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| ORIGINAL ARTICLES |
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| Year : 2023 | Volume
: 38
| Issue : 1 | Page : 24-31 |
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Is tension band wiring (osteosynthesis) with three Kirschner wires provide better outcome as compared with two Kirschner wires in patella fracture: A prospective randomized study
Sachin Kumar, Mohit Singh, Satish Kumar, Rahul Khare, Ajay Kumar Yadav, Deepak Kumar
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Science & Dr. RML Hospital, New Delhi, India
| Date of Submission | 02-Dec-2022 |
| Date of Acceptance | 30-Dec-2022 |
| Date of Web Publication | 20-Apr-2023 |
Correspondence Address:
Mohit Singh
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Science & Dr. RML Hospital, New Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jbjd.jbjd_48_22
Background: Fractures of the patella constitute approximately 1% of all skeletal injuries, resulting from either direct or indirect trauma. Many forms of internal fixation for patellar fractures have been described in the literature but perfect anatomical reduction during surgery has an excellent outcome irrespective of the method of fixation used. The conventional method of patellar tension band wiring (TBW) is being done always with the help of two parallel Kirschner wires (K-wires). Objectives: Here in our prospective study, we intended to see whether the use of three parallel K-wires in comparison to the conventional one results in superior functional outcomes. Materials and Methods: A prospective cohort study was carried out in New Delhi from November 2016 to November 2019 in a total of 44 patients with patellar fractures operated by TBW with 22 patients in two parallel K-wires and three parallel K-wires groups, respectively. Patients were followed up postoperatively for 1 year and assessed by Lysholm knee score (LKS), pain status, working status, and other variables Normality of data was tested by Kolmogorov–Smirnov test and paired t test/Wilcoxon rank-sum test. Results: The total mean age was 40.27 years (41.86 in 2K-wire and 38.68 in 3K-wire) in this study. LKS (0.00 in both groups on first day; 99.23 and 99.45 after 1 year in 2K-wire and 3K-wire groups, respectively, pain status (was 5.0 in both groups on the first day and 1.0 after 6 month), and working status (was 5.0 in both groups on the first day and 1.09 after 1 year), were not significantly different throughout the mean to follow up periods for both groups (P > 0.05). Conclusions: No significant difference was observed between patellar TBW in 3K-wire and 2K-wire groups. Keywords: Patella fracture, tension band wiring, 2-Kirschner wire, 3-Kirschner wire, Lysholm score, articular reduction
How to cite this article:
Kumar S, Singh M, Kumar S, Khare R, Yadav AK, Kumar D. Is tension band wiring (osteosynthesis) with three Kirschner wires provide better outcome as compared with two Kirschner wires in patella fracture: A prospective randomized study. J Bone Joint Dis 2023;38:24-31 |
How to cite this URL:
Kumar S, Singh M, Kumar S, Khare R, Yadav AK, Kumar D. Is tension band wiring (osteosynthesis) with three Kirschner wires provide better outcome as compared with two Kirschner wires in patella fracture: A prospective randomized study. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:24-31. Available from: http://www.jbjd.in/text.asp?2023/38/1/24/374433 |
| Introduction | |  |
The patella regulates to increases the force of the quadriceps apparatus by improving the leverage.[1],[2] Also, it protects the anterior articular surface of the distal femur against external violence. Fractures of the patella are approximately 1% of all skeletal injuries, due to either direct or indirect trauma.[3] Transverse fractures of the middle third of the patella are the most common patella fracture[4] and twice in men as compared to women around the age of 20–50 years.[5]
The decision to operate should be made expeditiously. The subcutaneous location of the patella makes it prone to concomitant soft tissue injury. Fixation of fracture may be achieved with either wires or screws, alone or in combination. Regardless of the method of fixation, an anatomical reduction is achieved.[6],[7]
The Swiss Association for the Study of Internal Fixation has popularized the modified tension-band technique as a method of fixation.[8] In this technique, two parallel K-wires are passed longitudinally through the cannulated screws, then over the anterior surface of the patella, through the center of the other cannulated screw, and then back over the anterior surface of the patella, where it is twisted to the other end of the wire.[9] Theoretically, this construct should provide resistance to fracture displacement from anterior distraction when the knee is in extension as well as resistance to displacement as the knee moves into flexion.[9] The tension band technique is most often used for patella fractures and has been shown to produce satisfactory outcomes.[3],[10]
The principle of tension band wiring (TBW) fixation for patellar fractures is to convert the tensile forces generated from the quadriceps complex at the anterior cortical surface of the patella into compressive forces at the articular surface (posterior surface). Metal implants, such as stainless-steel K-wires and screws have generally been used for this method of fixation.[11] The ultimate goal of treatment is to regain the continuity of the extensor mechanism and congruity of patella-femoral articulation so that the normal function of the knee can be restored. The ideal fixation for the fractured patella is that it should be strong enough to allow early mobilization, reduce posttraumatic stiffness and gain a full range of motion, which can be achieved by using of 3K-wire during TBW procedure. We are going to compare the functional outcome of the TBW in patients with fracture patella fixed with 3K-wire versus 2K-wire.
