Patella Fractures - Approach To Treatment

Review Article
Patella Fractures: Approach to Treatment
Damayea I. Hargett, MD
Brent R. Sanderson, DO
Milton T.M. Little, MD
ABSTRACT
Patellar fracture morphology varies based on the mechanism of injury.
Most fractures are either a result of direct impact or through an indirect
eccentric extensor contraction injury. Each fracture pattern requires
appropriate preoperative planning and individualization of the fixation
method. Displaced fractures affect the extension apparatus, and
often require surgical fixation. Surgical treatment is recommended
in fractures with any of the following features: articular step-off
. 2 mm, . 3 mm of fracture displacement, open fractures, and
displaced fractures affecting the extensor mechanism. Meticulous
handling of the soft-tissue envelope is of the utmost importance,
given the patella’s tenuous blood supply and limited
soft-tissue envelope. Incongruent articular surface can result in
detrimental long-term effects; therefore, surgical treatment is
directed toward anatomic reduction and fixation. The evolution of
patellar fracture fixation continues to maximize options to balance rigid
fixation with low-profile fixation constructs. Improving functional
outcomes, minimizing soft-tissue irritation, and limiting postoperative
complications are possible by using the therapeutic principles of rigid
anatomical fixation and meticulous soft-tissue handling.
From the Ventura County Medical Center

(Hargett), Ventura, CA, the Community Memorial Anatomy
Health System (Sanderson), Ventura, CA, and
the Cedars-Sinai Medical Center (Little), Los As the largest sesamoid bone in the body, the patella’s primary ossification
Angeles, CA. typically occurs by the age of 5 or 6 years. The patella forms from a single
Little or an immediate family member serves as a ossification center in 97% to 98% of patients, whereas in 2% to 3% of the
paid consultant to DePuy Synthes and Globus
Medical; and serves as a board member, owner, cohort, it develops as a bipartite patella. This usually occurs when the sec-
officer, or committee member of OTA and AO ondary ossific nucleus fails to unite with the primary nucleus. The supero-
North America. Neither of the following authors
nor any immediate family member has received
lateral aspect of the patella is the most common site of the secondary nucleus.
anything of value from or has stock or stock The patella is located anterior to the knee joint with musculotendinous
options held in a commercial company or
insertions of the quadriceps tendon and tensor fascia lata into the ante-
institution related directly or indirectly to the
subject of this article: Hargett and Sanderson. rosuperior margin. The patellar ligament arises from the inferior pole at-
J Am Acad Orthop Surg 2021;29:244-253 taching to the tibial tubercle. The lateral and medial retinacula are formed by
DOI: 10.5435/JAAOS-D-20-00591 the quadriceps aponeurosis, vastus lateralis, iliotibial band, and vastus me-
Copyright 2021 by the American Academy of
dialis, respectively. Posteriorly, the articulating surface is composed of a
Orthopaedic Surgeons. medial facet and larger lateral facet, separated by a median vertical ridge. The
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JAAOS® March 15, 2021, Vol 29, No 6 © American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Damayea I. Hargett, MD, et al
Review Article
medial facet contains a far medial portion known as the Clinical History and Assessment
odd facet, which is in contact with the femoral condyle in A thorough history and physical examination must be
full flexion. The thickest articular cartilage in the body done for patients presenting with anterior knee pain.
