The Journal of Arthroplasty xxx (2021) 1e6

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The Journal of Arthroplasty

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Patellar Fracture After Total Knee Arthroplasty With Retention: A

Retrospective Analysis of 2954 Consecutive Cases
Jung-Su Choe, MD a, b, Seong-Il Bin, MD a, *, Bum-Sik Lee, MD a, Jong-Min Kim, MD a,
Ju-Ho Song, MD a, Hyung-Kwon Cho, MD a
a
Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
b
Department of Orthopedic Surgery, Cheju Halla Hospital, Jeju, Korea

a r t i c l e i n f o a b s t r a c t

Article history: Background: To the best of our knowledge, there have been no large case studies on patellar fracture after
Received 5 December 2020 total knee arthroplasty (TKA) with patella retention.
Received in revised form Methods: From 2005 to 2019, 2954 consecutive TKAs with patella retention were retrospectively
13 February 2021
reviewed. The incidence of patellar fracture was confirmed. Perioperative demographic factors associated
Accepted 29 March 2021
Available online xxx
with patellar fracture were compared between the nonpatellar fracture control (randomly selected after
age and sex matching) and patellar fracture patient groups. To confirm the prognosis of identified
patellar fractures, Hospital for Special Surgery knee score, union rates, and complications after treatment
Keywords:
total knee arthroplasty
were evaluated. Treatment outcomes were compared as per the treatment method, and fracture type
patella retention was classified by shape.
patellar fracture Results: For primary TKAs with patella retention, patellar fracture occurred in 32 of 2883 cases (inci-
incidence dence 1.11%). When comparing the preoperative demographic factors between the patellar fracture and
prognosis control groups, there was a significant difference in knee flexion of the affected limb. Twenty-three cases
were treated nonoperatively, and nine cases were treated operatively. Of the 32 patellar fractures, 28 had
confirmed union, and the HSS score at the latest follow-up increased significantly from the preoperative
score. The only complication noted after treatment was nonunion in three cases. We found no significant
differences in treatment results as per the treatment method and fracture type.
Conclusion: Patellar fracture after TKA with retained patella is infrequent, with relatively improved
clinicoradiological results over those of patellar fracture after TKA with resurfaced patella reported in the
literature. The improved results did not differ as per the treatment method and fracture type.
© 2021 Elsevier Inc. All rights reserved.

Despite the success of total knee arthroplasty (TKA), the deci-
sion to resurface or to retain the patella is controversial [1e6].
Previous studies have compared anterior knee pain of retained
patella and resurfaced patella in TKA and reported inconclusive
Each author certifies that he or she has no commercial associations that might
pose a conflict of interest in connection with the submitted article.
This study was approved by our institutional review board (approval no. 2020-
1313).
No author associated with this paper has disclosed any potential or pertinent
conflicts which may be perceived to have impending conflict with this work. For
full disclosure statements refer to https://doi.org/10.1016/j.arth.2021.03.053.
* Address correspondence to: Seong-Il Bin, MD, Department of Orthopedic Sur-
gery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro
43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
evidence to identify the superior method [4,7e10]. In determining
the appropriate patella management, the prognosis of patellar
fracture after TKA should also be investigated.
In TKA with resurfaced patella, bone thickness is reduced and an
additional implant is inserted. Fractures in such cases are referred to
as periprosthetic patellar fractures. In TKA with retained patella, the
former patellar shape is maintained as much as possible [2,9e11].
Thus, the incidence and prognosis of patellar fracture in these two
cohorts would be different. However, previous large case studies
have reported mainly on patellar fractures in resurfaced patellae
[12e17]. To the best of our knowledge, there have been no large case
studies on patellar fracture after TKA with retained patella.
Therefore, this study aimed to investigate the incidence of patellar
fracture, demographic factors associated with patellar fracture, and
progression after patellar fracture in a large number of TKAs with
retained patella. We hypothesized that the incidence and prognosis

