51
Case Report
J Korean Knee Soc, Vol. 23, No. 1, March 2011A Case of Delayed Recurrent Hemarthrosis after Percutaneous Pin Fixation of the Patellar Fracture
Smarajit Patnaik, M.S., Jin Ho Cho, M.D., Kook Hyun Wang, M.D., Bo Hoon Chang, M.D. and Kyung Wook Nha, M.D.
Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
Received: March 26, 2010
Revised: (1st) April 20, 2010, (2nd) June 4, 2010, (3rd) July 27, 2010, (4th) August 30, 2010, (5th) November 24, 2010
Accepted: December 2, 2010
Corresponding author: Kyung Wook Nha, M.D.
Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, 2240 Daehwa-dong, Ilsanseo-gu, Goyang 411-702, Korea
TEL: 82-31-910-7968, FAX: 82-31-910-7967 E-mail: [email protected]
A 24-year-old man underwent percutaneous fixation with pins for an undisplaced patellar fracture. At 7 months follow-up postoperatively, he presented with recurrent, painful swelling of the operated knee following trivial activities of daily life. Aspiration had been performed two times before he presented to us with symptoms. An x-ray showed that one of the pins was suspected to be protruding at the inferior pole of the patella. Magnetic resonance imaging confirmed effusion in the joint. Arthroscopy revealed that the pin was prominent intraarticularly, and the adjacent infrapatellar fat pad with surrounding synovial tissue seemed to be abraded. The pins were removed under arthroscopic guidance and any pain or hemarthrosis disappeared thereafter.
Key Words: Recurrent hemarthrosis, Patellar fracture, Percutaneous pin fixation
The patellar fracture constitutes almost 1% of the skeletal injuries3). Conservative treatment is limited to fractures with minimal displacement and those with no significant incongruity of the articular surface, while operative treatment is indicated if there is more than 2
−3 mm of fragment separation and/or articular incon- gruity1). The goal of operative fixation is to achieve an anatomic reduction of the articular surface and a stable fixation to allow early motion of the knee. There have been reports about arthroscopic-assisted reduction and percutaneous stabilization of minimally displaced frac-
tures without extensor mechanism disruption. This tech- nique may lead to less morbidity and rapid recovery2). Although local irritation of adjacent subcutaneous tissue by wires or pins used for fixation of the patellar frac- ture had been frequently reported, this patient has com- plained painful, recurrent hemarthrosis by pin irritation against synovium and fat pad.
CASE REPORT
A 24-year-old male visited our office owing to re- current, painful swelling of left knee on trivial round of daily life and difficulty in stair climbing. He underwent percutaneous pins fixation for patellar fracture about 7 months ago and has complained the painful swelling of the operated knee. Aspiration had been perfomed two times before he presented to us. There were obvious knee swelling, quadriceps wasting, tenderness on the in- ferior pole of the patella, and painful knee flexion.
대한슬관절학회지：제 23 권 제 1 호 2011
52 Volume 23, Number 1, March 2011
Fig. 1. Lateral radiographs of left knee shows the bone union and pin protruding below inferior pole of patella into soft tissue shadow (white arrow).
Fig. 2. T2 weighted magnetic resonance imaging scan of the knee joint shows hyperintense signal intensity suggesting hemarthrosis (white arrow).
Fig. 3. Arthroscopic finding reveals the pin placed intra- articularly with yellowish brown discolouration of synovial tissue suggesting repeated hemarthrosis.
Blood was aspirated from the joint under sterile precau- tions. Lateral radiographs showed the bony union and pin protruding into soft tissue shadow below the inferior pole of the patella (Fig. 1). T2 weighted magnetic reso- nance imaging revealed heterogenous, hyperintense sig- nal intensity suggesting hemarthrosis in the joint (Fig.
2) but no suspected lesions causing hemarthrosis such as meniscal or ligamentous injury. Arthroscopy revealed intraarticular pin protrusion as well as abraded, dark brownish adjacent fat pad and synovium, probably due to pin irritation and resultant recurrent hemarthrosis (Fig. 3). Pins were removed by pulling out through stab incisions percutaneously under arthroscopic visualization.
There was no recurrence of pain or hemarthrosis in one year follow-up after pin removal.
