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Bioabsorbable K-wire fixations for osteochondral fractures: A promising choice in sports medicine? – Functional outcomes and clinical insights
*Corresponding author: C. R. Jithin, Department of Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India. drjithincradhakrishnan@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Jyothiprasanth M, Jithin CR, Thomas AK, Aghosh MC, Venkatesh Kumar S. Bioabsorbable K-wire fixations for osteochondral fractures: A promising choice in sports medicine? – Functional outcomes and clinical insights. J Arthrosc Surg Sports Med. doi: 10.25259/JASSM_60_2025
Abstract
Osteochondral fractures, involving both cartilage and underlying bone, present significant challenges due to their impact on joint function and potential for long-term complications. Traditional metallic fixations, such as K-wires, are effective but can lead to complications, including infection and hardware irritation. In such scenarios, bioabsorbable materials can be an alternative. This case series explores the use of bioabsorbable K-wires for osteochondral fracture fixation in the elbow, distal femur, and patella, focusing on functional outcomes and clinical insights. Four cases involving pediatric patients with osteochondral fractures were reviewed. Cases included a 16-year-old dancer with a distal femur and patella fracture, a 12-year-old girl with an elbow fracture, and two 14-year-old girls with knee injuries. Surgical interventions used bioabsorbable K-wires for fixation, with follow-up assessments including imaging and functional evaluations at 6 and 12 months. Case 1: The 16-year-old dancer diagnosed with osteochondral fracture of the lateral femoral condyle achieved full range of motion (ROM) and walked without discomfort at 6 months post-surgery. Magnetic resonance imaging (MRI) ruled out avascular necrosis (AVN) of the osteochondral fragment. Case 2: The 12-year-old girl with an osteochondral fracture of the capitulum had a full, painless ROM by 2 months post-operation and resumed daily activities without pain at 6 months. Case 3: The 14-year-old girl with a knee injury regained full ROM by 3 months, and an MRI at 6 months showed successful healing of the osteochondral injury. Case 4: The 12-year-old girl with a patellar dislocation and osteochondral fracture patella had a full ROM and no pain at 2 months post-surgery, and there was no evidence of AVN at 6 months. Bioabsorbable K-wires are an alternative fixation option for osteochondral fractures. Despite potential issues such as non-infectious inflammatory reactions and osteolysis, these materials can be used in pediatric orthopedic surgery. Further research with larger sample sizes is warranted to fully assess long-term outcomes and optimize their use.
Keywords
Bioabsorbable K-wires
Distal femur fracture
Elbow fracture
Functional outcomes
Osteochondral fractures
Patella fracture
Pediatric orthopedics
INTRODUCTION
Proper management of osteochondral fractures on the articular surface necessitates a thorough and precise approach tailored to the fracture’s unique characteristics. The treatment focuses on restoring the articular surface’s congruity, facilitating effective healing, and preserving cartilage tissue integrity.
Osteochondral fractures are complex injuries that involve both the cartilage and underlying bone, often resulting from high-impact trauma or repetitive stress. These fractures can occur across various anatomical locations, including the knee, elbow, and patella, and are particularly challenging to manage due to their impact on joint function and the risk of long-term complications. The traditional management of these injuries has involved the use of metallic fixation devices, such as K-wires, which, while effective, are associated with several potential complications, including infection, irritation, and the need for subsequent hardware removal. In recent years, the use of bioabsorbable materials for fixation has emerged as a promising alternative, offering the potential to stabilize fractures without the long-term complications associated with retained metal hardware. This article presents a case series exploring the functional outcomes of osteochondral fracture fixations using bioabsorbable K-wires across various anatomical locations, including the elbow, distal femur, and patella.
