1. James Iandoli DO – OhioHealth Orthopedic Surgery Residency
2. Scott Hyland DO – OhioHealth
3. Matthew Glazier DO – OhioHealth
4. Jia Bao Lin DO – OhioHealth
5. Anthony Wing DO – OhioHealth

Abstract

Introduction
This case series aims to investigate the potential of 2-octyl cyanoacrylate (2OCA) as a novel tool for stabilizing severely comminuted osteochondral defects in patients with distal femur fractures and significant bone loss at the articular surface. Traumatic distal femur fractures in young patients often lead to long-term complications and poor outcomes. Stabilizing the articular surface is crucial, but current treatment options are limited especially in those with complex injuries. The search for advanced techniques for achieving this goal is ongoing with few methods demonstrating consistent success. The internal use of 2-octyl cyanoacrylate (2OCA) for cartilage stabilization has shown some promise but lacks sufficient literature. Evaluating cases where this technique was used will help determine if further investigation is warranted.

Methods
This case series presents three cases of high-energy trauma patients with distal femur fractures and severe bone loss at the articular surface; ages ranged from 17-37 years old. The patients all underwent surgical interventions involving the use of 2OCA for the stabilization of their comminuted osteochondral defects. Post-operative management and outcomes were assessed including pain control, range of motion, ambulation, and complications.

Results
Using a combination of open reduction with internal fixation and 2-octyl cyanoacrylate for stabilization of the osteochondral surface in our case series yielded good outcomes in some subjects while one subject had persistent pain and limited range of motion. In the cases where the use of 2OCA showed promise, patients had early mobility, increased range of motion, and pain was well controlled. None of the cases had complications within the follow-up periods.

Discussion
The use of 2OCA as an adjunctive tool for stabilizing comminuted osteochondral defects in high-energy trauma patients with severe bone loss at the articular surface shows promise in this case series. It represents an innovative approach that may address the challenges associated with complex distal femur fractures. However, further research is warranted to optimize the technique, establish its long-term effectiveness, and evaluate its potential complications. Comparative studies to establish differences between groups that underwent 2OCA stabilization as well as collaborative studies involving multiple institutions are recommended to increase the sample and enhance the generalizability of the findings.

Keywords: Comminution, Articular surface, GSW, Distal Femur, Bone loss, 2-Octyl Cyanocrylate, glue

Use of 2-Octyl Cyanoacrylate for Stabilization of Femoral Articular Injuries

High energy distal femur fractures are most common among young patients, and these injuries contribute to significant long term sequelae for this patient population. Condylar involvement in addition to articular surface comminution adds significant complexity and few good options for the treatment of these injuries. Extensive involvement of the joint surface also increases the potential for post traumatic arthritic changes of the knee; therefore, stabilization of the articular surface is the principal goal in these complex injuries, and has been shown to be the most important contributor to outcomes.^3-5 Several case reports describing advanced techniques to preserve the joint surface using osteochondral and osteoarticular allografts have shown some success.  Younger patients with massive condylar bone loss have been shown to have good outcomes with appropriate-d allograft to build up the joint anatomy.^9-13 However, depending on injury pattern, the success of these techniques can be limited, which contributes to post-operative morbidity.

The internal medical use of 2-octyl cyanoacrylate (2OCA) is scarce in literature as it is commonly known for its use externally as adhesive in wound closure.¹⁴ However, there are otorhinolaryngology studies that have demonstrated its use in the context of cartilaginous grafts. This literature has shown utilization of 2-octyl cyanoacrylate in prefabricating and securing nasal cartilage grafts have been effective and even superior to suture techniques for cartilage stabilization.^15-17 The literature, however, is still very limited, and there has been conflicting evidence reporting post-operative inflammation with 2OCA off label use beneath the skin.¹⁸ The purpose of this case series is to evaluate the use of 2OCA as a tool to aid stabilization of significantly comminuted osteochondral defects in high energy trauma patients with distal femur fractures that have severe bone loss at the articular surface. 

Case 1
Patient is a 17-year-old male with no past medical history presenting with a medial bullet wound to the right knee. Bullet entered anteromedially through the medial condyle articular surface causing delamination and bone/cartilage loss of the anterior 1/3 of medial femoral condyle. We proceeded with operative management through a midline incision and medial parapatellar approach. Entrance wound was excised with incision, and quad tendon disruption was incorporated into arthrotomy. A clamp was used to aid in placement of headless compression screws through large articular segments of the medial femoral condyle. At this point there was still significant bone loss from the bullet and delaminated cartilage. Crushed cancellous chips were used to fill bony void which gave reasonable support to the delaminated cartilage. We then placed gel-foam over the graft followed by 2-octyl cyanoacrylate to fix the cartilage. This fixation was then covered with gel foam. 