https://doi.org/10.1016/j.arth.2021.03.053
0883-5403/© 2021 Elsevier Inc. All rights reserved.
2 J.-S. Choe et al. / The Journal of Arthroplasty xxx (2021) 1e6
of patellar fracture in retained patella would be different from the
reported results of resurfaced patella in previous literature.
Materials and Methods
Patient Selection
The study was approved by our institutional review board. We
retrospectively reviewed 2954 consecutive TKA cases with retained
patella performed by a single surgeon in 1921 patients at our
hospital between 2005 and 2019. Of the patients, 71 who had un-
dergone a revision surgery were excluded. The final 2883 TKA cases
were investigated, and the mean follow-up period was 49.9 ± 38.9
months. We intensively reviewed the medical records and radio-
graphs of all patients, confirming the incidence of patellar fracture
after TKA with retained patella. After identifying 32 patellar frac-
tures, the control group was established by randomly selecting 64
cases among patients without patellar fracture after sex and age
Fig. 1. Classification of patella fracture after TKA with retained patella as per the shaped(A): type I (vertical), (B): type II (osteochondral), (C): type III (transverse), (D): type IV
(superior or lower tip), (E): type V (comminuted displaced), and (F): type VI (others).
matching with fracture patients. To indirectly identify the risk
factors associated with patellar fracture, we analyzed differences in
perioperative demographic factors between the patellar fracture
and control groups. Weight, height, body mass index (BMI),
affected knee range of motion (ROM), preoperative alignment,
number of previous surgeries, and bone mineral density were
investigated as preoperative demographic factors. The type of
implant, lateral release, postoperative alignment, patella tendon
length, and Insall-Salvati ratio were investigated as postoperative
demographic factors.
TKA Surgical Procedure and Rehabilitation
All surgeries were performed by a senior surgeon. An anterior
midline skin incision and medial parapatellar arthrotomy were
used. The distal femoral and tibial bones were resected using an
intramedullary guide. The posterior cruciate ligament was removed
in all cases. Appropriate flexion and extension gaps and optimal
 J.-S. Choe et al. / The Journal of Arthroplasty xxx (2021) 1e6 3

Table 1
Comparison of Perioperative Demographic Factor Related to Patella Fracture Between the Patella Fracture Group and the Control Group.

Variable The Patella Fracture group (32) The Control Group (64) P-Value

Preoperative demographic factor

Age, y 68.4 ± 6.0 68.4 ± 6.0 1.000
Male/female, n 4/28 8/56 1.000
Weight, kg 64.1 ± 12.8 62.8 ± 8.3 .542
Height, cm 152.0 ± 7.3 153.2 ± 6.6 .417
BMI, kg/m2 27.7 ± 4.8 27.1 ± 4.3 .531
Flexion contracture of affected knee, degreea 7.3 ± 7.3 8.7 ± 7.8 .378
Further flexion of affected knee, degreea 122.7 ± 28.1 133.0 ± 22.0 .050
Preoperative mechanical alignmentb 9.9 ± 6.2 9.0 ± 6.2 .510
Diagnosis OA: 30, RA:1, OA: 61, RA:1, .800
Traumatic OA: 1 Traumatic OA: 1,
Synovial chondromatosis: 1
Number of previous operation, n No: 26, 1time: 5, 2times: 1 No: 58, 1time: 5, 2times: 1 .424
Bone mineral density, T-scorec 1.5 ± 1.3 1.5 ± 1.1 .950
Postoperative demographic factor
Lateral release 0 0
Postoperative mechanical alignmentb 1.6 ± 2.6 0.5 ± 3.2 .110
Patella tendon length, mmd 40.1 ± 5.7 39.8 ± 5.0 .771
Insall-Salvati ratio, %d 1.0 ± 0.1 1.0 ± 0.1 .825

n, number; kg, kilogram; cm, centimeter; BMI, body mass index; OA, osteoarthritis; RA, rheumatoid arthritis. Preop, preoperative; HSS, hospital special score; OA, osteoar-
thritis; RA, rheumatoid arthritis; mm, millimeter.
Data are reported as mean ± SD unless otherwise indicated.
Continuous variables are analyzed by paired t-test, categorical variables are analyzed by the chi-square test, and P-value <.05 is considered statistically significant.
a
Range of motion of affected knee measured without anesthesia immediately before surgery.
b
Hip-knee-ankle angle of affected knee measured on full-length standing hip-to-ankle radiographs performed 1 d before surgery and 1 wk after surgery; A positive value
indicates varus alignment, whereas a negative value indicates valgus alignment.
c
The lowest T-Score measured in spine and femur with dual energy X-ray absorptiometry before surgery (excluding word's area).
d
Patella tendon length and patella tendon length/patella length (Insall-Salvati ratio) measured on an immediate postop knee lateral image performed with full extended
knee.

