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Total excision of the patella for fracture
TOTAL EXCISION OF THE PATELLA
FOR FRACTURE*
REPORT OF FOURTEEN CASES W.
RUSSELL BOSTON,
I
MACAUSLAND,
in the treatment of fractures of the pateIIa by tota excision was stimulated by the strikingly good results reported by Brooke”2 in 1937. Patellectomy was not a new method of treatment; it has been occasionally practised from 1860 in treating Iesions of the pateI1a other than fractures, and it had been used in isoIated cases of fractures from x890. Despite the enthusiastic endorsement of the method foIIowing Brooke’s report, particularly in England, and despite the many pubIications that have appeared on excision of the pateha, the cases reported have actually been few in number. Indications for patellectomy in the treatment of fractures are stiI1 not well defined. The following report covers a series of fourteen cases in which patehectomy was considered to be indicated, and in eleven of which observations after an adequate lapse of time permitted evahration of the method. The excision method was the outgrowth of the attempt to find a more promising procedure than operative suture of the patella. The latter method, which is still the orthodox form of treatment, is folIowed by prolonged disability. The knee must be immobiIized for from four to six weeks to ensure union. Then foIIows a Iong period of incapacity while union becomes firm and the quadriceps regains power. At best, work of a strenuous nature can seldom be resumed in Iess than six months. The resuIts of the open suture method in comminuted fractures are far from satisfactory. In a study of fifteen comminuted fractures that had been treated by suture methods in our clinic, only NTEREST
* From the MacAusland
M.D.
MASSACHUSETTS
two good functiona resuIts were observed. As a ruIe, the pateIIa in heaIing becomes exceedingly hypertrophied, spreading out over the femoraI condyIes Iike a pie pIate. The function is limited, and the flexion movement seldom passes beyond the right angle. In time the irregularities of the patelIar surface lead to the deveIopment of arthritic changes. Some operators claim that the results of operative suture of transverse fractures Iikewise are unsatisfactory, and that the method shouId be discarded in favor of patellectomy. Brooke213 is a staunch advocate of its use in transverse fractures, Among the objections raised to operative suture of this type.of fracture is the danger of refracture because of the fibrous union that takes pIace. It is also cIaimed that complete function is never regained, and that the knee remains weak, Ieaving a person handicapped in climbing stairs. Moreover, if it is not possibIe to secure exact aIignment of the fragments, there is the IikeIihood that the friction between the roughened patelIar joint surface and the condyIes will Iead to the deveIopment of arthritic changes. At the present time, surgeons are not quite ready to accept pateIIectomy as the routine treatment for transverse fractures, even though it is acknowIedged that the method has given excellent results. A surgeon is reIuctant to sacrifice the pateIIa when the fracture is a fresh and simple break in a young or middIe aged aduIt, because its removal presents certain possible drawbacks. Moreover, it must be admitted that the rest&s of suture fixation of the fragments and IateraI aponeurosis in transverse fractures are, on the whoIe,
Orthopedic 510
Clinic, Boston, Mass.
VOL.
LXXII,
No.
4
MacAusIand-Excision
FIG.
I. Closure of the tendon and Iateral aponeurosis with interrupted chromic catgut sutures.
satisfactory. The proIonged convalescence, which is the great objection to the method, may be shortened materiaIIy by using screw fixation, which permits motion to be started in ten days, in contrast with the four or six weeks’ deIay when suture fixation is used. Among the drawbacks to the remova of the pateIIa is the appearance of the knee, particuIarIy if the patient is a woman. Then, too, the patella undoubtedIy protects the knee joint from direct injury in Aexion positions. The possibiIity of the deveIopment of arthritic changes as the resuIt of the quadriceps passing directIy over the conin the absence of the dyIar surfaces, pateIIa, is another objection that may be raised. Bruce and WaImsIey* and Cohn,5 in experimenta observations, noted degenerative changes in the articuIar cartiIage of the joint folIowing the remova of the pateIIa. Whether simiIar changes
of PateIla
A merican Journal of Surgery
511
Frc. 2. Closure of a wide gap between the tendon edges by means of strips of fascia lata.
