Patella Fractures

PATELLA FRACTURES
 INTRODUCTION
► Itconstitutes to 1 % of all the fractures of
the skeletal injuries.

► The anterior subcutaneous location of the

patella makes it vulnerable to the injury.

► The patella is of great importance in the

extension of the knee joint.
► It increases the force of the quadriceps by
increasing the leverage, protects the
articular surface of the distal femur against
violence but may be easily injured due to its
unprotected position.
 INTRODUCTION
► Huxton in 1945 and Kaufer in 1971 on the
basis of experimental work showed that the
patella was not without importance in the
knee joint and was responsible for
improving the efficacy.
► In a country like India the need to preserve
the whole or part of patella becomes
important where social habits require full
range of knee flexion.
 HISTORICAL BACKGROUND
► Before 1870, non operative method of
extension splinting were used that
attempted to reapproximate the fractured
fragment and relax the pull of quadriceps
muscle.
► In 1877 Cameron in Glasgow, Scotland
performed the first operation.
► In 1907 Willer is probably the first person to
perform total patellectomy.
 HISTORICAL BACKGROUND
► In 1915 Phemester advocated direct repair
of patellar fracture using silk sutures.
► In 1935 Thomson advocated partial
patellectomy in the treatment of certain
fracture.
► In 1950 Pouwel reported on the treatment
of patella fracture using an anterior tension
band wiring.
 HISTORICAL BACKGROUND
► The AO group (Muller 1970) modified
anterior tension band wiring by introducing
anterior application of wires and advocate a
dynamic and functional form of patellar
fixation.
 Anatomy
► Largest sesamoid bone
► Develops in the tendon
of quadriceps femoris
► Thick articular cartilage
proximally 4-5mm
thick
 Anatomy
► It is situated in front of
the lower end of femur
about 1 cm above the
knee joint
► Ossification 2-3 years
but delayed to 6 years
► Triangular in shape
base directed
proximally and apex
distally
 Anatomy
► Articular surface
divided into medial and
lateral facets by
longitudinal ridge and
it has an odd facet
► The medial and lateral
facets are divided into
superior medial and
inferior facet
► Distal pole non
articular
 ANATOMY
► Patellar osteology has been classified by
Wiberg based on the size of the facets into
3 types:
1. Where both medial and lateral facets are
equal in size
2. Lateral facet more than medial
3. Medial progressively smaller than lateral.
 Anatomy
Blood Supply
Extra osseous
 Primarily derived from
loose connective tissue
primarily by dorsal
arterial ring derived
from genicular branches
around the knee
► Intraosseous
The primary blood supply of the patella
enters the bone by the way of the
anastomotic vessels through the midline of
the anterior portion of the body of the
patella and the distal pole vessels.
► PATELOFEMORAL
CONTACT AREAS AT
DIFFERENT DEGRES
OF FLEXION
 Biomechanics
► The patella undergoes approximately 7 cm
of translation from full flexion to extension
► Only 13-38% of the patellar surface is in
contact with the femur throughout its range
of motion
 Biomechanics
► The patella increases
the moment arm about
the knee
 Contributes up to 30%
increase in force with
extension
► Patellawithstands
compressive forces
greater than 7X body
weight with squatting
and climbing stairs
 Biomechanics
► Greatest forces are at 60
degrees of flexion
► 3-4 times greater strain
are at the insertions
compared to the
midsubstance prior to
failure
► Forces through the patellar
tendon are 3.2 times body
weight while climbing
stairs
 Biomechanics
► Duringthe full extension
The patella lies in the supra patellar fossa
in a bed of fat and synovium on the anterior
aspect of shaft of the femur.

