title: Stress avulsion of the tibial tuberosity after tension band wiring of a patellar fracture: a case report.
abstract: BACKGROUND
  To the best of our knowledge there is no other report of an elderly patient who was surgically treated for a patellar fracture with tension band wiring and who subsequently suffered from an avulsion fracture of the tibial tuberosity. The combination of a patellar fracture and avulsion of the patellar ligament has only been described as complication after bone-patellar tendon-bone anterior cruciate ligament reconstructions. However, due to demographic changes and more elderly patients treated this injury may become more frequent in future.
  
  
  METHODS
  We present the case of an 81 year old female who sustained an oblique patellar fracture after a direct contact injury of the left knee when falling on ice. Consequently the patellar fracture was openly reduced and stabilized with tension band wiring. The follow-up was uneventful till three months after surgery when the patient noticed a spontaneous avulsion fracture of the tibial tuberosity (Ogden type 3). The tibial tuberosity fragment was reattached with two non-resorbable sutures looped around two modified AO cortical 3.5 mm long neck screws. Intraoperatively multiple bone cysts were seen. Biopsies were not taken to prevent further fragmentation of the tibial tuberosity. The patient was followed up with anteroposterior and lateral full weight bearing radiographs and clinical assessment at 6, 12 weeks and 6 months after surgery. Recovery was completely pain free with full satisfaction.
  
  
  CONCLUSIONS
  In conclusion in elderly patients with a patella fracture a possible associated but not obvious fracture of the tibial tuberosity should be ruled out and the postoperative rehabilitation protocol after tension band wiring of the patella might have to be individually adjusted to bone quality and course of the fracture.
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Kantonsspital Bruderholz, CH-4101 Bruderholz, Switzerland.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Hirschmann
authors.forename: Björn
authors.initials: B
authors.lastname: Wind
authors.forename: Christian
authors.initials: C
authors.lastname: Mauch
authors.forename: Gesa
authors.initials: G
authors.lastname: Ickler
authors.forename: Niklaus F
authors.initials: NF
authors.lastname: Friederich