Fractures

BY

JAMES

F. (ARPENTER.
AND

An

M.D.t.

LARRY

Instructional

of the Patella*
ARBOR.

ANN

5. MATTHEwS.

Course

Lecture,

The

human
sesamoid
bone,
lies
functional
component
of the
Most of the quadriceps
apo-

neurosis
inserts
directly
into the superior
pole of the
patella.
while
the patellar
ligament
arises
from its infenor pole. Some
fibers,
however,
bypass
the patella
anteniorly

and

are

confluent

with

the patellar

ligament.

ANN

American

Anatomy
The patehla.
the largest
within
and is an important
knee extensor
mechanism.

ROBERTA

M.D.t.

KASMAN.

ARBOR.

Acadenv

M.D4.

DETROIT.

MICHIGAN

of Ort/iopaedic

Surgeons

equals
the tibial
force
multiplied
by the tibial
moment
arm), he was able to determine
the effective
quadriceps
moment
arm (the quadriceps
moment
arm equals
the
knee
found

moment
that the

divided
patella

of the quadriceps
tion made
by the

by
serves

the quadriceps
to increase

moment
arm
patella
increases

and

the

force).
He
magnitude

that the contnibuwith progressive

cx-

Only

the skin,
a thin layer
of subcutaneous
tissue,
and the
pnepatellar
bursa
overlie
the patella.
This subcutaneous
location
makes
the patella
prone
to injuries
from direct
blows
and falls. Posteriorly.
of the surface
of the patelha

the proximal
are covered

cartilage

thickest

the

that

body.

is among

This

anterior

surface

trochlea.

It has

the

surface

only

found

partially

of the

distal

aspect

major

medial

and

three-quarters
with articular
anywhere

conforms
of the

lateral

femur

in
to

the

and

the

Tension

facets.

Biomechanics
The

patehla

the quadriceps
tella. and the
two

important

principal
transmits

is one

link

muscle,
patellar

in the

the quadriceps
ligament.
The

biomechanical

site
the

mechanism

comprising

tendon.
mechanism

functions.

First,

of insertion
of the quadriceps
tensile
forces
generated
by

the paserves
as it is the

the

muscle,
it
quadni-

ceps to the patellar

ligament.
Second,
the patella
effectivehy
increases
the lever
arm
of the knee
extension
mechanism
increases
traction
this

the

of the

mechanical

cadavenic
force with
tibia
the

from the axis of knee flexion-extension.

knee extensor
moment
generated
quadriceps.

Kaufer5

clearly

enhancing

function

of the

knees,
he
a restraining

balanced
force

at 0 to 120 degrees
moment

about

the

a simulated
at the distal

of knee
knee

flexion.
axis

(the

This
by con-

documented
patehla.

Using

quadriceps
aspect
of the

FIG.

in tenpatello-

tension

at

of

By calculating

extension.

knee

and

moment

*printed

with

permission

of The

American

Academy

of Ortho-

1550

the
His

they

tomy

paedic
Surgeons.
This
article
will appear
in Instructional
Coitrse
Lectures,
Volume
43, The American
Academy
of Orthopaedic
Surgeons,
Rosemont,
Illinois,
March
1994.
tSection
of Orthopaedic
Surgery.
Department
of Surgery.
University
of Michigan
Medical
School,
Ann Arbor,
Michigan
48109.
Henry
Ford
Hospital.
Detroit.
Michigan
48202.

Drawing
demonstrating
that the patella
is loaded
primarily
sion when
the knee
is in full extension.
In this position.
the
femoral
contact
force
is minimum.

knee,

support

should

being

findings
be

have

almost

30

been

confirmed

pen

the

contention

that

avoided

in

treatment

the

cent

full

by others
total

patellecof

patehlar

disorders.
The
knee

quadriceps
tension
nor

patella

extension,
(Fig.

surface

is subjected
it transmits

to complex
almost

loading.

all of the

With

force

of the

contraction
and thus is loaded
primarily
in
1). However,
with knee
flexion,
its postecontacts
THE

the
JOURNAL

distal
OF

aspect
BONE

of the
AND

JOINT

femur

and

SURGERY

FRACTURES

OF

THE

1551

PATELLA

tion of the knee is a transversely

mined
experimentally
the contact
femoral

joint

for

a range

of

linear
area

knee

band.
We deterfor the patello-

flexion

angles

patellofemoral
loads2.
These
studies
showed
tact areas
of approximately
two to four square
tens

throughout

(Fig.

3). The

most
force

of the
with

anticular
surface
of the
be estimated
analytically
quadriceps

Three
point
bending

patellofemoral
and
ten

angles,
newtons

tamed

FIG.
Drawing
demonstrating
loaded
in three-point
moment
increases
with

is subjected
face

joint

creates

the

anterior

that

naturally

the

surface

of the

generated

quadriceps.
of loading

position

knee

of the

degrees
of knee
Loads
across
but

they

newtons

of tensile

load

As

at

is additive

to

the

have

of
primarily

knee

and

may

not
on

men5. Considering
bending
stress,

by Smith3
and
data

stress.

and

by Morn-

knee
flexion
for estimation

For

virtually

angles.
of the

all activities

by the tibiofemoral
millimeter)

joints.
tance
ment

These
high
of maintenance
of patellar
stress

joint

and

(two

by other

to five

major

newtons

per

weight-bearing

contact
stresses
magnify
the imporof articuhar
congruity
in the treatfractures
in order
to facilitate
and
distribution.

these
on

moves

into

near

45

precisely

order

to 6000

rise

reported

increasingly
in the ante-

been

the

the

the patellofemoral
contact
stresses
(two to
per square
millimeter)
exceed
those
sus-

square

maximize

extension

contacts

distal
aspect
of the femur
can
with
the use of the primary

of activities
essential

contact

and

patella

contraction

a maximum

are

data

the

in the

from

reaches

probably

the
sun-

which

forces
become
of tensile
forces

patella

called
on this
in tension

contribution
depends

joint.

flexion.
the patella

measured,

young,
trained
sion, three-point

patella,

is

results

by distraction

the bending
magnitude

patella
bending

configuration

load

The relative
of the patella

of the

surface

Loading

bending
bending

the
The

generally

force.

2). This

greater
flexion.
important.
The
non

force,

reactive

a three-point

(Fig.

of the
modes

with the knee

in flexion.
as well
as in tension.
knee
flexion.

to a compressive

patellofemoral
patella

that,
bending
increasing

force

son23 for a variety

This
provides
the

arc of flexion

which

and

small concentime-

of 3000

newtons

the magnitude
and compressive

in

of tenforces

that occurs
on the posterior
surface
of the patella
in a
loaded,
flexed
knee, the recognized
prevalence
of patellan fracture
is not surprising.
Studies
in our laboratory
of strain
on the anterior
patellan
surface
that normal
activities,
such as stair-climbing,
ate

magnitudes

of surface

close
to values
microstrain).

that
These

major

the

role

in

equally
important
ods of treatment
The

strain

result
large
initiation

of

anticular

fractures
efficacy

VOL.