wiI1 appear in the knee of the human joint remains to be determined. Brooke3 observed no arthritic changes in a roentgenographic examination of twenty-nine cases in which the pateIIa had been excised from five to fifteen years previously. In the series of cases herein reported, no degenerative changes were observed in a Iate roentgenographic examination of the knees of three patients, aged thirty-five, fifty-six and seventy years, respectively. The question aIso arises as to whether the pateIIa pIays a r6Ie in the function of the knee by adding to the extension movement through a puIIey effect, whereby the quadriceps is raised up from the condyles. There is no unanimity of opinion on the function of the pateIIa. Brooke2 beIieves that the patelIa contributes nothing to the function of the knee; rather, it IS his opinion that the pateHa Acts as a deterrent to function. P: .,oke’slrz,R SUC-
512
American Journal of Surgery
MacAusIand-Excision
A
of PateIIa
OCTOBER. 1946
B
FIG. 3. A, roentgenogram taken three months after patellectomy, showing islands of ossification; B, roentgenogram of the same knee taken one year after patellectomy, showing increased density of ossified areas.
cessful results wouId certainly substantiate his opinion. HaxtonG has discussed in detai1 the r61e of the pateIIa in the knee mechanism. In Haxton’s experimenta and anatomical study, as we11 as in the experimenta1 observations of Carey, Zeit, and McGrath7 and Bruce and WaImsIey,4 the patella was found to have an important functiona vaIue. Other observers in their cIinica1 experience have noted a slight Ioss of the extension power and buckIing of the joint foIlowing pateIIectomy.*~g~10 In the series of cases being reported, a sIight Iaxity was noted in four cases. Whether a11 of these objections to pateIIectomy may be obviated by regenerated areas of bone at the former site of the pateIIa remains to be determined. The subject of regeneration is discussed further on in the paper. At the present time when so many factors are in doubt, indications for pateIIectomy are, for the most part, Iimited to certain types of fracture. In severeIy comminutea fractures, whether recent or of Iong standing, :ucision offers the onIy
soIution to the diff%zuIt problem of treatment. ExceIIent functiona resuIts are obtained in contrast with the uncertain results from the suture method of treatment. The convaIescence is rapid, and hospitalization is usuaIIy necessary for onIy two weeks. Excision of the pateIIa is indicated in cases of malunion or non-union in transverse fractures that have been unsuccessfuIIy treated by other methods. In such fractures, good function is recovered folIowing pateIIectomy, and the deveIopment of arthritic changes from the irreguIar pateIIar surface is checked. OPERATIVE
TECHNIC
When the patient’s condition permits, operative excision of the pateIIa is carried out in forty-eight hours after the injury. (Figs. I and 2.) In view of the earIy deveIopment of atrophy of the quadriceps folIowing a fracture of the pateIIa, it is advisabIe not to deIay the operation for more than five days. During the period of waiting, the knee is kept tightIy bandaged
VOL. LXX1
1.
No.
MacAusIand-Excision
Q
of Patella
A
FIG. 4. A, roentgenogram of the same
taken three years knee taken six years
A mcricnn
Journd
oI’Sur~rr,y
5 1
B
after after
pateIIectomy, patellectomy,
to prevent sweIIing, and it is splinted in the position of extension and elevated. A IongitudinaI incision, extending from the region of the lower quadriceps tendon down to about I inch aIong the pateIIar tendon, and just a shade lateral to the midline, is made through the skin. If a u-shaped or a transverse preferred, incision may be used. Dissection is carried the fracture cavity, the out, exposing capsuIar tears and the traumatized quadriceps expansions. Blood clots are cIeaned out of the joint. The pateIIar fragments are easily shelled out from the quadriceps tendon, care being taken to keep cIose to the anterior and IateraI surfaces of the fragments in order to avoid sacrificing any of the tendon. The frayed edges of the extensor tendon and its medial and IateraI expansions are trimmed. The freshened edges are then approximated, if possible, the quadriceps tendon being forced down to the pateIIar tendon. It is we11 to suture the aponeurosis first, as by so doing the main part of the tendon can be sutured more easiIy. The
showing showing
idands of hone; H, roentgenogram increase in bony areas.
ends of the tendon proper are united with interrupted chromic catgut sutures. When the ends of the tendon cannot be approximated because of contracture, strips of fascia Iata taken from the thigh may be used as a running suture to close the gap. The skin is closed with interrupted sutures of silk. A compression dressing, a snug fIanne1 bandage and a ha.m splint are applied. Penicillin is given for two or three days. Postoperative Care. Most important in the postoperative treatment is the prevention of weakness of the quadriceps muscle by early mobilization. Just when contraction exercises may begin wiI1 depend upon the extent of the damage in the soft tissues as well as upon the postoperative reaction. In the average case, contraction exercises may be started at the end of the first postoperative week, and by the tenth day the patient can carry them out well. The spIint is removed on the tenth day, and the patient begins to ffex the knee gently by swinging the leg over the
3 I4
American
Journal
of Surgery
MacAusIand-Excision
of Patella
1g4h OCTOBER,
weeks after the operation. A Iaboring man is ready to resume Iight work in from six to eight weeks. Return to strenuous work is possible within three or four months foIIowing the operation. No heavy work should be undertaken unti1 the tissues are we11 healed and unti1 the quadriceps, which exerts excessive tension, is strong. REGENERATION
FIG. 5. Roentgenogram showing Iarge osseous flakes at the sixth postoperative month.