covers this patellar articular surface. The ligamentous High-energy dashboard knee injuries should be evalu-
and tendinous insertions maintain the patellar articula- ated for associated femoral neck fractures, posterior wall
tion within the femoral trochlea while enhancing the acetabular fractures, and hip dislocations. Athletes pre-
biomechanical advantage of the knee extensor senting with indirect mechanisms or twisting mecha-
mechanism.1 nisms should also be assessed carefully for associated
The vascular supply to the patella is primarily derived injuries. It has been reported that 95% of patients with
from an extraosseous and intraosseous blood supply acute lateral patella dislocations have articular cartilage
arising from an anastomotic ring from the genicular and injuries to the patellofemoral joint.6
anterior tibial recurrent arteries and midpatellar vessels. A physical examination may reveal swelling, palpable
Lazaro et al2 demonstrated that the inferomedial ves- defects, lacerations, or abrasions. Detection of traumatic
sels were the most dominant vessel in 80% of cadavers arthrotomy of the knee can be accomplished with the
in their vascular evaluation of the patellar blood detection of intra-articular air on CT as recent literature
supply. has demonstrated improved sensitivity and specificity
compared with a saline load test.7 Competence of the
extensor mechanism should be assessed using an active
straight leg raise test. To avoid a false-positive sec-
Patella Biomechanics ondary to pain, a knee aspiration and intra-articular
The patella serves as an articulating fulcrum to increase injection of local anesthetic may be required.
the moment arm of the extensor mechanism. In addition,
it notably improves the efficiency of the quadriceps Imaging
muscle by elevating the extensor mechanisms from the AP, lateral, and two oblique knee radiographs should be
axis of rotation of the knee and increases the torque obtained for patella fractures. This four radiograph
generated. It also aids in reducing frictional wear that combination has been shown to notably improve sensi-
would otherwise deteriorate the extensor mechanism tivity for fracture detection in comparison with conser-
tendon. When the knee is fully flexed, the patella is a link vative two radiographic views (AP, and lateral).8 Four
between the quadriceps and patellar ligament. Daily views including the use of a flexed lateral view may
activities generate patellofemoral compressive forces of provide additional information to guide surgical
3.3 times body weight while climbing stairs and 7.6 times decision-making and help determine retinacular integrity.
body weight while squatting.3 The patella engages the Advanced imaging may be considered for commi-
femur from 45° flexion to full extension, and this dis- nuted, occult, or stress fractures. CT scan has been shown
places the extensor mechanism from the mechanical axis to affect surgical management plans in 49% of patients
of the knee, increasing torque generation to allow for and change fracture classification in 66% of patients
terminal extension.1,4 assessed.9 MRI is highly sensitive for the detection of
occult fracture, cartilage damage, and subchondral
Mechanism of Injury fracture and provides additional information regarding
Patellar fractures may result from either direct or indirect the integrity of the extensor mechanism; however, this is
forces but usually involve a combination of the two not indicated for acute displaced patella fractures.
forces. A direct blow to the patella usually results from a
ground level fall or dashboard injury from a motor
vehicle collision. This mechanism of injury typically re-
sults in a comminuted/stellate fracture pattern with Classification
articular injury. Indirect trauma typically occurs when Patella fractures are commonly described by fracture
the mechanical properties of bone are overcome by pattern and amount of displacement. The Arbeitsge-
eccentric loading forces. The patella fails under tension meinshaft für Osteosynthesefragen (AO) classification
by rapid knee flexion against a contracted quadriceps. uses the long bone classification system described by
These indirect injuries present as a transverse fracture Müller. In contrast, and the Orthopaedic Trauma
pattern with larger displacement, retinacular injury, and Association is based on the degree of articular
less articular injury/impaction.5 involvement and the number of fracture fragments.
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Patella Fractures
Figure 1
Management
Optimal treatment of patella fractures includes restora-
tion of a functional extensor mechanism, the reestab-
lishment of articular congruity, and preservation of
patella bone stock.
