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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 138-141

Migration of a broken kirschner wire to the popliteal fossa following tension band wiring of a patellar fracture


Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission18-Feb-2021
Date of Decision25-Feb-2021
Date of Acceptance11-Mar-2021
Date of Web Publication12-Apr-2021

Correspondence Address:
Abhishek Vaish
Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_12_21

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  Abstract 


Kirschner wires (K-wires) are commonly used in the orthopedic trauma practice and liable to breakage and migration. We report the case of a middle-aged man with the migration of K-wire to the popliteal fossa after 11 years of patella fracture fixation and describe the technique of removal of the migrated and retained K-wires. A regular radiographic follow-up should be done to identify the presence of hardware breakage or migration following the use of K-wires. Once the wire migration is identified, it should be removed on an urgent basis regardless of symptoms, to avoid any major or minor complications.

Keywords: Foreign body, knee joint, open reduction and internal fixation, patella fracture, wiring


How to cite this article:
Vaish A, Ansari AH, Gupta AK, Vaishya R. Migration of a broken kirschner wire to the popliteal fossa following tension band wiring of a patellar fracture. Apollo Med 2021;18:138-41

How to cite this URL:
Vaish A, Ansari AH, Gupta AK, Vaishya R. Migration of a broken kirschner wire to the popliteal fossa following tension band wiring of a patellar fracture. Apollo Med [serial online] 2021 [cited 2021 Jun 21];18:138-41. Available from: https://www.apollomedicine.org/text.asp?2021/18/2/138/313695


  Introduction Top


Kirschner wire (K-wire) is one of the most commonly used implants in orthopedic trauma surgery, being cheap, effective, and easily available. Tension band wiring (TBW) using K-wires is the gold standard treatment for the displaced patellar fractures. It is estimated that around 18% of cases have complications related to the K-wires such as infection, loss of fixation, loosening breakage, and migration.[1] K-wire breakage, either intraoperatively or postoperatively, is a known complication of K-wire application.

The broken wire may migrate in the adjacent tissue or to a distant site and may cause various complications.[2] We report a case of migrating broken K-wire to the popliteal fossa, which was used for the TBW of the patellar fracture, 11 years ago.


  Case Report Top


A 43-year-old male presented with a complaint of pain and discomfort in the back of the right knee for 2 weeks. It started after sustained a jerk while coming down the stairs. The plain radiograph was done to rule out any bony injury. However, it revealed a migrated K-wire lying in the popliteal fossa and a retained K-wire in the patella [Figure 1]a and [Figure 1]b.
Figure 1: (a and b) Plain radiographs of the knee joint (anteroposterior and lateral views) 11 years after the index surgery demonstrating migration of the lateral Kirschner wire posterior in the popliteal fossa and a retained medial Kirschner wire in the patella

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A Computed tomography (CT) scan demonstrated that the broken wire was located in the popliteal fossa adjacent to the posterior femoral condyle [Figure 2]a and [Figure 2]b. Clinical examination of the right knee on presentation had tenderness in the popliteal fossa on the posterolateral side but did not have any patellar or joint line tenderness. The range of motion of the knee was slightly painful.
Figure 2: (a and b) Three-dimensional reconstructed images of the computed tomography scan confirming the presence of a broken metallic wire deep in the popliteal fossa

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He had sustained a right patellar fracture 11 years ago and had undergone open reduction and internal fixation using TBW at another institution. After surgery, the patient was recovering well. Four years ago, he noticed deep-seated pain in the right knee, especially during exercises. The plain radiographs of the knee revealed broken K-wire and cerclage wires [Figure 3]a and [Figure 3]b.
Figure 3: (a and b) Plain radiographs of the knee joint (anteroposterior and lateral view) 7 years postoperatively demonstrating a healed patella fracture with a break in the proximal aspect of both Kirschner wires and a break in the proximal loop of the cerclage wire

