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This story is from the Anamnesis episode called Mysteries at 39:53 in the podcast. It's from Sonya M. Sloan, MD, aka #OrthoDoc, an orthopedic surgeon and a travelling locum tenens doctor for CompHealth.
This is "Stranger Things" edition of medical cases in patients that have baffled us. As an orthopedic surgeon, we see quite a few things, but things that strike me specifically are things that we don't see on the regular and/or extenuating circumstances in which they occur. This is that case.
I had a patient, 26-year-old Native American male, that presented to the emergency room after a few days of a knee injury. Upon listening to the full story, he was trying to be the nice guy and help his cousin who had been inebriated in a local bar; he went to go pick him up. The bouncer [had] mistaken him for the cousin and threw him out on the sidewalk. He landed hitting his knee on the curb, thereby fracturing his patella. The patella, of course, is the kneecap, and it was a fracture that was transverse or straight across.
Thus, once he came to clinic I saw him, got the x-rays, realized he needed surgery; we discussed the options of the risk and benefits. Without any questions, we took him to surgery without complications.
Upon the surgical procedure, injuring the knee, these fractures usually do have a large blood collection or hematoma due to the bleeding in and around it, but with the tourniquet on, we were able to remove the hematoma and all bleeding was managed without any complications. The surgery was straightforward -- I placed two K-wires after reducing the fracture, checked it on the AP [anteroposterior] and lateral in the surgical suite under x-ray and got a great reduction with a tension band, which is -- we use stainless steel 18-gauge wire in a figure-8 format or fashion that pulls it together, so actually, even when they do start flexing the knee, they can sometimes actually help with the reduction and the healing.
Normally after the surgery, the patient has staples. He is seen in the clinic about 10 days later. I take the staples out and keep him pretty much in a knee immobilizer, which is a type of brace. But he is able to walk on it after surgery.
I tend to keep these patients in the brace and walking on it for approximately 2 to 3 weeks. Then again, the x-rays are checked again on the first post-op visit, and then every time they come back in every 2 weeks. I don't usually start actually flexing the knee in what we call a hinged knee brace, at 30 or 60 degrees, until realistically at the 4- to 6-week period.
Because I am a travelling doctor, this patient was seen by my physician assistant on his return, and the wound was checked and x-rays were not done, even though that's the norm. So therefore, the next x-rays that were seen were when he had come back without the brace on, and he was walking with his knee extended and on one crutch, not two.
Then it was checked on x-rays, and it was noted that he started to have a little bit of separation of the patella, thus he was placed back in the knee immobilizer until he could walk on it, but could not bend the knee anymore. The patient at that time told the physician assistant that because he had to work and was the only financial support for the family, he had to take the brace off; he couldn't go to work with the brace on. Thus, it was problematic for the healing process for the patient. He states that once he gets home after a 10-hour day of construction work, which was very labor intensive on his knee, and who knows how much he was flexing, but he would put the brace back on for nighttime.
When I finally did see the patient, 3 to 4 weeks later after I returned from my travelling physician spot, he had a repeat x-ray that were of two interests: 1) The fracture had separated a little bit more, which meant that the patient had not been in the brace and was flexing his knee, then 2) he had what looked to be on the lateral, or the side view, of the patella, a little bit of extra bone. This didn't really bother me; it's sometimes very common and [I] didn't realize if it was maybe just a chip of bone that was missed on initial x-rays. Nonetheless, I proceeded to cast him, because I knew he was noncompliant. I placed him a little bit of flexion, just like comfortably at 20 degrees, so he could stay off of it and allow it to heal where it was.
Approximately a week later, he did call back and had gotten the cast wet and somehow got it off, which was just quite amazing because it's a fiberglass cast that is not easy to remove. Thus, he had tried and was unsuccessful, so he had to come back in and have it removed and changed because it was wet. We didn't want the damage to the wound or the skin.
He told the nurse at that time -- because, again, I was a travelling physician, and he was under the care of another doctor during that week -- that he apparently had been trying to chop wood for the family that lives in a hogan and essentially has to have firewood, and he was the only healthy, viable person in the family that could actually do this task. With the knee immobilizer on, or sorry, with the cast on, he was not able to achieve this type of motion.
Nonetheless, the patient's cast was removed, and then noted again on x-rays there's more of this strange calcium buildup and/or bony deposits below where the fracture had been healed. Upon my return, he is now at 6 weeks, which should be totally healed. Taking the patient out and still again I notice some gapping in the fracture site. Thus, I told him it would have to be redone and revised, and that whatever the calcification that I did see, if that was a chip of bone or whatever else, we would manage it at the time of surgery.