The cases illustrate the clinical application of bioabsorbable K-wires in pediatric patients, highlighting both the technical aspects of the surgical procedures and the post-operative rehabilitation protocols. In addition, this series provides insights into the healing process, as confirmed by follow-up imaging, and discusses the advantages and challenges of using biodegradable materials in orthopedic surgery. Through this exploration, we aim to contribute to the growing body of evidence supporting the use of bioabsorbable implants in the management of osteochondral fractures, with a focus on their efficacy in restoring joint function and minimizing the need for additional surgical interventions.
CASE SERIES
Case 1
A 16-year-old dancer sustained a left knee injury during a dance routine involving a twisting motion, which led to an abnormal patellar position that she managed to correct herself. Post-injury, she experienced difficulty walking, significant knee swelling, and limited range of motion (ROM), although there were no signs of neurovascular impairment. The Beighton score of 3/9 indicated minimal ligament laxity, ruling out generalized ligamentous issues. Tenderness was noted over the medial aspect of the patella, with no history of systemic bone disease or prior trauma-related hospitalizations. Further investigations, including computed tomography (CT) with 3D reconstruction and magnetic resonance imaging (MRI), revealed an osteocartilage fracture of size 4 cm × 2 cm × 2 cm which involves more than 50% of the lateral articular surface of the distal femur, as well as a medial patellofemoral ligament (MPFL) injury from a self-reduced patellar dislocation [Figures 1 and 2]. The patient underwent open reduction and internal fixation (ORIF) through a posterolateral approach. A significant osteochondral defect was found on the lateral articular surface [Figure 3a], with the detached fragment located anteriorly, making retrieval through the posterior approach impractical. The patient was repositioned supine, and an anterior midline incision was made with a medial parapatellar approach due to the MPFL injury. The MPFL was found avulsed from the medial patellar periosteum, and the medial parapatellar approach was adapted to access the joint through this rent. The osteochondral fragment was successfully retrieved after releasing the attached anterior cruciate ligament (ACL) stump.
- (a and b) Axial computed tomography section and 3D reconstructions showing a large osteochondral fracture of the lateral articular surface of the distal femur with articular surface involvement.
- (a-c) Coronal, sagittal, and axial sections of magnetic resonance imaging showing a large osteochondral fragment and medial patellofemoral ligament injury.
- (a-c) Intraoperative images showing a large osteochondral fragment and its fixation with biodegradable K-wire and screw.
MPFL repair involved reattaching the avulsed ligament to the patellar periosteum with absorbable 1.0 Vicryl sutures. The patient was then repositioned prone, and the fractured fragment was secured over the osteochondral defect using two biodegradable K-wires and a biodegradable compression screw [Figure 3b and c]. Intraoperative assessment confirmed the stability of the fixation. ACL repair was performed using fiber wire, with bites taken through the remaining femoral condyle fragment and tibial attachment. Post-surgery, a CT was taken, and joint congruity was confirmed in all planes [Figure 4]. A cylinder slab was applied for 4 weeks, followed by gradual mobilization beginning at 6 weeks. Rehabilitation focused on achieving full ROM and strengthening the vastus medialis obliquus, quadriceps, and hamstring muscles under the guidance of the sports surgeon and rehabilitation team. A follow-up MRI at 6 months showed no signs of avascular necrosis (AVN) and intact ACL continuity [Figure 5]. The patient achieved full ROM, walked without discomfort or limp [Figure 6], and the Lachman test was negative. Lysholm score was 92 at 6 months, and this good patient-reported outcome highlights the success of the surgical and rehabilitation interventions.
- (a and b) Post-operative lateral articular surface of distal femur computed tomography 3D reconstruction.
- (a-e) Sixth-month post-operative magnetic resonance imaging in axial, sagittal, and coronal planes without any evidence of avascular necrosis of the fixed fragment.
- (a-f) Sixth post-operative month clinical images showing a complete range of motion and weight bearing.