Two thirds of the posterior surface of the patella

articulates with the supratrochlear facet depending
on varying degree of knee flexion.
 Biomechanics
► As the flexion proceeds the force upon the
patella gradually increases and the patella
articulates with the trochlea in a distal to
proximal fashion.
► This increasing force is dissipated by the
increased patellar femoral contact with
increasing flexion.
 Biomechanics
► As the force increases more rapidly than
the surface area of contact the, the stress
on the patella increases significantly with
flexion.
► This increases the mechanical advantage of
quadriceps tendon by elevating the extensor
mechanism from the axis of rotation of the
knee joint.
 Biomechanics
► Twice as much torque
is needed to extend
the knee the final 15
degrees than to extend
from a fully flexed
position to 15 degrees
of flexion (additional
60% of energy)
 Functions of Patella

► Elevating the extensor mechanism from

the axis of rotation of the knee joint.
► Provides cartilage on cartilage articulation,
this increases the efficiency of extensor
apparatus to tolerate high compressive load.
 Functions of Patella
► Centralises the divergent forces of the
quadriceps.
► Acts as a protective shield for the joint and
protects the articular cartilage of the
anterior femur and tibia from direct trauma.
► It aids in the nourishment of femoral
articular surface.
► The most significant effects of fracture of
the patella are loss of continuity of the
extensor mechanism of the knee and
potential incongruity of the patellofemoral
articulation.
 Mechanism of Injury
► Direct blow to the
anterior knee
(dashboard injury)
► Fall from height
► Rapid knee flexion with
quadriceps resistance
 Mechanism of Injury
► Indirect injury – occurs from a near fall, a
fall from a height or as a combination.
► This occurs when the force from the
extensor mechanism exceeds that of the
intrinsic strength of the patella.
 Clinical Features
► Age 20-50 years
► Male>Female

► Pain,
swelling, contusions, lacerations
and/or abrasions at the site of injury
 Physical Examination
► Palpable defect
► On palpation
► Displaced maximum tenderness, a
defect or separation of fragments with signs
of effusion.
► Undisplaced tenderness with or without
swelling.
 Physical Examination
► Fractures with quadriceps mechanism intact
fractures are difficult to diagnose.
► Assessment of ability to extend the knee
against gravity or maintain the knee in full
extension against gravity
 Etiology
► Allows prediction of outcome
► Direct trauma
 Dashboard injury
 Increasing cases with
penetrating trauma
 Often with comminution and
articular damage
► Indirect trauma
 Violent flexion directed
through the extensor
mechanism against a
contracted quadriceps
 Results in simple, transverse
fractures
 Radiographic Evaluation
► AP & Lateral
 Note fracture pattern
► Articular step-off,
diastasis
► AP-May be difficult due
to the superimposition of
distal femoral condyles.
► Lateral- Fracture line,
fragment displacement,
congruity of the articular
surface, patellar position.
 Radiographic Evaluation
► Special views
 Axial or sunrise
 Assess vertical fracture line and displacement
and osteochondral defects.

Presence of fat globules in the X-rays without any

evident fracture line strongly suggests the
presence of an intra-articular fracture.
 Radiographic Evaluation
► Bipartite Patella
 Obtain bilateral views
 Often involves
superolateral corner
 Accessory ossification
center
► CT Scan
 -Occult fractures
 Comparison to differentiate with biparette
patella.
► MagneticResonance Imaging
Osteochondral defects
► Bone scan
Is useful in the diagnosis of stress
fractures.
 Classification
► Allowsprediction of
treatment
► Types
 Transverse
 Marginal
 Vertical
 Comminuted
 Osteochondral
 Classification
► Non displaced
► Transverse (Indirect)
► Stellate (direct)
► Vertical (direct)
► Displaced
► Transverse
► Stellate
► Multifragmented
► Polar
► Proximal
► Distal
► Osteochondral
 STRESS FRACTURES
► Occur due to combination of tension and
bending forces leading to break in the
patella.
► They occur in periprosthetic fractures
following total knee replacement or
following anterior cruciate ligament graft
harvest for ACL reconstruction surgery.
 SALINE TEST
► An open wound in the vicinity of a patellar fracture
may be a sign of an open fracture, which is a
surgical emergency. If uncertainty exists as to
whether the open wound communicates with the
joint, the saline test can be used. Under sterile
conditions, an 18-gauge needle and a 50-ml
syringe are used to aspirate the knee joint. The
needle is left in place, and 50 ml of sterile saline is
injected into the joint. If the saline flows out
through the wound, then the fracture is open.
 Treatment
► Restoration of the fracture fragment or
excision of patella partially or totally with
repair of quadriceps mechanism.
► Rest to the part till healing of the
quadriceps expansion or fracture healing.
► Restoration of quadriceps power and normal
knee function.
 TREATMENT
► Non displaced
► Transverse (Indirect) Fragment separation <3mm Cylindrical cast
► Stellate (direct) Articular displacement <2mm ROM brace
► Vertical (direct) Intact extensor mechanism
► Displaced
► Transverse Fragment separation >3mm MTBW
Articular displacement >2mm Lag screws
Disrupted extensor mechanism LAB