Nonoperative
Nonoperative management may be indicated for patella
fractures with an intact/competent extensor
mechanism, ,1 to 4 mm of fracture displacement, and
less than 2 to 3 mm of articular incongruity or articular
step-off.10 Patient age, functional status, and bone Intraoperative image of the lateral parapatellar approach with
quality must also be considered. Nonsurgical treatment articular reduction via kirschner wires.
regimens include weight-bearing as tolerated with long

leg immobilization (cylinder cast, knee immobilizer, or often requires palpation of the articular surface to assess
hinged knee brace) for a duration of 4 to 6 weeks, articular reduction. This approach is most useful for the
followed by the initiation of range of motion. Previous fixation of noncomminuted transverse fractures with
evidence supported that nonsurgical management is large fracture fragments. Accessory fluoroscopic patellar
associated with good-to-excellent outcomes,10 but views of 17° of patellar external rotation (range
recently, Cooper et al11 reported poor functional out- 12°–35°) and 26.5° of patellar internal rotation provide
come scores with minimally displaced fractures. Further tangential views of the lateral and medial facets,
long-term clinical trials are needed to define appropriate respectively. This aids in confirmation of anatomic
nonsurgical treatment indications. articular reduction.13
Nonoperative treatment for displaced patella frac- The lateral parapatellar approach allows for visuali-
tures is reserved for those with limited functional status zation of the articular surface for comminuted articular
or contraindications to surgery. At the 2-year follow-up, fractures requiring direct reduction (Figure 1). This
Pritchett12 reported all 18 patients with displaced technique can be done with a midline skin approach or a
patella fractures developed a $20° extensor lag, but more lateral skin approach.14 It preserves the major
only three patients reported notable limitations in their inferomedial blood supply of the patella while providing
activities. The natural history, as well as the implications extensive visualization of the articular surface.
and limitations of nonoperative treatment of non- The median parapatellar approach has also been
displaced and displaced patella fractures, should be described, but it does include a risk to the inferomedial
discussed with patients. blood supply of the patella. However, retrospective
evaluation of Yoon et al15 of this approach demon-
strated no cases of osteonecrosis or weakening of the
extensor mechanism with this approach.
Surgical
Common indications for patella fracture fixation in-
cludes incompetent extensor mechanism, fracture sepa-
ration greater than 2 to 4 mm or step-off greater than 2 to Tension Band Construct Fixation
3 mm, and intra-articular loose bodies. Active commu- Tension-band construct is the most common surgical
nication and patient/injury-specific discussions should technique for patellar fractures. The technique converts
occur regarding open reduction and internal fixation the anterior tension forces produced by the extensor
because of the myriad of treatment options and their mechanism and knee flexion into compression forces at
associated risks and benefits. the articular surface. Two 2.0 mm K-wires are placed
Three common surgical approaches exist to patellar perpendicular to the fracture line along the subchondral
fracture fixation. The most common being a longitudinal surface after fracture reduction. A metal low-gauge wire
midline extensile incision centered over the patella. tension band is applied in a figure eight-shaped manner
Direct visualization of the articular surface is difficult and to compress the fracture. The ends of the K-wires are bent
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Review Article
and buried in the proximal and distal aspects of the ther clinical comparison of these techniques is still
patella. The tension band wires are then twisted and indicated.
buried in the patella. Prominent hardware in tension
band wiring has led to hardware removal rates reported
as high as 31.6%.16 This has led to a progressive evo-
lution in the fixation technique. Plate Fixation
Improved longitudinal stabilization of the patellar Patella fracture plating has increased in popularity for the
fracture with the use of screw fixation rather than treatment of displaced, comminuted stellate, and inferior
K-wires was the first advancement of the tension band. pole type injuries with improvements in low-profile
Screws provide greater rigidity and improved resistance plating options.