edge af the bed. Care is taken aIways to keep the motion within the limits of pain. Hot fomentations are appIied for twenty minutes, three times a day. After the tenth day the patient may waIk with the aid of crutches. At the end of the second postoperative week, the patient is discharged from the hospita1, and given instructions to continue exercising and using the Ieg. Swimming, or exercising the Ieg in a tub of hot water, Within twice a day, is recommended. from two to three weeks, motion to the right angIe is usually established. By the third week, the patient is bearing weight and waIking without the aid of crutches. In the average case the quadriceps is strong and we11 controIIed in from six to eight weeks. The knee functions we11 and is stabIe. The patient can waIk normaIIy and go up and down stairs. The rate of recovery depends to a great extent u’pon the cooperation of the patient. Just when the patient may resume work depends upon the nature of his occupation. A person who has a sedentary position may return to work in from four to six
OF THE
PATELLA
In experimenta studies by Carey, Zeit, and McGrath’ and Bruce and WaImsIey,d caIcified areas have been found to repIace the excised pateIIa. Similar foci have been noted foIIowing the remova of the pateIIa in humans by Dobbie and Ryerson,l’ AIbert,12 Wass,13 Mehriz,‘4 Murphy’5 and Schmier.16 Whether actua1 regeneration of the pateIIa takes pIace in response to a mechanica need, or whether the areas of caIcification deveIop from remaining osteobIasts is stiI1 in question. Certainly isIands of density are seen in roentgenograms foIIowing excision of the pateIIa. In a study of the Iate roentgenograms in eIeven of the cases being reported, isIands of caIcification were noted in a11 except two cases. In one case the foci were present at the third postoperative month, and one year Iater showed considerabIe increase in density. (Fig. 3.) A simiIar increase in density was seen in the roentgenograms of another case that were taken during the, third and sixth postoperative years. (Fig. 4.) A roentgenogram of one other case showed Iarge osseous flakes at the sixth postoperative month. (Fig. 5.) ANALYSIS
OF CASES
.
The series incIudes fourteen cases of fractures of the pateIIa that were treated by tota excision of the bone. Nine of the patients were maIes. In age the patients ranged from twenty-nine to seventy-seven years. The fracture is most common at middie age. Twelve fresh fractures were of the comminuted type, the patella being shat tered throughout in six cases, broken into three pieces in two cases, the Iower
VOL. LXXII,
No. x+
MacAusIand-Excision
of PateIIa
A mericnn Journal of Surgery
3 15
II
B
A
FIG. 6. A, comminuted
fracture of the patella; B, roentgenogrnm patellectomy.
haIf alone being com’minuted in three cases, and the upper half in one case. One case was a cornminuted fracture of Iong standing in which the pateIIa was extremeIy broadened. The remaining case was a transverse fracture of Iong standing, which had been treated unsatisfactorily by other methods. One fracture onIy was compound. Eight of the tweIve fresh cornminuted fractures were associated with other injuries. In two cases there were Iacerations of the knee; in two cases, abdomina1 injuries; in one case, there was a Monteggia’s fracture; in one case, a compound cornminuted fracture of the lower third of the femur on the same side as the pateIIar fracture; in one case, a fracture of the elbow; and in the eighth case, the rectus femoris muscIe was partIy severed. The period of hospitalization in a11 except one of these cases was proIonged because of the concomitant injuries, and the fina result in the case of the associated fracture of the femur was complicated by that injury. Six of the tweIve fresh fractures were oDerated uDon within four davs of the
taken two years after
injury. In the other six cases, operative interference was deIayed from one week to seventeen days because of associated in juries. The period of hospitaIization in three of the twelve cases of fresh cornminuted fractures and in the two cases of Iong standing averaged two .weeks. In one uncompIicated case, the patient was kept in the hospital for twenty-four days because of his advanced age. In the remaining eight cases, the postoperative hospitalization was deIayed because of associated injuries. Results. In eleven of the fourteen cases in this series, sufficient time has eIapsed to permit judging the Iate results. (Fig. 6.) The postoperative check in two cases was made more than six years after the remova of the pateIIa; in four cases within two to four years; in another four cases in one year after the operation ; and in one case after a period of eight months. The pateIIectomy in the remaining three patients was carried out too recentIy to permit judging the end resuIts, but the progress made in recovery has been very raDid and favorable.
