TECHNICAL TRICK
Patella Osteotomy: A New Approach for Complex Trauma
Around the Knee
Simon M. Donald, MB ChB* and Edward R. Bateman, FRACS†
Summary: Complex floating knee injuries, comprising complete
articular distal femur and proximal tibia fractures, are a significant
challenge in Orthopedic Traumatology. Traditional surgical
approaches can result in a limited exposure, compromising osteosyn-
thesis, with an extensive soft tissue dissection predisposing to
adhesion of the quadriceps and arthrofibrosis. The Patella Osteotomy
technique provides unrivaled visualization of the articular surfaces of
the knee, with a limited soft tissue dissection to permit the
anatomical reconstruction of the articular injury, while minimizing
the risk of postsurgical complications and reducing intraoperative
fluoroscopy time.
Key Words: distal femur fracture, proximal tibia fracture, complex
knee trauma, floating knee, patella osteotomy, surgical approach
(J Orthop Trauma 2013;27:e161–e167)
INTRODUCTION
Fractures of the distal femur and proximal tibia comprise
0.4% and 1.2% of all fractures, respectively.1,2 Complete artic-
ular fractures around the knee, as defined by the Orthopaedic
Trauma Association (OTA) classification system, are Type-C
injuries, with C1 denoting a simple fracture pattern, C2 repre-
senting metaphyseal comminution, and C3 characterized by
both metaphyseal and articular comminution.3 The floating
knee injury describes a knee discontinuous with the axial skel-
eton due to ipsilateral fractures of the femur and tibia.4 Com-
plete articular fractures of the proximal tibia (Fraser type IIA),
distal femur (type IIB), or both (type IIC) are variants of the
original floating knee diaphyseal injury.5
This more complex knee trauma is most prevalent in
a younger age group, frequently males, and is usually as
a result of high-energy trauma, particularly motor-vehicle
accidents and pedestrian-versus-vehicle accidents.2,3,6–11 Mul-
tiple long bone fractures, pelvic fractures and distant trauma
including thoracic, abdominal, and intracranial injuries are
frequently found to coexist.9,10,12,13 Numerous surgical
approaches to the knee have been described for the treatment
Accepted for publication June 28, 2012.
From the *Department of Orthopedic Surgery, Mona Vale Hospital, Mona
Vale, NSW, Australia; and †Department of Orthopedic Trauma, John
Hunter Hospital, Newcastle, NSW, Australia.
No outside funding or grants were received that assisted in this study.
Neither author, nor their immediate families, or any research foundation with
which they are affiliated received any financial payments or other benefits
from any commercial entity related to the subject of this article.
Reprints: Simon M Donald, MB ChB, 17/102 Lawrence St, Freshwater, NSW
2096, Australia (e-mail: dr.simon.donald@gmail.com).
Copyright © 2012 by Lippincott Williams & Wilkins
J Orthop Trauma  Volume 27, Number 7, July 2013
of fractures around the knee. These approaches have potential
limitations, which can adversely affect the complicated, dif-
ficult surgery required for these injuries.
In this article, we report a new approach for the treatment
of complex knee trauma, using an anterior incision in combi-
nation with an oblique osteotomy of the patella, to facilitate an
unrivaled surgical field for the reduction and fixation of complex
fractures of the distal femur and proximal tibia.
TECHNIQUE
The patient is positioned supine on a radiolucent table
with a bump under the ipsilateral hip. The contralateral leg is
padded and secured with a side support. The skin is prepared
from the groin distally to include the toes and then draped
using an extremity leg drape with the openings enlarged as
required to fit the proximal thigh. If the patient’s injuries are
bilateral, both lower limbs are prepared and draped so as to
facilitate timely surgery on both. A bilateral extremity leg
drape is used in this situation. The toes and opening of the
extremity drape are secured with Ioban antimicrobial adhe-
sive incise drapes (3M, St Paul, MN) to ensure sterility is
maintained intraoperatively. Preformed foam ramps are
placed in sterile drapes to enable their use intraoperatively
for limb positioning. Tourniquets are not used.
