Patella Fractures PDF

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Patella Fractures and Extensor Mechanism Injuries
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Michael T. Archdeacon, M.D. Roy W. Sanders, M.D.
HISTORICAL BACKGROUND
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Before the beginning of the 20th century, treatment of patella fractures was extremely controversial. Nonoperative methods, usually extension splinting and rest, were most commonly used. Results were poor, bony union was rare, and permanent disability was expected.31 As improvements in surgical asepsis occurred, two operative solutions to the problem emerged: arthrotomy with open wiring and patellectomy. Heineck reviewed 1100 patella fractures and advised operative treatment over extension splinting for the following reasons: improved fracture reduction, maintenance of reduction until union, reestablishment of soft tissue continuity, and restoration of the functional integrity of the knee joint.48 Open reduction and wire xation subsequently became the treatment of choice for patella fractures. Although reduction of simple transverse fractures was made possible by an open procedure, stable xation remained difcult. Various materials were tried, including silver, aluminum, and copper wire; chromic suture; kangaroo tendon; cancellous bone pegs; Achilles tendon; and fascial strips.50 In 1936, Blodgett and Fairchild reported 35 patella fractures treated with open reduction and wire suture; less than 50% had good results.10 They then reported on the use of partial or, in certain cases, total excision of the patella for fractures and described excellent clinical results.10 A year earlier, Thompson also recommended partial excision of the patella.100 In the same year as Blodgett and Fairchilds study, Brooke published a revolutionary paper on the treatment of patella fractures by total excision.16 Quoting embryologic data to support the vestigial nature of the patella, his functional studies showed that postpatellectomy limbs were stronger than their normal counterparts. Based on these studies, patellectomy gained signicant popularity.31, 40, 44, 45, 50
This initial enthusiasm was tempered by many experimental and long-term clinical studies that disproved the benets of patellectomy as routine treatment of fractures of this bone.* Cohn27 and Bruce and Walmsley18 studied patellectomized rabbits and found degenerative changes on the femoral condyles. They suggested that this complication could occur in humans as well. Haxton and others presented biomechanical evidence that the patella served a necessary purpose in the extensor mechanism.30, 47, 58, 67, 105, 109 In long-term clinical studies evaluating patients after total patellectomy, variable results were also found.30, 35, 56, 70, 76, 99, 110, 112 These studies revealed poor patient satisfaction, decreased quadriceps power, prolonged recovery time, and signicant changes in activities of daily living.35, 89, 99, 112 Treatment of patella fractures with the anterior tension band principle was rst reported in the 1950s.79 This technique was subsequently advocated by the Arbeitsgemeinschaft fu r Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) group as the treatment of choice for transverse patellar fractures.79 Weber and colleagues compared the tension band principle with cerclage and interosseous wire suture in cadavers and found that modied anterior tension band wiring with retinacular repair gave the most stable xation of a transversely fractured patella.108 Additionally, this construct was the only one that allowed early active range of motion of the knee.108 Other authors subsequently conrmed this fact clinically.11, 12, 54, 64 At present, three forms of operative treatment survive: various types of xation, usually with tension band wiring; partial patellectomy; and total patellectomy. Denitive indications for each procedure are related to the type of
*See references 18, 27, 30, 35, 47, 56, 58, 67, 70, 76, 89, 99, 105, 109, 110, 112.
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Copyright 2003 Elsevier Science (USA). All rights reserved.
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SECTION V Lower Extremity
fracture encountered, and good results can be expected with proper treatment.
ANATOMY
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Skeletal Anatomy
The patella lies deep to the fascia lata and the tendinous bers of the rectus femoris (Fig. 541A). It is at and roughly ovoid and comes to a rounded point, known as the apex, on its anteroinferior margin. Its proximal part is called the basis (see Fig. 541B). Wiberg classied patellas into three types based on the size of the medial and lateral facets.111 In type I, the medial and lateral facets are approximately equal, whereas in types II and III, the medial facets are progressively smaller than the lateral. Baumgartl described a fourth type, the Ja gerhut patella, in which the medial facet is lacking altogether.5 These facets have importance with respect to the functional anatomy of the patellofemoral joint (see the section Extensor Apparatus Biomechanics).
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Soft Tissue Anatomy

QUADRICEPS MECHANISM The quadriceps muscle complex is composed of four separate muscles: the rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius (Fig. 542). Classically, the quadriceps tendon is described as trilaminar in structure; it inserts onto the patella with the rectus femoris supercial, the vastus medialis and lateralis in the middle, and the vastus intermedius deep.67 The actual arrangement is more complex because of blending of the tendons as they insert on the patella.86 The rectus femoris is a long fusiform muscle that assumes the central and supercial position in the quadriceps structure.86 The bers angle 7 to 10 medially in the frontal plane relative to the shaft of the femur.67
FIGURE 542. Soft tissue attachments of the patella. Major components of the extensor mechanism include the quadriceps tendon proximally and the patellar ligament (tendon) distally. The medial and lateral retinacula help position the patella and can provide active knee extension if they remain intact after a patella fracture without signicant displacement.
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FIGURE 541. A, Supercial aspect of the patella, with extensive soft tissue attachments indicated by roughened surface. B, Articular surface of the patella (see text). Note the extra-articular distal pole occupying a signicant portion of the bones length. The articular surface is divided into seven facets by several ridges (see Fig. 541A). A major vertical ridge separates the medial from the lateral facets, and a second vertical ridge near the medial border isolates a narrow strip known as the odd facet. In addition, two transverse ridges create superior, intermediate, and inferior facets (Bostro m, 1972; Reider et al., 1981).
The vastus medialis divides into two parts. The more proximal bers are known as the vastus medialis longus and enter the patella at an angle of 15 to 18. The more distal bers, the vastus medialis obliquus, enter the patella at an angle of 50 to 55.67 The bers of each group are divided by fascia into separate fascicles. Innervation of the vastus medialis obliquus is by a separate branch of the femoral nerve.67, 86 The bers of the vastus lateralis approach the patella at an angle of approximately 30 and terminate more proximally than do the bers of the vastus medialis. The most medial bers insert into the supralateral edge of the patella, with the more lateral bers traveling laterally past the patella. These bers contribute to the lateral retinaculum and, at their lateral extreme, fuse with the iliotibial tract. The vastus intermedius lies in a plane deep to the other three elements of the quadriceps. Most of the bers insert directly into the superior aspect of the patella. Deep to the major components of the quadriceps lies the articularis genus. This muscle is highly variable in occurrence and arises from the anterior aspect of the supracondylar por-
CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries
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tion of the femur. It inserts on the joint capsule at the suprapatellar pouch. PATELLAR RETINACULUM The deep investing fascial layer of the thigh is known as the fascia lata. As it spreads over the anterior surface of the knee, its medial and lateral extensions combine with aponeurotic bers from both the vastus medialis and the vastus lateralis to form the patellar retinaculum, which inserts directly into the proximal part of the tibia (see Fig. 522). The patellofemoral ligamentsdeep transverse bers that are palpable thickenings of the joint capsule connecting the patella with the femoral epicondyles complete the retinaculum.13, 86 In addition, the lateral aspect of the vastus lateralis and the iliotibial tract both contribute to the thicker lateral patellar retinaculum. Together, the patellar retinaculum and the iliotibial band serve as the auxiliary extensors of the knee.13 PATELLAR TENDON Derived primarily from bers of the rectus femoris, the patellar tendon is at and strong and inserts onto the tibial tubercle. Its average length is slightly less than 5 cm. The fascial expansions of the iliotibial tract and the patellar retinaculum blend into the patellar tendon as it inserts onto the anterior surface of the tibia.
ARTERIAL BLOOD SUPPLY The anterior surface of the patella is covered with an extraosseous arterial ring derived mainly from branches of the geniculate arteries28 (Fig. 543). The intraosseous blood supply of the patella is supplied by two systems of vessels, both derived from this extraosseous vascular ring: the midpatellar vessels, which penetrate the middle third of the anterior surface of the patella, and the polar vessels, which enter the patella at its apex.3, 87 The patellar tendon receives its blood supply from two sources. The infrapatellar fat pad supplies the deep surface of the patellar tendon with contributions from the inferior medial and inferior lateral geniculate arteries. The anterior or supercial surface of the tendon is supplied by the retinaculum, which receives its supply from the inferior medial geniculate artery and the recurrent tibial artery.3
EXTENSOR APPARATUS BIOMECHANICS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The principal function of the extensor mechanism of the knee in humans is to maintain the erect position. Ambulation, rising from a chair, and ascending or descending stairs are examples of this ability to overcome gravity. The biomechanical principles necessary for these actions should be understood to treat extensor mechanism injuries rationally. A moment is a force that produces rotation about an axis. It is equal to the product of a force and the perpendicular distance from the line of action of that force to the axis of rotation. This perpendicular distance is the moment arm.91 The force necessary for knee extension (torque) is directly dependent on the perpendicular distance between the patellar tendon and the knee exion axis (moment arm)58 (Fig. 544A). Twice as much torque is needed to extend the knee the nal 15 as to bring it from a fully exed position to 15.67 To do so, the knee requires a moment arm that increases during extension so that it can maintain a constant level of torque. The patella provides this mechanical advantage by two separate mechanisms: linking and displacement.58 As the knee begins extension from the fully exed position, the patella functions primarily as a link between the quadriceps and the patellar tendon. This linking function allows for generation of torque from the quadriceps muscle to the tibia.58 Maximal forces across the quadriceps tendon have been recorded at 3200 N, whereas those across the patellar tendon are 2800 N.52 These values are between four and ve times the standard body weight of 700 N. For young, physically trained men, these forces can reach up to 6000 N.52 Typically, the linking function occurs in the more exed positions. At 135 of exion, the patella slips into the intercondylar notch. The patellar facets of the femur have an extensive contact area with both the patella and the broad posterior surface of the quadriceps tendon. Load bearing shifts to a combination of the patellofemoral and the tendofemoral areas, with the latter being the greater of the two after 90 of exion.41 Without patellofemoral
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FIGURE 543. Blood supply of the patella. Note the extraosseous arterial anastomotic ring, which receives inow from branches of each of the genicular arteries. (From Scapinelli, R. J Bone Joint Surg Br 49:563570, 1967.)
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FIGURE 544. Mechanical role of the patella. A, The patella increases the moment arm of the extensor mechanism (i.e., the distance between the vector of applied force and the knees instant center of rotation). B, After patellectomy, this moment is decreased, and thus extensor force is effectively diminished. (A, B, Redrawn from Kaufer, H. J Bone Joint Surg Am 53:15511560, 1971.)
contact, the moment arm is small41 (see Fig. 544B). From 135 to 45 of exion, the odd facet engages the femur. It is the only part of the patella that fails to meet the true patellar facets of the femur and the only part to articulate with the true tibial surface of the medial femoral condyle of the femur.41 From 45 of exion to full extension, the patella is the only component of the extensor mechanism that contacts the femur. It acts to displace the quadriceps tendonpatellar tendon linkage away from the axis of knee rotation. This action increases the effective moment arm of the quadriceps mechanism and contributes the additional 60% of torque that is needed to gain the last 15 of knee extension.67 This second action therefore creates a mechanical advantage analogous to that of a pulley.58, 109 By displacing the tendon away from the axis of rotation, greater excursion of the quadriceps is needed for a given range of motion.109 Theoretically, when performing a patellectomy, a quadriceps-shortening or tubercleelevating procedure may be performed to take this requirement into account.
of the wound, if any, and the presence of any associated injuries. The history usually describes a fall from a height, a near fall, a direct blow to the patella, or a combination of these mechanisms. Correlation with the mechanism of injury allows the physician to anticipate the fracture pattern. If the patient has an open wound, the history should include questions regarding the location of the accident (e.g., at home, in the water, on a farm). The physical examination should include an evaluation of the skin to look for contusions, abrasions, blisters (if treatment has been delayed), and the presence of an open fracture or an open-joint injury. In patients with a displaced patella fracture, physical examination will reveal a visible or palpable defect between the fragments. Signicant hemarthrosis usually develops secondary to the fracture. If a palpable bony defect is present with little or no effusion, a large retinacular tear should be expected. Knee extension is then evaluated. A tense hemarthrosis will make this part of the examination extremely painful for the patient. Arthrocentesis with injection of lidocaine or bupivacaine into the joint is often helpful. The patients ability to extend the knee does not rule out a patella fracture and may simply mean that the patellar retinaculum is intact. An inability to extend the knee, however, suggests a discontinuity in the extensor mechanism. With a patellar fracture, such inability implies a tear of both the medial and the lateral quadriceps expansion.13, 73, 92 Occasionally, a laceration may be noted in proximity to a patella fracture. It may represent an open fracture or an open-joint injury. Because both are surgical emergencies, it is imperative to diagnose these injuries early. A simple means of evaluation is the saline load test. A large-bore needle (18 gauge or higher) and a 50-mL syringe are used to perform joint aspiration. A signicant amount of bloody uid may be removed, usually resulting in relief of pain. The needle is left in place while the syringe is removed and lled with saline solution, which is then injected into the knee joint. Any communication between the fracture or joint and the outside environment will become obvious if the saline solution exits the wound. After the history and physical examination, radiographic evaluation is performed. Once a diagnosis is made, the knee is splinted in a position of comfort (usually slight exion), iced, and elevated. If the patient requires immediate transfer to the operating room or intensive care unit, portable radiographs will sufce.
DIAGNOSIS
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History and Physical Examination