75-A,

joint
NO.

10.

OCTOBER

through

much
1993

dangerously
(1000
patella
and

of various

to 2000
play a
have

an

methFI;.

surface

dominantly
convex.
The anterior
femur
is convex
as well. Thus, the
patellofemoral

are

in a fracture
strains
in the

effect
on the
of fractures.

posterior

that

demonstrated
can gener-

of the

patella

articular
surface
point of contact
of the

range

is preof the
for the
of mo-

The
tact
flexion.

dark
regions
in this photograph
area
of the patella
on the femur
These

patellofemoral
b area).

small

areas

in combination

joint

result

in very

high

of the knee
indicate
the conat different
positions
of knee
with
high loads
across
the
contact
stresses
(force
divided

1552

J. E.

CARPENTER.

ROBERTA

Transverse

undisplaced

Vertical

Transverse

displaced

Osteochondral

Comminuted

KASMAN.

AND

L. S. MATTHEWS

)L.

undisplaced

Sleeve

Comminuted

displaced

FIG.
Classification

Classification

the
two

Patelhar
fractures
mechanism
of
major

of patellar

of Patellar
are
injury

mechanisms

injury:

direct

to
There
and

both
are

indirect

trauma.The
patella
may be fractured
by a direct
blow
during
a fall onto the knee or when
it hits the dashboard
in an automobile
accident.
Because
of the small amount
of prepatehhar

soft

distal

aspect

force

of a direct

direct

trauma

tissue

of the

tion,

but

tune

fragments.

and

femur

blow

causes
is little

With

certainty,

area

Indirect
to jumping

trauma
on, more

contact

posteriorly,

there

the contact

direct

is damaged

with

nearly

is delivered

frequently

often

the

to the

displacement
the

articular

by this

that
causes
frequently,

the

all of the

patella.

considerable

Such

comminuof the

mechanism
fractures
can
to unexpectedly

of

of injury.
be

due
rapid

flexion
of the knee against
a fully contracted
quadriceps.
The natural
anatomy
and biomechanics
of the knee,
as
previously
described,
create
tension,
three-point
bending, and compressive
strains
in the
values
sufficient
to cause
a fracture.
from

indirect

those
often

from direct
transverse.

than

with

direct

injury

tend

to be

trauma,
but
The articular

less

patella
that exceed
Fractures
resulting
comminuted

they are displaced

cartilage
is less

than
and are
damaged

trauma.

Most
patehlar
fractures
occur
as a result
of a combination
of direct
and
indirect
trauma.
Rarely
does
anyone
hit a dashboard
with a relaxed
quadriceps.
In
addition,
Thompson
et ah.33 clearly
demonstrated
that

basis

of fracture

direct

blows

those

sufficient

morphology.

to

the

patella

to cause

of

magnitudes

less

fractures

predictably

patellan

than

damage
the contacting
articular
cartilage
of the patella
and femur
and that early
biochemical
and histological
changes
after
such blows
are consistent
with the initiation

of post-traumatic
osteoarthrosis.
In general,
to facilitate
treatment,

are

classified

occur
These
of

frac-

cartilage

on the

Fractures

classified
according
and morphology.
of

fractures

patelhar

(Fig.

in a medial-lateral
direction
fractures
are usually
in the

the

patella.

inferior

Vertical

direction,

edge
tella

morphologically

of the
and

patella

that

are

they

that
not

do

are

in

are

rare.

not

extend

associated

fractures

Fractures

that

are called
transverse.
central
or distal
third

fractures

and

4).

with

the

superior-

Fractures

of the

across

the

disruption

pa-

of the

extensor
mechanism
are called
marginal
fractures.
Displaced
fractures
are those
with
articuhar
incongruity
(step-off)
of more
than two millimeters
or separation
of
the fragments
of more
than
three
millimeters5.
Fractunes
with
multiple
fragments
are called
comminuted
fractures.

Some

comminuted

tenized
as stellate
also demonstrate

fractures.
comminution

fractures

can

be

Some
transverse
of one or both

Osteochondral
fractures
are primarily
A direct blow, or more commonly
a patellar
may cause
an immediate
fracture
around

chanacfractures
poles.

of two types.
dislocation,
the point
of

contact,
separating
a single
fragment
that includes
anticular cartilage,
subchondral
bone, and supporting
trabecular bone.
This piece
may never
displace,
and in this
case the fracture
usually
heals with time and causes
little
THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

FRACTURES

OF

1553

THE

PATELLA

tune
tical

or separation
fractures
are

radiographs22.

of the fragments,
or both.
Some
yenbest seen on tangential
on Merchant

Rare

marginal

must
be distinguished
tens that never
fused
ing

a bipartite

or

peripheral

fractures

from secondary
ossification
with the body of the patella,

patella.

Radiographs

of the

cencreat-

contralateral

knee
can help in this differentiation
because
bipartite
patella
rarely
occurs
unilaterally.
Computed
tomography or other
advanced
imaging
techniques
are usually

unnecessary.
fractures,
contrast
FIG.

used

Drawing
showing
the
AO
modified
tension-band
fracture
fixation.
Two 2.0-millimeter
Kirschner
wires
tension
band
are used.
As the knee
is flexed,
the
pressed
at the articular
surface.

technique
of
and an anterior
fracture
is com-

to help

However,

the

fragment

come
a mechanically
has been recommended28
fragments,
Herbert

may

troublesome
in these

displace

loose
situations

stabilization
by transosseous
screw
has been
described27.

osteochondral
curs infrequently,

fracture,
when

a child

or adolescent

enable

amount

a so-called
the inferior
is pulled

of articular

and

be-

body. Excision
but, for large

The

fixation
other

with a
type of

sleeve
fracture,
pole of the patella

off together

cartilage2.

with

Such

ocof

a consid-

a fracture

be difficult
to see on standard
radiography.
Clinical
findings of local pain and tenderness,
an extension
lag (the
inability

to fully

graphs

showing

extend

the

knee

a high-riding

actively),

patella

and

indicated
appropriate,
of the

that

conservative
depending
on

fragments

niceps

and

mechanism.

the

importance

tella

in

the

Conservative

and

of subluxation

treatment

of patellar

operative

repair

carefully

examination,

same

time

flexion
with

extend

the

extension,
tenderness,
accurate

while
localized
knee,

the

a thorough

is nearly

diagnosis.

some
lateral
VOL.

anteropostenior
nadiognaphs
75-A,

NO.