Case 2
A 12-year-old girl with no significant comorbidities sustained an injury to her left elbow after a fall and presented to the emergency department. Clinical examination revealed diffuse swelling around the elbow, ecchymosis over the lateral aspect, tenderness, and crepitus in the lateral condyle area. ROM was globally restricted due to pain, but distal pulsations and sensations were normal and comparable to the opposite side. Initial anteroposterior and lateral X-rays showed a capitulum fracture [Figure 7]. A CT scan of the elbow with 3D reconstruction further confirmed an osteochondral fracture of the capitulum [Figure 8]. Given the size of the fragment, 2 × 1 × 1 cm, ORIF was planned. A brachial block was administered, and a pneumatic tourniquet was applied. The fracture site was approached through a lateral incision, and reduction was confirmed through direct visualization and fluoroscopy. Biodegradable K-wires were used to fix the fragment in divergent directions [Figure 9]. Postoperatively, x was taken, reduction confirmed [Figure 10], the patient was immobilized with an above-elbow slab for 3 weeks, followed by gradual mobilization. At the 2-month follow-up, she had achieved a complete, painless ROM in flexion, extension, pronation, and supination. She was able to resume her daily activities without pain by the end of the 2-month post-operative period. At the 6-month follow-up, an MRI was taken, and confirmed that there was no evidence of AVN in the fixed fragment [Figure 11]. She had a full ROM without any pain or deformity during both daily activities and strenuous activities, with Mayo elbow performance score of 90 [Figure 12]. Follow up x ray at 6 th month showed complete fracture healing [Figure 13].
- Pre-operative X-ray showing capitulum fracture (Red arrow) in anteroposterior and lateral views.
- Pre-operative computed tomography elbow with 3D reconstruction showing the larger osteochondral fragment.
- (a) Intra-operative reduction of fragment under fluoroscopy, (b and c) intra-operative fixation using biodegradable K-wires in divergent directions.
- Immediate post-operative X-ray in anteroposterior and lateral projections showing a congruent elbow joint.
- Magnetic resonance imaging taken at 6-month follow-up ruled out the presence of avascular necrosis in the fixed osteochondral fragment (a) in the T2-weighted image in axial section and (b) in the sagittal section.
- Elbow complete (a) flexion and (b) extension at 6-month follow-up.
- Follow-up X-ray at 6 months showing complete fracture healing.
Case 3
A 14-year-old girl presented with a 1-week history of right knee pain and swelling following a twisting injury while dancing. She had persistent pain since the injury, with no signs of generalized ligamentous laxity. Examination revealed swelling, tenderness, and a painful ROM in the right knee, while distal neurovascular status was intact. The apprehension test for the MPFL was positive, but all other ligament tests were negative. An X-ray revealed a chip fracture, and an MRI further identified a large, unstable osteochondral injury measuring 1.6 × 1 × 1 cm, along with a subchondral injury [Figure 14]. The findings led to a diagnosis of a large, unstable osteochondral injury with subchondral involvement and an MPFL injury in the right knee. The patient underwent osteochondral fragment fixation using a biodegradable K-wire. She was positioned supine, and a pneumatic tourniquet was applied. A midline incision was made, followed by a medial parapatellar approach to expose the displaced osteochondral fragment and chondral lesion of the femoral cartilage. The ACL and posterior cruciate ligament were found to be intact. The osteochondral fragment was fixed using a biodegradable K-wire (TRIM-IT pin, 1.5 × 100 mm), and the MPFL was repaired [Figure 15]. The wound was closed in layers, and a sterile dressing was applied. Postoperatively, the patient was immobilized with a knee brace for 3 weeks, after which gradual ROM exercises were initiated. Weight-bearing began in the 4th week under supervised physiotherapy. By 3 months postoperatively, she had achieved a full ROM, and by the 4th month, she was able to walk without pain or limping, fully resuming her daily activities without discomfort [Figure 16]. She had a Lysholm score of 95 at 6 months. An MRI performed at the 6-month post-operative showed no loose bodies, no signs of AVN in the fixed fragment [Figure 17], and confirmed that the fragment remained in position, indicating successful healing of the osteochondral injury.