Fractures of the patella are diagnosed by obtaining a history of the injury, performing a thorough physical examination, and acquiring the appropriate radiographic studies. Completion of these investigations should result in a nal diagnosis that includes the fracture type, the presence or absence of retinacular disruption, a description
Radiographic Evaluation
Radiographic evaluation of the patella includes standard and specialized radiographic techniques, tomography, computed tomography (CT), bone scanning, and magnetic resonance imaging (MRI). When time permits, standard radiographic evaluation of the uninvolved knee should be obtained. Such imaging affords the physician a comparison
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view for evaluation and assists in any preoperative planning that might be necessary.
STANDARD VIEWS Anteroposterior The normal anteroposterior (AP) radiograph is taken with the patient standing, but this position is impossible for a patient with an acute fracture. Instead, the lm must be taken with the cassette underneath the knee of a supine patient. The extremity should be aligned so that the patella points straight up. Such alignment is especially important in a patient with an ipsilateral femoral shaft fracture. If the patient has a large hemarthrosis creating moderate knee exion, the x-ray beam must be angled accordingly. Because of the possibility of concomitant occult ipsilateral leg
injuries, the largest cassette possible (14 17 inches) should be used. Evaluation of the AP radiograph requires analysis of several factors. Patella position should be assessed; the patella should lie in the midline of the femoral sulcus. In addition, patellar height should be examined; the inferior pole of the patella is normally located just above a line drawn across the distal prole of the femoral condyles (Fig. 545A). At times mistaken for a patellar fracture, a bipartite or tripartite patella is a developmental residuum from a variation in which the patella arises from two or more ossication centers that fail to fuse (Fig. 546). It is usually a bilateral nding. The most common type is a bipartite patella, in which a bony mass is located in the upper outer quadrant of the patella. It is separated from the main patellar mass by opposing smooth bony surfaces. The
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FIGURE 545. Radiographic indicators of an abnormal patellotibial relationship. An excessive distance between the distal pole of the patella and the tibial tubercle may represent disruption of the patellar ligament or chronic patella alta. A, On the anteroposterior view, the distal pole of the patella lies no more than 20 mm above the plane of the femoral condyles. B, When the knee is exed 90, a lateral radiograph should show that the proximal pole of the patella lies posterior to the anterior surface of the femoral shaft. C, On a lateral radiograph, the length of the patellar ligament (from the distal pole of the patella to the tibial tubercle) approximates that of the patella. If the patella-to-patellar ligament ratio is less than 0.8, the patella is excessively high. D, Blumensaats line, the plane of the residual distal femoral physeal scar, normally projects near the distal pole of the patella (see Fig. 547). (AD, Redrawn from Resnick, D.; Niwayama, G. Diagnosis of Bone and Joint Disorders, 2nd ed. Philadelphia, W.B. Saunders, 1988.)
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Tangential Tangential or axial (sunrise, sunset, or skyline) views of the patella are primarily used in the analysis of patellofemoral disorders (Fig. 548). In fractures of the patella, these studies aid the surgeon in diagnosis of longitudinal (i.e., marginal or vertical) fractures and osteochondral defects. The three most common views are those of Hughston, Laurin, and Merchant.21, 74 Although all give approximately the same information with respect to patellofemoral congruence, the views of Hughston and Laurin are impractical in a trauma setting. The former requires that the patient be prone, whereas the latter requires patient participation. Merchant and associates in 1974 described a method of obtaining an axial view of the patella74 (see Fig. 548A). The patient is placed supine on the x-ray table with the knees exed 45 over the end. The knees are elevated slightly to keep the femurs horizontal and parallel with the table surface. An x-ray beam is angled 30 from the horizontal. The cassette is then placed about 1 ft below the knees and perpendicular to the x-ray beam. This method is simple, easily reproducible by x-ray technicians, and able to obtain accurate radiographs in a patient with a painful, partially exed knee secondary to hemarthrosis (see Fig. 548B).
FIGURE 546. Radiograph of a bipartite patella demonstrating the characteristic proximal lateral ossication center with a curved, welldemarcated lucent zone of separation.
TOMOGRAPHY The principal use of tomography in the evaluation of bony injuries about the knee is in the detection of occult fractures. Apple and associates recommended tomography over bone scanning in these cases, especially for stress fractures and in elderly patients with osteopenia and hemarthrosis.2 In their series, routine radiographs were negative in all cases; 71% of the fractures were identied
condition is generally asymptomatic and requires no treatment, but it can cause confusion when treating patients with a history of injury to the knee area.73 In such cases, a radiograph of the opposite patella should be obtained. Invariably, a similar pattern will be found, thus making the diagnosis. A true unilateral bipartite patella is very rare and may represent an old marginal patella fracture.32 Lateral Although a lateral radiograph is easy to obtain, attention to detail is necessary because rotation of the limb will negate the benets of this view. The proximal end of the tibia must be seen so that rupture or avulsion of the patellar ligament can be excluded (Fig. 547). This view of the knee will portray a transverse or comminuted patellar fracture rather dramatically. Unfortunately, however, it may prevent discovery of more subtle ndings. With the knee exed 90, the proximal patellar pole normally lies posterior to the anterior surface of the femur; with a ruptured patellar tendon, the proximal part of the patella rests anterior to the anterior surface of the femoral shaft (see Fig. 545B). The most reliable means of assessing patellar height is the method of Insall and co-workers,21, 55 which involves determination of the ratio of the greatest diagonal patella length to patellar tendon length. In a normal subject, this ratio is 1.0. A ratio less than 1.0 suggests a high-riding patella (patella alta) or rupture of the patellar tendon. Up to 20% variance is normal (see Fig. 545C). Blumensaats line, the plane of the residual distal femoral physeal scar, normally projects near the distal pole of the patella (see Fig. 545D).
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FIGURE 547. Lateral radiograph of a normal patella. (From Resnick, D.; Niwayama, G. Diagnosis of Bone and Joint Disorders, 2nd ed. Philadelphia, W.B. Saunders, 1988.)
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FIGURE 548. A, A Merchant tangential view of the patella is made with the knee exed 45 and the radiograph exposed as shown (see text). B, A skyline radiograph exposed in this fashion demonstrates the patellofemoral relationship, which may be made incongruent by quadriceps contraction. The image on the left is normal; that on the right shows lateral subluxation. (B, From Resnick, D.; Niwayama, G. Diagnosis of Bone and Joint Disorders, 2nd ed. Philadelphia, W.B. Saunders, 1988.)
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with tomography versus only 30% with bone scans.2 Tomography may also be of benet in the evaluation of patellar nonunion or malunion.107 Although theoretically of benet to the diagnostician, CT scanning is rarely used for evaluation of an isolated patella fracture. It is generally performed as an incidental study during the evaluation of distal femoral or proximal tibial fractures. The information presented rarely adds to that obtained with more conventional techniques. CT may aid the surgeon in evaluation of articular incongruity in cases of nonunion, malunion, and patellofemoral alignment disorders (Fig. 549).
BONE SCANNING Scintigraphic examinations with technetium-labeled phosphate compounds are helpful in the diagnosis of stress fractures, although our preference would be to obtain plain tomograms. A bone scan may also be useful with indiumlabeled leukocytes or gallium scanning for the assessment of patellar osteomyelitis.
MAGNETIC RESONANCE IMAGING MRI has become increasingly useful in the early diagnosis of extensor mechanism injuries. A normal quadriceps tendon has a laminated appearance on MRI studies, whereas the patellar tendon has a homogeneous low signal intensity. The normal patella has the signal intensity of cancellous and cortical bone.115 Injuries of all types can produce hemorrhage and edema, which cause increased signal intensity on T2weighted images. Patella fractures and avulsions of the tibial tubercle do not generally require MRI evaluation but will result in changes in marrow signal intensity.115 Complete rupture of the quadriceps tendon is well demonstrated by MRI, and transection of all layers of the tendon is diagnostic of a complete rupture. In the more unusual patellar tendon ruptures, MRI evaluation shows absence of distinct margins and increased signal intensity within the patellar tendon.115 Dislocation of the patella produces a characteristic pattern of change on MRI that allows diagnosis of this
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FIGURE 549. Computed tomographic scan of a fractured patella. Note the extent of comminution, as well as the secondary sagittal fracture and the resulting articular incongruity.
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SECTION V Lower Extremity TABLE 541
injury even if the patient is initially seen after relocation of the patella.104 These ndings include contusion of the lateral femoral condyle (manifested as low signal intensity on T1-weighted images), tear of the medial retinaculum, and joint effusion.
Fracture Classication
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FRACTURE CLASSIFICATION
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The three major categories of patella fractures are transverse, stellate, and vertical. Transverse fractures that are proximal (basal) or distal (apical) are termed polar. Because
A. Nondisplaced fractures 1. Stellate 2. Transverse 3. Vertical B. Displaced fractures 1. Noncomminuted a. Transverse (central) b. Polar 1. Apical 2. Basal 2. Comminuted a. Stellate b. Transverse c. Polar d. Highly comminuted, highly displaced C. Fractures associated with bonepatellar tendonbone autograft 1. Longitudinal 2. Transverse
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these usually extra-articular disruptions of the quadriceps pose different therapeutic challenges, they are classied separately13, 68 (Fig. 5410). Wide variations within each fracture pattern have prevented the creation of a useful classication scheme.11, 13, 92 Because of this difculty, most authors have reviewed long-term results according to treatment rather than fracture type.11, 13, 14, 25, 68, 82, 92, 100 For the purposes of this chapter, existing classication schemes were combined for better understanding11, 13, 68, 100 (Table 541). Although the terms stellate and comminuted are interchangeable in much of the published literature, we recommend distinguishing comminuted transverse fractures, which often have retinacular disruption, from stellate patellar fractures, which are associated with an intact retinaculum.
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Nondisplaced Fractures
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STELLATE Stellate fractures of the patella are the result of a direct compressive blow that forces the bone against the femoral condyles. Damage to the articular cartilage of the femoral condyles and the creation of osteochondral fragments may occur and must be ruled out.19 Typically, well over half (65%) of these fractures are nondisplaced. In these fractures, the blow is insufcient to tear the patellar retinaculum, and active extension of the knee is therefore possible. Displacement between fragments is, by denition, less than 3 mm, and displacement between the articular surfaces, less than 2 mm. Unless an osteochondral fragment is present and requires arthrotomy or arthroscopy, nonoperative therapy is indicated (Fig. 5411).
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FIGURE 5410. Examples of patellar fractures. A, Undisplaced fractures may have any degree of comminution, but fragments are displaced no more than 3 mm. The articular surface as seen on the lateral view should have a step-off of no more than 2 mm. B, Displaced transverse fracture with comminution of the apical pole. C, Displaced transverse fracture with comminution of both the apical and basilar poles. D, Highly comminuted, highly displaced fracture.
TRANSVERSE Transverse fractures of the patella are the result of a tensile stress applied to the extensor mechanism. Typically, 35% or more of all transverse patellar fractures are nondisplaced.1, 13 Damage to both the femoral and the patellar articular surface is minimal,89 and the force is usually
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insufcient to tear the medial and lateral patellar retinaculum.13, 42, 73, 89, 92 As a result, the patient retains the ability to extend the knee. In addition, the intact soft tissue envelope maintains patellar alignment; typically, less than 3 mm of fragment diastasis and 2 mm of articular incongruity exist. If these conditions are met, nonoperative treatment is suggested (see Fig. 5410). VERTICAL Vertical fractures (marginal or longitudinal fractures), contrary to earlier reports, are a common type of patellar fracture, with a combined incidence of 22% (384/1707) in several large series.9, 14, 32 The fracture may be caused by different mechanisms. Dowd stated that direct compression of the patella in a slightly hyperexed knee creates this ms series, lateral avulsions accounted fracture.32 In Bostro for more than 75% of all vertical fractures.14 Bony separation is most commonly found at the junction of the middle and lateral thirds of the patella; less commonly, a medial pole avulsion may occur. Clinically, the patient has a somewhat painful knee and a mild effusion. Full extension of the joint is possible because the patellar retinaculum is intact.9, 14, 32 A diastasis of greater than 3 mm is most unusual.13, 14 The fracture may be missed on standard radiographs, and therefore axial views are usually necessary to make the diagnosis.9, 14 If the defect is seen on the AP radiograph, it may easily be mistaken for a bipartite patella, so radiographs of the opposite limb should be obtained. Because the fracture fragments are minimally displaced and the patellar retinaculum remains intact, these fractures are best treated nonoperatively.
patella. The diagnosis is made in a patient with loss of active extension of the knee (after aspiration), more than 3-mm separation between fracture fragments, or an articular step greater than 2 mm.810, 73, 92 These ndings suggest retinacular disruption and joint incongruity. Either nding warrants operative repair (Fig. 5412). Some patients may have a gap of 4 to 5 mm between fracture fragments but can extend their leg actively. McMaster warned of nonunion in these patients when treated m, in reviewing the results of his conservatively.73 Bostro and other large published series, however, concluded that active extension implied retinacular continuity and that these patients could heal satisfactorily without surgery.13 We concur with his advice. Polar Polar fractures of the patella are transverse fractures occurring either proximal or distal to the patella equator and taking varying amounts of bone. Proximal, or basal pole, fractures imply avulsion of the quadriceps mechanism from the patella. The amount of accompanying retinacular rupture determines the patients ability to extend the leg. Displacement is extremely rare and was seen in less than 4% of patients in several large series.13, 92 Distal, or apical, fractures are bony avulsions of the proximal patellar tendon (Fig. 5413). These fractures, which occur toward the distal margin of the retinaculum, are almost invariably associated with loss of knee extension. As a result, displacement in apical fractures is almost three times as common (11.5%) as in basal injuries.
Displaced Fractures
NONCOMMINUTED Transverse/Midpatellar Displaced fractures account for slightly more than half (52%) of all noncomminuted transverse fractures of the
COMMINUTED Stellate A result of direct compression, comminuted stellate fractures usually exhibit displacement with varying degrees of comminution.19 Although the patellar retinaculum is intact, operative intervention is indicated because of existing articular incongruity (Fig. 5414).
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FIGURE 5411. Nondisplaced stellate fracture of the patella. Radiographic projections are anteroposterior (A), oblique (B), and lateral (C).
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FIGURE 5412. Displaced transverse fracture of the patella. A, Anteroposterior radiograph. B, Lateral radiograph.
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FIGURE 5413. Displaced distal polar fracture of the patella. A, Anteroposterior radiograph. B, Lateral radiograph.
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FIGURE 5414. Displaced stellate fracture of the patella. A, Anteroposterior view. The fracture is difcult to see. B, Lateral view. The fracture is apparent, but displacement appears to be only moderate. C, A skyline radiograph clearly indicates displacement and incongruity of the articular surfaces.
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FIGURE 5415. Comminuted transverse fracture of the patella. A, Anteroposterior view. The details of the fractures conguration are hard to see. The main displaced transverse component and secondary vertical fracture lines are evident. B, Lateral view. Displacement is more obvious, but comminution is less apparent.
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Transverse/Polar These comminuted fractures exhibit varying degrees of comminution of one major patellar fragment. Upper fragment comminution is usually accompanied by one or two additional fracture lines that are minimally displaced. Lower fragment comminution is generally more severe and may be accompanied by upper pole comminution.11, 13 Comminution is much more prevalent in the lower pole than the upper pole. Highly Comminuted, Highly Displaced Highly comminuted and displaced fractures consist of either transverse fractures with massive comminution secondary to compression or stellate fractures with massive diastasis secondary to a violent quadriceps contraction (Fig. 5415). All major fragments are separated by more than 6 mm, and sagittal splits are often present as well. These fractures frequently occur as open injuries and can be accompanied by supracondylar femur fractures.
osteotome at the time of graft harvest.7, 75 These fractures are treated by neutralization with screws directed in the coronal plane. The screws are not placed in a lag fashion because of the potential to create a distracting force at the articular surface secondary to the defect from harvesting of a graft.6 The rehabilitation protocol need not be modied if the fractures are rigidly xed, and rehabilitation should be aggressively pursued.
TREATMENT
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Management of patella fractures is based on the morphology of the injury. Options include nonoperative treatment, tension band wiring, lag screw xation, partial patellectomy, partial patellectomy combined with tension band wiring, and total patellectomy. These techniques are performed with careful reconstruction of the extensor mechanism and the patellar joint surface whenever possible. Figure 5416 outlines this chapters proposed algorithm for the management of patella fractures. Specic details of xation may need to be modied to accommodate a given fracture pattern.
Fractures Associated with BonePatellar TendonBone Autograft