medial and lateral ligament balancing were achieved in the testing
of the trial components. Special caution was taken to prevent in-
ternal malrotation of either the femoral or tibial components.
Adequate patellar tracking was confirmed throughout the knee
motion with the no-thumb technique. Patelloplasty was performed
for all cases instead of patella resurfacing. First, the marginal
osteophytes around the patella were removed with a rongeur. If a
concave surface was present on both patella facets, the facets were
resected to flatten the surface. In addition, circumferential dener-
vation of the patella rim was implemented using electrocautery.
Immediately after surgery, the patients performed exercises such as
quadriceps sets, straight leg raises, and calf pumps. Two days after
surgery, continuous passive motion machines were used for ROM
and tolerable weight bearing was commenced in all patients.
Treatment of Patellar Fracture After TKA With Retention
The surgical indications of patellar fractures in nonresurfaced
patellae are fracture line displacement of
3 mm on radiography
and extensor mechanism injury. The surgery was performed using
open reduction and internal fixation with a tension band or cerc-
lage wiring depending on the fracture type. Conservative treatment
was performed if no damage to the extension mechanism was
confirmed or the fracture line was displaced by < 3 mm on radi-
ography. For conservative treatment, cylinder cast immobilization
was performed for 4 weeks with 10 knee joint flexion without
weight-bearing restrictions. After 4 weeks, the cast was removed
and a patella brace was used until the symptoms improved. Active
ROM exercise was initiated.

Table 2
The Prognosis of Patellar Fractures After TKA With Retained Patellae.

Categories Variables Value

Patella fracture demographics Interval from primary TKA to fracture, mo 25.2 ± 30.6
Traumatic/nontraumatic, n 18/14
Operation (reoperation)/conservative treatment, n 9 (1)23
Operation fixation method, n Tension band wiring: 7
Cerclage wiring: 2 (1a)
Radiological outcomes Union (ossoeus/fibrous), n 28 (19/9)
Nonunion, n 3
Follow-up loss, n 1
Clinical outcomes Preoperative HSS score 58.9 ± 14.5b
Latest follow-up HSS score 91.6 ± 6.5
Other complications (infection, patella subluxation, etc.), n 0

mo, month; n, number; BMI, body mass index; HSS, hospital special score.
Data are reported as mean ± SD unless otherwise indicated.
a
Tension band wiring was first performed, but it was not united and revision was carried out with cerclage wiring.
b
Hospital special score, with the total score based on 100 points.
4 J.-S. Choe et al. / The Journal of Arthroplasty xxx (2021) 1e6

Table 3
The Prognosis of Nonunion Patients.

Patient Sex/Age, Y Typea Treatment Prognosis

Female/73 Transverse Conservative treatment Recovered ROM with no symptoms

Male/62 Vertical Conservative treatment Recovered ROM with no symptoms, HSS 95
Female/67 Transverse OR and IF c tension band Attained no union even after reoperation, leaving an extension lag of 45

ROM, range of motion; HSS, hospital special score; OR and OF c tension band, open reduction and internal fixation with tension band.
a
Patella fracture types categorized by shape.