516
A me&an
Journal
of Surgery
MacAusIand-Excision
Ten of the eIeven patients obtained good functiona knees with perfectIy free joint motion and stability. In five of the cases, every test of power and motion couId be met. The patients couId hoId the Ieg out straight in fuI1 extension; they couId squat fuIIy and with ease on the operated leg; they couId go up and down stairs normaIIy; and they couId waIk Iong distances with comfort. It was impossibIe to detect any difference between the function and stabiIity on the operated side and on the uninjured Ieg. Four of these patients had returned to their respective occupations, one as a freight handier, another as a railroad Iaborer, the third as a housewife, and the fourth as a chicken farmer, in from three to four months after the operation. The other patient had no. occupation. In four cases, the quadriceps was not so strong as in the norma knee, and there was a Iaxity of about IO degrees that prevented compIete extension. Notwithstanding, the quadriceps stiI1 had good power, the Aexion movement was normaI, and the patients reported no disturbance of function. The onIy compIaint was that the knee buckIed occasionaIIy. Three of these patients did arduous work, two of them in a miI1 and one in a foundry. The tenth patient, aged seventy-seven years, had compIete motion of the knee in both extension and flexion when she was examined in one year. However, she had to go down stairs a step at a time. In the eIeventh case, the outcome was poor. FIexion of the knee was possibIe to only the right angIe. There was a tender area over the bridge between the pateIIar and quadriceps tendons, indicative of weakness. SUMMARY
A report has been presented on the treatment of fourteen fractures of the pateIIa by tota excision of the bone. In eIeven of the cases, sufficient time had eIapsed to judge the end resuIts. Ten of these patients obtained good functiona knees. The convaIescence was rapid, and
OCTOBER, ,946
of PateIIa
the patients had returned to work in much shorter time than is possibIe under suture fixation methods. The procedure is considered to be indicated onIy in certain fractures. It offers a soIution of treatment in severeIy comminuted fractures, whether recent or in which under the of Iong standing, orthodox suture methods, the period of disabiIity is proIonged and the resuIts are unsatisfactory. PateIIectomy is also indicated in transverse fractures of long standing in which maIunion or non-union has resulted. The method is not recognized as the estabIished treatment of fresh transverse fractures. REFERENCES I. BROOKE, R. Effect of remova of pateIIa for simple transverse fractures on function of knee joint. Proc. Roy. Sot. Med. (Ortbop. Sect.) 30: 203-207, 1937. 2. BROOKE, R. Treatment of fractured pateha by excision. Study of morphology and function. Brit. J. Surg., 24: 733-747, 1937. 3. BROOKE, R. Fractured pateIIa. An anaIysis of 54 cases treated by excision. Brit. M. J., I: 231233, 1946. 4. BRUCE, J. AND WALMSLEY, R. Excision of pateha; some experimenta and anatomical observations. J. Bone @ Joint Surg., 24: 31 r-325, 1942. 5. COHN, B. N. E. Total and partial patehectomy: experimental study. Surg., Gynec. CT Obst., 79: 526536, 1944. 6. HAXTON, H. A. Function of pateIIa and effects of its excision. Surg., Gynec. TV Obst., 80: 389395, 1945. 7. CAREY, E. J., ZEIT, W. AND MCGRATH, B. F. Studies in the dynamics of histogenesis. Am. J. Anat., 40: 127-158, 1928. 8. HEINECK. A. P. Fractures of oatella: I too cases treated by open method. S&g., Gynec. &+ Obst., 9: 177-248, 1909. 9. WASS, S. H. AND DAVIES, E. R. Excision of pateha for fracture with remarks on ossification in quadriceps tendon foIIowing operation. Guy’s Hosp. Rep., 91: 35-57, 1942. IO. LOOMIS, L. K. Fractures of pateIIa-analysis of 150 cases at Charity HospitaI. New Orleans M. 0 S. J., 97: 173-176, 1944. I I. DOBBIE, R. P. AND RYERSON, S. Treatment of fractured patella by excision. Am. J. Surg., 55: 339-373, 1942. 12. ALBERT, S. M. Excision of the pateha. J. Iowa M. sot., 33: 184-187, 1943. 13. WASS, S. H. Treatment of fractures of patella. M. Press, 210: 87-90, 1943. 14. MEHRIZ, M. M. SimpIe fracture of pateIIa treated by removal of fragments. Lancer, I : gr, 1939. 15. MURPHY, J. J. BilateraL fracture of pateIIa. Brit. M. J., I: 725, 1943. 16. SCHMIER, A. A. Excision of the fractured patella. Surg., Gynec. & Obst., 8 I : 370-378. 1945.
