Total patellectomy

Total REPORT W. RUSSELL

Patellectomy OF TWENTY-EIGHT

MACAUSLAND,

.4ND

DISADVANTAGES

CASES

Boston, Xlassachusetts

tion, the relative freedom from pain after the operation and the rapidity of recovery. Due to the short period of immobilization, atrophy of the quadriceps muscIe, a compIicating factor of a11 injuries of the knee, is obviated. After proper surgery there is no weakness or impairment of the function of the knee joint. Few drawbacks of the method have been mentioned. The alteration of the exterior of the joint may be a factor of importance if the patient is a woman. The protection of the femoral condyles, which is normally provided by the patefla, is lacking after the operation. It is asserted by some observers that arthritic changes are IikeIy to deveIop from the rubbing of the quadriceps tendon on the condylar surfaces.

simpIe procedure of tota patelIectomy is today wideIy recognized as an efficacious therapeutic recourse. Since the writer, seven years ago, reported on a series of fourteen fractures treated by this operative measure, numerous contributions on the subject of pateIIectomy have appeared in literature, severa of them documented by analyses of successful cases. Few surgeons u-i11 now dispute that the remova of the pateIIa resoIves the problem of treatment of certain types of fracture, primariIy the severeIy cornminuted fracture involving the greater part of the bone. Indications for this operation have been extended to incIude other Iesions of both the pateIIa and knee joint. WhiIe there is genera1 agreement on the practice of patellectomy in certain types of fracture, the controversy continues regarding its use in other types and concerning the diffusion of the measure in the treatment of various Iesions of the pateIIa and knee joint. Studies of long-term results of pateIIectomy are of particuIar interest. Has there been satisfactory functiona restitution? Is there any remaining disabiIity in the form of weakness, Iaxity or buckIing? Have arthritic changes developed as the resuIt of the quadriceps tendon passing directIy over the condylar surfaces? For the purpose of making an end-result study the fourteen patients in the series reported in 1946 were requested to report for examination. Late observations were aIso made in a new series of fourteen cases. In the second group indications had f)een extended to recurrent disIocation of the patella and arthritis of the knee joint. PateIIectomy was not carried out indiscriminately in either series, but practiced onIy when precise indications were recognized. THE

ADVAi’iTAGES

M.D.,

d

INDICATIONS

FOR

TOTAL

PATELLECTOMY

The recognition of indications for patellectomy is infIuenced in no Iittle measure by the individua1 surgeon’s conception of the function of the patella. If it is postulated, as Brooke and a number of other surgeons maintain, that the pateIIa contributes nothing to the function of the knee joint, total pateIIectomy wiI1 be considered every time the bone is the seat of a pathoIogic process. The surgeon who looks upon the pateIIa as a usefu1 element, attributing to it a protective and functional roIe, wiI1 be discriminatory in recognizing indications. The writer supports the schoo1 of thought that this component part is undoubtedly of importance in the articular mechanism. On the other hand, the results in the series of cases being reported substantiate the experience of numerous surgeons proving that the pateIIa may be removed \vithout detriment to the function of the knee joint. In tfle category of fractures indication for total pateIIectomy is universally recognized in the cornminuted fracture involving tfle greater part of the bone with separation of the frag-

OF

PATELLECTOMY

The advantages of pateIIectomy that map be pointed out are the simplicity of its execu221