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He was then operated on for the implant removal (broken K-wire and cerclage wire), but the broken intraosseous part of the K-wires could not be removed from the patella [Figure 4]a and [Figure 4]b.
Figure 4: (a and b) Plain radiographs of the knee joint (anteroposterior and lateral view) after removal of broken Kirschner wires and cerclage wires confirming the presence of two retained intraosseous Kirschner wires in the patella

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The patient underwent surgery for removal of the migrated and the retained K-wires, by using an intraoperative fluoroscopy. First, the migrated K-wire from the popliteal fossa was removed by a posterior approach in the prone position. The migrated K-wire was found lying deeply adjacent to the lateral femoral condyle, between the sciatic nerve and the popliteal vein, but there was no injury to the neurovascular bundle. This broken K-wire was removed carefully [Figure 5].
Figure 5: Intraoperative picture showing the removal of the migrated Kirschner wire from the popliteal fossa

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Then, the patient was turned supine, and the intraosseous patellar K-wire was removed via a midline anterior knee incision along the old scar. This wire was deeply buried in the bone, and hence, a hollow mill was used under fluoroscopy to push the wire inferiorly and could then be removed [Figure 6]a and [Figure 6]b. This procedure was done at the persistent request of the patient for his concern about the later migration of this in situ wire.
Figure 6: (a and b) Intraoperative images demonstrating the removal of anterior retained Kirschner wire from the patella using a hollow-mill technique

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Postoperatively, the patient did not have any neurovascular or wound healing problem, and radiographs confirmed the complete removal of both the K-wires [Figure 7]a and [Figure 7]b. The weight-bearing was started immediately using a walking stick and the range of motion exercises started. His complaints of knee pain and discomfort resolved completely following the surgery, and the patient was able to resume work at 2 weeks.
Figure 7: (a and b) Plain radiographs of the knee joint (anteroposterior and lateral view) after the removal of both Kirschner wires and the picture of removed wires

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  Discussion Top


K-wires are prone to migration, and several cases have been reported of their migration, following an open reduction and internal fixation of sternal fractures, acromioclavicular joint dislocations, proximal humerus fractures, distal radius fractures, finger fractures, and patellar fractures.[2] The broken K-wires can migrate into the adjacent soft tissue or distant migration to other sites or a visceral organ. Local migration of broken wire may cause chondral damage and neurovascular injury like a popliteal neurovascular bundle in this case. In distant migration, the broken wire may enter the vessels and act as emboli causing damage to distal vessels or cardiac complications such as cardiac arrhythmia, pericardial tamponade, and even death.[3]

We have identified the following possible factors that increased the chances of breakage and migration of wires:

  1. Young, active patients have a higher risk of migration of wire due to a wider range of knee motion, that causes repeated stress on the wires.[4]
  2. Smaller diameter wires are weaker and are more prone to fatigue failure[2]
  3. Conventional TBW technique as recommended by the AO group has decreased the chances of breakage and migration of wire[2]
  4. If cerclage wire is placed too posterior around the patella[5]
  5. Longer duration from fracture fixation to implant removal also increased the risk of wire breakage[6]
  6. Bending of K-wire at both the proximal and distal tips around the cerclage wire decreases the migration of the K-wire.[7]


We believe that the broken K-wire in our case migrated because it was inserted more posterior in the patella [Figure 4]b and it migrated from the lateral side of the patella to the lateral gutter and finally to the popliteal fossa [Figure 8]a and [Figure 8]b.
Figure 8: (a and b) The proposed route of migration of the lateral Kirschner wire on the axial computed tomography (CT) scan image drawing

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Although these complications are rare, awareness of these potential complications will allow surgeons to appropriately counsel their patients for clinical and radiographic follow-up. Removal of migrated K-wire from the popliteal fossa is a challenging surgery, and careful surgical planning and execution are required. We preferred an open procedure to arthroscopic surgery for the fear of further movement of the K-wire during the arthroscopic procedure, due to knee movements, and fluid distension. Choi et al. reported an unsuccessful attempt at arthroscopic removal of migrated K-wires from the popliteal fossa.[2] Meena et al.[8] also preferred to remove the migrated K-wire from the popliteal fossa by an open procedure. Retained and deeply buried K-wires in the patella are difficult to remove, and we found the use of hollow mill quite useful.