FOR FRACTURE*
REPORT OF FOURTEEN CASES W.
RUSSELL BOSTON,
I
MACAUSLAND,
in the treatment of fractures of the pateIIa by tota excision was stimulated by the strikingly good results reported by Brooke”2 in 1937. Patellectomy was not a new method of treatment; it has been occasionally practised from 1860 in treating Iesions of the pateI1a other than fractures, and it had been used in isoIated cases of fractures from x890. Despite the enthusiastic endorsement of the method foIIowing Brooke’s report, particularly in England, and despite the many pubIications that have appeared on excision of the pateha, the cases reported have actually been few in number. Indications for patellectomy in the treatment of fractures are stiI1 not well defined. The following report covers a series of fourteen cases in which patehectomy was considered to be indicated, and in eleven of which observations after an adequate lapse of time permitted evahration of the method. The excision method was the outgrowth of the attempt to find a more promising procedure than operative suture of the patella. The latter method, which is still the orthodox form of treatment, is folIowed by prolonged disability. The knee must be immobiIized for from four to six weeks to ensure union. Then foIIows a Iong period of incapacity while union becomes firm and the quadriceps regains power. At best, work of a strenuous nature can seldom be resumed in Iess than six months. The resuIts of the open suture method in comminuted fractures are far from satisfactory. In a study of fifteen comminuted fractures that had been treated by suture methods in our clinic, only NTEREST
* From the MacAusland
M.D.
MASSACHUSETTS
two good functiona resuIts were observed. As a ruIe, the pateIIa in heaIing becomes exceedingly hypertrophied, spreading out over the femoraI condyIes Iike a pie pIate. The function is limited, and the flexion movement seldom passes beyond the right angle. In time the irregularities of the patelIar surface lead to the deveIopment of arthritic changes. Some operators claim that the results of operative suture of transverse fractures Iikewise are unsatisfactory, and that the method shouId be discarded in favor of patellectomy. Brooke213 is a staunch advocate of its use in transverse fractures, Among the objections raised to operative suture of this type.of fracture is the danger of refracture because of the fibrous union that takes pIace. It is also cIaimed that complete function is never regained, and that the knee remains weak, Ieaving a person handicapped in climbing stairs. Moreover, if it is not possibIe to secure exact aIignment of the fragments, there is the IikeIihood that the friction between the roughened patelIar joint surface and the condyIes will Iead to the deveIopment of arthritic changes. At the present time, surgeons are not quite ready to accept pateIIectomy as the routine treatment for transverse fractures, even though it is acknowIedged that the method has given excellent results. A surgeon is reIuctant to sacrifice the pateIIa when the fracture is a fresh and simple break in a young or middIe aged aduIt, because its removal presents certain possible drawbacks. Moreover, it must be admitted that the rest&s of suture fixation of the fragments and IateraI aponeurosis in transverse fractures are, on the whoIe,
Orthopedic 510
Clinic, Boston, Mass.
VOL.
LXXII,
No.
4
MacAusIand-Excision
FIG.
I. Closure of the tendon and Iateral aponeurosis with interrupted chromic catgut sutures.
satisfactory. The proIonged convalescence, which is the great objection to the method, may be shortened materiaIIy by using screw fixation, which permits motion to be started in ten days, in contrast with the four or six weeks’ deIay when suture fixation is used. Among the drawbacks to the remova of the pateIIa is the appearance of the knee, particuIarIy if the patient is a woman. Then, too, the patella undoubtedIy protects the knee joint from direct injury in Aexion positions. The possibiIity of the deveIopment of arthritic changes as the resuIt of the quadriceps passing directIy over the conin the absence of the dyIar surfaces, pateIIa, is another objection that may be raised. Bruce and WaImsIey* and Cohn,5 in experimenta observations, noted degenerative changes in the articuIar cartiIage of the joint folIowing the remova of the pateIIa. Whether simiIar changes
of PateIla
A merican Journal of Surgery
511
Frc. 2. Closure of a wide gap between the tendon edges by means of strips of fascia lata.
wiI1 appear in the knee of the human joint remains to be determined. Brooke3 observed no arthritic changes in a roentgenographic examination of twenty-nine cases in which the pateIIa had been excised from five to fifteen years previously. In the series of cases herein reported, no degenerative changes were observed in a Iate roentgenographic examination of the knees of three patients, aged thirty-five, fifty-six and seventy years, respectively. The question aIso arises as to whether the pateIIa pIays a r6Ie in the function of the knee by adding to the extension movement through a puIIey effect, whereby the quadriceps is raised up from the condyles. There is no unanimity of opinion on the function of the pateIIa. Brooke2 beIieves that the patelIa contributes nothing to the function of the knee; rather, it IS his opinion that the pateHa Acts as a deterrent to function. P: .,oke’slrz,R SUC-
512
American Journal of Surgery
MacAusIand-Excision
A
of PateIIa
OCTOBER. 1946
B
FIG. 3. A, roentgenogram taken three months after patellectomy, showing islands of ossification; B, roentgenogram of the same knee taken one year after patellectomy, showing increased density of ossified areas.