‘I’otal Patellectomy ments. Any attempt at approximation of the fragments faiIs and terminates in an irreguIar pateIIar surface. The pateIIa becomes pie shaped, enIarging not infrequentIy one-quarter or one-third its norma size. The constant irritation from the roughened articuIar surface predisposes to the development of arthritic changes. Little questioned is the vaIue of tota patelIectomy in treating the long-standing unreduced fracture, comminuted or transverse in type, the case of refracture, or the ununited or maIunited fracture in which prior suture or other method of treatment failed. In some of these cases a degenerative process is aIread? existent in the knee joint, and there is aIwa\-s a predisposition to the development of arthritic changes when the articuIar patellar surface is irregular in contour. There is genera1 agreement on the management of the eccentric fracture lying cIose to the upper or lower pole of the pateIIa. When the fragment is in good position and the extensor mechanism undamaged, conservative treatment gives satisfactory resuIts. The best treatment when the fragment is rotated or retracted and the articuIar cartiIage intact is excision of the smaI1 fragment and reattachment of the quadriceps or pateIIar tendon to the main fragment. The treatment of margina fractures, whether by conservative means or excision of the chip fragment, depends Iikewise on the degree and type of displacement. Vertical fractures may be treated conservativeIy or by operative screw fixation depending upon the amount of separation of the fragments. There is stiI1 no unanimity of opinion on the handling of the transverse fracture with the Iine approximateIy in the mid-pateilar region, separation of the fragments and minimal articuIar damage. A smal1 group of surgeons accept systematic excision of the patella for all transverse fractures even when the displacement is slight. The majority of surgeons favor operative reduction and fixation of the fragments. The writer’s experience has shown that excellent resuIts are obtainable by accurate reduction and fixation of the fragments 65 means of a screw. This type of fisation obviates prolonged recuperation. It is necessary to consider total pntellectomy only in the exceptiona I transverse fracture in which the damage of the articuIar surface is severe, or in which a wide

cliastasis makes proper reduction and fixation of the fragments impracticabIe. Patellectomy alone or c*ombined with surgery of adjacent structures has proved of value in disabling arthritis of the knee joint of both the rheumatoid and osteoarthritic types. A hypertrophic process may be the result 01 chondromaIacia, trauma or other types of lesions, or occur secondary to the normal lvcar and tear changes that take place in joints. The best results from patellectomv ma\- be expected in cases in which the arthritic process is confined to the femoropatellar segment, but even in more extensive involvement, pain is relieved and function improved following the removal of the pateIIa. hIerIe d’Aubign6 f>clieves that this operation has a favorable effect in advanced arthritis of the entire knee joint because of the fact that the changes in the femoropateIIar joint tend to be more pianful than those of the femorotibial joint. The opinion has been expressed by some writers that the execution of a pateIIectom)earl)-, while the arthritic changes stil1 predominate in the patellar joint, would prevent the spreacling of the process to the rest of the joint. As pointed out previousIy, excision of the pateIIa is useful in advanced cases of chondromaIacia with symptoms of osteoarthritis. Degeneration of the entire cartilaginous surface has taken pIace in such cases and marginal osteophytes have developed. Many satisfactor! results of tota patellectomy in chondromalacia have been reported, showing that good function may be obtainecl and further degenerative changes prevented. Indications have of late been extended to recurrent dislocation of the pateIIa and the results in the limited number of cases reported appear to be encouraging. Patellectomy is considered justified because of the likelihood that concomitant changes have taken place in the cartilaginous surface of the patella, which predispose to degenerative arthritis. In some cases the deformation of the pateIIa is such that reposition would be difficult. It is the writer’s opinion that excision of the patella should be considered in recurrent dislocations only in patients over forty-five :Tears of age, when tither there are definite signs of degenerative changes or trochlear-pntellnr disharmony, or realignment metflocls have been unsuccessful. In .y?;punger patients the compIication of arthrltIs need not be considered and realignment 222

TotaI

PatelIectomJ

I

FIG. I. CXxure

2

of the extensor

apparatus

FIG. 2. Reconstitution of the extensor the pateller and quadriceps tendons.

with intcrruptcd

apparatus

catgut.

by means of strips of fascia Iatn when a wide gap exists between

The vertica1 approach to the pateIIa is the most satisfactory in that it permits earIy contraction exercise of the quadriceps and earIy motion of the joint with the Ieast risk of spIitting the suture line. The writer prefers a Iongitudina1 incision which traverses the pateIIa sIightIy IateraI to the midIine, and extends above over the Iower segment of the quadriceps and beIow over the patelIar tendon for the distance of I inch. The skin and subcutaneous tissues are dissected and the flaps reffected, exposing the pateIIa and quadriceps expansion. If the case is one of a fracture, the extensor mechanism is aIready ruptured transversely. The pateIIar fragments are removed through this transverse opening, which is extended on either side if necessary. DoubIe hooks are used to grasp the fragments, and sharp dissection is used, taking meticuIous care to preserve the quadriceps expansion. Accurate cIosure of the extensor mechanism is vital to the success of the operation. Suture is more easiIy accomplished if the IateraI edges of the extensor apparatus are first approximated and then the quadriceps and patelIar tendons sutured. (Fig. I.) In order to make certain that the suture knots in the tendons are