Weak

ment.
Usually,
disrupted
at the
of immobilization

the extensor
time of such
followed
and,

later,

quadriceps-strengthening

produces
good
results.
While
a few
flexion
are frequently
host, the over-all

satisfied

patient

of the

with

little

patients

and

surface,
cast
treat-

mechanism
is not totally
fractures.
Four to six weeks
by gentle
but progressive

exercises
extreme

or no discomfort

of 212 fractures
Bostr#{246}m5 found

on

millime-

degrees
result

of
is a

on disability.

followed
after non-operative
slight on no pain in 89 per cent

normal

on slightly

in 91 pen cent. The range

in more
than 90 pen cent.

of motion

impaired
was

function

0 to 120 degrees

as the

Most

Treatment
patellar

tively. Treatment
patellar
function
open reduction

is important

fractures

should

be

treated

opera-

should
be aimed
at the preservation
of
whenever
possible,
preferably
through
and internal
fixation
of the fragments.
It

to obtain

comminution

secure

fixation.

for secure

open

If there

reduction

and

is too
inter-

blow, an
rapid

voluntary
contusion,
to make
an

radiographs

are

neces-

and facilitation
is difficult
to see

radiographs.
More
reveal
the comminution
1993

two

evaluation

and localized
the examiner

of the fracture
The patella

10, OCTOBER

comminuted,
with

was contracted,
toinability
to strongly

diagnostic.

High-quality

sary for classification

management
decisions.

peripheral,
associated

physical

radiographic

quadriceps
pain and the

a palpable
defect,
and swelling
help

fractures

tens or less of step-off

incongruity
in the articuhar
immobilization
in a cylinder
or an above-the-knee
with the knee in extension
has provided
successful

much

ensure
diagnostic
success.
A history
of a direct
extraordinary
muscle
contraction,
or unexpected,
knee
gether

Fractures

Fractures

history,
accurate

pa-

recommended

mechanism.

of Patellar

an

emphasized

at the

extensor

recorded
and

of the quadof the

of Patellar

vertical,

transverse

Operative

Alkire4
and

even

fractures.

is

capacity
or dislocation

fractures

instability

of the

Evaluation
A

functional

with

with

stress

and osteochondral
with or without
use of
Bone
scans have been

Treatment

undisplaced

In a series
treatment,

this diagnosis.
operative
neauthors2
have

or operative
treatment
the extent
of the separation

Heckman

association

radio-

in comparison

the contralateral,
uninjured
side support
Houghton
and Ackroyd5
recommended
pair
of these
avulsion
fractures.
Other

to identify

range-of-motion

can

for occult

tomography,
may be helpful.

Treatment

For
trouble.

However,

computed
medium,

often

of
on

than not,
of the frac-

FIG.
Drawing
showing
with 4.5-millimeter

stabilization
lag screws

6
of

alone.

a transverse

patellar

fracture

1554

J. E.

(ARPENTER.

ROBERTA

KASMAN.

AND

fracture.

L. S. MATTHEWS

In

addition,

quently
develops,
Care
should
be
the soft
flexion,
ment

a large

tissues
from compressive
or direct
contact
with

must

be delayed,

stretching

the

necessary

to postpone

unusual.
cording
Fu;.

nal fixation,
but
with a substantial

a major
amount

is present,
partial
proach.
Occasionally,

fragments

are

(usually
of normal

patellectomy
good

present

with

distal

superior)
articuhar

comminution

situations.
we
mid-portion,

the

poles.

proximal

and

functional

The

and

the

appole

of the

middle

created

a smaller

Operative

soft

direct

but

tissue

overlying

the

patella

or abrasion

is often
time

of the

patellar

fracture

after

FIG.

Radiograph
autogenous

showing
graft.

a displaced.

transverse

knee
treatthat

is

considered.

If

skin, so that postat risk,

it may
be

repair;

internal

fixation

and

wound
is clean.
The fracture
can

knee

treated
followed

however,

this

delayed

and

Often

there

the

primary

be approached

closure

when

via a midline

longi-

or a transverse
incision.
Although
the
is superior
after
a transverse
incision,
seldom
be used for other
procedures
on

should

gated,

these

become

necessary

integrity

in the

incision.
Once
in the extensor
medially
fracture

of the

is comminution

or laterally,
site is then

fragments
that

future;

the fracture
mechanism

was

or
inn-

is evaluated.
not

regarding
and internal
patellectomy

recognized
whether
fixation,
is then

7-B

a reconstruction

is

with
immediate
by open reduction

on the radiographs.
The
decision
to proceed
with an open reduction
a partial
patellectomy,
or a total
re-evaluated.

injured

at the

be

the
be

operative

extending
several
centimeters
both,
is usually
identified.
The

Principles

compression

should

of
could

thus, we prefer
a longitudinal
has been
exposed.
a defect

have
successfully
preserving
both

fretissues.
injury
to

of a hematoma

skin

the skeleton
are
and d#{233}bnidement

tudinal
incision
cosmetic
result
this incision
can

patella.

General

from

distal

the

fragment
cartilage

is the appropriate
and proximal

of the patelha.
In such
removed
the comminuted

and

soft

Open
fractures
of the patella
are treated
acto the same principles
as open fractures
of other

parts
of
irrigation

7-A

hematoma

splints,
excessive
ice. If operative

aspiration

anterior

there
is severe
compromise
operative
wound-healing

Figs. 7-A. 7-B. and 7-C: A fixation

technique
in which
cannulated
screws
as well as a tension
band
are used.
This construct
has proved
to be stronger
than
that
achieved
with
screws
alone
or with
the
modified
tension-band
technique
alone
in cadaveric
knees.
Fig. 7-A: Drawing
showing
the technique.

fracture

further
compromising
the
taken
to minimize
additional

of the

anterior

THE

cruciate

JOURNAL

ligament

OF

BONE

with

AND

a patellar-ligament

JOINT

SURGERY

FRACTURES

OF

FIG.
Radiograph

Open

are
tion

made

cannulated

Reduction

Transverse
the most
and

after

and

fractures
amenable

internal

screws

Internal

tension-band

wires

Fractures

a small

it

amount

best

portion.
suited

The
for

3.5-millimeter

this

pect
of operative
reduction
of the
should
be achievable

application.

cortical
The

repair
is assurance
patellan
articular
in the treatment

most

screws
important

VOL.

75-A,

NO.

the

technique

10. OCTOBER

of partial

as-

of a congruous
surface.
This
goal
of transverse
frac-

1993

patellectomy.

This

is difficult

the

are

the

fracture.

procedure

to visualize

The

fracture

subsequently

united.

or palpate

the

articular

there
and
surface.

reduction
of the anterior
surface
of the
not guarantee
an anatomical
reduction

articular

surface.

It is not

some
plastic
non aspect

deformation
of the patella

this

makes

this

the

adequacy

Therefore,

FIG.