A subset of patella fractures has been reported in patients who have had a bonepatellar tendonbone autograft for reconstruction of the anterior cruciate ligament.6, 17, 75, 103 An incidence of approximately 0.2% has been reported in one study involving 1320 anterior cruciate reconstructions.103 The etiology of these fractures is most often related to a traumatic fall or injury, but it has been hypothesized that an accelerated rehabilitation protocol may put patients at higher risk than the traditional rehabilitation protocol.17 These fractures occur in two patterns. A transverse fracture is the most common and is generally treated with traditional tension band wiring or screw xation techniques.6 Vertical, or ssure, fractures have been noted as well. These injuries are thought to occur from a stress riser created by a rectangular bone plug in the patella or as a nondisplaced fracture created by the
Biomechanics of Patellar Fracture Fixation

Carpenter and colleagues compared three internal xation constructs for transverse patella fractures in a cadaver model.20 The three constructs included a modied tension band (AO technique), two parallel 4.5-mm interfragmentary lag screws, and a 4.0-mm cannulated lag screw technique with a tension band through the cannulated screws20 (Fig. 5417). A signicant difference in displacement was noted between the modied tension band construct and the lag screw techniques. The highest load to failure occurred with the cannulated lag screw and tension band construct. They concluded that the cannulated lag
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NONDISPLACED Transverse Stellate Vertical
DISPLACED
Noncomminuted
Comminuted
LAB/C Wiring Transverse Modified anterior tension band wire Print Graphic Polar Modified anterior tension band plus screws Transverse Stellate
Presentation
Partial excision Polar Highly comminuted Highly displaced Total excision
Cylinder cast/cast brace

FIGURE 5416. Displacement and the fracture pattern both guide the choice of treatment with which to obtain the two primary goals of quadriceps mechanism continuity and stable anatomic reduction of the patellar articular surface. Nondisplaced fractures are managed nonoperatively. Displaced articular fractures are repaired, if possible, by using tension band wiring techniques with or without screws or interosseous wiring. Polar avulsion fractures may be excised, but secure reattachment of the quadriceps or patellar tendon is required. If comminution prevents satisfactory repair, total patellectomy may be the only option to restore the quadriceps. Abbreviation: LAB/C, longitudinal anterior band plus cerclage.
screw and tension band technique provided improved stability in the xation of transverse fractures of the patella. Scilaris and associates compared tension band techniques with a monolament wire versus a braided cable in a transverse patella fracture cadaver model.88 The braided cable construct allowed signicantly less fracture displacement in cyclic loading than did the monolament construct. They concluded that the braided cable plus tension
band construct was superior to the monolament technique and was more predictable in cyclic loading.
Open Fractures
Open patellar fractures are surgical emergencies, and surgeons must be aware of the possibility of osteomyelitis
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and septic arthritis. Irrigation, de bridement, and stable xation remain the principles of treatment. Devitalized fragments should not be saved, and heroic efforts at salvage are not indicated. Fixation should be performed with a minimum of soft tissue stripping and must be stable. Subsequent repeat de bridement will be necessary, and closure may require skin grafts, muscle aps, or free tissue transfer. Catalano and co-workers retrospectively reported on a series of 79 open patella fractures with an average of 21 months of follow-up.22 Open fractures were classied as grade I (15%), grade II (53%), and grade III (32%) injuries. Additionally, most open patella fractures were displaced, with 22% being transverse fractures and 39% being comminuted fractures. Approximately 80% of the patients sustained multiple injuries. Treatment consisted of operative de bridement and irrigation with appropriate antibiotics, followed by open reduction and internal xation in 57% and partial patellectomy in 32%. Eleven percent were treated with de bridement only, and no patients had a primary total patellectomy. They reported no deep infections, and only one patient required repeat open reduction and internal xation. Seventy-six percent of the patients were available for follow-up, and they had an average of 112 of knee motion.22
fractures. Treatment consists of extension splinting for 4 to 6 weeks.13, 42, 73, 89, 92 If plaster is used, care should be taken to extend the cast from a few centimeters above the malleoli to the groin (not the middle of the thigh). If the patient is elderly or has varicose veins, an Unna boot is applied to the foot and ankle before casting to minimize swelling.92 Immediate weight bearing as tolerated is permitted. Isometric quadriceps exercises and straight leg raises are encouraged within several days.13, 42, 73 After radiographic evidence of consolidation, usually at 4 weeks, the plaster may be removed, and progressive active (not passive) exion and strengthening exercises are begun. In reliable patients, we prefer the use of an off-the-shelf hinged knee brace. These braces are lightweight and easily adjustable and permit controlled motion of the knee joint. The knee hinge is locked in extension during ambulation but may be opened to permit controlled motion during the convalescent period. This type of brace may be advantageous for elderly patients. A simple knee immobilizer of adequate length is a similar alternative.
Operative Treatment
PREOPERATIVE PLANNING Before embarking on surgical repair of the patella, an operative plan should be rmly established. Formulation of the plan requires radiographic evaluation of the normal opposite patella. On tracing paper or clear x-ray lm, the normal patella is outlined. The fracture fragments are then
Nonoperative Treatment
Indications for nonoperative management include transverse, stellate, and vertical nondisplaced closed patellar
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Presentation
C
FIGURE 5417. Comparison of constructs for internal xation of patella fractures. A, AO modied tension band construct. B, AO compression screws, 4.5 mm. C, Cannulated 4.0-mm screws combined with a tension band. (From Carpenter, J.E.; et al. J Orthop Trauma 11:351356, 1997.)
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superimposed onto this outline in both the AP and the lateral planes. In effect, such superimposition reduces the fracture. Attention is then turned to xation, be it wires, screws, partial excision, or a combination of methods. These elements should be drawn onto the plan and numbered in sequence. Finally, contingency plans, as well as the necessary equipment, should be listed. The surgeon should be aware that superimposition of the patella on the femur makes this exercise difcult at times. It therefore requires optimal radiographic technique and an awareness that unanticipated comminution may be encountered. Preoperative planning allows the surgeon to think through the operative procedure and become acquainted with the personality of the fracture. In addition, equipment requirements will be known beforehand, thus promoting a smoother operation without unnecessary delays. When this plan is followed, the postoperative lm will appear remarkably similar to the preoperative plan. EQUIPMENT A wire set incorporating Kirschner wires (K-wires), 1.2-mm (18-gauge) and 1-mm (19-gauge) wire on spools, wire holders, wire tighteners, wire pliers, and a wire passer is necessary, along with a power drill and a wire driver (Fig. 5418). A small-fragment instrument and implant set and Weber (large, pointed) bone reduction forceps are also useful. A special patella clamp is an invaluable device because the Weber clamps may rotate. Angiocatheters (14 or 16 gauge) are helpful for passing wire. A
large-fragment set should always be available. Large osteochondral fragments will require minifragment screws or Herbert screws, and for small fragments, absorbable polyglactin 910 (Vicryl) pins (Ethipins) should be on hand. SETUP The patient is placed in the supine position, and a tourniquet is applied high on the thigh, if desired. Trapping of the quadriceps may cause difculty in repositioning the patella when the tourniquet is inated. This complication may be prevented by exing the knee carefully beyond 90 to bring the quadriceps and proximal patella fragment down before inating the tourniquet. In patients with complete retinacular disruption and a high-riding proximal patellar fragment, a sterile tourniquet can be inated, if necessary, after the patella has been brought down with an Esmarch bandage wrapped in a proximal-to-distal direction.23 INCISIONS Although any anterior knee incision can be used, a transverse, midline longitudinal, or lateral parapatellar incision is preferred (Fig. 5419). In patients with severe retinacular disruption, a transverse incision should parallel this disruption to minimize the development of aps.68, 79 In more comminuted fractures, a midline longitudinal or lateral parapatellar incision is necessary, especially if concomitant injuries suggest the possibility of joint replace-
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FIGURE 5418. Instruments and implants helpful for xation of patella fractures include pointed reduction forceps for large bones (A), patella forceps (B), wire tightener (C), wirebending pliers (D), wire cutter (E) for Kirschner wires, wire bender/impactor (F), Kirschner wire (G), and malleable wire at least 1 mm in diameter (H).
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Tension Band Wiring Modied Anterior Tension Band Wiring. For displaced noncomminuted two-part transverse patellar fractures, open reduction and internal xation using the modied anterior tension band technique is the treatment of choice (Fig. 5420). A midline longitudinal incision is made through the skin and overlying bursa. The fracture edges are exposed and completely cleaned of debris and clot, with care taken to not devitalize the fragments. The knee joint is then irrigated to remove any loose fragments. A preliminary reduction is performed to evaluate the proper position of the fragments. The reduction is then taken down, and the proximal fragment is exed 90. A hole is drilled through the proximal fragment in a retrograde manner with a 2-mm drill bit. This hole should start within the fracture line, approximately 5 mm from the anterior surface of the patella and at the junction of a line separating the patella into thirds. The drill bit is then exchanged for a 1.6-mm K-wire that is pushed proximally until it is ush with the fracture edge. A second hole (parallel to the rst and at the junction of a line separating the patella into thirds) is drilled. The drill bit is exchanged with a K-wire in a similar manner. The fracture is then reduced and held with Weber or patellar reduction forceps. The wires are sequentially removed and the holes drilled distally with a 2.0-mm drill bit up to, but not through, the distal cortex. A prebent 1.6-mm K-wire is inserted into the drill hole and hammered through the far cortex. Next, a 1.2-mm (18-gauge) wire is placed underneath the upper hooks and the lower protruding pin tips. The wire is loosely tightened with a wire tightener. The reduction is
FIGURE 5419. Incisions for exposure and treatment of patellar fractures. Either a longitudinal or a transverse approach may be used. Sufcient exposure to see and effectively repair medial and lateral retinacular tears is important. Supercial dissection should be avoided to preserve thickness and viability of the skin aps.
TABLE 542
Treatment of Patella Fractures