cessful results wouId certainly substantiate his opinion. HaxtonG has discussed in detai1 the r61e of the pateIIa in the knee mechanism. In Haxton’s experimenta and anatomical study, as we11 as in the experimenta1 observations of Carey, Zeit, and McGrath7 and Bruce and WaImsIey,4 the patella was found to have an important functiona vaIue. Other observers in their cIinica1 experience have noted a slight Ioss of the extension power and buckIing of the joint foIlowing pateIIectomy.*~g~10 In the series of cases being reported, a sIight Iaxity was noted in four cases. Whether a11 of these objections to pateIIectomy may be obviated by regenerated areas of bone at the former site of the pateIIa remains to be determined. The subject of regeneration is discussed further on in the paper. At the present time when so many factors are in doubt, indications for pateIIectomy are, for the most part, Iimited to certain types of fracture. In severeIy comminutea fractures, whether recent or of Iong standing, :ucision offers the onIy
soIution to the diff%zuIt problem of treatment. ExceIIent functiona resuIts are obtained in contrast with the uncertain results from the suture method of treatment. The convaIescence is rapid, and hospitalization is usuaIIy necessary for onIy two weeks. Excision of the pateIIa is indicated in cases of malunion or non-union in transverse fractures that have been unsuccessfuIIy treated by other methods. In such fractures, good function is recovered folIowing pateIIectomy, and the deveIopment of arthritic changes from the irreguIar pateIIar surface is checked. OPERATIVE
TECHNIC
When the patient’s condition permits, operative excision of the pateIIa is carried out in forty-eight hours after the injury. (Figs. I and 2.) In view of the earIy deveIopment of atrophy of the quadriceps folIowing a fracture of the pateIIa, it is advisabIe not to deIay the operation for more than five days. During the period of waiting, the knee is kept tightIy bandaged
VOL. LXX1
1.
No.
MacAusIand-Excision
Q
of Patella
A
FIG. 4. A, roentgenogram of the same
taken three years knee taken six years
A mcricnn
Journd
oI’Sur~rr,y
5 1
B
after after
pateIIectomy, patellectomy,
to prevent sweIIing, and it is splinted in the position of extension and elevated. A IongitudinaI incision, extending from the region of the lower quadriceps tendon down to about I inch aIong the pateIIar tendon, and just a shade lateral to the midline, is made through the skin. If a u-shaped or a transverse preferred, incision may be used. Dissection is carried the fracture cavity, the out, exposing capsuIar tears and the traumatized quadriceps expansions. Blood clots are cIeaned out of the joint. The pateIIar fragments are easily shelled out from the quadriceps tendon, care being taken to keep cIose to the anterior and IateraI surfaces of the fragments in order to avoid sacrificing any of the tendon. The frayed edges of the extensor tendon and its medial and IateraI expansions are trimmed. The freshened edges are then approximated, if possible, the quadriceps tendon being forced down to the pateIIar tendon. It is we11 to suture the aponeurosis first, as by so doing the main part of the tendon can be sutured more easiIy. The
showing showing
idands of hone; H, roentgenogram increase in bony areas.
ends of the tendon proper are united with interrupted chromic catgut sutures. When the ends of the tendon cannot be approximated because of contracture, strips of fascia Iata taken from the thigh may be used as a running suture to close the gap. The skin is closed with interrupted sutures of silk. A compression dressing, a snug fIanne1 bandage and a ha.m splint are applied. Penicillin is given for two or three days. Postoperative Care. Most important in the postoperative treatment is the prevention of weakness of the quadriceps muscle by early mobilization. Just when contraction exercises may begin wiI1 depend upon the extent of the damage in the soft tissues as well as upon the postoperative reaction. In the average case, contraction exercises may be started at the end of the first postoperative week, and by the tenth day the patient can carry them out well. The spIint is removed on the tenth day, and the patient begins to ffex the knee gently by swinging the leg over the
3 I4
American
Journal
of Surgery
MacAusIand-Excision
of Patella
1g4h OCTOBER,
weeks after the operation. A Iaboring man is ready to resume Iight work in from six to eight weeks. Return to strenuous work is possible within three or four months foIIowing the operation. No heavy work should be undertaken unti1 the tissues are we11 healed and unti1 the quadriceps, which exerts excessive tension, is strong. REGENERATION
FIG. 5. Roentgenogram showing Iarge osseous flakes at the sixth postoperative month.
