Patellectomy, an old treatment in patellar fracture which is still alive: A case report

INTRODUCTION

Comminuted patella fractures comprise 55 % of patellar fractures. In spite of advances in internal fixation of patella, patellectomy remains an effective treatment in comminuted fractures. In the shadow of different efficient methods of internal fixation, little attention is paid to patellectomy as an old treatment in patellar fracture which is a treatment option in circumstances like comminuted fractures and osteomyelitis.

PRESENTATION OF CASE

A 54-year-old male presented with complaint of knee pain and limited range of motion. The patient experienced patella fracture four years ago and several sessions of surgery have been performed on his patella including tension band wiring, partial patellectomy, and arthroscopic release. Lastly, pain and severe limited range of motion, convinced us to perform total patellectomy. The result is satisfactory after one year; flexion is up to 90° and no limping or extension lag is observed. The only complaint is mild anterior knee pain.

DISCUSSION

Patella has two important biomechanical functions including linking and displacement. Preserving even a single fragment of the patella substantially improves linking and displacement function of the patella. Total patellectomy is reserved for conditions like failed internal fixation, comminuted fractures, and patellar osteomyelitis. Although function of the knee cannot be thoroughly restored after removing of the patella, total patellectomy can lead to a relative satisfaction in performing activities of daily living.

CONCLUSION

In spite of various types of treatment for patellar fracture, total patellectomy, is still an efficient treatment option in circumstances like comminuted fractures, failed internal fixation, and osteomyelitis.

Myopericytoma of the patella with local recurrence and patellectomy: A case report

INTRODUCTION AND IMPORTANCE

Myopericytomas are tumors originating from perivascular myoid cells and exhibiting a wide range of histologic growth patterns. They rarely occur in bones, and no case of myopericytoma in the patella has been reported so far.

CASE PRESENTATION

A 74-year-old male presented with a chief complaint of pain in the left knee. Magnetic resonance imaging revealed bone tumor and osteolytic lesions of the patella. The patient underwent bone tumor curettage and filling of the cavity with artificial bone. However, as the tumor reoccurred, a patellectomy was performed. The patient regained premorbid functional status after surgery. Additionally, there was no radiological evidence of recurrence of the lesion 3 years after patellectomy.

CLINICAL DISCUSSION

Myopericytoma of the patella is very rare. However, it should be considered for the differential diagnosis of lytic lesions of the bone. Although surgery is curative, patellectomy may be necessary for recurrent cases.

CONCLUSION

In conclusion, we report the first case of patellar myopericytoma. Although patellar myopericytoma might be rare, it should be considered for the differential diagnosis of lytic lesions of the bone. Surgery is curative; however, patellectomy may be necessary in recurrent cases.

Metastatic patellar bone tumor due to gastric cancer resembling a primary or secondary aneurysmal bone cyst: A case report

INTRODUCTION AND IMPORTANCE

Patellar bone tumors are very rare, and most are benign or of intermediate type. In this report, we describe our experience of a metastatic patellar bone tumor caused by gastric cancer, which resembled a very rare primary or secondary aneurysmal bone cyst and review the literature.

CASE PRESENTATION

A 65-year-old man presented with severe pain in the patellar region and marked limitation of the knee joint range of motion. He had a history of gastric cancer; however, epidemiological, clinical, and imaging findings led us to strongly suspect an aneurysm-like bone cyst. Thus, we performed bone tumor curettage and autologous artificial bone grafting without biopsy because of the severe pain. Pathology results showed gastric cancer metastasis; hence, patellectomy and patellar tendon augmentation with femoral fascia were performed. The Musculoskeletal Tumor Society (MSTS) score was taken postoperatively to assess pain and function.

CLINICAL DISCUSSION

We experienced a very rare gastric cancer-related metastatic patellar bone tumor, which resembled a primary or secondary aneurysmal bone cyst in frequency and imaging findings. Patellectomy was ultimately performed, and the patient's MSTS score improved markedly.

CONCLUSION

Despite its very low frequency, patellar metastatic bone tumors must be taken into account without being misled by the frequency or imaging findings and a biopsy should necessarily be performed.

Fracture-related infection of the patella: Treatment options and outcome

BACKGROUND

Fracture-related infection (FRI) after the operative management of patella fractures is a serious complication that can result in prolonged hospitalization, multiple revision procedures and permanent functional impairment. Till today, treatment modalities and outcome of FRI of the patella are not well described. Therefore, the main objective of this retrospective cohort study was to evaluate treatment options, functional outcome and healthcare costs related to FRI of the patella.

METHODS

This study evaluated 111 consecutive patients that were surgically treated for patella fractures, at the department of trauma surgery of the University Hospitals Leuven (Belgium), between January 2015 and April 2020. Patients were excluded if they (1) were younger than 18 years at the time of injury or (2) died during follow up. The minimal follow-up for all patients was 18 months.