Outcome Measures
All patients were assessed preoperatively and followed up at
6 weeks, 3 months, 6 months, and then annually after 1 year
postsurgery. If a patellar fracture was found, a short-term follow-
up was performed with radiography to confirm the fracture
union after treatment. Clinical assessment and radiographic
examination using weight-bearing anteroposterior, lateral,
skyline, and full-length standing hip-to-ankle radiographs were
performed during follow-up. Clinical outcomes were evaluated
using the Hospital for Special Surgery (HSS) knee score. We
intensively reviewed the medical records and radiographs of all
patients, confirming the incidence of patellar fracture after TKA
with retained patella. After identifying 32 patellar fractures, the
treatment outcomes of the 32 cases were evaluated. The union
rate of patellar fracture included both osseous union and fibrous
union. Osseous union was defined as a case in which the gap of
the fracture site disappeared on follow-up radiography. Fibrous
union was defined as a case with a visible gap of the fracture site
(within 2 mm) on 6 months postoperative radiography but no
symptoms due to the fracture such as extension lag or ROM
limitation. In addition to nonunion, we thoroughly investigated
complications after patellar fracture treatment. The fractures
were classified by shape as types I (vertical), II (osteochondral),
III (transverse), IV (superior or lower tip), V (comminuted dis-
placed), and VI (others) (Fig. 1). Then, the treatment results of the
patellar fractures were compared as per the treatment method
and fracture type.
Statistical Analyses
All statistical analyses were performed using SPSS Version
21.0 (IBM Corporation, Armonk, NY), with the statistical signifi-
cance set at P < .05. For continuous variables, paired t-test and
the Mann-Whitney test were used for cross-group comparisons.
The Kruskal-Wallis test was used to compare the results in
accordance with the fracture type. The chi-square test and
Fisher’s exact test were used to compare categorical variables
between the groups.
Results
Of the 2883 TKAs with patella retention, patellar fracture
occurred in 32 cases (an incidence of 1.11%). The mean interval from
primary TKA to fracture of 32 cases was 25.2 ± 30.6 months. Peri-
operative demographic factors for patellar fracture patients are
presented in Table 1. When comparing those factors between the
patellar fracture and control groups, significant differences be-
tween the two groups were observed only in flexion ROM of the
affected knee (patellar fracture group: 122.7 ± 28.1, control group:
133.0 ± 22.0, P ¼ .05).
Of 32 patellar fractures, 23 were treated conservatively and 9
were treated with surgery. Union was confirmed in 28 cases, and
the HSS score of the patients with patellar fracture at the latest
follow-up increased significantly from the preoperative score (P <
.001; Table 2). The only complication noted after treatment was
nonunion in three cases. In two cases, nonunion occurred after
conservative treatment and full-extension ROM was recovered
without symptoms. In one case, nonunion occurred after operation
and with reoperation, leaving an extension lag of 45 in the affected
limb (Table 3). No complications were observed other than
nonunion.
When the groups were compared as per the treatment method,
there was a significant difference in the injury mechanism alone
(Table 4). The distribution of cases in accordance with fracture
types was as follows: type I (vertical), 5 cases; type II (osteochon-
dral), 6 cases; type III (transverse), 5 cases; type IV (superior or
lower tip), 10 cases; type V (comminuted displaced), 3 cases; and
type VI (others), 3 cases. We found no significant differences in
treatment results in accordance with the fracture type (Table 5).

Table 4
Comparison by Treatment Method Implemented in Patella Fracture After TKA With Retained Patella (Operative Vs Nonoperative).

Variable Operative (9) Nonoperative (23) P-Value

Age, y 69.9 ± 6.2 67.8 ± 5.9 .341

Male/female, n 9/0 19/4 .181
BMI, kg/m2 28.8 ± 5.9 27.2 ± 4.4 .458
Preoperative mechanical alignmenta 8.8 ± 6.35 10.0 ± 6.9 .433
Mechanism of injury (traumatic/nontraumatic), n 9/0 9/14 .002
Preoperative diagnosis, n OA: 9 OA: 21, RA: 1, Traumatic OA: 1 .659
Preoperative HSS scoreb 49.5 ± 15.3 61.8 ± 13.4 .108
Last follow-up HSS scoreb 88.5 ± 7.7 92.9 ± 5.8 .178
Union (osseus/fibrous), n 8 (8/0) 20 (11/9) .882
Nonunion, n 1 2

n, number; BMI, body mass index; HSS, hospital special score; OA, osteoarthritis; RA, rheumatoid arthritis.
Data are reported as mean ± SD unless otherwise indicated.
Continuous variables are analyzed by paired t-test, categorical variables are analyzed by the chi-square test, and P-value <.05 is considered statistically significant.
a
Hip-knee-ankle angle of affected knee measured on full-length standing hip-to-ankle radiographs performed 1 d before surgery; A positive value indicates varus
alignment, whereas a negative value indicates valgus alignment.
b
HHS score, with the total score based on 100 points.
 J.-S. Choe et al. / The Journal of Arthroplasty xxx (2021) 1e6 5