A midline anterior incision is made from the superior
pole of patella to the tibial tubercle. Full thickness skin
flaps are created with electrocautery so as to expose the
superficial surface of the patella, the patella tendon, the
distal end of the quadriceps tendon, and both the medial and
lateral retinaculum.
Once the exposure is completed, the following land-
marks required for performing the osteotomy and associated
soft tissue incisions are identified and marked (Fig. 1):
1. Inferolateral border of the patella tendon insertion on to the
tibial tubercle.
2. Inferior pole of the patella vertically superior to patella
tendon insertion landmark above.
3. Medial border of the quadriceps tendon insertion on to the
superior surface of the patella.
4. Recesses of the medial and lateral retinacula adjacent to
the collateral ligaments at the level of the joint line.
A longitudinal incision is first made from the inferior
pole of the patella to the marked point on the tibial tubercle.
The patella paratenon is dissected as a separate layer. Sharp
dissection is performed in a single action following the line of
the patella tendon fibers to prevent undue trauma to the
patella tendon. A second straight incision is then created in
the lateral retinaculum from the tibial tubercle to reach the
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Donald and Bateman J Orthop Trauma  Volume 27, Number 7, July 2013

2 large pointed reduction forceps with one 1.25-mm threaded

FIGURE 1. Diagram of the patella osteotomy technique with
the side, landmarks, direction of osteotomy, and cannulated
screws illustrated. Landmarks are numbered as in the text.
guide wire passed through each of the predrilled tracts.
Compression is achieved with two 4.0-mm cannulated screws
(Synthes, Oberdorf, Switzerland). The screws used are 3–5 mm
shorter than measured to ensure compression with the tension
band is possible. Fixation is completed with the passing of a dou-
ble #2 FibreWire tension band suture (Arthrex, Naples, FL).
Retinacular repair is achieved with a running #1 absorb-
able braided suture, while a layered repair is used for the patella
tendon with a running 2/0 slowly absorbable monofilament
suture in the tendon itself and a running 3/0 dyed absorbable
suture for the paratenon. Subcutaneous closure uses interrupted
2/0 absorbable braided sutures with either surgical skin staples
or horizontal mattress 3/0 nonabsorbable monofilament sutures.
The knee is placed in a controlled motion knee brace
postoperatively. The range of movement is set to 0–608 ini-
tially. A continuous passive motion device is used to encour-
age immediate passive movement of the knee. Static open
chain isometric quadriceps exercises and active knee range
exercises are undertaken from the first postoperative day. If
other injuries or medical interventions prevent the patient
from being able to begin active physiotherapy immediately,
continuous passive movement machines are used until
the patient is able to begin active physiotherapy. Progressive
exercises are commenced from 2 to 3 weeks and the range of
the controlled motion knee brace gradually increased until

lateral collateral ligament at the level of the joint line. Both

collateral ligaments are protected from iatrogenic injury
throughout the procedure.
Next, the line of the patella osteotomy is marked from
the medial border of the quadriceps tendon insertion on the
superior patella to the inferior patella pole. To ensure accurate
reduction and stable osteosynthesis of the patella is achieved
at the conclusion of the operation, K-wire insertion, predril-
ling, and tapping of the patella perpendicular to the osteotomy
is performed before proceeding. It is vital that a blunt retractor
is placed between the patella and trochlea to prevent injury
to the retropatella structures of the knee. The osteotomy is
performed using a microoscillator, with a fine osteotome to
complete the cut through the patella articular surface so as to
reduce iatrogenic chondral trauma.
The final soft tissue incision is then made from the
superior end of the osteotomy into the medial retinaculum to
the level of the joint line adjacent to the medial collateral
ligament. If required, a short section of Vastus Medialis is
released to complete this final step. In this situation, a cuff of
tissue is left attached to the superior pole of the patella for
later reattachment. The superolateral and inferomedial
margins of the osteotomy are now retracted for access to
the distal femur and proximal tibia for osteosynthesis of the
injury (Fig. 2). To improve exposure of the proximal tibia, the
intermeniscal ligament can be cut and the meniscii reflected.
When fracture fixation is completed, the joint is
meticulously lavaged to remove any reamings and debris.