► Stellate Cerclage wire MTBW

► Multifragmented Cerclage wire Partial patellectomy Patellectomy

► Polar
► Proximal Lag screw
► Distal Partial Patellectomy
► Osteochondral loose body repair/removal
 Nonoperative Treatment
► Indicated for nondisplaced fractures
 <2mm of articular stepoff and <3mm of
diastasis with an intact extensor mechanism
► May also be considered for minimally
displaced fractures in the elderly
► Patients with a extensive medical
comorbidities
 Nonoperative Treatment
► Long leg cylinder cast for 4-6 weeks
 May consider a knee immobilizer for the elderly
► Immediate weightbearing as tolerated
► Rehabilitation includes range of motion
exercises with gradual quadriceps
strengthening
 Operative Treatment
► Goals
 Preserve extensor function
 Restore articular congruency
► Preoperative Setup
 Tourniquet
► Prior to inflation, gently flex
the knee
► Approach
 Longitudinal midline incision
recommended
 Transverse approach
alternative
 Consider future surgeries!
 SURGICAL TECH
► THE PATIENT IS
PLACED IN SUPINE
POSITION.THE KNEE
IS SUPPORTED IN A
SEMIFLEXED
POSITION WITH
BOLSTER
 SURGICAL TECH
► THE STRAIGHT MID LINE
SKIN INCISSION STARTS
2 cms PROXIMAL TO
DISPLACED PROXIMAL
FRAGMENT OF THE
PATELLA AND RUNS
DISTALLY TO THE TIBIAL
TUBEROSITY
 Operative Treatment
► Indications
► Patellafractures with >2mm of articular
displacement or 3mm of fragment
separation.
► Osteochondral fracture with displacement of
loose body in the joint.
► Open fracture of patella.
 Operative Treatment
A. Open reduction and internal fixation
1. Circumferential wire loop (Dengre Martin)
2. Wire loop fixation through both fragments
(Magnusson).
3. Tension band wiring by AO group.
 Operative Treatment
B. Partial patellectomy
C. Total patellectomy
 COMMON APPROACH
►A transverse curved incision.
► The apex of the curve on the distal
fragment.
► If the fracture fragments are significantly
separated tears in the extensor mechanism
are presumed and should be carefully
explored.
 COMMON APPROACH
► Remove all detached fragments of bone and
inspect the interior of the joint especially
the patellofemoral groove for an
osteochondral fracture.
► Thoroughly irrigate the joint to remove the
blood clots.
► Repair the extensor mechanism.
 Circumferential wire loop
► Dengre Martin
► Formerly the most common technique.
► A delay in knee mobilisation for 3-4 weeks.
► It has largely been replaced by more rigid
fixation techniques to permit early
mobilisation of the knee joint.
► It can be used in conjunction with other
techniques for fixation of comminuted
fractures.
 WIRE LOOP FIXATION THROUGH
BOTH FRAGMENTS
Magnusson
► Make two holes through the proximal fragment
beginning at the medial and lateral borders of the
quadriceps tendon and directed obliquely
downward to open on the fracture surface
posterior to a point midway between anterior and
posterior surfaces.
► Drill two holes in the distal fragment, their
apertures being opposite those the proximal
fragment.
 WIRE LOOP FIXATION THROUGH
BOTH FRAGMENTS
► Then thread a No.18 wire distally through
medial holes and then proximally through
the lateral holes.
► After properly opposing the fragments draw
the ends of the wire taut and twist them
together.
► Cut of the extra wire and embed the twisted
ends in the soft tissue.
► Supplemental internal fixation using
threaded pins or lag screws in addition to
wire loops is occasionally required.
► Lag screws produce interfragmentary
compression.
 TENSION BAND WIRING
► The AO group in Switzerland has used and
recommended tension band wiring principle
for fixation of fractures of patella.
► The proper placing of wires converts
distracting forces into compressive forces,
resulting in earlier union and allowing early
mobilisation of the knee joint.
 TENSION BAND WIRING
► Shawecker describes a similar technique but
crosses the wire in a figure of eight over the
anterior surface of the patella.
► Again supplemental lag screws or Kirshner
wires may be used to increase fixation in
comminuted fractures.
 Operative Techniques
► Modified tension band wiring
► Lag-screw fixation
► Cannulated lag-screw with tension band
► Partial patellectomy
► Patellectomy
 Modified Tension Band Wiring
► Transverse,
noncomminuted fractures
► After reduction, fracture is
fixed with two parallel,
2mm Kirschner wires
placed perpendicular to
the fracture which are
placed from inferior to
superior
► 18 gauge wire passed
