PMC6362484_01
(a) Preoperative radiograph. (b) Preoperative clinical examination.
CRIOR2019-5915701.001.jpg
PMC6362484_01_CRIOR2019-5915701.001.jpg
fig1
At the present consultation, the patient presented with an active range of motion (ROM) of 70  to 120  and passive ROM of -5  to 120  (Figures 1(a) and 1(b)).
The traction pin is positioned (a, b), and traction is applied (c).
CRIOR2019-5915701.002.jpg
PMC6362484_01_CRIOR2019-5915701.002.jpg
fig2
In the first phase, transskeletal patellar traction was performed, and a Steinmann pin with a 3.5 mm thick central thread (Figures 2(a)-2(c)) was inserted transversely into the proximal pole.
Serial radiological images.
CRIOR2019-5915701.003.jpg
PMC6362484_01_CRIOR2019-5915701.003.jpg
fig3
Serial radiological images were obtained to quantify the decrease in the distance between the two poles of the area of pseudoarthrosis (Figure 3).
Measurements of the approximate distance between the bone fragments of the patella during transpatellar traction based on radiological images of the knee in full extension.
CRIOR2019-5915701.004.jpg
PMC6362484_01_CRIOR2019-5915701.004.jpg
fig4
On day 11, diastasis between the fragments, which was 9 cm preoperatively, was reduced to 1.2 cm with the knee in full extension (Figure 4).
Contact between the fragments is not possible.
CRIOR2019-5915701.005.jpg
PMC6362484_01_CRIOR2019-5915701.005.jpg
fig5
We attempted to reduce the fragments with two Backhaus clamps (Figure 5), but the contact between the fragments was not possible.
Cerclage wiring with the figure-of-eight tension band and two Backhaus clamps are used in attempt to reduce the distance between the pseudoarthrosis foci.
CRIOR2019-5915701.006.jpg
PMC6362484_01_CRIOR2019-5915701.006.jpg
fig6
This technique considerably reduced the distance between the pseudoarthrosis foci, but the contact was insufficient (Figure 6).
(a) Good contact between the fragments of the patella with autologous spongy graft. Radiographs in the anteroposterior (b) and lateral (c) views of the left knee in the immediate postoperative period.
CRIOR2019-5915701.007.jpg
PMC6362484_01_CRIOR2019-5915701.007.jpg
fig7
After thoroughly cleaning the site with 0.9% physiological saline, we focused on the pseudoarthrosis, an autologous spongy osseous graft from the proximal tibia, and removed it through a small osseous hole made in the anteromedial tibia (Figures 7(a)-7(c)).
Radiograph obtained during postoperative month 3.
CRIOR2019-5915701.008.jpg
PMC6362484_01_CRIOR2019-5915701.008.jpg
fig8
During postoperative month 3, a passive ROM of 0  x 25 , active ROM of 10  x 25 , grade IV quadriceps strength, VAS score of 4, and consolidated patella on radiography (Figure 8) were observed.
Clinical examination at 18 months postoperatively.
CRIOR2019-5915701.009.jpg
PMC6362484_01_CRIOR2019-5915701.009.jpg
fig9
During postoperative month 18, the patient had an active and passive ROM of 0  x 90  (Figure 9), grade V quadriceps strength, and VAS score of 1.