Table 5
Comparison by Type of Patella Fracture After TKA With Retained Patella Which Was Classified by Shape.

Variable Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 P-Value

Age, y 66.4 ± 7.0 66.6 ± 6.0 69.2 ± 3.9 68.1 ± 7.3 73.3 ± 1.2 70.3 ± 5.0 .608
Male/female, n 2/3 1/5 0/5 0/10 1/2 0/3 .198
BMI, kg/m2 30.1 ± 5.7 25.8 ± 4.5 28.6 ± 4.2 29.2 ± 4.9 22.1 ± 2.4 26.6 ± 2.2 .199
Preoperative mechanical alignmenta 11.6 ± 5.7 12.7 ± 5.5 9.8 ± 5.2 10.6 ±. 6.7 1.3 ± 7.2 7.7 ± 2.1 .134
Mechanism of injury(traumatic/nontraumatic) 2/3 2/4 5/0 7/3 1/2 1/2 .170
Preop diagnosis, n OA: 4, RA: 1 OA: 6 OA: 5 OA: 10, OA: 2, Traumatic OA:1 OA: 3 .115
Preoperative HSS scoreb 64.7 ± 19.6 65.2 ± 13.8 54.3 ± 10.4 54.4 ± 15.0 61 59.7 ± 20.5 .572
Last follow-up HSS scoreb 88.6 ± 8.5 97.5 ± 3.5 96.5 ± 2.1 91.3 ± 7.2 91.5 ± 9.2 89.3 ± 0.6 .575
Union/nonunion, n 5 (2/3) 5 (4/1) 3 (2/1) 10 (10/0) 2 (1/1) 3 (0/3) .198
Nonunion, n 0 1 2 0 0 0

n, number; BMI, body mass index; preop, preoperative; HSS, hospital special score; OA, osteoarthritis; RA, rheumatoid arthritis.
Data are reported as mean ± SD unless otherwise indicated.
Continuous variables are analyzed by Kruskal-Wallis test, categorical variables are analyzed by the chi-square test, and P-value <.05 is considered statistically significant.
The fractures were classified by shape as types I (vertical), II (osteochondral), III (transverse), IV (superior or lower tip), V (comminuted displaced), and VI (others).
a
Hip-knee-ankle angle of affected knee measured on full-length standing hip-to-ankle radiographs performed 1 d before surgery; A positive value indicates varus
alignment, whereas a negative value indicates valgus alignment.
b
HHS score, with the total score based on 100 points.