behind proximally and
distally
 Modified Tension Band Wiring
► These wires are inserted as parallel as
possible and should be 5 mm deep to
anterior surface.
 Modified Tension Band Wiring
► Wire converts anterior
distractive forces to
compressive forces at the
articular surface
► Two twists are placed on
opposite sides of the wire
 Tighten simultaneously to
achieve symmetric tension
► Repair any retinacular
tears
 Lag-Screw Fixation
► Indicated for
stabilization of
comminuted fragments
in conjunction with
tension band wiring or
cerclage wires
► May also be used as
an alternative to
tension band wiring for
transverse or vertical
fractures
 Lag-Screw Fixation
► Contraindicated for extensive comminution
and osteopenic bone
► Small secondary fractures may be stabilized
with 2.7mm or 3.5mm cortical screws
► Transverse or vertical fractures require
3.5mm or 4.5mm cortical screws
 Retrograde insertion of screws may be
technically easier
 Cannulated Lag-Screw With
Tension Band
► Fully threaded screws
placed with a lag
technique
► Wire through screws
and across anterior
patella in figure of
eight tension band
 Cannulated Lag-Screw With
Tension Band
► Most stable construct
 Screws and tension band wire combination
eliminates both possible separation seen at the
fracture site with modified tension band and
screw failure due to excessive three point
bending
 AFTERTREATMENT
► The limb is placed in extension in a posterior plaster splint
or removable knee brace.
► The patient is allowed to ambulate while bearing weight as
tolerated on the first postoperative day.
► Isometric and stiff-leg exercises are encouraged, beginning
on the first postoperative day.
► In patients with stable fixation and limited retinacular
tears, continuous passive motion can be initiated
immediately after surgery if desired.
► Active range-of-motion exercises can be performed when
the wound has healed, at approximately 2 to 3 weeks.
► Progressive resistance exercises can be begun and the
brace discontinued at 6 to 8 weeks if healing is evident on
roentgenogram.
► Unrestricted activity can be resumed when full quadriceps
strength has returned, at approximately 18 to 24 weeks.
► In patients with less stable fixation or extensive retinacular
tears, active motion should be delayed until fracture
healing has occurred.
► Initiating range-of-motion exercises by the sixth
postoperative week is desirable but not always possible. A
controlled-motion knee brace can be used, allowing full
extension and flexion to the degree permitted by the
fixation as determined intraoperatively.
 AFTERTREATMENT
► If fixation is lost and the fragments separate 3 to 4
mm or 2 to 3 mm of articular incongruity is
present, revision surgery may be required.
► If the reduction improves with the knee in full
extension, the patient can be treated by 6 weeks
of splinting or casting with the knee in full
extension. If the reduction does not improve,
revision fixation or partial patellectomy should be
considered.
► Hardware can be removed after fracture healing if
it causes symptoms.
 Advantages of open reduction and
internal fixation
► It restores the functional integrity of bone.
► It restores the protective mechanism that is
necessary for a normal knee.
► The symmetry of the knee joint is
maintained.
► The period of immobilisation is reduced.
► The residual disability is minimum.
 Disadvantages
► There is often difficulty in restoring a
smooth articular surface and some degree
of roughening may occur which predisposes
to early osteoarthritis.
► Comminution of fragments will not allow
proper reduction.
► The use of metal screws and wires for
fixation near a joint is likely to cause
reaction.
 Disadvantages
► Circumferential repair is detrimental
because it may strangulate the nutrient
vessels resulting in avascular necrosis.
► Separation of fragments may occur inspite
of fixation due to the continuous distraction
forces of the quadriceps which is largely
responsible for the occurrence of fibrous
union.
 Partial Patellectomy
► Indicated for fractures
involving extensive
comminution not
amenable to fixation
► Larger fragments repaired
with screws to preserve
maximum cartilage
► Smaller fragments excised
 Usually involving the distal
pole
 Partial Patellectomy
► Tendon is attached to fragment with
nonabsorbable suture passed through drill holes in
the fragment
 Drill holes should be near the articular surface to