| Materials and Methods | | |
Study design
This was a prospective cohort study which was carried out from the period of November 2016 to November 2019 at the Department of Orthopaedics. Forty-four patients were randomized into two groups for the study of patella TBW by 2K-wires and 3K-wires with help of a computer.
Inclusion criteria and exclusion criteria
All patients with displaced transverse fracture patella AO type C1.1 (18–60 years of age) both male and female attending Out Patient Department (OPD) and the Emergency Department of the hospital were included. But those patients were excluded having the following complications:
- Type II and type III compound fractures
- Grossly comminuted, vertical, or marginal fractures.
- Old fractures (more than 3 weeks).
- Undisplaced transverse fractures.
Consents and IRB
The patients and/or their families were informed that data from the research would be submitted for publication, and gave their consent. This research has been approved by the IRB of the authors’ affiliated institutions.
Surgical procedure
Under spinal anesthesia, after positioning of the patient, scrubbing, painting, and draping of the affected knee was done and an anterior longitudinal midline incision was given [Figure 1]A. Cleaning the fracture surfaces with normal saline was done to remove the blood clot and small fragments. Whenever the major proximal and distal fragments are large, we reduced them accurately, with special attention to restoring a smooth articular surface. In the first group (2K-wires), the fracture was reduced and held firmly with clamps, drill two 2-mm K-wires through both the fragments of fracture after holding the reduction with the reduction clamp. We inserted the wires as parallel as possible [Figure 1]B. In the second group of 3K-wires [Figure 1]C, the patella was divided in the sagittal plane into three equal parts and three K-wires were put equidistance in the center of each part then TBW was done. After that Pass a strand of 18/20 gauge stainless steel wire transversely through the quadriceps tendon attachment, as close to the bone as possible, deep to the protruding K-wires, over the anterior surface of the reduced patella in a figure of “8” manner. Then the reduction was checked by palpating the undersurface of the patella with the knee extended. Bend the upper ends of the 2K-wires acutely anteriorly, and cut them short. When they were cut, rotate the K-wires 180°; with an impactor, embed the bent ends into the superior margin of the patella posterior to the wire loops. Cut the protruding ends of the K-wires short inferiorly. Repair the retinacular tears with multiple interrupted sutures. Suction drainage was used and closure of the wound was done in multiple layers. After aseptic dressing cylindrical slab was applied in full extension of the knee for 10–14 days. | Figure 1: A midline vertical incision for exposing the patella for surgical procedure (A). Image showing TBW with 2 k wire (B). Image showing TBW with 3-K wire (C)
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Evaluation and follow-up
The limb was placed in full extension in a posterior plaster slab or cast. The patient was allowed to ambulate while bearing weight as tolerated on the first postoperative day. Isometric and stiff-leg exercises are encouraged, beginning on the first postoperative day. The extent of active motion permitted in the immediate postoperative period is determined intraoperatively based on the fracture repair stability. Active range-of-motion exercises were performed when the wound has healed, at 2–3 weeks. Progressive resistance exercises were started and the brace was discontinued at 6–8 weeks if healing is evident on the radiograph as compared to pre-operative radiographs [Figure 2]A, [B] and [Figure 3]A. The unrestricted activity was resumed when full quadriceps strength has returned, at 18–24 weeks. In patients with less stable fixation or extensive retinacular tears, the active motion should be delayed until fracture healing has occurred. Initiating range-of-motion exercises by the end of the second week is desirable but not always possible. A controlled motion knee brace can be used, allowing full extension and flexion to the degree permitted by the fixation as determined intraoperatively. A follow-up was also done after 1 year for X-ray and other parameters [Figure 2]C and [Figure 3]B. | Figure 2: Anterior–posterior and lateral radiograph of the left knee showing wide displaced fractured patella (A). Postoperative X-ray of the same patient operated with TBW by 2K-wire (B). X-ray after 1 year showing union of the fractured patella (C)