against tensile loading when compared with K-wires. A diverse selection of plating options exists to treat the
The modified tension band construct with cannulated various patella fracture morphologies. Dorsal 2.7 mm
screws has been shown to be superior in preventing fixed-angle plates and dorsally based x-shaped plates
fracture displacement and improving bending have been compared with tension band wiring for
strength.17-19 transverse patella fractures with excellent results.19,30
The tension-band technique has continued to evolve Locking plate fixation has demonstrated increased
with the introduction of braided and nonabsorbable su- ultimate strength of fixation when compared biome-
tures. Replacement of low gauge wire with high strength chanically with tension band fixation.30 Wurm et al31
sutures has demonstrated comparable strength and demonstrated notably improved patellar fixation using
improved stress distribution while limiting soft-tissue an anatomically shaped locking plate with unicortical
irritation.20-22 Nonabsorbable braided suture or tape screws in comparison to cortical screws with tension-
has also been used to replace wire for this construct and band wiring. During biomechanical testing, the tension
has been shown to display less creep, greater stiffness, band construct developed a 5 times larger fracture gap
and less extensibility than other sutures.23 Utilization of compared with plate fixation. In addition to biome-
braided/nonabsorbable sutures has decreased the over- chanical success, Wurm et al31 reported only a 6%
all risk of revision surgery and wound compro- complication rate in the study participants. This com-
mise.21,24,25 In a recent retrospective report on fixation plication rate is considerably lower than the complica-
using headed cannulated screws with high strength tion rate typically reported for patella fractures treated
nonabsorbable suture, Busel and colleagues showed with tension band wiring, which is estimated about 20%
high union rates at 96% and a low rate of symptomatic to 30%.32 Their patients achieved 77% of full function,
hardware at 8%. Three of the four cases of symptomatic with patients complaints most commonly regarding
hardware were due to screw prominence.26 kneeling or squatting.
The ultimate goal of the tension band technique is a Multiaxial longitudinal cortical and unicortical
biomechanically superior construct with little hardware locked plating for comminuted fractures has been done
irritation that will allow for early rehabilitation and with the use of a moldable low profile minifragment
range of motion. Screw fixation has also evolved along locked plate as well. This technique has demonstrated
with the high strength suture incorporation. Screw head clinical and biomechanical superiority, with less fracture
prominence has been shown to reduce the constructs gap formation over tension band constructs.33-36 The
ability to resist gap formation during cyclic loading low-profile plate allows for the use of 2.4 and 2.7 mm
testing.27 Dual-pitched buried compression screws with cortical and locking screws through a variable angle
suture tension band demonstrated superior biome- mesh. Each plate is custom cut and contoured to fit the
chanical behaviors over standard headed screw fixation fracture morphology (Figures 2 and 3). These provide
including increased construct rigidity, smaller inter- excellent fixation options for comminuted fractures in
fragmentary motion, increased resistance to failure, and patients with and without osteoporotic bone.
greater fixation strength. Martin et al28 showed that the Mesh-type plating techniques have demonstrated suc-
mean clinical failure strength for the headless screws cessful radiographic union while limiting reoperations for
construct was almost double that of the headed screws nonunion, infection, and symptomatic outcomes.35,37-39
construct. Alayan et al29 demonstrated comparable In addition, patients have reported improved subjective
fixation; however, greater fracture gapping was found outcome scores, thigh circumference, strength with closed
with buried compression screws and suture fixation and open chain knee exercise programs, and 70% less
compared with wire/cannulated screw constructs. Fur- anterior knee pain compared with tension band
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Patella Fractures
Figure 2
Intraoperative photograph of comminuted patella fracture in a 59-year-old woman after fall from ladder demonstrating (A) low
profile minifragment mesh plate contoured to the patient’s patella resulting in (B) anatomic reduction of the articular surface with a low-
profile construct (C).
constructs.34 Prominent hardware is still a concern with Matejcic et al42 evaluated the basket plate in the
patellar plating, but hardware removal rates have been treatment of comminuted fractures of the distal pole of
reported between 0 and 11%16,33,39,40 that is improved the patella. It showed excellent functional outcomes in
over previously reported removal rates of 32% to 37% 81% of patients and good results in the other 18%. In
with metal tension band constructs.41 addition, minifragment fixation can be used for fixa-
tion of inferior pole fractures that are reconstructable
(Figure 4). The goal of fixation is to restore inferior
pole alignment while avoiding patellar baja, which may
Management of Inferior Pole Patella result with inferior pole patellectomy.