Post-operatively, the patient was made non-weightbearing in a hinged knee brace when mobilizing and otherwise range of motion as tolerated. Patient was placed on DVT prophylaxis medications and received antibiotics for 24 hours. At three week follow up, the patient’s pain was being controlled with NSAIDS and he was mobilizing with crutches. His tolerable ROM was 0-30. At eight weeks he was ambulating unassisted pain-free, and his ROM increased to 0-90. At six months his main complaint was early fatigue and knee locking when sitting for long periods of time for which he was undergoing therapy for quadriceps strengthening. Patient has had no other complaints or issues with his knee.

Case 2
Patient is a 31-year-old male with no significant past medical history and a social history that consists of regular fentanyl and marijuana use. He presented with gunshot wounds to right knee and the left humerus. Injuries to the right knee consisted of traumatic arthrotomy with retained bullet fragments in the posterior patella, comminuted patella with longitudinal split, and a comminuted medial femoral condyle with posterior involvement. A midline incision was made for a medial parapatellar approach. Several loose osteochondral pieces were encountered and saved throughout the case. Bullet fragments were removed from the patella, and a transverse screw was placed to stabilize the superomedial comminution of the patella. Moving to the femur, we first addressed the posterior condyle Hoffa fragment with two anterior to posterior screws then fixed the lateral fragment with two 3.5mm headless screws. This was followed by placement of a medial buttress plate using a proximal humerus locking plate with a 3.5 cortical screw and three locked screws. At this point we irrigated out the knee and replaced the salvaged osteochondral pieces. We then applied 2OCA glue between the cancellous portions of the osteochondral pieces to stabilize the fragments, and then reinforced the union by applying 2OCA to the joint surface. After fixation, medial femoral condyle did have irregularity but appeared well aligned.

At one week post op patient’s pain regime consisted of Oxycodone 5mg Q4 and Methocarbamol with scheduled ibuprofen. By six weeks all narcotic medications had been stopped and physical therapy was recommended; however, patient never began therapy and was not compliant with home exercises provided. At 12 weeks he had developed significant stiffness and range of motion was limited for which arthroscopy was recommended and physical therapy was encouraged.

Case 3
Patient is a 47-year-old female with no relevant past medical history with an open comminuted medial femoral condyle and comminution of the inferior pole of the patella secondary to an MVC. She also underwent exploratory laparotomy and was left with an open abdominal wound. There was a 15x2x2 cm laceration that was used to access the fracture distally, and from there a medial parapatellar approach was used. After the site was thoroughly irrigated and debrided the comminuted medial condyle fracture was addressed. This fracture was extensively comminuted and involved a significant portion of the articular surface, and there was also bone missing from the posterior condyle. The medial condyle was pieced together using headless screws and one 3.5 cortical screw. A proximal humerus pre-contoured plate was then used to buttress this comminution. Three screws were placed in the proximal plate and distally locking screws were used to hold the condylar fracture. The distal end of the plate had to be rotated posteriorly to catch the fracture which did put the proximal end of the plate anterior.

At this point there was a large osteochondral piece that was loose so 2OCA glue was used to fix the piece in place. There was still a large defect present in the condyle so high viscosity gentamicin cement was used to fill the defect and was contoured to the shape of the condyle to improve excursion and prevent catching. For the inferior pole patella fracture with medial comminution we passed two strands of #5 Ethibond suture through a drill hole in the inferior pole and wrapped around both sides of the bony fragment. Next a central hole was made in the proximal fragment as well as two more holes on either side. At this point the two central strands were passed through the central proximal hole and out medial and lateral holes. The retinaculum was also repaired to the medial and lateral sides of the patella. She was made non-weightbearing for 4-6 weeks locked in extension for the patella fracture. She will be allowed to start range of motion at 3-4 weeks; at 3 weeks 0-45 degrees then progress to 90 degrees at 5-6 weeks, and at this time she can start weightbearing.

Discussion
Our case series included three patients who underwent surgical interventions involving the use of 2OCA for the stabilization of comminuted osteochondral defects. The outcomes varied among the cases which provided valuable insights into the feasibility and potential benefits of using 2OCA in these injury patterns. While the outcomes observed in this case series are promising, it is important to acknowledge certain limitations. The sample is small, and these cases represent a specific subset of high-energy trauma patients with severe bone loss at the articular surface. This patient population inherently trends towards poor outcomes which makes it difficult to identify the direct benefits of our intervention with 2OCA in this small sample; therefore, larger-scale studies are necessary to further evaluate the efficacy and safety of using 2OCA for these types of fractures. Additionally, long-term functional outcomes and the differences in post-traumatic arthritis rates is beyond the current follow-up periods in these cases. Tracking long-term complications directly due to the internal use of 2OCA is of less concern because the literature has shown that any adverse reaction would present in the acute period.¹⁸ 

Figure 1 | Figure 2

Figure Captions
Figure 1 (left) shows exposure using medial parapatellar approach of the distal femur with a significant bony void at the articular surface of the medial femoral condyle due to significant comminution. Figure 2 (right) shows the articular surface after multiple osteochondral fragments were replaced and stabilized using 2-Octyl Cyanoacrylate. 

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