Patella Fracture Type A. Nondisplaced fractures 1. Transverse 2. Stellate 3. Vertical B. Displaced fractures 1. Noncomminuted a. Transverse b. Polar 1. Apical 2. Basal 2. Comminuted a. Stellate b. Transverse
Treatment Cylinder cast
ment in the future. These latter incisions also avoid damage to the saphenous branch of the femoral nerve medially. A percutaneous xation technique for patella fractures has been described. This method might be considered with severely compromised skin.69 Berg has described an extensile exposure for comminuted fractures of the patella that involves osteotomy of a tibial tubercle for retropatellar exposure and fracture xation.7 This technique facilitates exposure and reconstruction of the patella and maintenance of bone stock without any morbidity associated with the tibial tubercle osteotomy. Additionally, ablative salvage procedures can be avoided and thus further improve joint reconstruction options in the future.
Modied anterior tension band wiring Partial patellectomy Modied anterior tension band wiring Modied anterior tension band wiring Longitudinal anterior tension band plus cerclage Independent lag screws plus modied anterior tension band wiring Longitudinal anterior tension band wiring Partial patellectomy Partial patellectomy Modied anterior tension band wiring Longitudinal anterior tension band wiring Partial patellectomy Total patellectomy
OPERATIVE TECHNIQUES All displaced fractures of the patella require operative intervention. As previously mentioned, the techniques used are based on the fracture pattern and concomitant injuries (Table 542).
c. Polar d. Highly comminuted, highly displaced
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B C
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FIGURE 5420. Modied AO tension band technique for patella fracture xation (see text). A, Retrograde drilling of the proximal fragment. Kirschner wires mark the proximal ends of the holes during reduction. B, Reduction, clamping, and antegrade partial drilling of the distal fragment. K-wires with prebent proximal ends are then hammered through the remaining bone of the distal pole. C, With a large-bore needle, the 1.2-mm tension band wire is placed deep to the proximal and distal ends of the K-wires immediately adjacent to the patella through the stout soft tissue attachments of the quadriceps tendon and patellar ligament. Medially and laterally, the tension band wire lies anterior to the patella and is not usually crossed. It is tightened and twisted securely, and the pigtail end is bent ush with the bone surface. A twist or a square knot is reliable. The AO bent-wire fastening technique is not secure enough for denitive xation. D, The prebent proximal ends of the K-wires are driven into the proximal pole, and the distal ends are trimmed if necessary. E, F, Anteroposterior (AP) and lateral radiographs show a displaced comminuted patellar fracture. G, AP radiograph after xation. Note the modications in technique for xation of comminuted fragments: supplementary K-wires, distal-to-proximal K-wire insertion, and a distally crossed tension band wire, which was tightened with medial and lateral twists to equalize tension. H, I, Lateral and skyline views show anatomic reduction and anterior placement of the tension band wire.
checked by extending the knee and palpating the undersurface of the patella with a nger. If a nger cannot be easily inserted through the retinacular tear (or if none exists), the retinaculum should be longitudinally incised to permit insertion. If articular congruity is satisfactory, the wire should be twisted tightly with a wire tightener and buried. The K-wires are twisted so that the bend is facing backward and then buried in the patella. The excess distal ends of the K-wires are cut off distally. Although certain authors recommend crossing the tension band wire, in our experience, crossing reduces the
area of patella that can be compressed and often leads to an unstable osteosynthesis. A prefabricated cerclage loop (AO type) is also not recommended for use as a tension band wire because it can come undone with early motion. Finally, the retinaculum is sutured closed with gure-ofeight 0 Vicryl interrupted sutures, and the wound is closed in layers over a drain. Modied Anterior Tension Band Wiring through Cannulated Compression Screws. When failure of the standard tension band technique is a concern in an elderly patient with osteopenic bone, an alternative is a modied
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FIGURE 5421. Tension band technique through cannulated compression screws. A, Transverse patella fracture. B, Anteroposterior view of 4.5-mm cannulated compression screw xation with a tension band wire. C, Lateral view demonstrating the tension band construct through cannulated compression screws.
anterior tension band through cannulated compression screws.8 Berg described this technique in which two parallel cannulated cancellous screws are placed longitudinally over guide wires with lagged interfragmentary compression. An 18-gauge AO wire is then passed in a gure-of-eight fashion through the cannulated screws and tightened with a Kirschner traction bow. The remainder of the xation technique remains the same as for the standard anterior tension band construct (Fig. 5421). Longitudinal Anterior Band plus Cerclage Wiring. Minimally displaced stellate fractures requiring operative intervention may not have a single fragment large enough to permit a modied anterior tension band technique. In these cases, either the K-wire should be angled appropriately or the longitudinal anterior band plus cerclage (LAB/C) wiring technique of Lotke and Ecker may be used68 (Fig. 5422). The patella is approached, and the fragments are cleaned as described in the section Modied Anterior
Tension Band Wiring. Two parallel Beath-Steinmann pins (with holes in the distal tip) are drilled 1 cm from the patellar edges through the aligned patella fragments in an antegrade manner. A 22-gauge wire is then inserted into both drill holes, and both pins are removed proximally. The distal loop is brought anteriorly, and one free proximal end is passed through this anterior loop. It is then tied to the other proximal end and tightened. This technique results in a strong and secure combination of anterior band and interosseous wiring techniques. Heavier-gauge wire may be safer for xationfor example, 18-gauge wire passed with the aid of a large angiocatheter placed over the K-wire and held in place when it is withdrawn. If marked comminution is present, a cerclage wire should rst be placed around the circumference of the patella, which can easily be done with a wire passer or a 16- or 14-gauge angiocatheter inserted immediately next to the patella. The LAB/C wiring is then performed. The retinaculum is sutured closed with gure-of-eight 0 Vicryl
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FIGURE 5422. Longitudinal anterior band plus cerclage technique for interfragmentary wire loop xation of patella fractures. A, For transverse fractures, the two ends of a wire loop are passed through longitudinal drill holes in the patella. One of these wire ends is then passed through the loop made by the middle of the wire distally. Next, the ends are pulled tight and twisted to provide a taut anterior tension band. B, Lateral view. C, In fractures with signicant comminution, xation is aided by rst placing a cerclage wire around the patella to trap the comminuted fragments and then drilling and applying the longitudinal anterior band wire as in A. (AC, Redrawn from Lotke, P.A.; Ecker, M.L. Clin Orthop 158:180184, 1981.)
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interrupted sutures, and the wound is closed in layers over a drain. Independent Lag Screws plus Modied Anterior Tension Band Wiring. Transverse fractures may have one or two additional fracture lines in the main fragments that separate the main fragments into halves or thirds. These secondary fracture lines are not usually displaced, but they may become so after operative intervention is attempted. The general principles of internal xation of fractures should be followed (i.e., to make many fragments into two main fragments and then unite these two into one). Such xation can usually be accomplished with independent lag screws placed in a horizontal direction, followed by a modied anterior tension band wiring technique. The size of the screw should t the size of the bone (e.g., 3.5-mm cortical screws will usually sufce, except in large adult men, in whom 4.5-mm screws should be used) (Fig. 5423). If the fragment is comminuted at the point of screw entry, a washer is used. Frequently, a fragment has or acquires a sagittal split during insertion of the lag screw; the split separates the anterior cortex from the main chondral surface of that fragment. If this fragment cannot
be salvaged by repositioning the screw, LAB/C wiring or excision of the fragment should be considered. Partial Patellectomy Not infrequently, patellar fractures exhibit signicant comminution of one pole, and the fragments may involve a smaller or larger portion of the patella. At times, indirect reduction with a modied anterior tension band or LAB/C wiring technique will be effective. If these techniques are not possible, the time-honored method of partial patellectomy should be performed1, 25, 79, 101 (Fig. 5424). The patella is approached and the fracture exposed as previously described. All large, stable, distal fragments should be retained, and all small, comminuted fragments should be excised. All loose strands of the torn quadriceps expansion are removed. If one large distal fragment is present, it may be lagged into position with screws after reduction has been secured. Care must be taken to not angle this fragment or patellofemoral arthritis will develop (see Fig. 5424C). This procedure can be simplied by placing a bolster underneath the ankle to extend the knee.
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FIGURE 5423. AO lag screw plus tension band technique. A, Small-fragment screws can be used alone to x vertical components or comminuted portions of the patella. B, These screws should be supplemented with a tension band wire for xation of displaced transverse fractures because screws alone may not withstand the signicant forces developed by the quadriceps mechanism. Anteroposterior (AP) (C), lateral (D), and skyline (E) radiographs show a displaced oblique (functionally transverse) patellar fracture. Postoperative AP (F) and lateral (G) radiographs show the use of 4.0-mm cancellous lag screws supplemented by an anterior tension band wire. The wire is crossed in this case to maintain its position anterior to the fracture.
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FIGURE 5424. Techniques of partial patellectomy. A, Extensive comminution of the central portion may be excised, with xation of the proximal-to-distal poles with screws or K-wires and a tension band. The results of this technique are not well documented. B, A small (usually extra-articular) bony fragment may aid in reattachment of the patellar ligament distally. Screws, K-wires, or sutures may be used, but they should always be protected with a tension band, either limited to the patella if the distal pole fragment is sufcient or from the patella to the tibial tubercle if it is not sufcient. C, When suturing the patellar ligament into a defect in the distal pole of the patella, it is essential to not attach it too anteriorly because such positioning will result in malalignment of the patella (left), the distal articular surface being forced too far posteriorly. The example on the right shows proper reattachment of the patellar ligament. A tension band from the patella to the tibia should protect this repair.
Because of the powerful tension developed in the quadriceps mechanism, signicant stress is placed on its repairs, which must be protected. This goal can be accomplished by using a crossed tension band through either the quadriceps insertion or the proximal part of the patella and through the proximal end of the tibia by a variety of means (Fig. 5425). We prefer wire passed directly through the bone because it is less bulky and easier to remove. Mersilene tape or fascia may also be used. If only small fragments remain distally, the following technique is used. The anterior periosteum is reected on the proximal fragment approximately 5 mm, and with a rongeur, a transverse groove is made in the proximal fragment within the fracture line itself. Three holes are drilled so that they are equally spaced from the fracture line and exit the superior aspect of the patella. Next, with a heavy, braided, nonabsorbable suture and an atraumatic needle, the suture is passed distally in a running, locking stitch along one edge of the tendon and then returned in the midline of the tendon. A second suture is passed in a similar manner along the opposite side of the tendon and
back along the midline. The suture ends are passed through the appropriate drill holes in the patella, with two sutures through the central hole. A straight, free needle can be used to pass the sutures. Each suture is tied to its opposite end. This step should be done while the knee is hyperextended and should bring the tendon end into close approximation with the trough in the distal aspect of the proximal part of the patella. A tension band should be added to neutralize stress on the repair. The retinaculum is then sutured closed with gure-of-eight 0 Vicryl interrupted sutures, and the wound is closed in layers, over a drain if desired. Total Patellectomy For highly displaced, highly comminuted fractures, an attempt at reconstruction should be made before total patellectomy is performed. Several authors have stressed the retention of even one fragment to maintain a lever arm.33, 92, 100, 101 A combination of partial patellectomy and modied anterior tension band or LAB/C wiring is usually tried before total excision is performed. Although many techniques exist, those presented in the
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FIGURE 5425. A tension band wire technique should be used to protect the patellar ligament reattachment after distal pole fracture xation, partial patellectomy, or repair of a ruptured patellar ligament (A). B, C, The 1.0- or 1.2-mm wire can be attached to a screw through the tibial tubercle. D, It can be placed through the quadriceps tendon just proximal to the patella or through a drill hole in the patella and through a drill hole distally. Anteroposterior (E) and lateral (F) radiographs show the tension band wire protecting the reattached patellar ligament after distal partial patellectomy.
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following paragraphs are the most favorably reviewed in the literature. Because total patellectomy is often a salvage procedure, the surgeon may nd various skin incisions and retinacular remnants. Once a decision for total extirpation has been made, all fragments of bone and shredded tendon are removed sharply, but as much tendinous expansion as possible is left. The critical feature of a total patellectomy is the tendinous repair. Because the quadriceps tendon is effectively lengthened by the removal of bone, this slack should be taken up by imbrication (i.e., in a pursestring repair), or an extensor lag will result. If insufcient tendon exists for primary repair, several options are available. These options can be separated into two categories: quadriceps turndown procedures and fascial or tendinous weaving. The former technique is used when prepatellar soft tissue is absent, whereas the latter is reserved for injuries with destroyed quadriceps tendon as well. The most common quadriceps turndown technique is the inverted V-plasty of Shorbe and Dobson.93 After the patella has been excised, the quadriceps tendon is exposed for approximately 3 inches (Fig. 5426). A full-thickness incision is made into the quadriceps tendon in the shape of a V, with the apex located 2.5 inches proximal to the former proximal patellar edge. The limbs of the incisions extend distally for 2 inches such that ] to 12 inch of tendon is continuous with the retinaculum. The corners may be reinforced with suture if necessary. The apex is subsequently folded down, inserted through the proximal portion of the patellar tendon, and sutured down. The quadriceps tendon should then be closed and all edges repaired. This repair is simple to perform, yet has the advantage of being strong enough to allow early motion. Should a large defect involving the quadriceps tendon
be present, a free fascial or tendinous strip is woven into the tendinous remnants after the method of Gallie and Lemesurier.39 First, all excess tendinous shreds are removed from the wound. The knee is extended with padding under the ankle and the defect measured. This length should be doubled and 2 inches added to obtain the ideal length of a fascial graft. A separate lateral incision is made or the wound is extended, and a strip of fascia lata or an iliotibial band of the appropriate length and 1 to 1.5 cm in width is obtained. The strip of fascia is rolled into a cylinder along its long axis and sutured to itself. It is then woven through the remaining quadriceps tendon or muscle, sewn to itself, passed through the patellar tendon, and tacked down after the slack is taken out. The graft should be of sufcient length to sew one end down to the other. Finally, all edges are rmly sutured down. If the defect requires an exceptionally long strip, plantaris tendon can be used.
POSTOPERATIVE MANAGEMENT With a stable osteosynthesis, the patient may begin using a continuous passive motion machine to tolerance immediately postoperatively. In our experience, use of this device decreases pain and stiffness. On the rst postoperative day, the patient can be out of bed with the leg elevated, and quadriceps isometric exercises are begun. Drains, if used, are generally removed after 48 hours. The patient is then placed in a removable knee brace and permitted to ambulate with weight bearing as tolerated and the knee locked in extension. The hinges may be loosened for active range-of-motion exercises. These exercises should not be performed until the wound is well healed, usually at 3 weeks. Active extension and straight leg raising exer-
FIGURE 5426. Inverted V-plasty technique of Shorbe and Dobson for repair of a patellectomy defect. A, The patella is resected, with a transverse defect left in the quadriceps mechanism. The retinacular rents are repaired rst. B, If a defect remains centrally, an inverted, distally based, V-shaped ap of quadriceps tendon is turned distally as shown. C, The ap is sutured in place to cover and reinforce the defect.
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SECTION V Lower Extremity TABLE 543
cises may be initiated as early as 1 week postoperatively. Progressive resistance exercises are performed after radiographic evidence of healing, usually at 6 weeks. The patient is then weaned from the brace and, by 3 months postoperatively, usually has a healed fracture and strong quadriceps. Sports and vigorous work may be resumed after rehabilitation is complete, usually in 4 to 6 months. For an unstable osteosynthesis, the repair must be protected. Ideally, a knee brace with locking hinges will permit controlled motion. The hinges are set to allow full extension. Flexion to the degree possible during intraoperative assessment of the repair is permitted, primarily for cartilage nutrition. The brace should be worn at all times, and active exion exercises should not begin until the fracture has healed. Isometric quadriceps extension exercises should be initiated at 2 weeks. Weight bearing in full extension can usually be allowed once comfort permits. Weight bearing on the exed knee should be avoided until fracture healing is secure. The patient should be made aware of possible knee stiffness. When the fracture has healed radiographically and is clinically stable, attempts at rehabilitation are begun to improve exion range and strength of all muscle groups. Implant removal should be delayed until fracture union is mature, which usually requires a minimum of 6 months. K-wires may be extracted if they are painful and protruding, but loss of xation with fracture displacement generally requires revision surgery. Asymptomatic implants may be retained indenitely. Wires used to protect tendon repairs should be left in place for a minimum of 3 to 6 months.
Clinical Grading Scale
Score 6 3 0 6 3 0 4 2 0 4 2 0 4 2 0 2 1 0 2 1 0 2 1 0
Clinical Grading Scale/Variable Range of motion (ROM) Full extension, ROM >120 Full extension, ROM 90120 Loss of full extension, ROM <90 Pain None or minimal on exertion Moderate on exertion In daily activities Work Original job Different job Cannot work Atrophy (10 cm, proximal part of patella) <12 mm 1225 mm >25 mm Aids None Cane part-time Cane full-time Effusion None Reported to be present Present Giving way No Sometimes All the time Stair climbing Normal Difcult Disabling
Results
No generally accepted outcome assessment system is available for patellar fractures. Most authors base outcome on subjective complaints of pain, limitation in activities of daily living, change in job status, and ambulation.14, 35, 92 Bo stman and colleagues developed the most complete evaluation of clinical results to date11 (Table 543). However, this table, like most reports in the literature, does not evaluate radiographic ndings. Radiographic criteria would include osteoarthritis, brous union or nonunion, the presence of osteochondral fragments, and the degree of articular step-off on the radiograph.11, 19, 92 The lack of a uniform assessment scale allows only broad generalizations to be made about the results of treatment of these injuries (Table 544). NONOPERATIVE TREATMENT Nonoperative treatment of nondisplaced fractures nearly always has a uniformly good outcome,13, 73, 89, 96 which implies full range of motion and no arthrosis, weakness, or pain (see Table 543). In Bostro ms series of 422 patellar fractures, 219 were treated nonoperatively and were available for follow-up.13 All cases initially had less than 4 mm of articular incongruity; 54% (118/219) had excellent results, and 44% (97/219) had good results. Only two failures occurred. His results agree with the ndings of
Excellent, 30 to 28 points; good, 20 to 27 points; failure, <20 points. Source: Modied from Bo stman, O.; et al. Injury 13:196202, 1981.
other large series in that the failure rate from nonoperatively treated, nondisplaced patellar fractures was 5%. OPERATIVE TREATMENT Results of operative repair are based on the type of fracture and the technique used (Table 545). Modied anterior tension band wiring has given the best results in the literature to date, with 57% excellent and 29% good results11, 12, 54, 64, 108 (Table 546). Unfortunately, many studies are vague in reporting results, and studies
TABLE 544
Combined Results of Various Forms of Operative Treatment in the Literature