of the pateIIa by one of the cIassic procedures gives satisfactory results. In addition to the previousIy mentioned lesions, pateIIectomy has been advanced for congenita1 dislocation, tubercuIosis confined to the pateIIa, and tumorous processes. OPERATIVE

sutures of chromic

TECHNIC

The important feature of a pateIIectomy is the safeguarding of the extensor mechanism of the knee. The surgeon on his part must protect and restore this apparatus by precise technic; the patient must cooperate in preserving quadriceps function by carrying out proper exercises. In cases other than fractures a preoperative training in quadriceps contraction exercises is advisabIe, in order to acquaint the patient with the idea of the function of this muscIe. In the case of a fresh fracture the operation shouId be performed within forty-eight hours after the injury provided, of course, that the condition of the knee permits. In any event it is we11 not to postpone the procedure for more than five days because of the danger of the deveIopment of atrophy of the quadriceps muscIe. 223

Total

Pateliectorny the pnticnt cncouragctl to begin :lcti\.c Ilcsion of the knee by gentl? swinging the kg o\.t’r t.hc cclge of the bed. Walking \\.ith crutches is aIso permitted after the tenth da).. From then on, leg exercises shouId be carried out periodically, aIways within the Jimits of fatigue and pain. S\vimming is recommended as \veIl as exercising the leg in a tuf, of flot water twice a da?;. B> the third postoperative week motion to the right angIe is usually possible and the patient is hearing weight without support. The period of postoperative disability varies and depends to a great extent upon the cooperation of the patient in carrying out the exercises. In the average case the knee regains active extension and flexion movements within two months after the operation. B,v that time the patient can walk with a normal gait and go up and down stairs. If the patient has a sedentary occupation, it is possible to return to work as early as the sixth postoperative week. No work of a strenuous nature shouId be undertaken for at least three months after a pntellectomy. CASE

under the same degree of tension, a Iargc pntellar clamp is used to hold the tendons in good approximation while the sutures are hcing tied. Interrupted sutures of chromic catgut are used. At times the space hetween the quadriceps and pateIIar tendons is Gde and closure presents tech&a1 dificulty. It ma,y he necessary to reconstitute the tendons from strips of fascia lata obtained from the thigh. (Fig. 2.) In other lesions in which the patella is to be removed in its entirety the extensor apparatus is divided longitudinally in the middle. Upon closure, as when a longitudinal skin incision is used, muscle contractions and motion of the joint may be started early without endangering the suture line. After closure of the wound a compression dressing is appIied and the joint hound snugly with a flannel bandage. Immobilization is obtained by means of a posterior pIaster shell. Postoperative Care. Most important in the postoperative care is the preservation of the quadriceps function. Contraction exercises are begun as soon as the surgical reaction has subsided and the soft tissues are sufflcientIy heaIed. In the average case it is possible to start these exercises in from seven to ten days. The spIint is removed on the tenth day, and

STUDY

Account may be given on the late results in twenty-one of the twenty-eight cases. Nineteen of the patients were re-examined and roentgenograms of the knee taken after a postoperative time lapse varying from five to fourteen years, and the other two patients were observed after approximately three years. Four patients failed to report for re-examination and the remaining three patients were treated only within the past year. Thirteen of the twenty-one patients were males and eight, females. The youngest was twenty-seven years of age and the otdest seventy-seven. Total patelIectomy had been performed in sixteen cases for fresfl comminuted fractures; in two old fractures, one of the transverse type in which prior screw fixation was unsuccessful, and the other of the cornminuted type with the patella enlarged to twice its normal size; in one case of osteoarthritis of the knee joint, primitive in origin; and in two cases of recurrent dislocation. Good results were obtained in fifteen of the twenty-one cases. Articular function in both extension and flexion is excellent. The patients are able to hold the leg out straight and crouch easiIy on the involved extremity. The knees are stable. AI1 patients walk with a norma gait.