Click here to view |
 | Figure 3: Postoperative X-ray of patient operated with TBW by 3K-wire (A). X-ray after 1 year showing union of the fractured patella (B)
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Functional outcome was recorded using Lysholm score immediately after surgery and then on the 3rd day, 7th day, 14th day 1 month, 6th month, and 1 year. Radiographs were obtained immediately postoperatively and then at first month, 6th month, and 1 year. Pain and work status were assessed using the Denis et al.[12] pain scale and work scale: immediately after the surgery, on the 3rd day, 7th day, 14th day, at 1 month, 6 months, and 1 year. Pain status was assessed for 6 months only.
Statistical analysis
Parameters for statistical analysis were the Lysholm score,[13] pain score,[12] and work status[12]. Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean ± standard deviation and median. Normality of data was tested by Kolmogorov–Smirnov test. A nonparametric test was used when the normality was rejected. Quantitative variables were compared using the paired t test/Wilcoxon rank-sum Test (when the data sets were not normally distributed) across follow-up. A value of P < 0.05 was considered statistically significant. The data was collected as per protocol in the MS EXCEL spreadsheet and analysis was done using the Statistical Package for the Social Sciences (SPSS) software program, version 21.0.
| Results | | |
This present study included the two groups of 22 patients with transverse fracture patella admitted to the department of Orthopedics from November 2016 to November 2019 and were operated with TBW with the help of 2K-wire in one cohort and with the help of 3K-wire in another cohort and followed up for 1 year.
In our study, we have two groups of patients (22 patients in each group) with fracture patella, one group got operated on by using TBW fixed with 2K-wires and another group with 3K-wires. We included patients of the age group between 18 and 60 years. Between the age group 20–30 years, six patients' fracture was fixed with 2K-wire, and five patients with the help of 3K-wire. Between the age group of 31–40 years, six patients' fracture was fixed with 2K-wire, and nine patients with the help of 3K-wire. Between the age group of 41–50 years, six patients' fracture was fixed with the help of 2K-wire and five patients with the help of 3K-wire. Between the age group of 51–60 years, four patients’ fracture was fixed with the help of 2K-wire and three patients with the help of 3K-wire. [Table 1]a. In this study, there were 31 males and 13 females [Table 1]b. Lysholm score calculates with some subjective questions. In the 2K-wire group, the Lysholm score was 0.0 postoperative on the day of surgery but on 3rd day, 7th day, 14th day, first month, 6th month, and after 1 year was 9.00, 29.00, 74.00, 86.73, 99.18, and 99.23, respectively. In the 3K-wire group the Lysholm score was 0.0 postoperative on the day of surgery but at the 3rd day, 7th day, 14th day, first month, 6th month, and after 1 year was 9.00, 29.00, 74.00, 85.36, 99.14, and 99.45, respectively [Table 2]. For measuring the pain, we use pain status and we have not found any significant difference between both groups. The value of pain status in the 2K-wire group on day 0, on 3rd day, 7th day, 14th day, first month, 3rd month, and after 6th was 5.0, 3.4, 2.8, 2.0, 1.0, 1.0, and 1.0, respectively. The value of pain status was almost the same in 3 k wire group, on day 0, at the 3rd day, 7th day, 14th day, first month, 3rd month, and after 6th was 5.0, 3.6, 3.0, 2.0, 1.0, 1.0, and 1.0, respectively [Table 3]. The last component of our study “work status” was same in both groups. Its values on day 0, at 3rd day, 7th day, 14th day, first month, 6th month and after 1 year were 5.00, 5.00, 5.00, 4.00,3.00, 1.09, and 1.09, respectively [Table 4]. The results indicate that there was no significant difference found between both groups.
