complications. So we must consider it carefully before using this method.