Fractures (Including Partial Patellectomy) Suture fixation for management of inferior pole
Inferior pole patella fractures are complex injuries due to comminution uses nonabsorbable braided sutures
the degree of comminution that often limits standard passed through the patellar tendon in a Krakow fashion
fixation techniques. Heterogeneity of patients and then passed through the inferior pole comminution.43
patella fractures in the current literature limits definitive These sutures can then be passed through intraosseous
conclusions when comparing open reduction and inter- tunnels in the patella and tied over the superior pole of
nal fixation with partial patellectomy. Reconstructable the patella (Figure 5). When comparing this technique
inferior pole fractures may be addressed with plate fix- to tension band wiring for inferior pole comminution,
ation, suture fixation, and suture anchor fixation. 7.6% of patients required reoperation in the suture
Figure 3
Preoperative (A) AP and (B) lateral radiographs of 45-year-old male cyclist after fall off bicycle demonstrating a comminuted patella
intra-articular fracture. One-year postoperative (C) AP and (D) lateral radiographs after fixation with a moldable low-profile minifragment
mesh plate construct.
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Review Article
Figure 4
One-year postoperative (A) AP and (B) lateral radiographs of 62-year-old woman displaying a minifragment T-plate with a free
cancellous screw fixation construct.
fixation cohort compared with 30.6% of patients in the patella baja.45 Anterior reattachment of the patellar
tension band wiring cohort. A similar technique using tendon to the patella remnant is recommended
suture anchors was described by Kadar et al.44 They to minimize the patellofemoral contact stresses.46
were able to demonstrate similar results to partial Satisfactory clinical results have been shown with
patellectomy. Inferior pole fixation is critical to maintenance of at least 60% of the patella, with a
appropriately align the inferior pole because malunion notable increase in resulting patellofemoral contact
can result in impingement and anterior knee pain. forces.47 Partial patellectomy has dramatic effects on
Current literature favors the use of nonabsorbable the patellofemoral mechanics, with up to 55% of pa-
suture compared with metal fixation to decrease the tients developing osteoarthritic changes at the 2-year
risk of hardware complications; however, future follow-up.45,46
research remains warranted.43,44
Partial patellectomy should be considered for highly
comminuted inferior pole patella fractures where ana- Total Patellectomy
tomic reduction cannot be achieved through the above As advances in fixation methods have increased,
mentioned techniques. Whether poor bone quality or the indication for total patellectomy has notably
complexity of fragmentation preclude fixation, the decreased. A 50% reduction of quadriceps strength is
goals of treatment shift to the retention of a stable seen with total patellectomy.5 Retention of any viable
portion of the patella to maintain a well-functioning patella will result in improved clinical results. In the
extensor mechanism. Partial patellectomy alters the setting of tumor, infection, failed internal fixation,
extensor mechanism by decreasing the lever arm about nonambulators, or severely comminuted fracture with
the knee joint, resulting in up to 33% of patients with no viable articular fragments, total patellectomy may
abnormal patellar tilting and 42% of patients with be indicated.
Figure 5
(A) AP and (B) lateral radiographs of 65-year-old woman with inferior pole fracture. One-year postoperative (C) AP and (D) lateral
radiographs demonstrating union of an all suture fixation construct for an inferior pole patella fracture.
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Patella Fractures
Open Patella Fractures nonabsorbable braided sutures or tape passed through

Six to nine percent of presenting patella fractures are parallel cannulated screws.
open injuries, most commonly as a direct result from a For comminuted patella fractures, our preferred
high energy vehicular trauma. 47 Associated injuries technique is a lateral parapatellar approach using inter-
have been reported as high at 80%.48 Anand et al47 fragmentary screw fixation with minifragment locked
showed that open patella fractures are associated neutralization plate. For all patterns, we supplement all
with higher injury severity scores and a greater fixation with anatomically approximated retinaculum
number of associated injuries. Most commonly, these closure.