Drawings
showing
fixation
is not possible.

to stabilize

Anatomical
tella
does

of comminution
can often
be first converted
to a simple
transverse
fracture
by lag-screw
fixation
of the comminuted

used

tunes. However,
once
the fragments
are reduced,
is no longer
a large gap in the extensor
mechanism

or no comminution
with open
neducwith

1555

PATELLA

7-C
were

Fixation

with little
to treatment

fixation.

and

THE

surface
of the

we

unusual

for

there

paof

to

unreliable
reduction

recommend

for
of the

extension

the

judgment

anticulan
of

the

of

surface.
exposure

8
is preferred

to total

be

or comminution
of the anteas a result
of the injury,
and

patellectomy

if open

reduction

and

internal

J. E.

1556

CARPENTER.

FIG.

with

Figs.

9-A

through

9-E:

Figs.

9-A

and

Preoperative

a medial

distance
release
ization

9-B:

A closed,

parapatellar

proximally

medially.

to allow
adequate
of the fracture
site

KASMAN.

The small
Provisional

fracture

incision
There

for

must

a short

be enough

and partial
anatomical

visualreduc-

can be closed
after fixation.
of the fracture
can usually

be obtained
with one or two
with Kirschner
wires. Definitive
with wires
and screws,
either
Weber

bone-reduction
forceps
on
fixation
can be achieved
alone
or in combination.

et al.35, in a biomechanical

study,

that, of all of the wining

methods,
band
technique,
as popularized
vided
the best
stability.
Curtis6
the tension-band
tial wining.
The
rently
shown

technique
modified

the most widely

a high percentage

demonstrated

the modified
tensionby the AO group,
prorecommended
use of

with additional
circumferentension-band
technique
is cur-

accepted,
and several
studies
have
of good results372#{176}.In a clinical

series,
Bostman
et al.4 found
superior
results
with the
modified
tension-band
technique
compared
with those
obtained
partial
erature

with

screw

patellectomy.
supports

possible4372.
The technique
millimeter
smooth

fixation,

with

circumferential

wining,

and

The contemporary
orthopaedic
litthe use of this technique
whenever
the

large

9-B

inferior

and

superior-pole

fragments.

18-gauge

and

over

the anterior
aspect
of the patella
to act as a tension
(Fig. 5)24. This anterior
tension
band neutralizes
the

band
large

use
wires

of two parallel
2.0combined
with
an

wire

looped

distraction
force
with contraction
of the knee.
sive forces
fracture
Failures
ative

the

Kirschner

As tension
are generated

is resisted
at the

wires

the anterior
and also with
by this
posterior

wire, compresaspect
of the
surface.
in open-

technique7.

the

then

placed

patella
reduction

longitudinal
through
the

fracture

technique
longitudinal

surface

across

and

fracture
more
wines

is the method
may be obtained

applied,

Kirschner
fracture
site,

wires
brought

in a retrograde

the

allows
for
Kirschnen

forceps,
after
in an antegrade
the fracture.

reliable
in the

band
poles
this

can

be
flush

manner,

after

reduction.

that we prefer.
and secured

and
This

placement
mid-portion

of the
of the

Alternatively,
with reduction

which
the Kirschner
wires
can be placed
fashion
through
the patella
and across
It is essential,
when
the tension
band
is
that

the

anterior

wire

be placed

adjacent
to the patella
as it courses
posterior
previously
placed
Kirschner
wines. The most
error
in this technique
is the failure
to bring
distal
When

surface
flexion

gap, improving
stability
at the articular
are often
directly
attributable
to errors

with

being

over

that occurs
across
of the quadriceps

The
parallel
placed
initially

sion
involves
Kirschner

intact,

radiographs.

palpation
to ensure

anthrotomy
stabilization

L. S. MATTHEWS

FIG.
patellar

tion of the articuhar

surface.
It is not necessary
to create
a large
medial
arthrotomy,
such as would
be necessary
for evension
and full visualization
of the articular
sunface.

AND

9-A
comminuted

capsular

and

ROBERTA

directly

into

of the patella,
happens
and
THE

JOURNAL

contact

with

the

BONE

AND

to the
common
the ten-

proximal

leaving
intervening
the fracture
is then
OF

directly

and

soft tissue.
loaded,
the

JOINT

SURGERY

FRACTURES

OF

THE

1557

PATELLA

FIG.
Radiographs
fragments
were

made
secured

fragments

may

the

band
effort

tension
In an

ment

separation,

ified

tension-band

after
the
to each

slip

significant
may not

be

apart

on

the

becomes
taut.
to overcome
which

can

fragments
a tension

and

the

use

of

frag-

tamed
and confirmed
with the
the arthrotomy
on the medial

of the

mod-

can

screw

or with reduction
forceps.
The screws
the fracture
in a lag fashion,
with the

intenfragmentary

advocated
study,

(Fig. 6).
reported

in better
stability
than
technique
for simulated
it is not clear
if this

difference.
Screw
able to resist
the

Benjamin
that
screw

et al.2,
fixa-

and

be achieved

internal

with

fixation,

patella
and
the larger.
to partial
patellectomy.

reduction

wires

problem

with

9-D

were
removed
from
the mid-portion
of the
hand.
This procedure
was done
as an alternative

until

Kinschner

occur

technique,

fixation
has been
in a biomechanical
tion resulted
tension-band
tunes.
However,

smaller,
comminuted
other
with screws

the

reduction

can

be

pole

oh-

aid of a small extension

of
side. Provisional
fixation

cannulated-screw

guide-wires
are placed
across
threads
engaging

did the modified

transverse
fracwas a statistically

fixation
alone,
large
bending

however,
forces
that

occur
with knee
flexion,
and the addition
of a tension
band
has been
advocated
by some.
Unfortunately,
it is
difficult
to secure
the tension
band
because
the screws
do not protrude
interlocking
with
treated
band

has

sufficiently
the wire.

No

from
the bone
to allow
clinical
series
of patients

with the combination

of screws
and
been
reported,
to our knowledge.

a tension

At our institution,
we evaluated
a method
in which
interfnagmentany
screw
fixation
can be easily
and securely
combined
with the use of an anterior
tension
band
(Fig. 7-A).
resistance
traction
tance
This

Theoretically,
to fracture
when

knee

to displacement
technique
was

of appropriately
screws.

As with

method
transverse
VOL.

the

75-A,

this construct
should
provide
displacement
from
anterior
disis in extension

as the knee
made
possible

sized

(4.0

NO.

to 4.5-millimeter)

the modified

is most appropriate
fractures.
As
10. OCTOBER

as well
moves
by the

tension-band

as resis-

into flexion.
development
cannulated
technique,

FIG.

this

for simple,
non-comminuted
with other
techniques
of open
1993

Intraoperative
the articular
of the patella.

photograph
surfaces
despite

9-E

demonstrating
removal
of the

the good
comminuted

alignment
mid-portion

of

1558

J. E.

(ARPENTER.

