Journal of

Orthopaedic
Article Surger y
Journal of Orthopaedic Surgery
25(2) 15
The Author(s) 2017
Surgery of patellar fractures using Reprints and permissions:
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a medial parapatellar approach DOI: 10.1177/2309499017719378
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Yong-Cheol Yoon1, Jae-Ang Sim2 and Jin-Hun Hong2

Abstract
Purpose: The general surgical approach for patellar fractures has a significant weakness, in that the articular facet is
invisible because the fixation is performed using radiation amplifiers after exposing the fracture site through vertical or
transverse dissection on the anterior patella. We report excellent outcomes in the surgical treatment of patellar fractures,
using a medial parapatellar approach. Methods: This study evaluated 20 patients who underwent surgery between August
2008 and April 2014 to correct patellar fractures with comminution or with displacement of the articular facet of !2 mm
and who had !1 year of follow-up. Surgery was performed using anatomical reduction with direct exposure of the
articular facet of the patella via a medial parapatellar approach. Bone union, severity of displacement, range of motion
(ROM) of the patella, and complications were evaluated after surgery, and patellar function was evaluated using the
Lysholm knee score. Results: Bone union was achieved in all cases, and average displacement of the articular facet
decreased from 3.2 mm (range: 1.27.3 mm) preoperatively to 0.2 mm (range: 00.5 mm) postoperatively. No particular
postsurgical complication was observed. All cases had a normal ROM, and the average Lysholm score at final follow-up
was 96.2 points. Conclusion: Anatomical fixation of the articular facet via a medial parapatellar approach appears to be
suitable for patellar fractures, which are intra-articular.

Keywords
medial parapatellar approach, patellar fracture

Introduction the articular facet when evaluating the reduction. Typi-

A patellar fracture is an intra-articular fracture that may
cause traumatic patellofemoral arthritis if the articular facet
is not accurately reduced during surgery. It may also result
in knee stiffness and reduction of the extensor mechanism
in the case of long-term immobilization.1,2 Although either
conservative treatment or partial or total patellectomy was
the previously used conventional strategy, the issue of
aftereffects and the importance of the patella in the exten-
sor mechanism of the knee joint have since been recog-
nized.3 Hence, the current trend involves the conservation
of as many bone fragments as possible to recover the orig-
inal length of the patella, even in severe comminuted frac-
tures. Moreover, the performance of open reduction results
in a more accurate anatomic reduction of the articular facet,
which allows for joint exercises by enabling stable internal
fixation, thereby minimizing problematic aftereffects.46
However, one disadvantage of the general surgical
approach for patellar fractures is the lack of visibility of
cally, an image intensifier is used following reduction of
the extra-articular portion of the patella using pointed
reduction forceps or K-wires, after exposing the site of the
patellar fracture via vertical or transverse dissection.7,8
This method differs from the one that is used for other
intra-articular fractures, wherein the reduction state is eval-
uated by directly observing the articular facet.
1
Orthopedic Trauma Division, Trauma Center, Gachon University Gil
Hospital, Namdong-gu, Incheon, South Korea
2
Department of Orthopedic Surgery, Gachon University Gil Hospital,
Namdong-gu, Incheon, South Korea
Corresponding author:
Jae-Ang Sim, Department of Orthopedic Surgery, Gachon University Gil
Hospital, 21, Namdong-daero, 774 beon-gil, Namdong-gu, Incheon
405-760, South Korea.
Email: sim_ja@daum.net