edge af the bed. Care is taken aIways to keep the motion within the limits of pain. Hot fomentations are appIied for twenty minutes, three times a day. After the tenth day the patient may waIk with the aid of crutches. At the end of the second postoperative week, the patient is discharged from the hospita1, and given instructions to continue exercising and using the Ieg. Swimming, or exercising the Ieg in a tub of hot water, Within twice a day, is recommended. from two to three weeks, motion to the right angIe is usually established. By the third week, the patient is bearing weight and waIking without the aid of crutches. In the average case the quadriceps is strong and we11 controIIed in from six to eight weeks. The knee functions we11 and is stabIe. The patient can waIk normaIIy and go up and down stairs. The rate of recovery depends to a great extent u’pon the cooperation of the patient. Just when the patient may resume work depends upon the nature of his occupation. A person who has a sedentary position may return to work in from four to six
OF THE
PATELLA
In experimenta studies by Carey, Zeit, and McGrath’ and Bruce and WaImsIey,d caIcified areas have been found to repIace the excised pateIIa. Similar foci have been noted foIIowing the remova of the pateIIa in humans by Dobbie and Ryerson,l’ AIbert,12 Wass,13 Mehriz,‘4 Murphy’5 and Schmier.16 Whether actua1 regeneration of the pateIIa takes pIace in response to a mechanica need, or whether the areas of caIcification deveIop from remaining osteobIasts is stiI1 in question. Certainly isIands of density are seen in roentgenograms foIIowing excision of the pateIIa. In a study of the Iate roentgenograms in eIeven of the cases being reported, isIands of caIcification were noted in a11 except two cases. In one case the foci were present at the third postoperative month, and one year Iater showed considerabIe increase in density. (Fig. 3.) A simiIar increase in density was seen in the roentgenograms of another case that were taken during the, third and sixth postoperative years. (Fig. 4.) A roentgenogram of one other case showed Iarge osseous flakes at the sixth postoperative month. (Fig. 5.) ANALYSIS
OF CASES
.
The series incIudes fourteen cases of fractures of the pateIIa that were treated by tota excision of the bone. Nine of the patients were maIes. In age the patients ranged from twenty-nine to seventy-seven years. The fracture is most common at middie age. Twelve fresh fractures were of the comminuted type, the patella being shat tered throughout in six cases, broken into three pieces in two cases, the Iower
VOL. LXXII,
No. x+
MacAusIand-Excision
of PateIIa
A mericnn Journal of Surgery
3 15
II
B
A
FIG. 6. A, comminuted
fracture of the patella; B, roentgenogrnm patellectomy.
haIf alone being com’minuted in three cases, and the upper half in one case. One case was a cornminuted fracture of Iong standing in which the pateIIa was extremeIy broadened. The remaining case was a transverse fracture of Iong standing, which had been treated unsatisfactorily by other methods. One fracture onIy was compound. Eight of the tweIve fresh cornminuted fractures were associated with other injuries. In two cases there were Iacerations of the knee; in two cases, abdomina1 injuries; in one case, there was a Monteggia’s fracture; in one case, a compound cornminuted fracture of the lower third of the femur on the same side as the pateIIar fracture; in one case, a fracture of the elbow; and in the eighth case, the rectus femoris muscIe was partIy severed. The period of hospitalization in a11 except one of these cases was proIonged because of the concomitant injuries, and the fina result in the case of the associated fracture of the femur was complicated by that injury. Six of the tweIve fresh fractures were oDerated uDon within four davs of the
taken two years after
injury. In the other six cases, operative interference was deIayed from one week to seventeen days because of associated in juries. The period of hospitaIization in three of the twelve cases of fresh cornminuted fractures and in the two cases of Iong standing averaged two .weeks. In one uncompIicated case, the patient was kept in the hospital for twenty-four days because of his advanced age. In the remaining eight cases, the postoperative hospitalization was deIayed because of associated injuries. Results. In eleven of the fourteen cases in this series, sufficient time has eIapsed to permit judging the Iate results. (Fig. 6.) The postoperative check in two cases was made more than six years after the remova of the pateIIa; in four cases within two to four years; in another four cases in one year after the operation ; and in one case after a period of eight months. The pateIIectomy in the remaining three patients was carried out too recentIy to permit judging the end resuIts, but the progress made in recovery has been very raDid and favorable.