ROBERTA

KASMAN.

AND

4.0 or
Screws

monly
preserve

are best left four to five millimeters

short
of the measured
length
of the hole.
to ensure
that
they
will not
protrude
beyond
the patella
and cause
stress
concentra-

patients

tion in the tension

is placed
through

patient.

only the far

4.5-millimeter

the

anterior

the other

side of the fracture.

We found
screws
to be the most appropriate.

band.The
18-gauge
one of the cannulated

surface
cannulated

of the

patella,

screw,

and

the

tension-band
screws,
then
through

the

back

over

then

wine
over

center

of

the
with

ported
ment

The

which

not

determined,

partial

the surgeon
It is helpful

institution

showed

analysis
this

of

cadavenic

construct

to

knees
fail,

on

at
the

our

and

standard

than

partial

surface

osteoarthrosis
ment
anteriorly
is important

that

Radiograph
band
repair

age.
knee

with

10

showing
loss of fixation
following
because
of comminution
at the distal

a quadriceps

flexed

45

force

degrees,

of 732

while

modified
tensionpole of the patella.

newtons

screws

with

alone

554 newtons
(p < 0.05) and the modified
technique
alone
failed
at 395 newtons
sites of fractures
that had been
repaired

the

failed

at

tension-band
(p < 0.05).
The
with the mod-

has

is performed

by

fragments.
length
of the

the

as

possito the

use of mulsutures
(for

polyester)
(Fig. 8). These
surface
should
enter
near
there
is a minimum
step-off

lead

or tendon

intact
change

to joint

without

cartilage.
in the an-

overload

excessive

important

distal
pole,
which
markedly,
lead to

FIG.

patellectomy

and

as well as to avoid
rotation
of the fragand posteriorly
in the sagittal
plane.
It
to try to maintain
the length
of the re-

is especially

normal

patellar

knowledge.

the remaining
any abrupt

could

was

of a partial

of the patehha
through
and heavy
non-absorbable

ligament

This

of the

or the quadriceps
tendon
or tendon
is then
brought

between
the tendon
and
The goal is to minimize

ing.

size

be-

results

performance

patellectomy

braided
fracture
so that

re-

fragment
poor

a complete

to our

example,
number-2
holes
through
the
the articular
surface

maining

patellar

minimum
the

results

retained
fragin only one

removing
all of the comminuted
to preserve
as much
of the

fractured
surface
tiple drill-holes

ticular

or excellent

yielded

the

established,

are techniques
to
In a series
of forty

size of the
centimeters

of the

to allow

patellar
ligament
bhe. The
ligament

aver-

good

size

rather

been

cent

et al.29, the
4.1 square
patellectomy

needed

(Figs.

not

but there
as well.

minimum

low

patellectomy

pole,
pole

78 per

by Saltzman
was less than

nor surface
of the patella,
where
it is twisted
to the other
end of the wire. Two twists
in the wire can be used to
tighten
each
limb
of the tension
band
symmetrically
7-B and 7-C).
Biomechanical

superior
inferior

the

fragment

the ante-

L. S. MATTHEWS

with

can shorten
a low-riding

patellofemoral

shorten-

excision

the patellar
patella,
and

of

the

ligament
create
ab-

biomechanics.

Some
in parallel
This
wire

surgeons
have found
it helpful
to place a wire
with the ligament
repair
to act as a checkrein.
or cable
carries
a portion
of the load
be-

tween

patella

the

and

the

tibial

tubercle,

thus

decreasing

the load across

the recently
repaired
patellar
ligamentpatella
junction.
Perry
et al.2 showed
that
this loadsharing
cable
improved
the stability
of repairs
in an
experimental
study.
An 18-gauge
wire is placed
versely
through
a drill-hole
across
the mid-portion
the

remaining

patella

and

through

the

tibial

transof

tubercle,

ified tension-band
technique
and cannulated
screws
also
demonstrated
superior
rigidity.
displacing
an average
of 1.0 millimeter
with simulated
knee
extension
compared
with 1 .5 millimeters
(p value not significant)
when
screws
alone
had been
used
and 4.4 millimeters
(p <

and it is then secured

as a loop. The tension
on the wire
should
be adjusted
so that the wire protects
the ligament
repair
but is not so tight as to draw
the patella
distally.

0.05) when
the modified
tension-band
technique
alone
had been
used.
Goings
and Cole
reported
nineteen
good
or excellent
results
in a series
of twenty-one
patients
who had been
managed
with a similar
technique.

ing the bone-to-ligament

goes fatigue
failure,

and

repair

has

at

though

no comparable

Partial

not

all patehlar

ble to open
reduction
and internal
found
that, in most of the remaining
ment

of the

patella

healed,

inferior
pole
ceps tendon,

Patellectomv

Unfortunately.

Use of this wire allows

the
motion
earlier
postoperatively

can

be preserved.

fractures

are

amena-

fixation.
We
cases, a large
This

is most

have
fragcom-

polyester)
drill-hole
centimeters
rein and

can

be

patella
suture

a range
of
of disrupt-

The wire often

underbe removed
when
the

approximately

placed

secured
proximal
protect
the
THE

repair.
it should
technique

of the
a heavy

and

patient
to obtain
with less fear

eight
can

weeks.

be used

is repaired
to the
(such
as number-S
through

a transverse

when

Althe

quadnibraided
patehlar

to the quadriceps
tendon
several
to the repair
site to act as a checkrepair.
We do not find these
tech-

JOURNAL

OF

BONE

AND

JOINT

SURGERY

FRACTURES

niques

to be routinely

to protect

sure one about

In
who

was

the safety

excellent

in

however,
repair

they

as well

of beginning

twenty

can

help

side.

drews
and
patellectomy
severely

Similar

results

Hughston.
be done

extensor

Total

that

none

mechanism

(50

per

cent),

patients

with

were

reported

of it can

by

An-

that
patella

total
is so

be used

as part

separation

of the

and

ment

of tight

may

compromise

prolonged
worrisome,

swelling
as they

and range-of-motion
begun.
Unfortunately,
are

strength,
common

Einola
had

power
the

et al.9 found
a patellectomy,

that

was

power

of

that,

equal
the

knee.

than

Jakobsen

continuous
of the knee

of fragments

and

bone
motion

However,
patellar

quadriceps
power
to be, on the average,
of the opposite
limb. Three
long-term

cent

al.5

cartilage.
This
an osteochondral

two-thirds
studies43237

surface.
after

evaluated
the clinical
results
of patellectomy,
and while
this treatment
was found
to be better
than no treatment
at all, there
were
very few excellent
results.
When
reported,
the
reduced98.

cal reduction

quadriceps
strength
was
Most
authors
concluded

always
markedly
that an anatomi-

ofthe
On
poles

Comminution

rare

ofthe

with

Adequate

occasions,

remain

but

adequate

the

central

severely
comminuted.
A patella
tune pattern
can sometimes
be
reduction

and

internal

the distal
pole
(after
ments)
with
use of
VOL.