Results Treatment ORIF Partial excision Total excision Totals Excellent 135 (37%) 32 (23%) 62 (28%) 229 Good 129 (36%) 67 (49%) 96 (44%) 292
Fair 97 (27%) 39 (28%) 61 (28%) 197
Total No. 361 138 219 718
Abbreviation: ORIF, open reduction and internal xation.
CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries TABLE 545
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Results of Operative Repair in Patellar Fractures

No. Patients
Results
Author, Year
Excellent
Good
Fair
OPEN REDUCTION, INTERNAL FIXATION Seligo,92 1971 35 Nummi,82 1971 66 75 Bostro m,13 1972 Bo stman et al.,12 1983 48 Ma et al.,69 1984 107 30 Levack et al.,64 1985 Totals 361 PARTIAL EXCISION Seligo,92 1971 Nummi,82 1971 Bostro m,13 1972 Mishra,76 1972 Bo stman et al.,12 1983 Totals TOTAL EXCISION Seligo,92 1971 Nummi,82 1971 Bostro m,13 1972 Mishra,76 1972 Einola et al.,35 1976 Wilkinson,112 1977 Bo stman et al.,12 1983 Levack et al.,64 1985 Jakobsen et al.,56 1985 Totals
10 3 19 17 77 9 135 (37%) 0 14 8 2 8 32 (23%) 14 0 0 3 6 7 0 20 12 62 (28%)
18 18 42 21 20 10 129 (36%) 1 28 15 1 22 67 (49%) 25 5 1 15 18 12 3 7 10 96 (44%)
7 45 14 10 10 11 97 (27%) 2 26 5 1 5 39 (28%) 5 8 4 8 4 12 7 7 6 61 (28%)
3 68 28 4 35 138
Partial Patellectomy Partial patellectomy may give functional results comparable to those of open reduction and internal xation, but comparison is difcult because the fracture patterns treated by these techniques are different.12, 13, 64, 68, 101 Sutton and co-workers showed that the only decit with partial excision of at least one third of the patella is an stman and as18 loss of motion.99 In studies by Bo sociates, Bostro m, Mishra, Nummi, and Seligo, a nearly normal outcome occurred when large fragments of patella were retained and articular congruity was maintained.12, 13, 76, 82, 92 Small fragments without soft tissue, sagittally split fragments, and those missing cartilage were excised. These authors found that saving these fragments did not improve function and even compromised it. Retention of one or two large fragments, however, improved quadriceps function.12, 13, 41, 58, 64, 101, 109 Hung and colleagues reported the results of a 25-month follow-up in a retrospective series of patients in which radiographic changes consistent with post-traumatic arthritis developed in 55% after partial patellectomy and tension band repair.53 However, most of these patients were asymptomatic within that time frame. Total Patellectomy Total patellectomy has yielded varying degrees of success. Before the 1970s, poor reconstructive results justied total patellectomy.16, 31, 40, 44, 45, 50 Investigators compared operative repair with a single cerclage wire and total excision. Although many stated that good clinical results were expected, more recent studies have questioned this conclusion11, 13, 64, 89 (see Table 545). Sutton and co-workers evaluated quadriceps strength, activities of daily living, and functional ability in patients who had undergone either partial or total patellectomy.99 The opposite normal knee was the control. Both groups had an average loss of 18 range of motion. A 49% reduction in strength of the extensor mechanism was present in the total-excision group. This reduction in strength was the result of loss of the lever arm produced by loss of the patella. Instability was greater in this group, with the patellectomized knee losing almost 50% of excursion in stance-phase exion. This loss was a result of the patellar tendon sinking into the intercondylar notch. Clinically, this
44 13 5 26 28 31 10 34 28 219
reporting this technique are few. Analysis of combined data shows tension band wiring to be superior to simple cerclage wiring clinically. In addition, Weber and colleagues showed the superiority of tension band wiring biomechanically108 (see Table 526). Modied wiring techniques can also be effective. In Lotke and Eckers report on LAB/C wiring, 16 cases were presented; 13 (81%) had excellent results.68
TABLE 546
Comparison of Anterior Tension Band vs. Cerclage Wiring
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Results of Anterior Tension Band Results of Cerclage Wiring Excellent 6 19 2 10 59 3 99 (35%) Good 6 42 5 14 15 18 100 (35%) Poor 3 14 9 7 7 45 85 (30%)
Author Bo stman et al.12 Bostro m13 Levack et al.64 Seligo92 Ma et al.69 Nummi82 Totals
No. Patients 29 75 30 31 81 66 312
Excellent 9 7 16 (57%)
Good 3 5 8 (29%)
Poor 2 2 4 (14%)
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
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instability was manifested as insufciency and inability to support the loaded knee in stair climbing. Biomechanical studies on cadaver knees performed by Watkins and associates, Wendt and Johnson, and others all showed that total patellectomy resulted in loss of tibial torque and, therefore, strength.42, 58, 105, 109 Srensen noted that the quadriceps did not improve in strength after patellectomy.96 All patients complained of frequent giving way and difculty running and walking down stairs. He concluded that none of his operative reconstructions would have fared better with total excision of the patella and thus justied attempts at salvage. Wilkinson evaluated 31 patients 4.5 to 13 years after total excision.112 In this study, less than a fourth of the patients had an excellent result. He also noted that maximal recovery took up to 3 years. Einola and colleagues were able to monitor 28 patients for an average of 7.5 years after total excision.35 Good results were seen in only six patients. The predominant complaint was weakness and pain on movement and exertion. The most common nding was quadriceps atrophy. Quadriceps power was within 75% of the normal knee in only seven cases. He concluded that saving as much patella as possible was advisable. Scott reported that only 6% (4/71) of patients were happy with their long-term outcome after patellectomy.89 Ninety percent had aching in the joint, and 60% complained of weakness. Quadriceps wasting was a constant nding. The present recommendations are to therefore retain as much patella as possible.1113, 33, 54, 64, 79, 100, 101 Total patellectomy is reserved for fractures that are so comminuted that repair is futile. This plan will offer the patient the best possible knee function for the longest period. How much patella should be saved? No denitive answer exists. It is our opinion that as little as 25% of the patella (i.e., one quadrant) may be retained with a subsequently good outcome. We have never found a patella so comminuted that one fragment could not be salvaged with repair. If no articular congruity exists, however, excision is the only option.
Breakage of Wires, Loss of Fixation, and Refracture

After osteosynthesis, especially with early motion, the tension band may break, but it is unusual for such breakage to occur before healing of the patella. If the fracture is healed, the wire, pins, or screws may be removed if they cause symptoms. Loss of xation during the healing phase will require revision if the fragments separate more than 3 to 4 mm or if the articular surface has an incongruity greater than 3 mm. Before returning to the operating room, a radiograph should be obtained in full extension. If reduction has improved, the patient may benet from 6 weeks of extension splinting. Usually, however, isometric exercises will continue to separate the fragments, and unless the patient refuses, revision should be undertaken. Refracture should be treated as a fresh fracture according to the principles previously described (i.e., nondisplaced fractures are treated nonoperatively and displaced fractures are treated operatively).
Delayed Union and Malunion

Delayed union, once a routine result, is extremely uncommon. If identied, a period of decreased motion is begun because the fracture will often spontaneously unite. Weber and Cech could nd only three cases of patellar pseudarthrosis in their large series of nonunions.107 All healed after revision surgery performed with established fracture xation methods. If it is an old nonunion with 4 to 5 inches of separation, reconstruction should be attempted. Quadriceps shortening will make this repair difcult, and formal quadricepsplasty may be required. Care must be taken to obtain the correct length or disability will continue. If chondromalacia exists, consideration should be given to performing a total patellectomy and fascial reconstruction according to the method of Gallie and Lemesurier.39
Loss of Knee Motion COMPLICATIONS Infection