RESULTS

During the 5-year study period, 107 patients with 108 patella fractures were included. A total of 10 patients were diagnosed with an FRI (9.3%). Four of these were treated with a DAIR approach and three patients underwent implant removal or exchange. Finally, three patients were treated with total patellectomy. Out of the 10 patients, two were diagnosed with a recurrence of infection. Overall, we observed substantial lower scores for all Knee Injury and Osteoarthritis Outcome Score subscales in the FRI group, compared to a reference population. Moreover, our study shows that direct hospital-related healthcare costs of FRI of the patella were nine times higher compared to non-FRI cases.

CONCLUSIONS

FRI of the patella is a challenging complication and recurrence of infection not uncommon. Although multiple treatment modalities exist, a multidisciplinary patient-specific approach is crucial. An early or delayed onset infection can be managed with a DAIR approach, but only when the construct is stable and the soft tissue coverage adequate. In patients with an FRI, implant removal is preferred when the fracture has healed. A total patellectomy can be used as a salvage procedure in complex cases with acceptable functional results. Overall, FRI of the patella leads to both a negative impact on the functional status of the patient and a ninefold increase in total healthcare costs.

Classification and Management of Periprosthetic Patella Fractures

Complications related to the extensor mechanism and patellofemoral joint continue to be the most common cause of pain and indication for surgical revision following total knee arthroplasty. Numerous risk factors related to the patient, implant, and technical performance of the procedure have been identified. The Ortiguera and Berry classification system is widely used for the systematic classification and management of these fractures. Because of the difficult nature of revision surgery for fracture and the high risk of complication, a careful assessment of the fracture and implants is vital to determining the best course of treatment.

Surgical Management of Non-Union Patella Fracture: A Case Series and Review of the Literature

BACKGROUND

The neglected patella fracture leading to non-union of the fracture in long term. Non-union patella is the rare entity with incidence of 2.4-12.5%. The fractured proximal fragment of the patella is retracted proximally leading to fracture gap of various centimetres. Various surgical modalities are described to manage such fracture morphologies.

METHODS

Ten neglected patella fracture morphology were included in the study. Five patients with transverse fracture was treated with ORIF with TBW. Two patients with communited fracture was treated with ORIF with TBW (K wires) and cerclage wire. Three patients with inferior pole patella was managed by open reduction and Krachow suture using fibre wire. The results were assessed in terms of time of union, knee range of motion, extension lag, quadriceps power, fracture gap, Knee society score, Kujala knee score and any complications. Follow-up with radiographs was done at 2, 4, 6 and 12 months.

RESULTS

All patients presented with a mean duration of 9.3 months (7-13months) after the trauma with mean gap between the fracture fragments of 5.2cm (3.8-6.6cm) in maximum flexion and 2.6cm (2.0- 3.0cm) in full passive extension. The mean duration of the radiological union was 5months (3-6months). The average range of motion achieved at the end of 12 months ranges from 10o to 110o. The quadriceps power in all patients were 4+ or 5 at 6 and 12months. The mean Knee Society Score was 75 (Range 72-82) and mean Kujala knee score was 73 (Range 70- 82) at the end of 12 months.

CONCLUSION

We conclude that in cases of non-union patella ORIF using TBW has the best result. V-Y plasty is rarely required for fracture reduction. The need for bone grafting can be assessed on case to case basis. Partial/total patellectomy should be avoided and Krackow suture technique is helpful in management of inferior pole patella fractures.

Three-dimensional-printed custom-made patellar endoprosthesis for recurrent giant cell tumor of the patella: A case report and review of the literature

BACKGROUND

Giant cell tumor (GCT) is a benign lesion and rarely involves the patella. This disease is characterized by a relatively high recurrence rate after primary treatment. En bloc resection has been a predominant option for recurrent GCT. However, total patellectomy can lead to disruption of the knee. Therefore, exploration of functional reconstruction of the extensor mechanism is worthwhile.

CASE SUMMARY

A 54-year-old woman presented with right knee pain and swelling, and was diagnosed as having a GCT in the patella following curettage and autograft. Medical imaging revealed a lytic and expanded lesion involving the whole patella with focal cortical breaches and pathological fracture. Based on the combination of histological, radiological, and clinical features, a diagnosis of recurrent GCT in the patella was made (Campanacci grade III). After a multidisciplinary team discussion, three-dimensional (3D)-printed custom-made patellar endoprosthesis was performed following en bloc resection for reconstructing the extensor mechanism. The patient was followed for 35 mo postoperatively. No evidence of local recurrence, pulmonary metastasis, or osteoarthritis of the right knee was observed. The active flexion arc was 0°-120°, and no extension lag was detected. A favorable patellar tracking and height (Insall-Salvati ratio 0.93) were detected by radiography.