75-A,

NO.

fixation

and
of the

inferior
patella

with this unusual

salvaged
with an
of the

proximal

is
fracopen

pole

with
use
be permitted

tion
that

of

1993

to maintain
postoperatively.

the patella
Even

fracture
is loaded
Weight-bearing

is satisfactory,

be permitted.
and the time

fractures,
a range
first several
weeks.
of motion
are

have

with

Thus,
for

of

in a
with
with
itself

weightbalance,

a range

of moof motion
before
a

The amount
that
is needed

depend
well fixed,

of motion
The ideal
not

minimized

state.
support

an external
as tolerated.

wound-healing

can generally
is allowed

on the
simple,

stability
transverse

of

can be initiated
within
the
techniques
for early range

been

identified.

active

flexion

mobilization

Disruptive
followed

forces
by

passive

techniques

can be safely per-

Resistive

for most patients

to begin
motion

exercises,

however,

who have
well before

should

be

had
this

delayed

until there
is evidence
of fracture-healing.
tective
splint
and crutches
can generally

Use of a probe discontinued

when

the

90 degrees

good

quadriceps

range

of motion
control

has
has

reached

and

returned.

Complications

to

removal
of the intervening
frageither
the modified
tension-band

10. OCTOBER

areas

of continuous
has not been

up in a non-weight-bearing

time.

Poles
superior

remaining

the role
fractures

held

Patellar

Mid-Part

portion

are

be most effective
been
treated
with

not increase
quadriceps
force;
it may actually
rethe force of the contraction
of the quadriceps
comwith the force
that results
from
the limb being

the knee. It is preferable

secure
operative
repair
Patella

there

motion
may
rehealing
of an-

formed
early
postoperatively.
A removable
splint
may
be used
for protection
between
periods
of rehabilitation. With rare exceptions,
a range
of motion
should
be
initiated
by six weeks
to prevent
prolonged
stiffness
of

patellectomy.
Severe

ice
and

extension.

and secure
internal
fixation,
or partial
patwere
preferable
to total
patellectomy.
Total
should
be reserved
for salvage
treatment
that cannot
be fixed or treated
with partial

ellectomy,
patellectomy
of fractures

might
has

extension,
the
of the quadriceps.

range
of motion
is initiated
the operative
repair.
With

that
have

with

enythema

does
duce
pared

Once

of

contact

passive
improve

technique
fracture

It is generally
impossible
mechanically
unloaded
state

bearing,
should

found

as the

occur
and are at times
infection;
however,
they

and

exposed
passive

75 per
et

commonly
may suggest

excision

an extension
after
total

as well

Marked

despite
reasonable

of twenty-five
patients
who
only
seven
had
quadriceps

to or greater

intact

prolonged

articulan

patellectomy.
had

or

ticular
when

and strengthena loss of range

is sustained

tissue,

resolve.

the knee
in full
each contraction

of knee extensor
discomfort

9-A

with these
injuries,
it is important
closely
after the operation.
Place-

wound-healing.

one method
on another.
After
operative
repair,
these
patients
should
be managed
with application
of a cylinden or above-the-knee
cast for six weeks,
after which
the

a loss
persistent

(Figs.

frequently

of soft

fracture

no major

total
patellectomy,
may be the only

that

layer

bandages

determined.

of motion,
lag, and

described

Management

trauma

swelling
that occurs
to monitor
the wound

treatment.
The defect
resulting
from removal
of the patella can be closed
in a ventical,purse-stning,
on transverse
fashion.
There
is no convincing
evidence
to recommend

cast is removed
ing exercises
are

already

overlying

Postoperative
duce
stiffness

comminuted

fragments

fragment
remaining
intact,
its recognized
limitations,

of the

thin

usually

knee.

a severely

technique

Because
by the

Patellectomy

For

screw
9-E).

Postoperative

of forty
patients
patellectomy,
the

patients

of the

1559

PATELLA

early motion.

study
partial

They
recommended
only when
the entire

comminuted

of the

THE

on the
through

as to reas-

in eleven
(28 per cent),
fair in six (15 per cent),
poor
in three
(8 per cent)29.
Quadriceps
strength
on the average,
85 pen cent of the strength
on the

uninjured

with

soft-tissue

one long-term
follow-up
had been
managed
with

result
good
and
was,

necessary;

a tenuous

OF

Infection:

patellar

Fortunately,
infection
after
is uncommon;
however,

fracture

a repair
because

of a
the

I560

F.

J.

thin overlying
skin is often
be delayed
and infections
treated
sionally,

with
with

local
open

by delayed

damaged,
wound-healing
may develop.
Infection

closure.

managed

initially

with

However,

if the

infection

ous

or if there

sis, a formal

ROBERTA

incision

and

antibiotics.

the

subcutane-

fracture

of septic

and

should

internal

fixation

be

may

osteoarthrobe performed,

of patehlar

complication
is most
commonly
or underappneciated
fragment
volving

the distal

fixation

wires

pole

(Fig.

fractures.

due to
comminution,

10). This

unrecognized
usually

condition

allows

of motion

prevent
further
displacement
while allowing
tory healing.
If, however,
major displacement
three

millimeters)

occurs,

a reoperation

sary. Partial
patellectomy
salvage
procedure.
This
avoidance
the

of open

quality

Knee
a patellar

of the

one

bone

or two

weeks)

and

internal

fixation

when

degrees
of flexion
Early
motion

may

help

to reduce

is lost
(within
the

full
first

incidence

of

stiffness,
so it is important
to obtain
Seat the time of the repair.
Prolonged
immohas been
contracture.

despite

treated
operatively
If an extension

develops

apy,
tune

operative
treatment
(removal
hardware
and knee
anthroscopy

intensive

of adhesions)
may be necessary.
verity
of the patellar
restriction,
lease,
or both,
may be necessary.
knee
should
be included
it should
be done
gently

Depending
lateral
or
Manipulation

of
with

osteoarthrosis:

Because

the patellofemorah
following
patellar

of the

1930

fractures.

to 1951,
patellar

needed
adequate

is probably
Irritation
subcutaneous

bone,

readily

after

not uncommon5.
S#{248}rensen3 evaluated
patients
ten to
thirty
years after a patellar
fracture
and found
that fortyfive (70 per cent) ofsixty-four
knees
demonstrated
patellofemoral
osteoanthrosis
compared
with twenty
(31 per

that

not

unite.

to be on the

treatment.
However,
if the
in noticeable
weakness
of

the

indicated

treatment

osseous
present,

hardware

defect.
partial

the

has

palpable.
irritating

bothersome.