prevent tilting of the tendon and minimize articular
step-off
► Watch for patellar tilt!
► Load sharing wire passed through drill holes in the
tibial tubercle and patella may be used to protect
the repair and facilitate early range of motion
 Perry et al
► The cable protects the patellar tendon
repair by transmitting tensile loads directly
from the quadriceps tendon or proximal
pole of the patella to the tibial tubercle.
► This technique also can be used to protect
tenuous internal fixation of patellar
fractures, and it allows more aggressive
rehabilitation.
 Total Patellectomy
► Indications
1. Displaced, comminuted fractures not
amenable to reconstruction.
2. Bone fragments sharply dissected.
3. In old ununited or malunited fracture
complicated by patellofemoral arthritis.
 Total Patellectomy
Disadvantages
1.Obvious atrophy of the quadriceps muscle
persists for months and often permanently.
2. Protection of knee by patella is lost.
3.Strength of quadriceps regains slowly but
motion of the knee is regained quite fast.
 Total Patellectomy
► 4. Pathological ossification may develop
where patella is excised.
► 5. Results in extensor lag and loss of
strength.
► 6. The purse-string suture shortens the
quadriceps mechanism and helps prevent
extensor lag, which is common after
patellectomy.
 Postoperative Management
► Immobilization with knee brace
► Immediate WBAT
► Early range of motion
 Based on intraoperative assessment of repair
 Active flexion with passive extension
► Quadriceps strengthening
 Begun when there is radiographic evidence of
healing, usually around 6 weeks
 Recent advancements in treatment
of patella fracture
► Osteosynthesis of inferior patella pole
avulsion fracture.
► Arthroscopic assisted percutaneous screw
fixation of selected fractures.
► Self locking tension band technique.
► Internal fixation of patellar fracture with
absorbable suture.
► Percutaneous tension band wiring for
minimally displaced fractures.
 Osteosynthesis of inferior patella
pole avulsion fracture
► Ideal treatment
► By preserving the normal length of the
patella we can maintain functional length of
the extensor mechanism.
► Immediate post operative mobilisation and
early full weight bearing.
 SURGICAL TECH
► THEDISTAL
FRAGMENT OF THE
FRACTURE ARE FIXED
WITH BASKET PLATE
 SURGICAL TECH
► THEPOLE
FRAGMENTS WITHIN
THE PLATE ARE
REDUCED AND FIXED
 SURGICAL TECH
► Preoperative X-Ray
showing avulsion
fracture of patellar
pole.
 SURGICAL TECH
► Post of X-Ray showing
reduction of the
fracture.
 Arthroscopic assisted percutaneous
screw fixation of selected fractures
► This is done percutaneously by using cannulated
screws and cerclage wire under arthroscopic
visualisation mainly for minimally displaced
transverse fracture patella.
► Minimally invasive and does not disturb the
vascular supply of patella.
► Direct visualisation of the reduction stability of
fixation and early post operative range of motion.
 Self locking tension band technique
► This is slight modification of AO modified
ATBW, to prevent proximal migration of K-
wires.
► In this the proximal ends of K-wire are bent
to form a loop and cerclage wire passed
through them.
► In this K-wires and cerclage wire lock each
other.
 Rest to the part till healing of
quadriceps expansion or healing of
fracture
► Posterior slab groin to ankle is applied.
► Encouraged to perform quadriceps setting
exercises and within a few days should be
lifting the leg off the bed.
► 10 th day suture removal and cylindrical
cast is applied with the knee in extension.
 Rest to the part till healing of
quadriceps expansion or healing of
fracture
► Patient is allowed to be ambulatory when
active muscle control of the leg is obtained.
► After 3 weeks active assisted exercises are
begun.
► In patients treated by MTBW Isometric
quadriceps exercises are begun as soon as
pain decreases and it helps healing of
fracture and prevents quadriceps wasting.
Restoration of quadriceps power and
normal knee function
► Watson-Jones “Redevelop the quadriceps :
exercise for five minutes hourly throughout
the day”. Almost every injury of the knee
should be treated from the first day regular
quadriceps drill.
1.Rhythmic quadriceps drill, quadriceps
setting or isometric contraction.
2. Straight leg raising.
3. Loaded straight leg raising.
 Complications
► Knee Stiffness
 Most common complication
► Infection
 Rare, depends on soft tissue compromise