Supercial wound infections should be treated by standard protocol based on the degree of soft tissue involvement. Osteomyelitis is aggressively treated with resection of all sequestra and dead tissue. Irrigation and de bridement of the knee must be repeated every 48 to 72 hours until the joint is free of necrotic tissue to prevent septic arthritis. Daily bedside aspiration is not indicated. The patient should receive 6 weeks of culture-specic intravenous antibiotics. Once the deep bone infection is under control, an attempt should be made to salvage any remaining patella by individualized and modied wiring techniques. If salvage is not possible, total patellectomy may be required. zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The advent of tension band wiring has permitted early range of motion, and functional range of motion can be expected in most cases. If exion is still decreased several months postoperatively, intensive physiotherapy is begun. If such physiotherapy does not sufce, manipulation under anesthesia should be contemplated. Care must be exercised in patients requiring manipulation who have had patellectomies because rupture of the repair may occur. A report has been published of a boutonnie ` re deformity after manipulation of a longitudinally repaired extensor retinaculum.81 If gentle manipulation is unsuccessful, consideration is given to arthroscopic lysis of intra-articular adhesions. Quadricepsplasty is performed only in exceptional cases, usually when no improvement is seen after 9 to 12 months. This situation is most often the case after concomitant injury to the distal end of the femur has resulted in binding down of the quadriceps mechanism.
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Occasionally after total patellectomy, the extensor mechanism is too long, which may result in loss of full extension. The patient has a sensation of instability and giving way.96 In this rare situation, consideration is given to a Maquet procedure to bring the patellar tendon forward and increase its mechanical advantage. This technique has been described by Kaufer in excellent biomechanical studies.58 Reports of clinical results of the Maquet procedure for this purpose are nonexistent. We would caution against using too large a bone block because of subsequent skin breakdown and pain. Other authors suggest reeng the extensor mechanism, but this maneuver runs the risk of rerupture.93
Quadriceps Rupture
Rupture of the quadriceps occurs primarily in the rectus tendon, usually 0 to 2 cm from the superior pole of the patella.90, 95 The diagnosis is often missed if the patient has little pain or effusion.84 Physical examination will reveal a palpable defect proximal to the superior pole of the patella.84 In addition, extension against gravity must be assessed. If the quadriceps tendon has a palpable defect but active, full extension is maintained, the tear is incomplete. Such a partial tear does not require operative repair.90 If the ability to extend the knee is completely lost, both the tendon and the retinaculum are torn. The patient will have difculty climbing stairs, and the knee will buckle with ambulation.84 Operative repair is required.95 Furthermore, if a complete quadriceps rupture is not treated acutely, the quadriceps may ride as far as 5 cm proximally on the femur and then bind down.90 For this reason, repair should be done as quickly as possible. ACUTE RUPTURES Most authors agree that an end-to-end repair produces excellent results in acute quadriceps tendon ruptures.62, 77, 94, 95, 102 In Miskew and co-workers series, 90% of their patients had an excellent outcome.77 Similarly, Larsen and Lund considered their results in 15 of 18 a and associcases (83%) to be excellent,62 and Vainionpa ates had only 1 failure in 12 cases.102 The largest series in the literature is that of Siwek and Rao, who reported 36 cases of rupture. They found that all 30 patients with an immediate end-to-end repair had excellent or good results with knee range of motion of 0 to 120.94 Complicating primary end-to-end repairs is the difculty in neutralizing forces across the repair. A review of the literature revealed only ve cases in which a stress-relieving wire was used to protect this repair.62, 94, 97, 102 Several authors reported on the use of a 5-mm Dacron graft to protect the primary repair.66, 77 Levy and colleagues used this technique and permitted early motion without the use of a cast postoperatively, but weight bearing was delayed for 6 weeks.66 Most published series used a local reinforcement ap as suggested by Scuderi, followed by 6 weeks in an extension cast.62, 84, 90, 94, 95, 102 Scuderi Repair In the Scuderi repair (Fig. 5427), the edges of the torn quadriceps are freshened and then pulled together so that a slightly overlapping repair is performed. A distally based, partial-thickness triangular ap of quadriceps tendon is then turned down over the suture line to protect the repair. This ap is an isosceles triangle, 3 inches along each side and 2 inches at the base. Alternatively, a variation involving the middle third of the patellar tendon may be used.24 In this case, the tendon is freed distally, folded proximally, and sewn down. After such repairs, immobilization in a cylinder cast for 6 weeks is advised. Haas and Callaway described a technique for repair of a ruptured quadriceps tendon.43 A midline incision is made, with dissection carried down to the level of the patella and
Osteoarthritis and Patellar Enlargement

Although Bruce and Walmsley18 and Cohn27 showed that osteoarthritis occurred in rabbits after patellectomy, this complication has never been borne out in long-term studies of postpatellectomy human knees.1, 13, 19, 35, 56, 76, 99, 112 In addition, articular incongruity causing osteoarthritis has not been reported in long-term studies.13, 96 Two situations have been demonstrated to increase the incidence of osteoarthritis. Patellar enlargement, a result of exuberant bone formation during the healing of comminuted fractures, has been unequivocally shown to cause patellofemoral arthritis. Total patellectomy should be entertained if such enlargement has developed. The second situation that will cause osteoarthritis is posterior rotation of the distal pole of the patella after reattachment of the patellar ligament in too anterior a position in distal pole patellectomy.33, 92 Care must be taken during repair to avoid such reattachment (see the section Partial Patellectomy and Fig. 5224C).
Tendon Rupture after Total Patellectomy

Rarely, the extensor mechanism will rupture after total patellectomy, usually at the proximal edge of the patellar tendon.36 This rupture should be repaired by the variety of techniques suggested in the following section.
EXTENSOR MECHANISM INJURIES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz A patient with post-traumatic loss of knee extension and negative results on radiographs should be suspected of having a quadriceps or a patellar tendon rupture. Rupture of the extensor mechanism appears to be age specic. Most quadriceps ruptures occur in patients older than 40 years, and most patellar tendon ruptures occur in patients younger than 40.94 The tendon may rupture from a tension tear, direct sharp or blunt trauma, metabolic abnormalities, collagen disease, repeated microtrauma, or repeated adrenocorticoid injections.77 In elderly patients, fatty degeneration and tendon scarring are the predisposing causes.90
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Print Graphic
Presentation
FIGURE 5427. Scuderi repair of a ruptured quadriceps tendon. A, The defect is exposed through a midline longitudinal incision. B, Fasciocutaneous aps are developed to reveal the defect. C, Interrupted nonabsorbable stout mattress sutures repair the tendon. These sutures may be directed to the patella centrally. D, An inverted, partial-thickness, distally based, V-shaped ap is used to reinforce the repair. (AD, Redrawn from Scuderi, C. Am J Surg 95:626635, 1958.)
tendon. Hematoma and brous debris are excised without removing an excessive amount of tendon. Three heavy nonabsorbable sutures are passed through the proximal tendon remnant in a Kessler-type stitch. A transverse trough is created in the proximal pole of the patella with a bur. Care must be taken to prevent placing the trough too
anterior to avoid subsequent tilting of the patella. Three longitudinal holes are drilled in the patella, and the sutures are passed through these tunnels and tied distally at the inferior pole of the patella. The retinaculum is repaired primarily with absorbable suture, and the leg is immobilized in full extension for 6 weeks (Fig. 5428).43
Print Graphic
Presentation
FIGURE 5428. Three heavy nonabsorbable sutures are passed through the proximal tendon remnant in a Kessler-type stitch. Three longitudinal drill holes are created in the patella, and the sutures are passed through these tunnels and tied distally at the inferior pole of the patella. (From Haas, S.B.; Callaway, H. Orthop Clin North Am 23:687695, 1992.)
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CHRONIC RUPTURES In patients with quadriceps ruptures older than 2 weeks, muscle retraction of as much as 5 cm with adherence of the quadriceps muscle to the femur is common.90, 94 The delay in treatment may require quadriceps lengthening, tendon or muscle transfers, or a combination of these methods as discussed in the sections that follow.24, 49, 83, 90, 94 Codivilla V-Y Lengthening For a Codivilla V-Y lengthening procedure (Fig. 5429), a standard midline or lateral incision is made, and all soft tissue adhesions are freed from the quadriceps tendon and muscle. The quadriceps muscle is then freed from the femur, with elevators used if necessary to break all scars. The knee should be in extension with a roll under the heel. The old tear is located, and the ends are freshened. The gap is then measured. A full-thickness, distally based, V-shaped incision is made in the quadriceps tendon. Partial-thickness incisions in the vasti may be necessary to aid in stretching. The original quadriceps defect is then repaired. The V may be turned distally to reinforce the repair as in the method of Scuderi. The proximal defect in the quadriceps tendon is then repaired in a side-to-side manner. A cylinder cast is worn for 6 weeks. Myoplasties and Tendon Transfers When quadriceps retraction and adhesions make standard techniques impossible (as in neglected tears), neither the Scuderi technique nor Codivilla V-Y lengthening may be sufcient. In these complex, long-standing cases, an aponeurotic vastus lateralis strip 2 to 5 cm thick may be used. This strip is left proximally based and swung medially. The remaining vastus lateralis and medialis are then closed around it. The patient is kept in a cylinder cast for 6 weeks.83 In cases in which large defects occur, as in major wounds of the anterior aspect of the knee, no quadriceps, patella, or patellar ligament may exist. The sartorius can be used as a rotational ap to cover the area.49 The tendon is freed distally and inserted into the tibial tubercle region.
The advantage of this transfer over a semitendinosus transfer is muscle bulk. Postoperatively, the patient is placed in a cylinder cast for 6 weeks. POSTOPERATIVE REHABILITATION In all cases, the patient is able to walk in a cylinder cast during the rst several weeks postoperatively. Isometric quadriceps-setting exercises are not begun until after the cast is removed (6 weeks). Controlled motion to 45, isometric exercises, and straight leg raises are then begun. One month later, range of motion may be increased to 115, and strengthening exercises are begun. The third month should be spent returning the limb to its preinjury status. The patient should expect that recovery will require at least 6 months.
Patellar Tendon Ruptures

ACUTE RUPTURES Patellar tendon rupture occurs most frequently in athletic patients younger than 40 years; however, it can be observed in patients with systemic illness in which the collagen structure is weakened.71 This condition is commonly seen in patients with systemic lupus erythematosus, rheumatoid arthritis, chronic renal failure, diabetes mellitus, and long-term corticosteroid therapy.106 In a younger, athletic patient, the injury is thought to result from cumulative microtrauma because the patella more often fractures when a healthy tendon undergoes acute overload.60 This theory is supported pathologically. Kannus and Jozsa reported that 97% of 53 patellar tendon ruptures demonstrated degenerative changes, including hypoxic tendinopathy, mucoid degeneration, tendolipomatosis, and calcifying tendinopathy.57 The patellar tendon ruptures most frequently at its proximal insertion site rather than midsubstance. This tendency has been hypothesized to result from a relative decrease in collagen ber stiffness observed at the insertion sites of the tendon and from the greater tensile strain
FIGURE 5429. The Codivilla V-Y plasty repair for neglected ruptures of the quadriceps tendon. A, A distally based V of quadriceps tendon is developed proximal to the defect. B, As much of the defect as possible is closed with nonabsorbable stout mattress sutures medially and laterally in the retinacula. C, The ap is turned distally and sutured in place over the defect in the quadriceps tendon to restore central continuity. As much as possible of the defect left by the V is closed in a proximal-to-distal direction.
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Presentation
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occurring in the insertion bers than in the midsubstance bers.114 The history of the injury almost always consists of an eccentric quadriceps contraction against the full body weight. Physical examination of an acute rupture reveals a hemarthrosis with an inability to extend the knee actively or maintain a passively extended knee against gravity. A palpable defect in the tendon itself may be appreciated. In the case of an isolated tendon rupture with an intact retinaculum, active extension may be possible, but an extension lag will be present.71 Over time, a neglected tear will permit knee extension with subsequent contracture of the quadriceps tendon and patella. Radiographically, patella alta will be apparent on a plain radiograph. Ultrasonography and MRI have been successful in identifying acute and chronic rupture of the patellar tendon.29, 115 Immediate repair, combined with a wire to relieve stress from the suture line, is standard treatment of these injuries.62, 72, 79, 94, 106 Although many authors place their patients in a cylinder cast for 6 weeks postoperatively, the original purpose of the pull-out wire as described by McLaughlin and Francis72 was to allow early knee motion.79, 106 Repair For repair of acute ruptures, a toe-to-groin Esmarch bandage is applied and then the proximal end is pulled down. This technique will help bring the patella down. The tourniquet is inated and the bandage is removed to prevent the quadriceps from getting stuck under the tourniquet.23 A standard midline longitudinal incision is made. The tendon ends are freshened, and if bony avulsion has occurred, several holes should be drilled in bone to allow for strong xation. Care should be taken when determining the length of the repair because studies have shown patellofemoral incongruence to occur when the length is incorrect.62 An 18-gauge wire should be placed closely along the medial, superior, and lateral borders of the patella. It may be attached to the tibia (posterior and slightly distal to the tubercle) through a drill hole or with a bolt or a screw (see Fig. 5425). In the latter two cases, a pull-out wire may be added for removal of the 18-gauge wire in the ofce. After the wire has been tightened, an end-to-end repair with heavy suture is performed. The tendon may be repaired through three bony tunnels in the patella with a modied Bunnell-type suture in the tendinous portion. This construct should be reinforced by transosseous cerclage as well.71 The torn retinaculum should also be repaired. The repair is then tested in exion in the operating room, and any loose sutures are tightened. Standard closure over a suction drain is then performed. Several authors have used fabric material (e.g., Dacron graft or Mersilene tape) for repair, reinforcement, or both.38, 62, 65, 66, 77 Levin presented a case with a 5-cm gap.65 Holes were drilled in the patella and tibia, and Dacron vascular graft was used to reconstruct the tendon, with the graft pulled tight for tension. At 15 months, the repair was still good. Levy and colleagues used Dacron in place of wire with good results, thus obviating the need for
subsequent wire removal.66 Miskew and co-workers used 5-mm Mersilene tape as suture to augment the primary repair.77 If the tendon was avulsed from the proximal part of the patella, holes were drilled into the distal aspect. If the tendon was avulsed distally, holes were drilled into the tibia. They reported 10 cases with good results. Postoperatively, isometric hamstring and quadriceps exercises are begun immediately, as is toe-touch weight bearing. At 2 to 3 weeks, active exion and passive extension are initiated, with active extension started at 3 to 4 weeks. At 6 weeks, the patient should be at full weight bearing. Resistance exercises are introduced at 6 to 8 weeks. Competitive sports should be delayed for 4 to 6 months until 90% of isokinetic strength has been regained.71
CHRONIC RUPTURES Reconstructions months and years later prove unsatisfactory because of difculty overcoming contracture and adhesions. Similar to repair of the quadriceps mechanism, reconstruction of tendon ruptures can be separated into quadriceps lengthening, tendon transfers, the use of fascial or synthetic grafts, or a combination of these techniques. Tendon Transfers For late repairs with large patellar tendon defects, the quadriceps may need to be released from the femur to translate the patella distally (Fig. 5430). For severe long-standing patella alta, extensor mechanism traction is applied with a Steinmann pin or K-wire placed transversely through the patella and 5 lb of skeletal traction for several days to several weeks. Passive range-of-motion exercises are done during the traction phase to improve postoperative knee motion.94 When lateral radiographs demonstrate the patella to be correctly positioned, the reconstruction can be accomplished surgically. Two holes are drilled into the patella and one oblique hole in the tibia. The semitendinosus and gracilis tendons are released proximally. The tendons are routed through the tibial hole; then each tendon is passed into the patella from opposite sides. A pull-out wire is cerclaged around the proximal part of the patella or through a transverse bony tunnel and passed through the tibial tubercle region, the primary repair is completed, and the wire is tightened. A cylinder cast is worn for 6 weeks. Isometric exercises are initiated immediately and active range-of-motion and resistance exercises 6 weeks after cast removal.34, 59 A second newly described method for reconstruction of the extensor mechanism involves the use of a rotational medial or lateral gastrocnemius ap.63 The muscle belly can be used for soft tissue coverage, and the tendon can be used to replace the patellar tendon or even larger portions of the extensor mechanism that may have been lost. The proximal portion of the Achilles tendon is sutured to the patellar or quadriceps tendon remnant, and the distal portion is sutured to the patellar tendon remnant. A bony block can even be harvested from the Achilles insertion for patients with massive loss of the extensor mechanism. A split-thickness skin graft is used to cover the muscle ap.
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Divide
Print Graphic Gracilis
Semitendinosus Gracilis
Semitendinosus
Presentation Fixation wire
Twisted fixation wire
FIGURE 5430. Late reconstruction of the patellar ligament with the semitendinosus and gracilis tendons (after the method of Ecker). A, The patella is brought down with traction, and the semitendinosus and gracilis tendons are cut as far proximally as possible. B, These tendons are routed as shown through drill holes in the patella. Also note the use of a tension band wire through both the patella and tibia. C, The tendons are sutured distally, and the wire is secured with appropriate tension. (AC, Modied from Ecker, M.L.; et al. J Bone Joint Surg Am 61:884886, 1979.)
Synthetic Grafts Mersilene tape, Dacron graft, and carbon ber materials have been advocated in the severe situation in which local tissues are not available or are of inadequate quality for substantial repair. More commonly, these materials have been used to augment primary repair or tendon transfers.36, 47, 94 OUTCOMES Clinical outcome appears to correlate with the interval between injury and repair. Siwek and Rao reported 80% excellent and 16% good outcomes in patients treated with primary repair within 7 days of injury. The results declined in patients treated 2 weeks or more after injury. This group had only 33% excellent and 50% good results.94 Larsen and Lund reported 70% excellent and good results in 10 patients treated acutely for patellar tendon rupture.62 The results of Hsu and colleagues were encouraging as well.51 Fifty-seven percent and 29% of their 35 patients treated acutely were rated as excellent and good, respectively.51 Overall, the literature supports acute primary repair supplemented with a stress-relieving wire or nonabsorbable suture as the treatment of choice for rupture of the patellar tendon.
Acute Patellar Dislocations