After this, patella osteosynthesis is performed first. Figure-of-
eight tension band suturing through 2 parallel cannulated
compression screws is used for definitive osteosynthesis of FIGURE 2. Completed patella osteotomy with visualization of
the osteotomy.14,15 The osteotomy is reduced and held with articular surface as performed in cadaveric knee joint.

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J Orthop Trauma  Volume 27, Number 7, July 2013
being discontinued at 6–8 weeks, by which time union of the
osteotomy is generally evident on plain radiographs. Weight-
bearing status and duration of reduced weight bearing is
determined by the original injury pattern.
CLINICAL SERIES
We have performed the Patella Osteotomy technique
4 times. Three of these cases involved complex trauma with
floating knee injuries. This technique has also been used once
for the removal of an intramedullary nail in a patient with an
infected tibial union and extreme patella baja, precluding
a traditional approach to the nail. All cases, with the exception
of the last patient, have follow-up exceeding 12 months. Our
longest follow-up is 9 years (case illustrated in Figs. 3–7). We
have had no osteotomy or fracture nonunions to date and
there have been no soft tissue complications. The average
postoperative range of movement is 0–1208. Retrograde
articular countersunk screws are removed arthroscopically
once union is confirmed.
The Patella Osteotomy technique has a select role in the
osteosynthesis of complex multifragmentary complete articular
fracture of the distal femur (OTA classification 33-C3), partic-
ularly in the presence of combined medial and lateral posterior
condyle or Hoffa fragments, in combination with complete
articular fractures of the proximal tibia (41-C), namely, the Fraser
Type IIC floating knee injury. It would also be a suitable
approach in the osteosynthesis of extraarticular or partial articular
fractures of the proximal tibia (41-A and 42-B, respectively), or
diaphyseal tibial fractures (42-A, -B, or -C) in the presence of
such complex C3 distal femur fractures as described above.
Other novel uses, as discussed above, may emerge. Due to the
complexity of such surgery, we recommend this technique to the
experienced Orthopedic Trauma Surgeon only.
FIGURE 3. A, B, Anteroposterior and lateral radiographs of
Fraser IIC floating knee injury (OTA 33-C3 and 41-C1).
Ó 2012 Lippincott Williams & Wilkins
Patella Osteotomy in Complex Knee Trauma
DISCUSSION
A number of surgical approaches have been described
for osteosynthesis of injuries around the knee. Historically,
extensile single incision anterior approaches to both the distal
femur and proximal tibia have been described.16–19 Combina-
tion with an osteotomy of the tibial tubercle and superior
reflection of the extensor apparatus to improve visualization
of the articular surface has also been reported.20,21 These
approaches necessitate an extensive surgical dissection, often
raising large soft tissue flaps to achieve surgical access, and
with the potential for devascularization of bone, infection and
nonunion, are now no longer recommended.22,23
Currently, the lateral parapatellar approach to the distal
femur and combined anterolateral and postero-medial
approaches to the proximal tibia are the approaches of choice
for complete articular fractures around the knee.24–26 These
generally enable sufficient visualization of the articular
surface to ensure anatomical reconstruction without the dam-
aging soft tissue dissection of the extensile anterior approach.
They frequently employ the technique of submuscular percu-
taneous plate insertion with fixed angled locking plates. The
direct lateral minimally invasive approaches to both the distal
femur and proximal tibia utilize this technique also.27–29 How-
ever, as they do not visualize the articular surface directly,
relying on fluoroscopic imaging to ensure a congruent joint
surface, direct lateral approaches are best suited to those frac-
tures where there is only a simple articular extension and
those with no or minimal displacement of the joint surface.
Recently, the fixation of selected complete articular distal
femur and proximal tibia fractures with retrograde femoral and
antegrade tibial nails augmented with compression screws and
bolts has been described using the patella tendon approach with
percutaneous insertion of the screws and bolts.30,31
Combinations of these approaches are required when
performing operative fixation on floating knee injuries. The
anatomy of the fractures, how the reductions will be achieved
and which methods of osteosynthesis are to be employed will
determine the approaches performed.
These current surgical approaches in complex trauma
around the knee give rise to several concerns. If visualization
FIGURE 4. Distal femoral articular reconstruction with tempo-
rary Kirshner wire fixation using patella osteotomy approach.