To avoid complications related to the metallic wires, bioabsorbable cannulated screws with a braided polyester suture or braided polyblend sutures and metallic ring pins can be used to treat transverse patellar fractures instead of K-wires. Chen et al. reported successful use of transosseous suturing of the displaced patellar fracture using raided polyester in their 25 cases and found this technique to be safe and effective.[9]

Regular radiographic follow-ups should be conducted to identify and treat the hardware breakage or migration as early as possible to prevent serious complications, in case of any symptoms. K-wires (broken or unbroken) display a tendency to migrate, and once this process of movement starts, it can cause significant damage.[10] Sammy M (2013) found from their retrospective review of 59 cases of TBW for fractured patella that more than 50% of cases had breakage of TBW in their series. They noticed that the risk of wire breakage increases with time and was more after 12 months of fracture fixation.[11] Hence, we suggest that the wires should be removed once their target purpose is completed, due to their likelihood of breakage and migration, later on.


  Conclusion Top


K-wires are prone to breakage and migration. Hence, a regular radiographic follow-up should be conducted to identify the presence of hardware breakage or migration, and once wire migration is identified, it should be removed on an urgent basis regardless of symptoms, to avoid any major or minor complications. Removal of the migrated K-wire from the popliteal fossa is preferred by an open procedure and that of the retained wire by a hollow-mill technique.

Consent for publication

Consent was obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

We are thankful to Dr. Rameshwar Gupta, an orthopedic surgeon at Gwalior, for referring this interesting and challenging case to us for the surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stahl S, Schwartz O. Complications of K-wire fixation of fractures and dislocations in the hand and wrist. Arch Orthop Trauma Surg 2001;121:527-30.  Back to cited text no. 1
    
2.
Choi HR, Min KD, Choi SW, Lee BI. Migration to the popliteal fossa of broken wires from a fixed patellar fracture. Knee 2008;15:491-3.  Back to cited text no. 2
    
3.
Konda SR, Dayan A, Egol KA. Progressive migration of broken Kirschner wire into the proximal tibia following tension-band wiring technique of a patellar fracture–case report. Bull NYU Hosp Jt Dis 2012;70:279-82.  Back to cited text no. 3
    
4.
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 2006;88:2057-9.  Back to cited text no. 4
    
5.
Chen YJ, Wu CC, Hsu RW, Shih CH. The intra-articular migration of the broken wire: A rare complication of circumferential wiring in patellar fractures. Changgeng Yi Xue Za Zhi 1994;17:276-9.  Back to cited text no. 5
    
6.
Sammy MN. Breakage and migration of metal wires in operated patella fractures: Does it correlate with time? J Orthop Trauma Rehabil 2013;17:13-6.  Back to cited text no. 6
    
7.
Wu CC, Tai CL, Chen WJ. Patellar tension band wiring: A revised technique. Arch Orthop Trauma Surg 2001;121:12-6.  Back to cited text no. 7
    
8.
Meena S, Nag HL, Kumar S, Barwar N, Mittal S, Singla A. Delayed migration of K-wire into popliteal fossa used for tension band wiring of patellar fracture. Chin J Traumatol 2013;16:186-8.  Back to cited text no. 8
    
9.
Chen CH, Huang HY, Wu T, Lin J. Transosseous suturing of patellar fractures with braided polyester – A prospective cohort with a matched historical control study. Injury 2013;44:1309-13.  Back to cited text no. 9
    
10.
Sadat-Ali M, Shehri AM, AlHassan MA, Tabash KW, Mohamed FA, Mokhles Aboutaleb MM, et al. Broken kirschner wires can migrate: A case report and review of literature. J Orthopaedic Case Rep 2020;10:11-4.  Back to cited text no. 10
    
11.
Samy MN. Breakage and migration of metal wires in operated patella fractures: Does it correlate with time? J Orthopaedic Trauma Rehabil 2013;17:13-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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