Although recurrent patellar subluxations are a common cause of knee injury, an acute traumatic patellar dislocation is a relatively rare event. These injuries are most commonly manifested as lateral dislocations, but intra-articular and superior dislocations may occasionally occur. LATERAL DISLOCATIONS The mechanism of lateral patellar dislocation is forced internal rotation of the femur on an externally rotated and planted tibia with the knee exed. Tension in the quadriceps pulls the patella laterally. If the medial retinaculum tears, the patella dislocates over the edge of the lateral
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Tibial Tubercle Avulsions

Repair of tibial tubercle avulsions, a variant of patellar tendon avulsions, should incorporate bony reconstruction with 3.5- or 4.5-mm lag screws and a stress-relieving wire, if possible, to guarantee accurate tendon length and patellar tracking. Anchorage may be improved with a small plate (Fig. 5431). If the tubercle is comminuted and the fragments are too small for screw xation, holes should be drilled distal and posterior to the avulsion site in the tibia. Fixation should then proceed as with tendon avulsions.
Presentation
FIGURE 5431. Repair of an avulsion fracture of the tibial tubercle can be made more secure with a small plate. The plate acts as a tension band to stabilize the head of a lag screw through the avulsed fragment.
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femoral condyle. Such dislocation results in shearing between the medial inferior edge of the patella and the lateral femoral condyle.78 Osteochondral fractures in these areas strongly suggest a lateral patellar dislocation, with the former having an incidence of 5%.78, 85 Diagnosis A patient with an unreduced lateral patellar dislocation will have a large lateral mass, hemarthrosis, medial retinacular pain, and an inability to ex the knee. An attempt should be made to reduce the patella on evaluation to decrease the patients discomfort. Standard radiographs are then taken, including a tangential view to rule out osteochondral fractures.78 If the bony portion of the osteochondral fragment is small, the lesion may be missed on radiographs. For this reason, as well as for comfort, arthrocentesis is performed. If blood from the hemarthrosis contains fat globules on aspiration, an osteochondral fracture should be considered.4, 78, 85 If the patella is already reduced, diagnosis of an acute traumatic dislocation will be made more difcult inasmuch as medial joint pain and an effusion may be the only ndings. This diagnosis is important to make because osteochondral fractures must be ruled out. Common symptoms associated with osteochondral fragments include blocking, locking, giving way, and tenderness to palpation on the medial side of the knee that is not meniscal or ligamentous in origin.78 Treatment Treatment of an acute lateral patellar dislocation consists of reduction and extension casting for 3 to 6 weeks. Coeld and Bryan evaluated 50 patients treated conservatively in extension casts with a follow-up period of 5 years or until operative reconstruction was needed. Patient age, sex, the mechanism of injury, and the length of time spent in a cast had no effect on outcome.26 Although a third of their patients were considered treatment failures, they concluded that initial surgery for acute patellar dislocations was not warranted except in cases with displaced intraarticular fractures exclusive of the medial border.26 We agree with these recommendations. Larsen and Lauridsen studied the incidence of redislocation after conservative treatment of 79 acute patellar dislocations.61 Treatment included a cylinder cast in 22 patients and an elastic wrap in 57 patients. The clinical results and the tendency to redislocate were independent of the treatment method. The risk of redislocation was statistically signicantly less in patients older than 20 years at the time of the rst episode of dislocation. The authors stressed initial conservative treatment and quadricepsstrengthening exercises, with realignment procedures considered only if the dislocation recurred. In Morschers series of 34 osteochondral fractures of the knee, the fracture was caused by an acute lateral dislocation of the patella in 21 of the 34 fractures (62%).78 Sixteen were found on the medial edge of the patella, 1 on the lateral femoral condyle, and 4 on both surfaces. Operative treatment was chosen in all cases. Currently, we recommend conservative treatment with a cast or brace in extension for ambulation for 3 weeks. Flexion can then be progressively increased as the patients
comfort permits, usually over another 3 weeks. If an osteochondral fragment is suspected, diagnostic arthroscopy is recommended, and if a fragment is present, operative repair or excision is warranted. INTRA-ARTICULAR DISLOCATIONS Though rare, intra-articular or horizontal dislocations of the patella usually occur in adolescent boys.80 In these dislocations, the patella is violently ripped off the quadriceps tendon and rotated around its horizontal axis such that the proximal part of the patella becomes stuck within the intercondylar notch. The knee is slightly exed, and the quadriceps tendon is intact.15, 37, 80, 98 Treatment consists of closed manipulation under anesthesia and extension casting for 6 weeks with quadriceps exercises. Healing is usually uneventful.15, 37, 80, 98, 113 SUPERIOR DISLOCATIONS Four cases of superior patella dislocation exist in the literature.46, 113 The injury occurs in an older population and results from hyperextension of the knee with the patella locked on a femoral osteophyte. Gentle manipulation in the emergency room is all that is usually required.46, 113
REFERENCES 1. Andrews, J.R.; Hughston, J.C. Treatment of patellar fractures by partial patellectomy. South Med J 70:809813, 1977. 2. Apple, J.S.; Martinez, S.; Allen, N.B.; et al. Occult fractures of the knee: Tomographic evaluation. Radiology 148:383387, 1983. 3. Arnoczky, S.P. Blood supply to the anterior cruciate ligament and supporting structures. Orthop Clin North Am 16:1528, 1985. 4. Ashby, M.E.; Shields, C.L.; Karmy, J.R. Diagnosis of osteochondral fractures in acute traumatic patellar-dislocations using air arthrography. J Trauma 15:10321033, 1975. 5. Baumgartl, F . Das Kniegelenk. Berlin, Springer-Verlag, 1964. 6. Berg, E.E. Management of patella fractures associated with central third bonepatella tendonbone autograft ACL reconstructions. Arthroscopy 12:756759, 1996. 7. Berg, E.E.B. Extensile exposure of comminuted patella fractures using a tibial tubercle osteotomy: Results of a new technique. J Orthop Trauma 12:351355, 1998. 8. Berg, E.E.B. Open reduction internal xation of displaced transverse patella fractures with gure-eight wiring through parallel cannulated compression screws. J Orthop Trauma 11:573576, 1997. 9. Black, J.K.; Conners, J.J. Vertical fractures of the patella. South Med J 62:7677, 1969. 10. Blodgett, W.E.; Fairchild, R.D. Fractures of the patella. JAMA 20:21212125, 1936. 11. Bo stman, O.; Kiviluoto, O.; Nirhamo, J. Comminuted displaced fractures of the patella. Injury 13:196202, 1981. 12. Bo stman, O.; Kiviluoto, O.; Santavirta, S.; et al. Fractures of the patella treated by operation. Arch Orthop Trauma Surg 102:7881, 1983. 13. Bostro m, A. Fracture of the patella. Acta Orthop Scand Suppl 143:180, 1972. 14. Bostro m, A. Longitudinal fractures of the patella. Reconstr Surg Traumatol 14:136146, 1974. 15. Brady, T.A.; Russell, D. Interarticular horizontal dislocation of the patella. J Bone Joint Surg Am 47:13931396, 1965. 16. Brooke, R. The treatment of fractured patella by excision. A study of morphology and function. Br J Surg 24:733747, 1936. 17. Brownstein, B.; Bronner, S. Patella fractures associated with accelerated ACL rehabilitation in patients with autogenous patella tendon reconstructions. J Orthop Sports Phys Ther 26:168172, 1997.
CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries 18. Bruce, J.; Walmsley, R. Excision of the patella. J Bone Joint Surg 24:311325, 1942. 19. Cargill, A.O. The long-term effect on the tibiofemoral compartment of the knee joint of comminuted fractures of the patella. Injury 6:309312, 1975. 20. Carpenter, J.E.; Kasman, R.A.; Patel, N.; et al. Biomechanical evaluation of current patella fracture xation techniques. J Orthop Trauma 11:351356, 1997. 21. Carson, W.G.; James, S.L.; Larson, R.L.; et al. Patellofemoral disorders: Physical and radiographic evaluation, part II: Radiographic examination. Clin Orthop 185:178186, 1984. 22. Catalano, J.B.; Iannacone, W.M.; Marczyk, S.; et al. Open fractures of the patella: Long-term functional outcome. J Trauma 39:439444, 1995. 23. Chari, P.R.; Kishore, R.G.; Satyanarayana, M.V. Repair of the quadriceps apparatus following patellectomy in recent fractures of the patella: A new technique with results. Aust N Z J Surg 48:99103, 1978. 24. Chekofsky, K.M.; Spero, C.R.; Scott, W.N. A method of repair of late quadriceps rupture. Clin Orthop 147:190191, 1980. 25. Chiroff, R.T. A new technique for the treatment of comminuted, transverse fractures of the patella. Surg Gynecol Obstet 145:909 912, 1977. 26. Coeld, R.H.; Bryan, R.S. Acute dislocation of the patella: Results of conservative treatment. J Trauma 17:526531, 1977. 27. Cohn, B.N.E. Total and partial patellectomy. Surg Gynecol Obstet 79:526536, 1944. 28. Crock, H.V. The arterial supply and venous drainage of the bones of the human knee joint. Anat Rec 144:199218, 1962. 29. Davies, S.G.; Baudouin, C.J.; King, J.D.; et al. Ultrasound, computed tomography and magnetic resonance imaging in patellar tendinitis. Clin Radiol 43:5256, 1991. 30. Depalma, A.F .; Flynn, J.J. Joint changes following experimental partial and total patellectomy. J Bone Joint Surg Am 40:395413, 1958. 31. Dobbie, R.P.; Ryerson, S. The treatment of fractured patella by excision. Am J Surg 55:339373, 1942. 32. Dowd, G.S.E. Marginal fractures of the patella. Injury 14:287291, 1982. 33. Duthie, H.L.; Hutchinson, J.R. The results of partial and total excision of the patella. J Bone Joint Surg Br 40:7581, 1958. 34. Ecker, M.L.; Lotke, P.A.; Glazer, R.M. Late reconstruction of the patellar tendon. J Bone Joint Surg Am 61:884886, 1979. 35. Einola, S.; Aho, A.J.; Kallio, P. Patellectomy after fracture. Acta Orthop Scand 47:441447, 1976. 36. Evans, P.D.; Pritchard, G.A.; Jenkins, D.H.R. Carbon bre used in the late reconstruction of rupture of the extensor mechanism of the knee. Injury 18:5760, 1987. 37. Feneley, R.C.L. Intra-articular dislocation of the patella. J Bone Joint Surg Br 50:653655, 1968. 38. Frazier, C.H.; Clark, E.M. Major tendon repairs with Dacron vascular graft suture. Orthopedics 3:323325, 1980. 39. Gallie, W.E.; Lemesurier, A.B. The late repair of fractures of the patella and of rupture of the ligamentum patellae and quadriceps tendon. J Bone Joint Surg 9:4854, 1927. 40. Geckler, E.O.; Queranta, A.V. Patellectomy for degenerative arthritis of the kneelate results. J Bone Joint Surg Am 44:1109, 1962. 41. Goodfellow, J.; Hungerford, D.S.; Zindel, M. Patello-femoral joint mechanics and pathology: 1. Functional anatomy of the patellofemoral joint. J Bone Joint Surg Br 58:287299, 1976. 42. Griswold, A.S. Fractures of the patella. Clin Orthop 4:4456, 1954. 43. Haas, S.B.; Callaway, H. Disruptions of the extensor mechanism. Orthop Clin North Am 23:687695, 1992. 44. Haggart, G.E. Surgical treatment of degenerative arthritis of the knee joint. J Bone Joint Surg 22:717, 1940. 45. Halliburton, R.A.; Sullivan, C.R. The patella in degenerative joint diseases. Arch Surg 77:677683, 1958. 46. Hanspal, R.S. Superior dislocation of the patella. Injury 16:487 488, 1985. 47. Haxton, H. The function of the patella and the effects of its excision. Surg Gynecol Obstet 80:389395, 1945. 48. Heineck, A.P. The modern operative treatment of fractures of the patella. Surg Gynecol Obstet 9:177248, 1909. 49. Hess, P.; Reinders, J. Transposition of the sartorius muscle for reconstruction of the extensor apparatus of the knee. J Trauma 26:9091, 1986.