fractures are classified as Gustilo Anderson type II For open fractures, we recommend urgent antibiotic
injuries, with rates reported between 53% and 76% administration, débridement, irrigation, and definitive
of presenting open fractures. Type III injuries have fixation when indicated. Skin grafting or flap coverage
been reported as high 32%, whereas type I injuries should be completed within 7 days to reduce the risk of
have been reported in 15% of open fractures. postoperative infection if the wound is not amenable to
Immediate management of open patella fractures primary closure.
requires urgent antibiotics, irrigation, and débride-
ment, followed by definitive fixation.48,49
Historically, open patella fractures are associated
Postoperative Management and
with higher incidences of complications compared
Rehabilitation
with closed fractures especially when comparing the No standard postoperative protocol exists after the sur-
rates of infection and nonunion. The rates of infection gical treatment of patella fractures. Postoperative pro-
and nonunion in closed patella fractures have been tocols allow for immediate weight-bearing in extension
reported as 0% to 5% and 0% to 3%, respectively. In using a cylinder cast, knee immobilizer, or hinged knee
open fractures, the rate of infection can be as high as brace locked in full extension. Initially, the knee range of
10.7% with a nonunion rate of 7%.5,48,49 Catalano motion is limited to 0 to 30 degrees for 4 to 6 weeks
et al48 evaluated a series of open fractures and postoperative. After 4 to 6 weeks, the range of motion is
reported an incidence of deep infection of 10.7%, slowly progressed. Early exercise programs should
which correlated with the magnitude of soft-tissue incorporate active flexion with passive extension to
injury. No infections were identified in type I and II allow for motion while minimizing the tensile and
fractures treated with immediate internal fixation or bending forces on the repair. After 6 weeks, the patient is
primary wound closure or both. allowed to range the knee freely without restrictions.
By contrast, a recent meta-analysis of 737 patella Each rehabilitation program should be modified to fit
fractures found that modern treatment of open frac- each individual case, given patient age, bone quality, fix-
tures, including prompt irrigation and IV antibiotics, ation type, and fixation stability. In cases of potential
decreased the risks of complications. In addition, open patient noncompliance, poor fixation, and partial pa-
fractures did not notably influence the frequency of tellectomy cases, a long leg cast in extension postopera-
reoperation, infection, or nonunion.41 tively should be considered.
It has been postulated that using multiplanar plate
Authors’ Preferred Method of Treatment fixation may allow for the implementation of earlier
We recommend determining the surgical approach based ranges of motion, although no high-level clinical literature
on fracture morphology. For midpole transverse exists comparing postoperative protocols. Singer et al38
fractures, a longitudinal midline incision with full- demonstrated success and no secondary fracture dis-
thickness medial and lateral subcutaneous flaps may be placement with mesh plating and early range of motion at
used. The articular surface is then exposed and visualized 2 weeks postoperatively in their series with a mean of
through the fracture site and along the retinacular rents. 19.6 months follow-up. All study patients except one
After the reduction of the fracture, the fracture reduction regained full knee range of motion.
should be assessed through the retinacular rents by We recommend a simplified approach, which may be
visualization, palpation, and fluoroscopic assessment modified pending fracture and patient variables. The
using the accessory views. Based on the current literature protocol includes 4 weeks of weight-bearing as tolerated
of failure rates, complications, and patient outcomes, the with immobilization in a hinged knee brace locked in
authors’ preferred method of fixation for transverse extension. Early physiotherapy and initiation of isometric
fractures is with figure-of-8 tension-band construct with quadriceps exercise programs may begin 2 weeks
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postoperatively. At the discretion of the surgeon and fix- fracture healing and fracture stability can be challenging
ation type, passive and active range of motion may be and is patient specific. Patients with postoperative lim-
progressively increased starting at 4 weeks postopera- itations in knee flexion may be considered for manipu-
tively. We recommend that a physiotherapist should lation under anesthesia and/or arthroscopic lysis of
supervise increases in range of motion. Patients should be adhesions after fracture union.53
allowed to range freely at 6 weeks. Clinical and radiologic The incidence of patellofemoral osteoarthritis is dif-
signs of healing should be used to advance the patient ficult to ascertain from the current literature. Patello-
through the postoperative protocol. femoral osteoarthritis has been reported in 8.5% of cases
The subcutaneous location of the patella and the treated with tension band wiring technique.54 The initial
demand for early knee motion contribute to the com- injury-related damage to the articular cartilage com-
plexity of patella fracture treatment. The reported rates pared with the quality of reduction as the cause of early
in the literature for hardware removal after patella open onset of post-traumatic osteoarthritis remains unclear.