► Loss of Fixation
 Hardware failure in up to 20% of cases
 Complications
► Osteoarthritis
 May result from articular damage or incongruity
► Nonunion < 1% with surgical repair
► Loss of quadriceps extension power
► Avascular necrosis
► Painful hardware
 Removal required in approximately 15%
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 Extensor Tendon Ruptures
► Patellarand quadriceps
tendon ruptures are
uncommon injuries
► Patients are typically
males in their 30’s or
40’s
 Patellar < 40 yo
 Quadriceps > 40 yo
► Fall, sports, MVA
 Quadriceps Tendon Rupture
► Typically occurs in patients > 40 years old
► Usually 0-2 cm above the superior pole
► Level often associated with age
 Rupture occurs at the bone-tendon junction in
majority of patients > 40 years old
 Rupture occurs at midsubstance in majority of
patients < 40 years old
 Quadriceps Tendon Ruptures
► Risk Factors
 Chronic tendonitis
 Anabolic steroid use
 Local steroid injection
 Inflammatory
arthropathy
 Chronic renal failure
 Systemic disease
 History
► Sensation of a sudden pop while stressing
the extensor mechanism
► Pain at the site of injury
► Inability/difficulty weightbearing
 Physical Exam
► Effusion
► Tenderness at the
upper pole
► Palpable defect above
superior pole
► Loss of extension
► With partial tears,
extension will be intact
 Quadriceps Tendon Rupture
Radiographic Treatment
Evaluation ► Nonoperative
► X-ray- AP, Lateral, and  Partial tears and strains
Tangential (Sunrise, ► Operative
Merchant)  For complete ruptures
 Distal displacement of
the patella
► MRI
 Useful when diagnosis
is unclear
 Operative Treatment
► Reapproximationof tendon to bone using
nonabsorbable sutures with tears at the
muscultendonous junction
 Locking stitch (Bunnel, Krakow) with No. 5
ethibond passed through vertical bone tunnels
 Repair tendon close to articular surface to avoid
patellar tilting
 Operative Treatment
► Midsubstance tears
may undergo end-to-
end repair after edges
are freshened and
slightly overlapped
 May benefit from
reinforcement from
distally based partial
thickness quadriceps
tendon turned down
across the repair site
(Scuderi Technique)
 Treatment
► Chronic tears may
require a V-Y
advancement of a
retracted quadriceps
tendon (Codivilla V-Y-
plasty Technique)
 Postoperative Management
► Knee immobilizer or cylinder cast for 5-6
weeks
► Immediate vs. delayed (3 weeks)
weightbearing as tolerated
► At 2-3 weeks, hinged knee brace starting
with 45 degrees active range of motion with
10-15 degrees of progression each week
 Complications