However,
patellectomy

the

that

is necessary,

is open

excision
of intervenbone-grafting
if it is

the procedure
of choice.
from
hardware:
Because

removal

magni-

did

reported

fixation
with
supplemental

to correct
a large
bone stock is not

routine

joint,
postfracture
is

in

S#{248}rensen3 found

was

not need
or results

mechanism,

are less commonly

is

However,

fractures

of non-union

and internal
tissue
and

fraclysis

quad-

of ad-

fractures
were
more
often
non-union
was more
comstudy of patients
who had

and
follow-up

son mechanism
does
non-union
is painful

then-

on the semedial
neof the

Quadnicepsplasty
an associated

displaced

fracture
fixation
is frequently
knots
seem to be particularly

as part of this procedure,

but
and with consideration
for the

compromised
extensor
mechanism.
not indicated
unless
there
has been
niceps
or femoral
injury.
tude of the loads
across
traumatic
osteoanthrosis

physical

minimization

in

order
of 1 pen cent or less34. If non-union
does
occur,
treatment
should
be based
on the symptoms.
A patient
with a painless
non-union
and a well functioning
exten-

reduction
ing fibrous

while
the

re-

surface.

patellar

of the

the rate

of damage
fracture

non-union
after
a fracture
of
because
of the frequent
opera-

of

from

the extensor
of knee motion
after
than the exception.

contracture

Post-traumatic

neces-

is questionable.

of a knee
that
to postoperative

secondary
fixation

be

management

the past, displaced

treated
non-operatively
mon. In a long-term

Recently,

type
good

Clearly,
the goal
of this complication
and

anticulan

Non-union:
Presently,
patella
is uncommon

cent

This

with

patellectomy.
is avoidance
reduction

to the

managed

blow.
even

Although
there
is no simple
way to
osteoanthrosis,
symptoms
may be
patellectomy.
elevation
of the tibial

fracture
insults

10 to 55 per

for satisfac(more
than
may

by accurate

been

the most successful

is best prevented
by

Some
slight
loss
is the rule rather

only a few
is maintained.

postoperative
cure fixation
bilization
can lead

reduction

stiffness:
fracture

Generally.
extension

is generally
problem

or even total
management

tive

may

suspension

tubencle,
fracture

the

with

a direct

and repair7.
post-traumatic
with partial

the

If it
and

and

the

from

to osteoarthrosis,

duction
manage
reduced

in-

the distal
pole with contraction
of the quadriceps.
is recognized
before
there
is marked
displacement
the development
of articular
incongruity,
immobilization
in extension

through

resulted
lead

ditional

of

knee

to slide

This

substance

the

or screws

knees.
Osteoarthroincongruity
and the
which
lead to over-

and

can

followed
by delayed
closure.
Occasionally,
joint
aspiration through
an uninfected
area,
with a cell count
and
culture
of the fluid, helps
to guide
treatment.
Loss
of fixation:
Loss
of fracture
fixation
and reduction
is a disheartening
complication
after
open
reduction

cent) of the contralaterah,

uninjured
sis may
be due to residual
joint
resulting
increased
contact
stresses,

care

is a question
drainage

L. S. MATTHEWS

below

infections

wound

extends

or, occafollowed

AND

load and premature

degeneration
of the articular
cartilage. Additionally,
the anticuhar
surfaces
are frequently
injured
at the time of the fracture,
especially
when
the

Superficial

local

KASMAN.

can
be

can

wound
care and antibiotics
irrigation
and d#{233}bnidement

wound

tissue

CARPENTER.

patella

been

is a

used

we

for

Wires
and wire
to tissues;
screws

We do not think
but

if

remove

that

hardware

fracture

is solidly

united

discomfort.
In summary,
distraction
and

if the

patient

patellar
three-point

fractures
bending

usually
occur
from
of the patella
as well

as from

blows.

has

direct

for fractures
that are
tens and may include

Operative

tion, partial
patellectomy,
We have presented
a new
of a simple
transverse
results
in laboratory

treatment

displaced
more
open
reduction
or rarely,
technique

than
and

is necessary
two millimeinternal
fixa-

total
patellectomy.
for the stabilization

fracture
that has provided
superior
tests. Postoperative
complications

can be minimized
by good
attention
to wound
care,
accurate
fracture
reduction,
secure
fracture
fixation,
and
an early
range
of motion.
Despite
the surgeons
best
efforts,
however,
post-traumatic
osteoarthnosis
may develop
and may lead to additional
treatment.
THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

FRACTURES

OF

THE

1561

PATELLA

References
1. Andrews,
2.

J. R., and

Benjamin,

Hughston,

.J.; Bried,

J. C.: Treatment

J.; Dohm,

M.;

fractures.

J. Orthop.

3.

Bostman,

0.;

Kiviluoto,

0.;

and

4.

Bostman,

0.;

Kiviluoto,

0.;

Santavirta,

Trauma

Surg.,

5.

Bostr#{246}m, A.:

6.

Curtis,

7.

Donohue,

of the

.J. M.;

D.;

11.

Buss,
and

Acta

G. S., and

Annual

Meeting

Goldstein,

of The

S. A.;

D. P.; Carey,

12.

Grogan,

13.

Haajanen,

J., and

14.

Heckman,

.J. D.,

424-428,
15.
16.
17.

displaced

J.; and

of 422
of the

T. R., Jr.;
65-A:

patella

patella.

and

948-957,

fractures

ofthe

WiIppuIa,

E.: Fractures

fractures.

Acta

various

Med.

forms

patella.
of the

use

American

Academy

Weiss,

J., 70: 809-813,

of

fixation

of

817,

1977.

transverse

patellar

Injury,

13: 196-202.

patella

treated

1981.

by operation.

Arc/i.

Orthop.

and

of two

T. P.; Leffers,

R. C., Jr.: The

Alkire,

C. C.:

screws

and

M.;

Ogden,

titanium

and

of indirect

follow-up.
follow-up

patella.

patellar

cable

B.;

and

hundred

fractures.

for

the

Francisco,

Joint

blunt

143,
Surg.,

1972.

72-B(2):

trauma

on

280-282,

adult

1990.

canine

articular

Acta Orthop.
Scandinavica,
60: 712-714.
1989.
results
with
special
reference
to functional
of patella

of the

Feb.

L. S.:

patella.

consecutive
A

fixation
California.

Matthews,

fractures

One

pole

San

Meller,

.J. A.: Avulsion

of the

Distal

effects

A 30-year
Long-term

Surgeons,

Grossnickle,

D.; and

Supplementum

J. Bone

1976.

of Orthopaedic

E.: Fractures

Scandinavica,
methods.

1983.

of cannulated

A.-P.;

Orthop.