- Unstable osteochondral injury measuring 16 × 4 mm, along with a subchondral injury right knee.
- Osteochondral fragment was fixed using a biodegradable K-wire (TRIM-IT pin, 1.5 × 100 mm).
- Sixth-month follow-up with a complete range of motion. (a) Extension; (b) Flexion; (c) Single stance.
- Magnetic resonance imaging performed at the 6-month post-operative showed no loose bodies, no signs of avascular necrosis in the fixed fragment in the T2-weighted sagittal section.
Case 4
A 12-year-old girl presented with a history of left knee injury, including a previous episode of patellar dislocation. Examination revealed swelling around the knee, a painful ROM, tenderness, and a positive apprehension test for the patella. She showed no signs of ligament laxity, with negative results on anterior drawer, posterior drawer, valgus, and varus tests.
An MRI of the left knee revealed a high-grade tear of the MPFL, a reduced patellar dislocation, and an osteochondral fracture with a separated loose body.
Surgical intervention began with the application of a pneumatic tourniquet, followed by standard preparation of the surgical site. Arthroscopic portals were created, and diagnostic arthroscopy confirmed the presence of a displaced osteochondral fracture. Arthroscopic lateral release of the patellar retinaculum was performed. Arthrotomy was done through a midline incision using a medial parapatellar approach. An osteochondral fragment of size 2 × 1 × 1 cm was found [Figure 18], reduced, and fixed using a biodegradable K-wire [Figures 19 and 20]. The wound was then closed in layers, and sterile dressings were applied.
- Osteochondral fracture of the articular facet of patella left knee.
- Osteochondral fragment was fixed using a biodegradable K-wire (TRIM-IT pin, 1.5 × 100 mm).
- Sixth-month follow-up with a complete range of motion.
Postoperatively, the patient was immobilized with a knee brace for 3 weeks. Gradual ROM exercises were initiated thereafter, and weight-bearing was introduced in the 4th week under supervised physiotherapy. By the end of 2 months, she had regained full ROM in the knee without any pain during movement [Figure 20]. Her Lysholm score was 94 at the 6th post-operative month, and an MRI ruled out AVN of the osteochondral fragment.
These cases were under regular follow-up, and results were tabulated [Table 1].[1,2]
| No. | Age | Sex | Site | Side | Osteochondral fragment size | Associated injuries | Functional outcome at 6 months, 12 months | |
|---|---|---|---|---|---|---|---|---|
| 1 | 16 | F | Lateral femoral condyle | L | 4×2×2 cm | ACL and MPFL injury | Lysholm score[1] 92 | Lysholm score 96 |
| 2 | 12 | F | Capitulum | L | 2×1×1 cm | Soft tissue injury | Mayo elbow performance score[2] 90 | Mayo elbow performance score 95 |
| 3 | 14 | F | Patella | R | 1.6×1×1 cm | MPFL injury | Lysholm score 95 | Lysholm score 98 |
| 4 | 12 | F | Patella | L | 2×1×1 cm | MPFL injury | Lysholm score 94 | Lysholm score 100 |
ACL: Anterior cruciate ligament, MPFL: Medial patellofemoral ligament
DISCUSSION
Osteochondral fractures, involving both cartilage and underlying bone, present significant challenges due to their impact on joint function and potential for long-term complications. Traditional metallic fixations, such as K-wires, are effective but can lead to complications, including infection and hardware irritation. Bioabsorbable materials are emerging as an alternative to handle these issues.