► Rerupture
► Persistent
quadriceps
atrophy/weakness
► Loss of motion
► Infection
 Patellar Tendon Rupture
► Less common than
quadriceps tendon
rupture
► Associated with
degenerative changes
of the tendon
► Rupture often occurs
at inferior pole
insertion site
 Patellar Tendon Rupture
► Risk Factors
 Rheumatoid
 Systemic Lupus
Erythematosus
 Diabetes
 Chronic Renal Failure
 Systemic Corticosteroid
Therapy
 Local Steroid Injection
 Chronic patellar
tendonitis
 Anatomy
► Patellar tendon
 Averages 4 mm thick but widens to 5-6 mm at
the tibial tubercle insertion
 Merges with the medial and lateral retinaculum
 90% type I collagen
 Blood Supply
► Fat pad vessels supply posterior aspect of
tendon via inferior medial and lateral
geniculate arteries
► Retinacular vessels supply anterior portion
of tendon via the inferior medial geniculate
and recurrent tibial arteries
► Proximal and distal insertion areas are
relatively avascular and subsequently are a
common site of rupture
 Biomechanics
► Greatest forces are at 60
degrees of flexion
► 3-4 times greater strain
are at the insertions
compared to the
midsubstance prior to
failure
► Forces through the patellar
tendon are 3.2 times body
weight while climbing
stairs
 History
► Often a report of
forceful quadriceps
contraction against a
flexed knee
► May experience and
audible “pop”
► Inability to weightbear
or extend the knee
 Physical Examination
► Palpable defect
► Hemarthrosis
► Painful passive knee
flexion
► Partial or complete loss
of active extension
► High riding patella on
radiographs
 Radiographic Evaluation
► AP and Lateral X-ray
 Patella alta seen on lateral view
► Patella superior to Blumensaat’s line
► Ultrasonagraphy
 Effective means to determine continuity of tendon
 Operator and reader dependant
► MRI
 Effective means to assess patellar tendon, especially if
other intraarticular or soft tissue injuries are suspected
 Relatively high cost
 Classification
► No widely accepted means of classification
► Can be categorized by:
 Location of tear
►Proximal insertion most common
 Timing between injury and surgery
►Most important factor for prognosis
►Acute- within two weeks
►Chronic- greater than two weeks
 Treatment
► Surgical treatment is
required for restoration
of the extensor
mechanism
► Repairs categorized as
early or delayed
 Early Repair
► Better overall outcome
► Primary repair of the tendon
► Surgical approach is through a midline
incision
 Incise just lateral to tibial tubercle as skin
thicker with better blood supply to decrease
wound complications
► Patellartendon rupture and retinacular tears
are exposed
 Early Repair
► Frayed edges and
hematoma are debrided
► With a Bunnell or Krakow
stitch, two ethibond
sutures or their equivalent
are used to repair the
tendon to the patella
► Sutures passed through
three parallel, longitudinal
bone tunnels and tied
proximally
 Early Repair
► Repair retinacular tears
► May reinforce with
wire, cable or umbilical
tape
► Assess repair
intraoperatively with
knee flexion
 Postoperative Management
► Maintain hinged knee brace which is gradually increased as
motion increases (tailor to the patient)
► Immediate vs. delayed (3 weeks) weightbearing as
tolerated
► At 2-3 weeks, hinged knee brace starting with 45 degrees
active range of motion with 10-15 degrees of progression
each week
► Immediate isometric quadriceps exercises
► All restrictions are lifted after full range of motion and 90%
of the contralateral quadriceps strength are obtained;
usually at 4-6 months
 Delayed Repair
►> 6 weeks from initial injury
► Often results in poorer outcome
► Quadriceps contraction and patellar
migration are encountered
► Adhesions between the patella and femur
may be present
► Options include hamstring and fascia lata
autograft augmentation of primary repair or
Achilles tendon allograft
 Postoperative Management
► More conservative when compared to early
repair
► Bivalved cylinder cast for 6 weeks; may
start passive range of motion
► Active range of motion is started at 6 weeks
 Complications
► Knee stiffness
► Persistent quadriceps weakness
► Rerupture
► Infection
► Patella baja
 Thank You!

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