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Donald and Bateman
FIGURE 5. Completed osteosynthesis of patella osteotomy.
of the articular surfaces is suboptimal, malreduction of the
joint, in particular a rotational mismatch between the femoral
condyles, can be missed.23,32 Malreduction in combination
with poor plate positioning can result in screw penetration
of the joint surfaces and the potential for iatrogenic injury
that, given adequate visualization, accurate reduction, and
correct plate positioning, could have been avoided.33
Fraser type II floating knee injuries are associated with
a significantly higher rate of complications than type I
injuries, one study showing an average postoperative range
FIGURE 6. Six-month postoperative anteroposterior and lat-
eral radiographs of osteosynthesis demonstrating radiological
progression to union of floating knee injury.
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J Orthop Trauma  Volume 27, Number 7, July 2013
of movement of only 968 and a 15% incidence of flexion
contractures.11–13,34 Such complex injuries frequently require
multiple surgical approaches to ensure adequate treatment,
and this can result in an adverse outcome. Scarring of the
quadriceps with or without arthrofibrosis secondary to soft
tissue trauma at the time of initial injury and as a result of
the surgical exposure is believed to be responsible for loss of
knee flexion in these patients.33 By limiting further surgical
trauma to the joint and meticulously handling soft tissues,
a “second hit” injury during surgery can be prevented
or minimized.
The patella osteotomy technique was designed to
reduce the complications described above. Making an anterior
incision and retracting the osteotomy obtains an unrivaled
view of the articular surfaces of the knee joint. This permits
accurate reconstruction of the articular components of both
the distal femoral and proximal tibia fractures. Unlike with
the lateral parapatellar approach, if a medial posterior condyle
fragment is found at the time of surgery, it can be adequately
addressed without extending the approach or performing an
additional approach, thereby preventing further surgical
trauma.35 By being confident in the accuracy of the reduction
and fixation, it is possible to reduce the use of intraoperative
fluoroscopy in cases that can rely heavily on this facility.
Using the landmarks set out in the description of the
technique ensures a focused, limited incision and minimizes
dissection of the quadriceps mechanism. This, together with an
aggressive rehabilitation program, is aimed at preventing
quadriceps scarring and adherence to the anterior femur and
the formation of arthrofibrosis, which limits postoperative range
of movement and associated patient satisfaction. Our experience
with this technique to date has been promising in this regard.
FIGURE 7. Patellar articular surface at 6 months demonstrat-
ing well-preserved articular cartilage and union of osteotomy.
Osteotomy is faintly visible in the center of image.
Ó 2012 Lippincott Williams & Wilkins
J Orthop Trauma  Volume 27, Number 7, July 2013
One concern with this technique is that of union of the
patella osteotomy. The senior author (E.B.) is based in a level
I trauma center and a busy level III regional hospital. He has
only felt this approach necessary 4 times in 9 years, so
experience with this technique is limited. However, to date,
we have not had a nonunion. In designing the osteotomy and
associated soft tissue incisions, we have sought to preserve
the genicular anastomosis. With this technique, the lateral
superior geniculate, lateral inferior geniculate, and medial
inferior geniculate arteries supplying the patella are preserved
with other perforating branches from the extensor mechanism
to ensure preserved vascularity of the entire patella.36 Non-
union of patella fractures is rare in surgically treated patients
with a reported rate of #1%.37 This indicates that a stable
construct for repair of a patella osteotomy under compression
is ideal for union. Our technique for osteosynthesis of the
patella using parallel cannulated screws and tension band
wiring has been shown to provide construct stability equiva-
lent to modified tension band wiring, with the advantage of
a lower implant profile and less soft tissue irritation.14
CONCLUSIONS
The Patella osteotomy technique, as described, is a new
approach for the treatment of complex knee trauma, ideal for use
in Fraser type IIC floating knee injuries. It provides unrivaled
visualization of the articular surfaces of the knee to permit the
anatomical reconstruction of the articular injury with a limited
soft tissue dissection, while minimizing the risk of postsurgical
complications common with these complex injuries.
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