516
A me&an
Journal
of Surgery
MacAusIand-Excision
Ten of the eIeven patients obtained good functiona knees with perfectIy free joint motion and stability. In five of the cases, every test of power and motion couId be met. The patients couId hoId the Ieg out straight in fuI1 extension; they couId squat fuIIy and with ease on the operated leg; they couId go up and down stairs normaIIy; and they couId waIk Iong distances with comfort. It was impossibIe to detect any difference between the function and stabiIity on the operated side and on the uninjured Ieg. Four of these patients had returned to their respective occupations, one as a freight handier, another as a railroad Iaborer, the third as a housewife, and the fourth as a chicken farmer, in from three to four months after the operation. The other patient had no. occupation. In four cases, the quadriceps was not so strong as in the norma knee, and there was a Iaxity of about IO degrees that prevented compIete extension. Notwithstanding, the quadriceps stiI1 had good power, the Aexion movement was normaI, and the patients reported no disturbance of function. The onIy compIaint was that the knee buckIed occasionaIIy. Three of these patients did arduous work, two of them in a miI1 and one in a foundry. The tenth patient, aged seventy-seven years, had compIete motion of the knee in both extension and flexion when she was examined in one year. However, she had to go down stairs a step at a time. In the eIeventh case, the outcome was poor. FIexion of the knee was possibIe to only the right angIe. There was a tender area over the bridge between the pateIIar and quadriceps tendons, indicative of weakness. SUMMARY
A report has been presented on the treatment of fourteen fractures of the pateIIa by tota excision of the bone. In eIeven of the cases, sufficient time had eIapsed to judge the end resuIts. Ten of these patients obtained good functiona knees. The convaIescence was rapid, and
OCTOBER, ,946
of PateIIa
the patients had returned to work in much shorter time than is possibIe under suture fixation methods. The procedure is considered to be indicated onIy in certain fractures. It offers a soIution of treatment in severeIy comminuted fractures, whether recent or in which under the of Iong standing, orthodox suture methods, the period of disabiIity is proIonged and the resuIts are unsatisfactory. PateIIectomy is also indicated in transverse fractures of long standing in which maIunion or non-union has resulted. The method is not recognized as the estabIished treatment of fresh transverse fractures. REFERENCES I. BROOKE, R. Effect of remova of pateIIa for simple transverse fractures on function of knee joint. Proc. Roy. Sot. Med. (Ortbop. Sect.) 30: 203-207, 1937. 2. BROOKE, R. Treatment of fractured pateha by excision. Study of morphology and function. Brit. J. Surg., 24: 733-747, 1937. 3. BROOKE, R. Fractured pateIIa. An anaIysis of 54 cases treated by excision. Brit. M. J., I: 231233, 1946. 4. BRUCE, J. AND WALMSLEY, R. Excision of pateha; some experimenta and anatomical observations. J. Bone @ Joint Surg., 24: 31 r-325, 1942. 5. COHN, B. N. E. Total and partial patehectomy: experimental study. Surg., Gynec. CT Obst., 79: 526536, 1944. 6. HAXTON, H. A. Function of pateIIa and effects of its excision. Surg., Gynec. TV Obst., 80: 389395, 1945. 7. CAREY, E. J., ZEIT, W. AND MCGRATH, B. F. Studies in the dynamics of histogenesis. Am. J. Anat., 40: 127-158, 1928. 8. HEINECK. A. P. Fractures of oatella: I too cases treated by open method. S&g., Gynec. &+ Obst., 9: 177-248, 1909. 9. WASS, S. H. AND DAVIES, E. R. Excision of pateha for fracture with remarks on ossification in quadriceps tendon foIIowing operation. Guy’s Hosp. Rep., 91: 35-57, 1942. IO. LOOMIS, L. K. Fractures of pateIIa-analysis of 150 cases at Charity HospitaI. New Orleans M. 0 S. J., 97: 173-176, 1944. I I. DOBBIE, R. P. AND RYERSON, S. Treatment of fractured patella by excision. Am. J. Surg., 55: 339-373, 1942. 12. ALBERT, S. M. Excision of the pateha. J. Iowa M. sot., 33: 184-187, 1943. 13. WASS, S. H. Treatment of fractures of patella. M. Press, 210: 87-90, 1943. 14. MEHRIZ, M. M. SimpIe fracture of pateIIa treated by removal of fragments. Lancer, I : gr, 1939. 15. MURPHY, J. J. BilateraL fracture of pateIIa. Brit. M. J., I: 725, 1943. 16. SCHMIER, A. A. Excision of the fractured patella. Surg., Gynec. & Obst., 8 I : 370-378. 1945.