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Number: Njmdr_2411_14
Early mobilisation is the aim of surgery after patellar fracture and the goal is to achieve
pre injury knee movements but this cannot be accomplished in every case because
of the variety of reasons. Some patients therefore would end up with some loss of
knee movements which is refractory to physiotherapy. We analysed our results of
arthroscopic arthrolysis in 10 patients with significant loss of knee flexion following
tension band wiring for patellar fracture. The patients included 9 males and 1 female.
The average age was 34.7 years. Initial rehabilitation efforts had failed. Arthroscopic
arthrolysis was performed to release intra articular adhesions and fibrous bands in the
supra patellar pouch. Intensive physiotherapy and continuous passive motion began
immediately post-operatively. Patients were followed every 2 weeks in physiotherapy
clinic till 8 weeks. Average flexion achieved at the time of surgery was 130 degrees
(range 120-140). All patients lost some flexion in follow up. The average loss was 20
degrees (range 10-30). Mean flexion at 8 weeks was 110 degrees (average 120-95).
There was no change in knee ROM between 4-8 weeks. Arthroscopic management
can be beneficial for patients suffering from arthrofibrosis following patellar fracture
surgery.
Key Words: Patella Fracture, Arthrofibrosis, Arthroscopic Arthrolysis
Introduction:
Patellar
fractures
account
for
approximately 1% of all fractures [1],
present a higher prevalence within the
age group of 20 to 50 years old [1,2]
and males are more commonly affected
than female [3]. Loss of knee flexion
following surgical fixation of fractured
patella is fairly a common problem. To
achieve satisfactory knee movements,
physiotherapy should be started early and
patients should be allowed unrestricted
knee movements. Despite commencing
early physiotherapy, some patients would
end up with a stiff knee. The reason could
be noncompliance or patient not coming
for regular follow-up. Sometimes surgeon
is not confident about the stability of
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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 36-40
Technique:
All cases were done under spinal anaesthesia in supine
position with a thigh tourniquet. Single dose of antibiotic
is given at the time of induction. Trochar is inserted from
standard anterolateral portal and swiped around the joint to
break patellofemoral adhesions and free medial and lateral
retinaculum from femoral condyles. A medial portal is
then made under direct vision and intraarticular adhesions
were released with a soft tissue shaver. Care was taken to
identify menisci and cruciate ligaments and protect them.
All shaving was done under direct vision. Arthroscope is
then pushed in supra patellar pouch. A radio frequency
probe is then introduced through superolateral portal and
adhesions released under direct vision. Soft tissue shaver
was used to remove the scar tissue after morselisation with
arthroscopic punch and scissor if radio frequency probe
is not available (in 4 cases). Tourniquet is then released.
This is followed by gentle manipulation of knee. Implant is
removed if k wires are impinging upon quadriceps tendon
(5 patients). Circlage wire was not removed in any of the
patient although it could be removed as well if patient
complaints of prominent hardware. Knee joint are injected
with 80 mg methyl prednisolone at the end of the procedure
after closure of the portals. No drain is used. A bulky but
loose dressing is given. Postoperative rehabilitation begins
in the recovery room, displaying the motion gain to the
patient and family while the patients pain is still controlled.
Patient is commenced on Immediate CPM in the recovery
room. Multimodal analgesia is used in postoperative
period (opiates, NSAIDs, ice packs). No antibiotics are
given postoperatively. On first postoperative day, dressing
is changed and light dressing (band aids) given. Patient is
commenced on knee ROM exercises and analgesics are
adjusted as per the severity of pain. Early weight bearing
37
Age
Sex
Pre-op
ROM
Final ROM
(4weeks)
42
25
115
45
30
95
28
25
120
35
40
110
32
35
105
40
40
110
25
25
120
38
25
110
35
25
105
10
27
30
110
Figure 3 - Arthroscopic trochar used to release patellofemoral adhesions and medial and lateral retinaculi
National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 36-40
Discussion:
Loss of motion or stiffness after Tension Band Wiring for
patella fracture is frustrating for the patient and surgeon.
Stiffness results in pain and loss of range of movement.
This decreased range of movement can severely affect the
patients ability to perform activities of daily living such
as walking, climbing stairs, or getting up from a seated
position. Biomechanical studies and gait analysis have
shown that patients required 67 of knee flexion during
the swing phase of gait, 83 of flexion to climb stairs, 90
100 of flexion to descend stairs, and 93 of flexion to stand
from a seated position [3]. Fibrosis and contractures in
different parts of the knee contribute to different types of
motion loss. Adhesions in the suprapatellar pouch typically
limit patellar mobility and can restrict knee flexion. The
proximal extent of the pouch should be approximately 3.5
cm from the superior pole of the patella. A foreshortened
pouch can lead to a further loss of knee flexion [4]. Other
structures of the knee that contribute to a loss of flexion
are the medial and lateral gutters, and the anterior interval.
The anterior interval is the region of the knee posterior to
the patellar fat pad and anterior to the antero superior tibial
plateau. This interval is an under recognized source of knee
flexion loss [5].
Results:
Average flexion achieved on operation table was 130
degrees (range 120-140). All patients lost some flexion in
follow up. At 4 weeks, the average loss was 20 degrees
(range 10-30). Mean flexion at 4 weeks was 110 degrees
(average 120-95). There was no further loss of flexion
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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 36-40
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