The study by Jensen and Jensen highlights the effectiveness of polydioxanone pins in fixing fractures, arthrodesis, and osteotomies, provided they are used in adequately sized bone. Unlike K-wires, these biodegradable pins cannot be inserted retrograde due to their softness, making it crucial to cut the pins flush with the osseous canals to prevent soft tissue irritation and pin tract infection. When used under these conditions, biodegradable pins can significantly reduce the need for additional surgeries compared to K-wires.[3] This advantage is particularly notable given the common complications associated with traditional metal implants. Orthopedic implants made from stainless steel and titanium alloys often lead to issues such as hardware failure, infection, malunion, poor bone healing, pain, joint stiffness, soft tissue irritation, tendon rupture, or adhesions, which may necessitate further surgical intervention.[4]
However, bioresorbable implants, such as those made from polylactic acid, can sometimes provoke a noninfectious inflammatory reaction due to the body’s response to foreign material. This reaction is associated with the natural degradation process of the implant, during which tiny particles are released that may elicit an immune response in some patients.[5] Despite these potential issues, bioabsorbable K-wires have demonstrated their utility in treating pediatric fractures, though complications such as osteolysis, loosening, and subsequent secondary displacement have been reported.[6,7]
In the context of knee injuries, osteochondral fractures of the lateral femoral condyle, although uncommon, can occur with or without a patellar dislocation. These injuries are often associated with knee joint sprains during intense physical activity, and open reduction is the standard treatment approach for such fractures. Distal femoral physeal fractures, frequently observed in adolescents, are prone to a high rate of physeal arrest due to factors such as fracture nature, degree of displacement, and methods of fracture reduction and fixation.[8]
During adolescence, the cartilage-bone interface in the knee joint is particularly vulnerable due to the lack of a distinct boundary between calcified and uncalcified cartilage.[9] There are anatomical and cost-effective techniques of fixation of osteochondral defect of femur with absorbable sutures, combining the benefit of being biological with no permanent residual implant and minimal implants that do not violate the fragment as an alternative in the literature.[10]
In pediatric elbow fractures, the use of bioabsorbable K-wires offers notable advantages over traditional Kirschner wires. Su et al.[11] report that Kirschner wires can delay functional recovery due to their protrusion from the skin and the need for removal before rehabilitation can commence. This can cause trauma and necessitate a second operation for removal. The introduction of absorbable self reinforced polylevolactic acid (SR-PLLA) rods for radial neck fracture fixation addresses these issues effectively.[11] Moreover, a clinical trial by Hope et al., compared biodegradable polyglycolic acid pins to Kirschner wires for displaced elbow fractures.[12] The study found that while both methods achieved successful fracture union, Kirschner wires were associated with complications such as infections and soft-tissue ossification, while biodegradable pins avoided these problems but were linked to a case of AVN and premature fusion of the medial epicondyle.
Regarding wrist injuries, Casteleyn et al.’s observation of osteolysis in 60% of cases, which had drill channels perforating both cortices, challenges Bostman et al. ’s hypothesis that osteolysis results from increased intra-osseous pressure from liquid polymeric debris in a drill channel open at only one end.[13,6] This highlights the importance of further research into the design and application of bioabsorbable materials to optimize their use and minimize complications. Overall, this case series demonstrates that bioabsorbable K-wires are a viable alternative for managing osteochondral fractures across various anatomical locations, offering benefits such as reduced need for additional surgeries and fewer complications compared to traditional metal implants. A limitation of this case series is that there is no control group for comparison, and the injuries are distributed in different anatomical locations. We are trying to add data to the data pool of bioabsorbable implant use in osteochondral fractures, and further research with larger sample sizes is warranted to fully assess long-term outcomes and optimize their use.
CONCLUSION
Bioabsorbable K-wires are an alternative fixation option for osteochondral fractures. Despite potential issues such as non-infectious inflammatory reactions and osteolysis, these materials can be used in pediatric orthopedic surgery. Further research with larger sample sizes is warranted to fully assess long-term outcomes and optimize their use.
Author’s contributions:
All authors contributed equally to conceptualization, format analysis, investigation, methodology, validation, visualization, and writing-review and editing.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflict of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Availability of data and materials:
All datas including images are available on demand and patient consent obtained for the same.
Financial support and sponsorship: Nil.
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