Discussion patellar fractures were identified. Thirty-two cases were treated

To the best of our knowledge, this study is the first large case
series on patellar fracture after TKA with retained patella. Medical
records and radiographs were reviewed intensively, and even
fractures that may have been missed owing to the absence of
symptoms were found. Therefore, accurate confirmation of the
incidence and prognosis of patellar fracture in TKA with patella
retention was achieved in our study.
In this study, the incidence of patellar fracture in TKA with pa-
tella retention was 1.11%. This result is similar to that of general
population (approximately 1%) and was better than that of the
resurfaced patella (0.2e21%) [18e20]. This is consistent with the
effort to preserve the patella shape as much as possible during TKA
with retained patella.
There have been several studies on the risk factor of periprostatic
patellar fracture in TKA with resurfaced patella. Seo et al. reported that
the number of previous knee surgeries, greater preoperative me-
chanical malalignment, smaller postoperative patellar tendon length,
thinner postresection patellar thickness, and a lower postoperative
Insall-Salvati ratio were associated with the prevalence of peri-
prosthetic fracture in TKA with resurfaced patella [21]. Lustig et al.
reported that preoperative varus >15 degrees increased the patellar
fracture rate [22]. In this study, the risk factor of patellar fracture in
TKA with retained patella was indirectly confirmed by comparing the
perioperative demographic factors between the patellar fracture and
control groups. There was a significant difference only in flexion ROM
of the affected limb. This is thought to be because restriction of knee
flexion increases the pressure on the patella. The ability to generalize
these results is limited due to the small number of patients, and
further studies will be needed in the future.
Unlike resurfaced patella, patellar fractures in TKA with
retained patellae are not periprosthetic fractures. Therefore, our
results showed differences between the prognosis of patellar
fractures in TKA with resurfaced patella and those with retained
patella. In a retrospective study on patellar fracture in resurfaced
patella [23], of the 4583 primary TKAs, 177 patellar fractures were
identified, of which, 164 were treated conservatively and 13 were
treated with surgery. Generally, patients who underwent conser-
vative treatment had no extension lag and had adequate clinical
scores. However, patients who underwent surgeries had a high
complication rate. Four of nine cases treated with excision of an
extruded patella button had or developed a deep infection, and
two patients treated with open-reduction internal fixation had a
nonunion. In the study by Ortiguera and Berry [17], 12,464
consecutive TKAs with resurfaced patella were reviewed and 78
with surgery, and 42 cases were treated conservatively. Among
these cases, 25 cases attained bone healing. The patellar fractures
were divided into three types as per the patella implant stability
and extensor mechanism disruption as follows: type I (implant/
extensor mechanism intact), type II (implant intact/extensor
mechanism disrupted), and type III (implant loose). Prognosis
significantly differed depending on the fracture type. In our study,
28 of 32 patellar fractures in retained patellae attained union. The
HSS score of the patients with patellar fracture significantly
increased at the latest follow-up. The only complication noted
after treatment was nonunion which occurred in three cases. Two
of the three cases recovered full extension ROM without symp-
toms. In particular, the 14 nontraumatic fractures mainly had
chronic nature as an incidental finding but also showed good
progress without complications (7 cases in osseus union and 5
cases in fibrous union). These results are superior to those of
resurfaced patellae published in the literature [17,21e24].
Furthermore, the clinical and radiological results had no mean-
ingful differences depending on the fracture type and treatment
method. Unlike a resurfaced patella, retained patella will not
result in patella thinning; even if fracture occurs, the contact area
that can be united will be wide and the patella implant will have
no interference. Moreover, because of the absence of patella
implant loosening, the possibility of access to the intra-articular
space during surgery is low. Therefore, in cases of surgery or in
cases of conservative treatment with severe form of patella frac-
ture, good union is attained and complications such as infection
and nonunion are less likely to occur.
This study has some limitations. First, the follow-up period was
relatively short. However, generally, patellar fractures after TKA
occur within the first 2 years [17]. In addition, the hospital acces-
sibility was excellent; hence, patients with symptoms due to
patellar fracture easily revisited the hospital. Thus, the possibility of
underestimation of the incidence owing to follow-up loss is less
than expected. Second, this study was a retrospective study.
However, nonselected, consecutive TKAs were included in our
study, and no variation in treatment over time was observed. In
addition, although our data were analyzed retrospectively, clinical
and radiographic results were prospectively collected. Third, there
was a small number of patellar fractures found in this study. The
results would be more meaningful if this study included more
patellar fractures in TKA with retained patellae. However, the small
number is due to the low incidence of patellar fracture in TKA with
retained patella. This observation is valuable. Further study of this
topic will be needed in the future.
6 J.-S. Choe et al. / The Journal of Arthroplasty xxx (2021) 1e6
Conclusions
This large case series analysis provides valuable information
regarding precise incidence and treatment outcomes of patellar
fracture in TKA with retained patella. Our findings suggest that
patellar fracture after TKA with retained patella is infrequent, with
relatively improved clinical and radiological results compared with
those of patellar fracture after TKA with resurfaced patella reported
in the literature [17,21e24]. The improved results did not differ as
per the treatment method and fracture type.
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