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2 Journal of Orthopaedic Surgery 25(2)
Materials and methods
Twenty patients (15 men and 5 women) who underwent
surgery for patellar fractures between August 2008 and
April 2014 and who had !1 year of follow-up were
included in this study. This was a retrospective cohort
study. The surgical indication for the treatment of a patellar
fracture via a medial parapatellar approach was limited to
fractures with comminution or with a !2 mm displacement
of the articular facet. Compression-type fracture was
defined as reduction in the thickness of the fracture frag-
ment by more than half of the thickness of the contralateral
side on a lateral radiograph.9 We used a medial parapatellar
approach in compression-type cases when the periosteum
and retinaculum were relatively intact and the articular
portion could not be identified through the fracture site.
Patients with other combined fractures were excluded from
the study. In cases in which active knee extension was
impossible owing to extensor mechanism injuries, only the
separation of bone fragments was done, without dislocation
of the articular facet. In cases of eminence fracture, which
is a type of extra-articular fracture, surgery was performed
using established methods involving a vertical incision.
Injuries were caused by traffic accidents involving auto-
mobiles or motorcycles in 12 cases, by a fall from a height
in 5 cases, and by a fall due to slipping in 3 cases; all cases
involved contact trauma that directly injured and damaged
the patella. Fracture of the patella was classified as follows,
based on the pattern of the fracture and degree of displace-
ment of the articular facet: 12 cases of comminuted frac-
ture, 5 cases of transverse fracture, and 3 cases of
longitudinal fracture. Excluding the comminuted cases, the
remaining eight were compression fractures. When defin-
ing separation, the value was obtained by calculating the
average of two distances measured between the two bone
fragments (one at the anterior side of one fragment and
another at the posterior side of another fragment in the
lateral view). Displacement was defined as the anteropos-
terior distance measured between the articular facets of the
two bone fragments.10 The preoperative lateral radiograph
showed an average separation of 4.2 mm (range: 2.010.0
mm) and an average displacement of 3.2 mm (range: 1.2
7.3 mm) (Figure 1).10
The patients were placed in the supine position under
spinal or general anesthesia, while wearing a tourniquet at
the proximal femoral region. The skin on the midline of the
patella was vertically dissected, followed by vertical dis-
section from the borderline between the medial one-third
and central one-third of the proximal quadriceps femoris
muscle, along the direction of the fibers. Following dissec-
tion from the midline of the patella to a point 45 mm
distally, further dissection was continued toward the prox-
imal tibia along the midline. In the case of a severe com-
minuted fracture of the medial patella or a ruptured patellar
tendon, the approach was made through the medial side.
The articular facet was then exposed by everting the
Figure 1. Definition of separation and displacement. Separation is
defined as (a b)/2 and displacement as c.
patella, after which accurate reduction of the articular facet
fracture was performed using pointed reduction forceps or
K-wires. Fixation was performed using the K-wire (1.5 mm
diameter) that was used for reduction by (1) applying ten-
sion band wiring for small bone fragments, (2) applying
modified tension band wiring with 3.5-mm-thick cannu-
lated screws, using the K-wire as a guide wire for bone
fragments with a maximum cross-sectional area of !1
cm2, or (3) using either additional K-wires or cannulated
screws to fix the comminuted articular facet in the case of
severe comminution. The K-wire was used mainly for tem-
porary fixation during surgery, and screws were used in
cases where the size of the main fracture fragment was
large enough to prevent dislocation of the fragment. At this
time, the soft tissue dissection was limited to the extent that
the fracture site could be confirmed while preserving the
maximum attached soft tissue. Dissection was only per-
formed 23 mm distal and proximal to the retinaculum,
and the soft tissue adhering to the bone fragment was not
damaged.
Straight-leg-raising exercises were allowed from post-
operative day 1, and continuous passive motion (CPM)
exercises were allowed from postoperative day 2. CPM
exercises were performed until the active range of motion
(ROM) of the knee joint reached 90" . Postoperative weight
bearing was performed as soon as possible with both
straight-leg-raising and quadriceps muscle-strengthening
exercises. If the patient experienced pain at the time of
weight bearing, then a crutch was used for assistance.
Follow-up was performed at 1 month, 3 months, 6
months, and 1 year after surgery. Statistical significance
was evaluated (Wilcoxon signed-rank test) by measuring
and comparing the pre- and postoperative degrees of articu-
lar facet displacement on the lateral radiographic view.
Level of statistically significant difference was set at
Yoon et al. 3

Figure 2. A 69-year-old man with displacement of !3 mm and

intra-articular fracture observed on radiographs and computed
tomography at the time of the visit for a pedestrian traffic
accident.

p < 0.05. The degrees of displacement were defined as

follows: A smooth articular facet with a displacement of
$1 mm was considered excellent, a displacement of 12
mm was good, a displacement of 23 mm was fair, and a
displacement of > 3 mm was poor. Bone union relative to
initial severity of displacement, ROM of the patella, and com- Figure 3. (a) Exposure of the fracture site using a medial para-
plications were radiologically evaluated after surgery, and patellar approach and (b) anatomical reduction of the articular
patellar function was evaluated using the Lysholm knee score. facet using pointed reduction forceps.