DISCUSSION
There are many surgical techniques described for fix- ation of displaced patellar fractures, including circlage wiring, tension band wiring with or without transfixing screws or k-wire, cannulated screws, percutaneous pins, percutaneous suture fixation and external fixators5). Although open technique is the standard, closed reduc- tion and percutaneous fixation under arthoscopic assis- tance are also reported4,7). Percutaneous pin fixation may be considered to provide adequate fixation in transverse fractures with good bone stock. But the per- cutaneous pin fixation may have limited applicability in
Smarajit Patnaik, et al：A Case of Delayed Recurrent Hemarthrosis after Percutaneous Pin Fixation of the Patellar Fracture 53
comminuted or multifragmented fractures. Also it is not possible to treat fractures accompanied by laceration of the medial and lateral retinacula with this method be- cause these cases require open repair of the soft tissues and internal fixation of the fracture. Sometimes lacer- ations or abrasions in overlying skin of the patella cause a delay in surgery6). To avoid this problem, percuta- neous fixation can be considered for these situation.
There have been various complications reported fol- lowing surgery for patellar fracture, including infection, skin and wound problem, post-operative adhesion, joint stiffness, cosmetically poor scar following surgery, im- plant irritation that was commonly reported as high as 36%7), and breakage or migration of fixator when re- tained for a protracted time.
We report a rare, but potential complication of pain- ful, delayed, recurrent hemarthrosis by irritation of synovium and infrapatellar fat pad after percutaneous pin fixation for the patellar fracture, although there is unclear whether inadvertent penetration or pin migra- tion into the joint was the source. In order to avoid the potential complication, first, we suggest that regular ra- diographic follow-ups be conducted to identify the pres- ence of pin migration or penetration and that patients should be made aware of risks related to follow-up loss.
Moreover, when any fixation pin movement is observed, careful regular follow-up should be advised. Second, af- ter achieving bony union regardless to irritation due to pin penetration, it should be considered to remove the pins as soon as possible. Third, after percutaneous pin fixation for the patellar fracture, arthroscope may be helpful to check whether the pin penetration while as- sessing reduction quality of the articular surface, al-
though additional incision is necessary to make a portal.
Although it was unclear that pin protruding was ini- tial finding or not, we suggest that intraoperative ar- throscopic confirmation or careful observation of pin status during follow-up is required to minimize the risk of pin migration related complications after percuta- neous pin fixation for the patellar fracture.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
REFERENCES
1. Biddau F, Fioriti M, Benelli G: Migration of a broken cerclage wire from the patella into the heart. A case report. J Bone Joint Surg Am, 88; 2057-2059: 2006.
2. Gardner MJ, Griffith MH, Lawrence BD, Lorich DG:
Complete exposure of the articular surface for fixation of patellar fractures. J Orthop Trauma, 19; 118-123:
2005.
3. Galla M, Lobenhoffer P: Patella fractures. Chirurg, 76;
987-997: 2005.
4. Makino A, Aponte-Tinao L, Muscolo DL, Puigdevall M, Costa-Paz M: Arthroscopic-assisted surgical technique for treating patella fractures. Arthroscopy, 18; 671-675:
2002.
5. Canale ST: Campbell’s operative orthopaedics. 11th ed.
St. Louis, Mosby; 3161-3169: 2008.
6. Canale ST: Fractures of lower extremity. Campbell’s operative orthopedics. 9th ed. St. Louis, Mosby; 2110- 2119: 1998.
7. Turgut A, Günal I, Acar S, Seber S, Göktürk E: Arthro- scopic-assisted percutaneous stabilization of patellar fractures. Clin Orthop Relat Res, (389); 57-61: 2001.
대한슬관절학회지：제 23 권 제 1 호 2011
54 Volume 23, Number 1, March 2011
슬개골 골절의 경피적 핀 고정술 후 지연 발생한 재발성 혈관절증
인제대학교 일산백병원 정형외과
Smarajit Patnaikㆍ조진호ㆍ왕국현ㆍ장보훈ㆍ나경욱
24세 남자환자로 비전위성 슬개골 골절에 대해 외부에서 경피적 핀 고정술을 시행받았다. 환자는 일상생 활 중 발생한 통증과 함께 재발성의 슬관절 부종을 호소하여 수술 7개월째 내원하였다. 내원 전 관절 천자를 2회 시행하였으며, 단순 방사선 촬영 상 슬개골 하부에 핀 돌출이 관찰되었다. 자기공명영상 검사 상 관절 내 삼출이 보였으며, 이에 시행한 관절경 검사에서 관절내로 돌출된 핀과 마찰로 인한 주변 활액막 및 지방패드의 비정상 소견이 관찰되었다. 돌출된 핀은 제거되었고 이후 외래 추시 상 통증완화 함께 더 이상의 관철 삼출은 발생하지 않았다.
색인 단어: 재발성 혈관절증, 슬개골 골절, 경피적 핀 고정술