| Discussion | | |
Functional outcome was recorded using Lysholm score immediately after surgery and then on 3rd day, 7th day, 14th day 1 month, 6th month, and 1year. Radiographs were obtained immediately postoperatively and then at first month, 6th month, and 1 year. Pain and Work status was assessed by Denis et al. pain scale and work scale. Immediately after the surgery, on the 3rd day,7th day, 14th day, 1 month, 6th month, and at 1 year.
In this study, we compared the functional outcome with TBW in fracture patella fixed with 2K-wire versus 3K-wire with the help of the Lysholm score and work status for 1 year, with pain status followed for 6 month.
In the study conducted by et al.,[14] percutaneous fixation was performed in 23 cases of transverse patellar fractures with TBW with two parallel k wires, the mean follow-up period was 20 months. One patient had patellofemoral arthritis, 2 had superficial infections in this study. In our study, we had a mean follow-up period of 1 year with no cases of infection, fixation failure, and patellofemoral arthritis reported.
In the study conducted by Cho,[15] percutaneous TBW was done for patella fractures using cannulated screws. In his study, the average age was 45 years, in our study is 40.27 years. The mean follow-up period is 15 months compared to 1 year in our study.
Findings by Miller et al.[16] showed factors predictive of failure of fixation. Age is a strong predictor of failure, the average age of patients who achieved successful fixation was 51 years compared to 65 years for those who had failed of fixation. In our study, the average age of the patients was 40.27 years with no case of fixation failure. Epidemiologic studies showed that the incidence of fracture patella in men is twice as high as in women.
The most frequent causes are traffic accidents in 78.3%, followed by work-related accidents in 13.7% and domestic accidents in 11.4% in Wild et al.’s[17] study. In our study out of 44 patients, 23 patients had road traffic accidents as a mode of injury (52.27%), 12(27.22%) were due to fall from stairs and 9(20.45%) were due to sports injury.
Lysholm score of all the patients on a postoperative day was 0. Mean Lysholm score post-operatively at 1 year in patients fixed with 2K-wire is 99.23 and fixed with 3K-wire is 99.45 with standard deviation +1.44 to –1.44 for 2K-wire and standard deviation +1.47 to –1.47 for 3K-wire, showing significant improvement in Lysholm score in both 2K-wire and 3K-wire fixation. The p-value for the Lysholm score at the end of 1 year was 0.608, indicating there was no significant difference in functional outcome between both the procedures (2K-wire and 3K-wire) at the end of 1 year. Four patients (two from the 2K-wire group & two from the 3K-wire group) having Lysholm score 95 at the end of 1 year, had slight difficulty in squatting and climbing the staircase.
On a post-operative day, all the patients showed maximum value on the pain scale was 5. At the end of the 6 months, patients of both groups had no complaint of pain, the value on the pain scale was 1. Work status immediately after surgery was 5 for all the patients. At the end of 1-year mean of the work status of the patients fixed with 2K-wire and 3K-wire is 1.09.
In the study conducted by Cho,[15] percutaneous TBW was done for patella fractures using cannulated screws. The mean Lysholm score was 93. In our study, 4 patients out of 44 had a Lysholm score of 95. The mean value of the Lysholm score was 99.23 in the 2K-wire group and 99.45 in the 3K-wire group.
In the study conducted by El-Sayed et al.,[18] 14 patients were included with displaced transverse fractures of the patella treated by arthroscopic-assisted closed reduction of the fracture with percutaneous screw fixation. The mean period of follow-up was 26 months. The mean final Lysholm score was 93.
| Conclusions | | |
In our study, the 3K-wire fixation TBW was done to improve the functional outcome and to allow early mobilization of the patient. But there was no significant difference in functional outcome amongst the 2K- wire group and 3K wire group. At present, there is no significant benefit to using 3K-wires instead of 2K-wires.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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