Results
The average duration of postsurgical follow-up was 18
months (range: 1232 months). Bone union was achieved
in all cases, and the average time required for bone union
was 12.7 weeks (range: 1017 weeks). Maximum knee
joint flexion was considered to be 140" and was achieved
within 1 week of surgery in all 8 transverse and longitudi-
nal fracture cases, and within an average of 3 weeks (range:
24 weeks) after surgery in the 12 comminuted fracture
cases. The final follow-up revealed full recovery of maxi-
mum flexion of 140" , with a flexion limitation of 0" in all
cases. Complications such as avascular necrosis (AVN) of
the patella; limitations in the ROM of the knee joint; non-
union; loss of fracture reduction; irritation due to implants,
dissociation, and translocation of the implants; and infec-
tion were not observed in any cases (Figures 2 to 5). Simi-
larly, postsurgical separation of the articular facet was not
found in any cases. The lateral radiographs revealed reduc-
tion (p 0.001, Wilcoxon signed-rank test) in the average
displacement from 3.2 mm (preoperative value; range: 1.2 Figure 4. Postsurgical anteroposterior and lateral radiographs.
7.3 mm) to 0.2 mm (postoperative value; range: 00.5 mm).
Therefore, an excellent outcome, including a smooth
articular facet with a displacement of $1 mm, was
Discussion
achieved in all cases (Figures 2 to 5). At the final follow- In this study, patellar fractures with intra-articular commi-
up, the average Lysholm knee score was 96.2 points (range: nution and displacement showed good clinical and radiolo-
90100 points). gical results, using a medial parapatellar surgical approach.
4 Journal of Orthopaedic Surgery 25(2)
Figure 5. Anteroposterior, lateral, and Merchant view radio-
graphs taken 6 months after surgery show strong subchondral
bone fixation of the screws (red arrow).
This approach is used for total knee replacement. The
advantages of this approach include easy eversion of the
patella and easy access to the articular facet owing to a
wide visual field.1113 Furthermore, instrument implanta-
tion into the articular facet can be assessed while inserting
the K-wire and cannulated screws, after the articular facet
is accurately reduced, direct stable fixation to the subchon-
dral bone can then be achieved.
Moreover, this anterior approach can reduce implant
irritation as theorized in many studies.1416 This approach
makes it possible to insert the implant deep into the sub-
chondral bone, thereby reducing irritation. Therefore, there
was no irritation in any of the 20 cases. Two patients
requested implant removal, which was accomplished with-
out difficulty using the same approach.
The extensor mechanism is known to be weakened by
injury to the medial superior and descending genicular
artery during dissection of the quadriceps femoris muscle
and patella and can be considered a disadvantage of the
medial parapatellar approach. However, no AVN or weak-
ening of the extensor mechanism due to arterial injury was
observed in this study. This may be explained by (a) a
careful approach to the ligament region of the quadriceps
femoris, (b) relatively intact periosteum and retinaculum
using this approach to a compression-type fracture, (c)
complete suturing of the ligament of the quadriceps femoris
and patella during surgery, and (d) allowing continuous
rehabilitation exercise. In addition, we limited surgery for
patellar fractures to the stated indications.
One specific technique that can be performed through
the wound involves the temporary maintenance of reduc-
tion using pointed forceps, after the bone fragments are
reduced by touching the articular facet either directly or
indirectly; exposure of the articular facet by dissection of
the lateral retinaculum has been reported.17 In addition, the
reduction can be evaluated using arthroscopy.18 However,
such a method has limited ability to evaluate the suitability
of reduction, since the evaluation is performed indirectly.
In comminuted fractures, the accuracy of reduction cannot
be determined using an approach through the wound or
partial dissection of the retinaculum. In addition, the blood
supply to the patella may be a consideration in a lateral
parapatellar approach to internal fixation.19 However, this
method involves difficult inversion in the fixation of
the patella.
Study limitations include the small number of patients,
possibly leading to inaccurate results; furthermore, a con-
trol group using other approaches to a patellar fracture
could not be prospectively analyzed. In addition, the mean
follow-up period was 18 months, which was insufficient to
evaluate patellofemoral arthritis after fracture.
Conclusions
In comminuted patellar fractures with displacement of the
articular facet and in compression-type patellar fractures, an
excellent treatment outcome can be achieved by performing
accurate reduction while directly observing the articular
facet of the patella via a medial parapatellar approach.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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