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50. Horwitz, T.; Lambert, R.C. Patellectomy in the military service. A report of 19 cases. Surg Gynecol Obstet 82:423426, 1946. 51. Hsu, K.Y.; Wand, K.C.; Ho, W.P.; et al. Traumatic patellar tendon ruptures: A follow-up study of primary repair and a neutralization wire. J Trauma 36:658660, 1994. 52. Huberti, H.H.; Hayes, W.C.; Stone, J.L.; Shybut, G.T. Force ratios in the quadriceps tendon and the ligamentum patellae. J Orthop Res 2:4954, 1984. 53. Hung, L.K.; Lee, S.Y.; Leung, K.S.; et al. Partial patellectomy for patellar fracture: Tension band wiring and early mobilization. J Orthop Trauma 7:252260, 1993. 54. Hung, L.K.; Chan, K.M.; Chow, Y.N.; Leung, P.C. Fractured patella: Operative treatment using the tension band principle. Injury 16:343347, 1985. 55. Insall, J.; Goldberg, V.; Salvati, E. Recurrent dislocation and the high riding patella. Clin Orthop 88:6769, 1972. 56. Jakobsen, J.; Christensen, K.S.; Rasmussen, O.S. Patellectomy a 20-year follow-up. Acta Orthop Scand 56:430432, 1985. 57. Kannus, P.; Jozsa, L. Histopathological changes preceding spontaneous rupture of a tendon: A controlled study of 891 patients. J Bone Joint Surg Am 73:15071525, 1991. 58. Kaufer, H. Mechanical function of the patella. J Bone Joint Surg Am 53:15511560, 1971. 59. Kelikian, H.; Riashi, E.; Gleason, J. Restoration of quadriceps function in neglected tears of the patellar tendon. Surg Gynecol Obstet 104:200204, 1957. 60. Kelly, D.W.; Carter, V.S.; Jobe, F .W., et al. Patellar and quadriceps tendon ruptures: Jumpers knee. Am J Sports Med 12:375380, 1984. 61. Larsen, E.; Lauridsen, F . Conservative treatment of patellar dislocations. Clin Orthop 171:131136, 1982. 62. Larsen, E.; Lund, P.M. Ruptures of the extensor mechanism of the knee joint. Clin Orthop 213:150153, 1986. 63. Leung, K.S.; Yip, K.M.H.; Shen, W.Y.; Leung, P.C. Reconstruction of extensor mechanism after trauma and infection by transposition of the Achilles tendon: Report of technique and four cases. J Orthop Trauma 8:4044, 1994. 64. Levack, B.; Flannagan, J.P.; Hobbs, S. Results of surgical treatment of patellar fractures. J Bone Joint Surg Br 67:416419, 1985. 65. Levin, P. Reconstruction of the patellar tendon using a Dacron graft. Clin Orthop 118:7072, 1976. 66. Levy, M.; Goldstein, J.; Rosner, M. A method of repair for quadriceps tendon or patellar ligament ruptures without cast immobilization. Clin Orthop 218:297301, 1987. 67. Lieb, F .J.; Perry, J. Quadriceps function. J Bone Joint Surg Am 50:15351548, 1968. 68. Lotke, P.A.; Ecker, M.L. Transverse fractures of the patella. Clin Orthop 158:180184, 1981. 69. Ma, Y.Z.; Zheng, Y.F .; Qu, K.F .; et al. Treatment of fractures of the patella with percutaneous suture. Clin Orthop 191:235241, 1984. 70. Macausland, W.R. Total excision of the patella for fracture. Am J Surg 72:510516, 1946. 71. Matava, M.J. Patellar tendon ruptures. J Am Acad Orthop Surg 4:287296, 1996. 72. McLaughlin, H.L.; Francis, K.C. Operative repair of injuries to the quadriceps extensor mechanism. Am J Surg 91:651653, 1956. 73. McMaster, P.E. Fractures of the patella. Clin Orthop 4:2443, 1954. 74. Merchant, A.C.; Mercer, R.L.; Jacobsen, R.H.; Cool, R.T. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am 56:13911396, 1974. 75. Miller, M.D.; Nichols, T.; Butler, C.A. Patella fracture and proximal patellar tendon rupture following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 15:640643, 1999. 76. Mishra, U.S. Late results of patellectomy in fractured patella. Acta Orthop Scand 43:256263, 1972. 77. Miskew, D.B.W.; Pearson, R.L.; Pankovich, A.M. Mersilene strip suture in repair of disruptions of the quadriceps and patellar tendons. J Trauma 20:867872, 1980. 78. Morscher, E. Cartilage-bone lesions of the knee joint following injury. Reconstr Surg Traumatol 12:226, 1971. 79. Mu ller, M.E.; Allgo wer, M.; Schneider, R.; Willinegger, H. Manual of Internal Fixation. Techniques Recommended by the AO Group. Berlin, Springer-Verlag, 1979, pp. 248253. 80. Murakami, Y. Intra-articular dislocation of the patella. Clin Orthop 171:137139, 1982.
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SECTION V Lower Extremity 100. Thompson, J.E.M. Comminuted fractures of the patella. J Bone Joint Surg Am 17:431434, 1935. 101. Thompson, J.E.M. Fracture of the patella treated by removal of the loose fragments and plastic repair of the tendon. Surg Gynecol Obstet 74:860866, 1942. 102. Vainionpa a , S.; Bo stman, O.; Pa tia la , H.; Rokkanen, P. Rupture of the quadriceps tendon. Acta Orthop Scand 56:433435, 1985. 103. Viola, R.; Vianello, R. Three cases of patella fracture in 1,320 anterior cruciate ligament reconstructions with bonepatellar tendonbone autograft. Arthroscopy 15:9397, 1999. 104. Virolainen, H.; Visuri, T.; Kuusela, T. Acute dislocation of the patella: MR ndings. Radiology 189:243246, 1993. 105. Watkins, M.P.; Harris, B.A.; Wender, S.; et al. Effect of patellectomy on the function of the quadriceps and hamstrings. J Bone Joint Surg Am 65:390395, 1983. 106. Webb, L.X.; Toby, E.B. Bilateral rupture of the patella tendon in an otherwise healthy male patient following minor trauma. J Trauma 26:10451048, 1986. 107. Weber, B.G.; Cech, O. Pseudarthrosis. New York, Grune & Stratton, 1976, pp. 224225. 108. Weber, M.J.; Janecki, C.J.; McLeod, P.; et al. Efcacy of various forms of xation of transverse fractures of the patella. J Bone Joint Surg Am 62:215220, 1980. 109. Wendt, P.P.; Johnson, R.P. A study of quadriceps excursion, torque, and the effect of patellectomy on cadaver knees. J Bone Joint Surg Am 67:726732, 1985. 110. West, F .E. End results of patellectomy. J Bone Joint Surg Am 44:10891108, 1962. 111. Wiberg, G. Roentgenographic and anatomic studies on the patellofemoral joint. Acta Orthop Scand 12:319410, 1941. 112. Wilkinson, J. Fracture of the patella treated by total excision. J Bone Joint Surg Br 59:352354, 1977. 113. Wimsatt, M.H.; Carey, E.J. Superior dislocation of the patella. J Trauma 17:7780, 1977. 114. Woo, S.; Maynard, J.; Butler, D.; et al. Ligament, tendon, and joint capsule insertions to bone. In: Woo, S.L.Y.; Buckwalter, J.A., eds. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1988, pp. 133166. 115. Yu, J.S.; Petersilge, C.; Sartoris, D.J.; et al. MR imaging of injuries of the extensor mechanism of the knee. Radiographics 14:541551, 1994.
81. Noble, H.B.; Hajek, M.R. Boutonnie ` re-type deformity of the knee following patellectomy and manipulations. J Bone Joint Surg Am 66:137138, 1984. 82. Nummi, J. Operative treatment of patella fractures. Acta Orthop Scand 42:437438, 1971. 83. Oni, O.O.A.; Ahmad, S.H. The vastus lateralis derived ap for repair of neglected rupture of the quadriceps femoris tendon. Surg Gynecol Obstet 161:385387, 1985. 84. Ramsey, R.H.; Muller, G.E. Quadriceps tendon rupture: A diagnostic trap. Clin Orthop 70:161164, 1970. 85. Rees, D.; Thompson, S.K. Osteochondral fractures of the patella. J R Coll Surg Edinb 30:8890, 1985. 86. Reider, B.; Marshall, J.L.; Koslin, B.; et al. The anterior aspect of the knee joint. J Bone Joint Surg Am 63:351356, 1981. 87. Scapinelli, R. Blood supply of the human patella. J Bone Joint Surg Br 49:563570, 1967. 88. Scilaris, T.A.; Grantham, J.L.; Prayson, M.J.; et al. Biomechanical comparison of xation methods in transverse patella fractures. J Orthop Trauma 12:356359, 1998. 89. Scott, J.C. Fractures of the patella. J Bone Joint Surg Br 31:7681, 1949. 90. Scuderi, C. Ruptures of the quadriceps tendon. Am J Surg 95: 626635, 1958. 91. Sears, F .W.; Zemansky, M.W. University Physics. Reading, MA, Addison-Wesley, 1970, pp. 3031. 92. Seligo, W. Fractures of the patella. Reconstr Surg Traumatol 12:84102, 1971. 93. Shorbe, H.B.; Dobson, C.H. Patellectomy. J Bone Joint Surg Am 40:12811284, 1958. 94. Siwek, C.W.; Rao, J.P. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am 63:932937, 1981. 95. Siwek, K.W.; Rao, J.P. Bilateral simultaneous rupture of the quadriceps tendon. Clin Orthop 131:252254, 1978. 96. Srensen, K.H. The late prognosis after fracture of the patella. Acta Orthop Scand 34:198212, 1964. 97. Stern, R.E.; Harwin, S.F . Spontaneous and simultaneous rupture of both quadriceps tendons. Clin Orthop 147:188189, 1980. 98. Stover, C.N. Interarticular dislocation of the patella. JAMA 200:966, 1967. 99. Sutton, F .S.; Thompson, C.H.; Lipke, J.; Kettlekamp, D.B. The effect of patellectomy on knee function. J Bone Joint Surg Am 58:537540, 1976.

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SECTION V Lower Extremity

Soft Tissue Anatomy

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

EXTENSOR APPARATUS BIOMECHANICS

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SECTION V Lower Extremity

History and Physical Examination

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

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SECTION V Lower Extremity

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

Nose X-ray plate

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SECTION V Lower Extremity TABLE 541

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

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SECTION V Lower Extremity

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

Fractures Associated with BonePatellar TendonBone Autograft

Biomechanics of Patellar Fracture Fixation

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SECTION V Lower Extremity

NONDISPLACED Transverse Stellate Vertical

Partial excision Polar Highly comminuted Highly displaced Total excision

Cylinder cast/cast brace

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

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SECTION V Lower Extremity

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

Treatment of Patella Fractures

c. Polar d. Highly comminuted, highly displaced

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SECTION V Lower Extremity

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION V Lower Extremity

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION V Lower Extremity

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries

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SECTION V Lower Extremity TABLE 543

Clinical Grading Scale

Combined Results of Various Forms of Operative Treatment in the Literature

Fair 97 (27%) 39 (28%) 61 (28%) 197

Total No. 361 138 219 718

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CHAPTER 54 Patella Fractures and Extensor Mechanism Injuries TABLE 545

Results of Operative Repair in Patellar Fractures

10 3 19 17 77 9 135 (37%) 0 14 8 2 8 32 (23%) 14 0 0 3 6 7 0 20 12 62 (28%)