A 27 -years old male sustained transverse fracture of the patella with gross displacement while playing football. The fracture was subsequently stabilized with tension band wiring with two Kirschner wires (K-wire) & figure of eight stainless steel wire. The immediate post operative period was uneventful. He was discharged after stitch removal with knee support and was advised partial weight bearing with knee bending exercises in between. However, he indulged in heavy manual work including bicycling after 15 days of surgery. This led to loosening of implants and failure of reduction. He reported after 2 months of failure with pain, swelling and stiffness of the knee joint. X-rays revealed wide displacement of the fragments with loose implants (Fig. 1).
The options for such a case were either patellectomy or apposing the fragments by some means. Patellectomy would lead to difficulty in apposing the ligaments as there were gross displacements of the fragments leading to contracture of soft tissues on either side of the patella. Apposing the fragments would require extensive soft tissue dissection and lengthening of the quadriceps tendon resulting in extensive scarring and stiffness. As we were accumulating experience by using Ilizarov in various situations, we opted for it to mend the difficult situation in this case. We felt gradual docking with slow stretching of the soft tissue without any dissection would be the perfect choice for the case. After removing the implants, the fracture margins were cleared of fibrous tissue taking care not to remove any bone. As acute docking was not possible, sub-acute docking was contemplated on the table. Opposing olive wires, 2 in number on either fragments (total 4 in number), attached to traction units were passed through the fragments which were mounted on two full rings on either side (joining two half rings). The rings were fixed to distal femur and proximal tibia by wires and interconnected with threaded rods. The fragments were brought together as close as possible on the table by turning the nuts on the traction units (sub-acute docking); subsequently gradual docking was done with the help of traction units till X-ray showed complete contact. The traction unit consisted of slotted threaded rod with mounted K-wire which was held in place by nuts. These units were mounted on the ring by male post. After docking, as confirmed by X-Ray, compression was applied across the fracture site at the rate of 1/4th turn every 3rd day till one millimeter of compression was achieved (Fig. 2). Full weight bearing was allowed as pain permitted. Patient was followed up every 2 weeks looking for pin site infections and loosening of the compression achieved. Assembly was removed when X-ray showed complete healing.