CONCLUSION

We depict a case of a GCT at the right patella, which was successfully treated by patellectomy and 3D-printed custom-made endoprosthetic replacement. The patella normal reconstruction, the precise-fit articular design, and gastrocnemius flap augmentation could lead to satisfactory knee function and a low rate of complications in the short-term follow-up.

Extensor mechanism reconstruction "Tubeplasty" in total knee arthroplasty with previous patellectomy: Surgical technique and clinical outcomes

PURPOSE

to evaluate our consecutive series of tubeplasty and extensor mechanism reconstruction during knee arthroplasty in patients with previous patellectomy.

METHODS

we describe our surgical technique and present a retrospective consecutive series of 4 patients with a minimum 6 months follow-up. Knee society score (KSS), clinical and radiographic outcomes were collected at final follow up.

RESULTS

we included 4 patients (2 males/2 females) with average age 65.5 years (range 58-76). There were 2 primary and 2 revision knee arthroplasties. The follow up ranged from 0.5 to 13 years. All 4 patients regained function and satisfactory clinical outcomes with KSS score 84.7 (range 79-90).

CONCLUSION

satisfactory clinical outcomes can be achieved with extensor mechanism reconstruction and tubeplasty in patients with previous patellectomy undergoing primary and revision knee arthroplasty.

LEVEL OF EVIDENCE

IV.

Changes in Cartilage and Subchondral Bone of Femoral Trochlear Groove After Patellectomy in Growing Rabbits

OBJECTIVE

To explore the effects of patellectomy on the bony and cartilaginous morphology of the trochlear groove in growing rabbits.

METHODS

Forty-eight 4-week-old New Zealand white rabbits were randomly assigned to two groups. The control group underwent a sham surgical procedure, whereas the patellectomy group underwent patella excision surgery. Half of the rabbits in each group were sacrificed 3 months postoperatively; the rest were sacrificed 6 months postoperatively. Hematoxylin and eosin staining was performed on collected samples. Measurements included the bony and cartilaginous sulcus angles of the trochlear groove. In addition, the thickness of the articular cartilage at the deepest sulcus position (central thickness) and at the mid-position of the medial and lateral facets was measured and compared between groups.

RESULTS

Three months after surgery, histological images revealed significant differences between the control group and the patellectomy group in cartilaginous sulcus angle (144.2° ± 1.5° vs 151.9° ± 2.4°, respectively; P < 0.001). No obvious difference in bony sulcus angle was found between the groups. Six months after surgery, significant between-group differences were observed in cartilaginous sulcus angle (136.3° ± 2.5° in control group vs 160.7° ± 3.0° in patellectomy group, P < 0.001) and bony sulcus angle (136.2° ± 2.2° in control group vs 160.4° ± 2.6° in patellectomy group, P < 0.001). However, there were no significant intra-group differences between cartilaginous and bony sulcus angles in either group. Three months after surgery, significant between-group differences were detected in articular cartilage thickness at the three different positions (medial facet: 324.3 ± 14.0 μm in control group vs 391.7 ± 98.8 μm in patellectomy group, P = 0.029; central position: 362.1 ± 13.6 μm in control group vs 730.3 ± 76.8 μm in patellectomy group, P < 0.001; lateral facet: 324.6 ± 12.7 μm in control group vs 358.5 ± 38.7 μm in patellectomy group, P = 0.009). No between-group differences in cartilage thickness were found at 6 months.

CONCLUSIONS

Abnormal mechanical stress (patellectomy) during a rabbit's development can cause flattening of the femoral trochlear cartilage, followed by changes in the subchondral osseous layer. Abnormal mechanical stress is a crucial factor in the development of trochlear groove dysplasia.

"Banana patella", fibrous dysplasia of patella: A rare case report

INTRODUCTION

Patella is a very uncommon site for primary bone tumours and fibrous dysplasia lesion in patella has never been reported. Fibrous dysplasia is a benign fibrosseous lesion of the bone where the fibrous connective tissue replaces the normal bone.

CASE REPORT

We report a case of 23 years female with 7 years history of progressive swelling and anterior knee pain. Radiographs showed enlarged, deformed patella like a shape of banana. The patient underwent patellectomy with extensor mechanism repair and biopsy proved to be fibrous dysplasia.

CONCLUSION

Fibrous dysplasia involving patella is very rare and never been reported earlier. Although primary patellar neoplasm are not common but should be kept in mind in chronic anterior knee pain with swelling for early diagnosis and intervention with intralesional therapy otherwise patellectomy has to be done in more advanced, deformed and enlarged lesions.

Outcome of low profile mesh plate in management of comminuted displaced fracture patella

PURPOSE

To assess the clinical results of using mesh plate in management of displaced comminuted fracture patella.