A comparison

Thompson,

Sept.

47: 441-447,

J. D.: The
E;

G. R., and

165-168,

1979.

Huberti,

H. H.;
2: 49-54,

proposed

common

in children:

a report

Patellar

J. Pediat.

cases.

fractures.

Ann.

surface
Orthop.,

Chir.

Poster

exhibit

at the

18. 1993.
strain.

70: 32-35,

of injury.

Am.

J. Bone

and

Res.,

4:

1990.

10: 721-730,

Gynaecol.,

mechanism

J. Orthop.

1981.

J. Sports

Med.,

12:

Hung,

Ackroyd,

Hayes,

C. E.: Sleeve

W. C.;

Stone,

fractures

J. L.; and

of the

Shybut,

patella

G. T.: Force

ratios

in the

of three

quadriceps

cases.

tendon

and

Joint

ligamentum

Surg.,

61-B(2):

patellae.

J. Orthop.

1984.

L. K.; Chan,

16: 343-347,

K. M.; Chow,

Y. N.; and

Leung,

P. C.: Fractured

patella:

operative

treatment

using

the

tension

band

principle.

Injury,

1985.

18.

.Jakobsen,

19.

Kaufer,

H.:

Levack,

B.;

20.

A study
fractures

Oegema,

Karaharju,
and

Southern

of

1984.

Houghton,

Res.,

patella.

Surg..

Coale,

1986.

Comminuted
S.; Nirhamo,

Scandinavica,

Cole,

372-377,

patellectomy.

evaluation

0.; and Redlund-Johnell,

I.: Patellar
fractures.
J.; and
Kallio,
P.: Patellectomy
after
fracture.

Orthop.

Goings,

by partial

Biomechanical

1987.

Nirhamo,J.:

for

Joint

B.; Johnell,
S.; Aho,
A.

fractures

M.:

1983.

fixation

J. Bone

Edwards,
Einola,

78-81,

Fracture

disability.
10.

102:

of patellar

McMurtry,

1: 219-222,

M. J.: Internal

cartilage.
8.
9.

Trauma,

and

J.; Christensen,

K. S.; and

Mechanical

function

Flannagan,

J. P.; and

Rasmussen,

of the

0.

patella.J.

Hobbs,

5.: Patellectomy.

Bone

A 20-year

andJoint

S.: Results

Surg.,

of surgical

follow-up.

53-A:

Ada

1551-1560,

treatment

of

Orthop.

Dec.

patellar

Scandinavica,

56: 430-432,

1985.

1971.

fractures.

J. Bone

and

Joint

Surg.,

67-B(3):

416-

419, 1985.
21.

Matthews,

L. S.; Sonstegard,

navica,
22.

48: 511-516,

Merchant,
Joint

A. C.; Mercer,

Surg.,

56-A:

D.

A.;

and

Henke,

J. A.:

Load

bearing

characteristics

of the

R. L.; Jacobsen,

1391-1396,

and

Cool,

C. R.:

Roentgenographic

analysis

Muller,

M.

25.

Group,
Peeples,

translated
by J. Schatzker.
Ed. 2, pp. 348-252.
New York,
Springer.
1979.
R. E., and Margo,
M. K.: Function
after
patellectomy.
Clin. Orthop.,
132:

26.

Perry,

C. R.;

McCarthy,

J. A.;

clinical

study.

J. Orthop.

Trauma,

Rae,

Rorabeck,

P. S., and

29.

Smidt,

31.

Sarensen,

32.

Sutton,
Thompson,

June

34.

Thompson,

35.

Weber,

36.

of the
Wendt,
Joint

37.

VOL.

75-A,

andJoint

M. J.; Janecki,

NO.

Scandi-

of patellofemoral

congruence.

J. Bone

and

J. Biomech.,
H.:

R. L.:

Manual

Patellar

3: 431-451,

1970.

Internal

Fixation.

of

180-186,

fixation

Techniques

Recommended

a load-sharing

cable:

by

the

AO

1978.

protected

with

a mechanical

and

1988.
fixation

of osteochondral

dislocation

of the

fractures

patella

with

of the

patella.

osteochondral

Injury,

fracture.

19: 1 16-1 19, 1988.

A review

of eighteen

cases.

J. Bone

McClellan,

R. T.; Schneider,
andJoint

of knee
after

flexion

fracture

C. H.; Lipke,

Surg.,

J.; and

L. A.;

72-A:

and

extension.

of the

Matthews,
Oct.

Acta

6: 79-92,

Orthop.

D. B.: The

L. S.:

Results

of

treatment

of

displaced

patellar

1990.

J. Biomech.,

patella.

Kettelkamp,

and

1279-1285,

1973.

Scandinavica,

effect

34:

of patellectomy

198-212,

1964.

on

function.

knee

J. Bone

and

Joint

Surg.,

1976.
experimental

study

of surface

67-A:

10, OCTOBER

73-A:

C. J.; McLeod,

726-732,

Fracture

T. R., Jr.; Lewis,

Surg.,

patella.
.1. Bone
and
P. P., and Johnson,

Wilkinson,J.:

Orthop.

injury

to articular

cartilage

and

enzyme

responses

within

the joint.

Cliti.

Orthop.,

1975.

Bone

Surg.,

Pearson,

screw

Bone

R. C., Jr.; Oegema,

model.J.

Acta

1976.

analysis

R. C., Jr.: An

107: 239-248,

and

Herbert

prognosis

F. S., Jr.; Thompson,

and

W. P.: Acute

J. A.;

late

Willenegger,

C. C.;

patellectomy.J.

K. H.: The

in locomotion.

R.;

2: 234-240,

237-240,

G. I.: Biomechanical

537-540,

Kain,

Z. M.:

Goulet,

function

Schneider,

Bobechko,

58-B(2):

by partial

30.

33.

and

C. L.;

fractures

58-A:

Khasawneh,

Surg.,

Saltzman,

of muscle

Allg#{246}wer, M.;

C. H.,

andJoint

mechanics

R. H.;

Morrison,

27.

joint.

1974.

24.

28.

J. B.: The

Oct.

23.

E.;

patello-femoral

1977.

990-1001.

J. L.; and
Aug.

P.; Nelson,

Wallace,

C. L.; and

Thompson,

Joint Surg.,
62-A:
215-220,
March
1980.
R. P.: A study
of quadriceps
excursion,
June

of the

L.: Osteoarthrotic

changes

after

acute

transarticular

load.

An

animal

1991.
J. A.:
torque,

Efficacy

and

the

of various
effect

forms

of patellectomy

of fixation
on

of transverse

cadaver

knees.

59-B(3):

352-354,

fractures
.1. Bone

1985.
patella

1993

treated

by total

excision.

A long-term

follow-up.J.

Bone

andJoint

Surg.,

1977.

and