224

Total

FIG. 4. Kocntgenograms of density.

Pntellectom~

of the same knee taken three, six and thirteen years after patcllcctomy,

showing increase

in areas

hIany patients had returned to their respective occupations in mills, a Iaundry, trucking, an insurance company and home-making. OnIy one patient had a definite complaint of buckhng of the joint which occurred after a long walk. Upon examination evidence of interna derangement was observed in this case. Two patients complained that the knee seemed to give way at times, particuIarIy when tired. One patient was unabIe to go up and down stairs easiIy. In this case a patelIectomy had been performed for a cornminuted fracture when the patient was seventy-seven years of age, and previous to the operation she had diffrcuIty climbing stairs. Two resuIts were unsatisfactory, neither of which couId be attributed to the operation. One was the case of a nun who had an oId recurrent shpping of the pateIIa comphcated by a cartiIage derangement and osteoarthritis of the knee joint. This patient now walks with the knee in a few degrees of ffexion and is unabIe to kneel. The other patient who had experienced a faII shortIy after the pateIIectomy, in which the attachment of the quadriceps and pateIIar tendons had been torn, has little quadriceps power. Arthritic Changes. One of the adverse criticisms of the operation of patehectomy is that, in the absence of the pateIIa, arthritic changes may deveIop on the condylar surfaces as the

result of friction from the quadriceps tendon. With the exception of two cases in which arthritic changes were aheady present in the knee joint at the time of the pateIIectomy, no evidence of erosion was observed in the twentyone cases on which clinical results are reported. Areas of caMcation in the Ossijcation. extensor apparatus at the former site of the patella were demonstrated in the roentgenograms of thirteen of the twenty-one cases. In nine cases the ossihcation was ConsiderabIe. (Fig. 3.) That these areas of density, which may represent actuaI regeneration of the bone or deveIop from remaining osteoblasts, tend to increase in size over a period of time may be observed in Figure 4 which shows roentgenograms taken three, six and thirteen years after the removal of the patella for a cornminuted fracture. SUMMARY

The ensemble of results reported definiteIy establishes that tota pateIIectomy has a place in the treatment of fractures. A simpIe intervention, it ensures rapid functiona recuperation complete and definitive, in severery comminuted fractures and in Iong-standing unreduced, ununited or maIunited fractures of either the transverse or cornminuted type. The method has not been generally accepted as the routine treatment of fresh transverse fractures, and it is the writer’s opinion that in the 225

majorit>, of transvcrsc arc‘ ohinablc scruv

fractures gootl results

I)y operatic

reduction

antI

lixrtion.

'l'ot;~lp~~tcllrcton~\~ is fii\.itlg cricour:lg:ing results in osteoarthritis of the knee joint, particularly when the process is confined to the pateIIofemora1 segment. The method is aIso proving of value in the treatment of advanced chondromalacia and recurrent dislocation of the pateIIa. The writer’s experience incIudes tu-entyeight cases of tota patelIectomy. Late observations were made in twenty-one of the cases, in nineteen, after a postoperative time lapse varying from five to fourteen years. Sixteen of the cases were fresh comminuted fractures, two were old fractres, one was an osteoarthritic process of the knee joint and two cases were recurrent dislocations. Fifteen of the twenty-one patients obtained completely satisfactory results, the mobility and strength of the knee being normaI. Two other patients mentioned having a sensation of insecurity at times. One patient complained of buckling of the joint and three patients had limited motion, but in none of these four cases could the resuIt be charged directIy to the operation. In the case of buckling there was evidence of a cartilage derangement, in two cases there were arthritic complications which had been present prior to the operation, and in the fourth case the patient had faIIen and torn the new attachment of the pateIIar and quadriceps tendons. With the exception of two cases in which arthritic changes were already present in the knee joint at the time of the operation, no evidence of erosion was observed on the condylar surfaces in any of the twentyone cases.

10. FKIBEKG, S. Urber Totalexstirpationen Artu cbir-. Scandinuv., 85: 361-388,

I I.