PATIENTS AND METHODS

Between January 2014 and October 2015, nine patients with closed displaced comminuted fracture patella were fixed using mesh plate and 2mm mini screws.

RESULTS

All fractures united after an average of 10 weeks. At final follow-up of an average 19.6 months, average postoperative Lysholm score was 89.1±4.9, and average Postoperative Böstman scale was 27.2±3.1. No hardware related complications were recorded.

CONCLUSION

Low profile mesh plate is a good option in management of comminuted fracture patella with good clinical outcome. This new surgical technique may be particularly useful in comminuted fractures when patellectomy would otherwise be considered.

Patellar reconstruction following previous patellectomy: a review of the literature and a case series using distal femoral autograft during total knee arthroplasty

During total knee arthroplasty, the reconstruction of the patella following a previous patellectomy is challenging, and is undertaken to improve functional outcomes and patient satisfaction. In this case series, we have reconstructed the patella using a femoral condyle resected during total knee arthroplasty. The resected femoral condyle with best available bone stock is selected and secured to the extensor mechanism. We reviewed the preoperative indications and postoperative outcomes of two patients who underwent the above procedure at our Institute, and compared this to the literature. The cases include a 68-year old male (6 months follow-up) who sustained a multi-fragmentary fracture of his right patella and underwent a patellectomy 30 years previously, and a 45-year old female (4 years follow-up) who underwent a left-sided patellectomy 15 years previously following polytrauma. As a result of progressive osteoarthritis they required total knee arthroplasty, and simultaneous patella reconstruction with a femoral condyle autograft. Compared to their preoperative range of motion, both patients demonstrated an improvement post-operatively with successful pain-free knee function, with no radiological signs of graft resorption. In this limited, small series we have reported two patients who are clinically and functionally satisfied by the outcome of surgery, with comparable outcomes to alternative methods. We believe the use of a femoral condyle autograft for patellar reconstruction is a safe and simple technique that optimises knee kinematics, without associated donor morbidity.

Total knee arthroplasty after patellectomy: A meta-analysis of case-control studies

BACKGROUND

Post-patellectomy patients represent a specific subset of patients who can develop painful and disabling knee osteoarthritis that requires Total Knee Arthroplasty (TKA). The aim of this study was to conduct a meta-analysis comparing the outcome of TKA in patients with previous patellectomy to those with an intact patella.

METHODS

A systematic search of electronic databases (PubMed, Medline, Embase, and Cochrane Library) was performed. Data on study setting, type of implant, outcome and associated complications were extracted. Quality assessment was performed using the Newcastle-Ottawa Scale. Random effects meta-analyses were used to combine the results of included studies.

RESULTS

Seven case-control studies were found that met the search criteria. Compared to patients with an intact patella, patients with a previous patellectomy were less likely to have an 'excellent' or 'good' outcome (OR: 0.3, 95% CI: 0.14 to 0.65). The weighted mean post-operative knee flexion arc was 6.58° less in patients with a previous patellectomy (95% CI: -12.79, -0.37). The risk of complication occurring in a patella-deficient knee was higher, with a pooled OR of 1.97 (95% CI=1.10 to 3.51).

CONCLUSIONS

The current evidence that compares the outcome of knee arthroplasty in patients with a previous patellectomy to patients with an intact patella is mostly based on TKAs performed in the 1980s and 1990s. Total knee replacement in patients with an intact patella results in superior outcomes compared to those with a previous patellectomy. In patients with a previous patellectomy, the arc of flexion is slightly less and the complication rate is significantly higher.

Internal fixation of patellar apex fractures with the basket plate: 25 years of experience

INTRODUCTION

Comminution of the patellar apex is amenable to internal fixation by standard techniques and usually requires partial patellectomy. In our institution, multifragmentary fractures of the distal pole are treated with the basket plate, which is shaped to fit the geometry of the patellar apex. This implant has been used in our institution for over 25 years. The aim of this study was to evaluate long-term results of internal fixation of comminuted fractures of the patellar apex with the basket plate.

MATERIALS AND METHODS

A total of 142 patients with fracture of the distal pole of the patella were treated with the basket plate between 1988 and 2013. Functional evaluation was conducted using the modified Cincinnati knee rating system. A total of 98 patients were available for late functional evaluation.

RESULTS

There were no infections or implant-related problems during the follow-up period. All fractures healed within 8 to 10 weeks. There were three cases of early revision because of improper use of the implant and incorrect indication. Functional outcome following internal fixation with the basket plate was excellent in 80 patients and good in 18; there were no poor results.

CONCLUSION

Internal fixation with the basket plate is recommended for management of multifragmentary fractures of the patellar apex because this method enables early, unrestricted knee motion, and provides reliable healing and good functional outcome. This method is an alternative to partial patellectomy and is considered a patella-saving procedure; therefore, the use of the basket plate is strongly recommended for the treatment of distal pole fractures.