reduction and internal fixation vary widely, ranging
from 0% to 60%. A meta-analysis investigating the
frequency of reoperation, infection, and nonunion after Summary
patella fracture fixation reported rates of 33.6%, 3.2%,
Patella fractures are relatively common and are amenable
and 1.3%, respectively.41 The rate of revision surgery is
to a variety of surgical fixation methods. Screws and a
most commonly secondary to symptomatic hardware.
modified tension band technique using braided suture or
This has led to the evolution in patella fracture fixation
metallic wire is the most frequently used technique for
and management with suture fixation in tension band
transverse fracture patterns. Advancements in low-
constructs. In an effort to decrease postoperative
profile locking plates have allowed fixation of more
complications, low-profile plating techniques have also
comminuted fractures that previously may have been
progressively improved, which has resulted in lower
treated with partial patellectomy. Open fractures must be
revision surgery rates reported between 5.9% and
managed with urgent débridement, intravenous anti-
11%.16,33,34
biotics, and early fixation. Internal fixation methods
Hardware failure is rare after patella fixation, with
must be tailored to the fracture pattern and patient
reported rates from 8% to 12%, in cases managed with
profile considering preoperative functional status, bone
screw and Kirschner wire anterior tension band de-
quality, and soft-tissue envelope. A thoughtful approach
signs.24 The overall risk of breakage and migration of
to treatment is required, including selecting the surgical
K-wires is low; however, case reports have been found
intervention that will preserve the most bone stock while
describing the incident. The fragmented metal pieces
providing stability and avoiding soft-tissue irritation.
can be benign or they can in rare cases migrate to
Using lower profile and suture fixation methods may
heart.50 Although this was one rare instance, generally,
reduce complications such as symptomatic hardware or
no distal or proximal migration exists of broken
need for additional procedures.
hardware.51
Substantial knee extensor weakness has been
observed after osteosynthesis partial and total patellec- Acknowledgement
tomy. Bayar et al52 found that patients with .1 mm
The authors acknowledge the contribution of Michael
articular incongruity postoperatively had notably higher
Bogard, DO, Community Memorial Health System
incidences of thigh atrophy, pain, and increased physical
Ventura, California.
deficits. The weakness and deficits have been shown to
last up to 12 months after surgical fixation. Lazaro
et al40 series reported that 80% of patients treated with References
tension band fixation reported anterior knee pain dur-
Levels of evidence are described in the table of contents.
ing activities of daily living and objective weakness in
In this article, reference 33 is a level II study. References
strength (241%), power (247%), and endurance
7, 9, 16, 21, 24, 32, 41, 44, and 47 are level III studies.
(234%). 57% of the patients in that cohort had
References 4, 6, 8, 10-12, 15, 25, 26, 31, 33, 37-40, 42,
radiographic evidence of patella baja.
43, 45, 48, 49, and 51-54 are level IV studies.
Knee arthrofibrosis and loss of knee range of motion
is an established complication after patella fracture. References printed in bold type are those published
Balancing early postoperative range of motion with within the past 5 years.
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Patella Fractures - Approach To Treatment

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Patella Fractures: Approach to Treatment

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regimens include weight-bearing as tolerated with long

Open Patella Fractures nonabsorbable braided sutures or tape passed through

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