1949. 12. GRAY, C. ChondromaIacia

pateIIae. Brit. hf. J., I : 427-430, 1948. I 3. GUILLEVINET, AI. Indications de Ia pnteIIectomir. Rev. mid. Meg-en-Orient, 7: 26-37, 1950. 14. f IAGGART,G. E. SurgicaI treatment of degenerative arthritis of the knee joint. Ne?u England J. Med.,

236: 971-973, 1947. 15. IIAKRIS, R. Discussion to: Cave, E. F. and Rowe, C. R. The patella; its importance in derangement of the knee. J. Bone CY Joint Surg., 32-A: 542553, ‘950. 16. LE&, B. S. PateIectomia. Acud. peruana cirug., 5: 208-2 I o, 195 I. 17. MAcAUSLAND, W. R. Total excision of the pateIIa for fracture. Report of fourteen cases. Am. J. Surg., 72: 510-516, 1946. 18. MAKION, J. and BARCAT, J. Les Iusations de 13 rotuIe en dehors des Iuxations traumatiques rbcentes. Rev. ortbop., 36: 181-241, 1950. 19. MCFARLAND, B. Excision of pateIIa for recurrent dislocation. J. Bone c>*Joint Surg., 30-B: 158‘59, ‘948. 20. MERLE d’Aumc&, R. Discussion to Marion and Barcat.‘* 21. RIEWLE d’AumGNk, R. Traitement chirurgical des arthroses du membre infC_rieur. Acta pbysiotber. et rbeumat. belg., 7: 50-55, 1952. 22. O’DOKOG~IUE, D. f I. The place of pateIIectomy in treatlnent of fractures of the pateIIa. Soutb. Surgeon, 15: 640-655, 1949. 23. PASCIIALL, J., JR., GHORMLET, R. II. and DOCKERTY, M. B. OId united and ununited fractures of the patella. Surgery, 26: 777-786, 1949. 24. ROUNTREE. C. F. Management of fractures of the patella. >. Missouri state M. A., 49: 549-553,

REFERENCES 1. RERKHEISER, E. J. Excision arthritis of the knee joint.

of the pateIIa J. A. M. A.,

der Patella.

1941. GIKAKDI, 1’. Tratamiento quirurgico de Ia artritis cronica primitiva de Ia rodiIIa (nuestra expericnciaj. Bol. Ligu urgent. contre reumat., 12: I--IO,

in

I 13:

2303-2308,

1939. 2. BRONITSKY, J. ChondromaIacia pateIIae. J. Bone r~ Joint Surg., 29: 931-945, 1947. 3. BROOKE, R. Effect of removal of pat&a for simple transverse fractures on function of knee joint. Proc. Roy. Sot. Med., 30: 203-207, 1937. 4. BROOKE, R. Treatment of fractured pateIIa by

1952. 25. SCOTT, J. C. Fractures of the pateIIa. J. Bone (Y Joint Surg., 31-B: 76-81, 1949. 26. THOMSON, J. E. M. Fracture of the patelIa treated by removaf of the loose fragments and pIastic repair of the tendon: study of 554 cases. Surg., Gynec. @YObst., 74 : 860-866, 1942. 27. TODD, J. The end-results of fracture of the patefla. J. Bone CYJoint Surg., 32-B: 281, 1950. 28. WATSON-JONES, R. Fractures and Joint Injuries,

excision. Study of morphoIogy and function. Brit. J. Surg., 24: 733-747, 1937. 5. BROOKE, R. Fractured pateIIa; an anaIysis of 54 cases treated by excision. Brit. M. J., 1: 231-233,

3d ed., vo1. II. BaItimore, 1946. The Williams and Wilkins Co. 29. YOUNG, H. H. and REGAN, J. M. Tots1 excision of the pateIIa for arthritis of the knee. Minnesota Med., 28: 909-914, 1945.

1946. 6. CARR, C. R. and HOWARD, J. W. ChondromaIacia

30. ZENO, L. and MAROTTOLI, 0. R. La patelectomia en Ias Iesiones crbnicas de Ia &uIa. Rev. ortop. .y traumatol., I I: 124-138, 1941.

of the pateIIa. U.S. Armed Forces M. J., 3: 185197. 1952. 226