Back to Surgery
Upon taking the patient back to surgery, a totally healthy young man, I noted that he had a lot of hard, bony build-up in the patellar tendon at the inferior edge laterally from where I had done the surgery, which was strange because as much of the deposit that was actually in the tendon did not show up on x-ray. Thus, it was nearly impossible to repair what appeared to be a patellar tendon tear, as well as what had been pulling away at the previous fracture site. I took down the previous construction or construct to repair the patellar tendon, repair the patella, and redid it, as well as remove whatever bony chips that I could in this heterotopic ossification that had started within 3 to 6 weeks of this patient's fracture and healing.
Upon the return of his first post-op visit, the patient's fracture had totally pulled away as well as the patella was now sitting very high, which we call patella alta, which is moved up, which means the patellar tendon had now pulled off of the bone.
The patient was taken back to surgery within that week and noted to have again massive amounts of bony deposits within the patellar tendon that had essentially avulsed away from the patella. At that time, I tried to... through the tendon, what we call a whip stitch, and was not able to because the patellar tendon was so hard, I had to drill through the bone to even get a suture through it. That's not ideal. I ended up using what we call bone staples just to hold it down and drill some holes through the interior part of the patella, and try to somehow engage the two edges so that hopefully it would heal with this bony healing that was already occurring. But upon closing it and waking the patient up, I told him that he would definitely need another surgery at some point and possibly a revision by a joint specialist that may need to use an allograft.
Upon completing this and really looking back now at this case, a few things. Number one, heterotopic ossification is where the osteoblast mesenchymal cells, or if you can think of as the basic cells of any type of bone, or cartilage, or whatever that cell is going to become, a fat cell, whatever that becomes, those cells are normally within our blood and they have a genetic component that will transform it to be what it needs to be; if it's bone, if it's cartilage, if it's tendon -- whatever it is. However, sometimes it gets mixed up and so this is the process where the bone actually was possibly due to the initial hematoma, as well as the ongoing movement of the knee where it should have been still and some other things that we just have no clue about, that cause this massive influx of bone in the patellar tendon.
Patients Aren't Always 'The Typical Book'
I definitely think there were some extenuating circumstances due to the lifestyle, as well as the culture. There were several times the patient missed appointments because he was working and could not come in. The fact that he had to remove the brace and/or chop wood for the family and could not get the leverage he needed in the cast, and had to remove it or have it removed, tried to remove it -- these were all things that possibly led to the failure of the initial surgery and the follow-up surgeries, but definitely not the heterotopic ossification. There was no way that anyone could have controlled what happened, but possibly the amount of heterotopic ossification that occurred in this patient's knee.
The second thing that's very important to know is it's never really been documented in the Navajo patient population to have heterotopic ossification in the patellar tendon after a patellar fracture. Normally, you see heterotopic ossification post-trauma in a hip fracture that has been fixed that will grow in and around that hip. We'll call it bridging bone or trauma, such as a bullet that goes through the bone and you can sometimes see it in the soft tissue afterwards. Or even other post-surgical procedures in and around soft tissue in the hand and stuff, you can sometimes see this calcification build-up.
There are very few cases that are documented in this age population and, again, not many that are documented within the United States. Most cases were documented in an Asian population, so it led me to think about a couple of things. One, we have to really consider patient population and their lifestyle when it comes to treating patients. They are not always the typical book. It's not going to follow a straight path and knowing that you have to be amenable to revisions, and considerations, and changes of course of treatment for patients like that.
Secondly, or another thing that I was thinking, was the patient was a healthy young man. However, he did have a history of COVID in the past 6 months and we know that this increases the inflammatory response. There is no literature really to lend towards post-trauma inflammatory response, and heterotopic ossification, in patients that have had COVID. We just don't know enough -- there is not enough research, there hasn't been enough time to look at these things. But it definitely crossed my mind, was this a factor in all of this that played out?
Still a Mystery
At this time: Mystery? Yes. This patient has now been sent as a referral to have another surgery, but he did return and was very concerned. Because to have the surgery, it means he will have to have an allograft. An allograft basically means part of a patella, and part of a patellar tendon, from a cadaveric source. For this population, religiously, spiritually, that is not really an option to have an outside body part from someone else.
So I'm not sure exactly what's going to happen. The thought that they could use autograft, which would be his own, is not really an option either because he has had a fracture already through the patella and the patellar tendon is already calcified very, very hard. I'm interested to see what happens with this patient, but so intrigued that in my 15-16 years of practicing that I have only seen heterotopic twice, and that was around a hip replacement and with a bullet that went through the femur, but never in the patellar tendon after a patella fracture.
I hope this helps and that we have all learned something -- stranger things in medicine -- you have to treat the entire patient.
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