

COPYRIGHT © 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Inferior Patellar Pole

Avulsion Fractures:
Osteosynthesis Compared
with Pole Resection
Surgical Technique
By Matjaz Veselko, MD, PhD, and Matej Kastelec, MD, MSc
Investigation performed at the Department of Traumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 696-701, April 2004

INTRODUCTION
ABSTRACT
In patients who have an avulsion fracture of the patellar pole (Fig. 1),
the extensor mechanism is disrupted and should be repaired. Preser- BACKGROUND:
vation of the inferior patellar pole and osteosynthesis maintain the The ideal treatment for avulsion
patellar height and the normal anatomic and biomechanical relation- fractures of the inferior pole of
ships of the patellofemoral joint and thus can provide better clinical the patella has not yet been
results compared with those of excision of the patellar pole fragments identified. The options include
(1) internal fixation of the pole
fragment and (2) resection of
the avulsed fragment and repair
FIG. 1 of the patellar ligament to the
Preoperative radiograph showing an patella. We are not aware of any
avulsion fracture of the patellar pole. previous study in which the re-
The main fragment is displaced prox- sults of internal fixation have
imally. Comminution of the pole frag- been compared with those of
ment can be seen. pole resection. The purpose of
the present study was to com-
pare the long-term results of
internal fixation (with use of a
basket plate) with those of pole
resection.

METHODS:
We retrospectively studied two
groups of patients who had had
operative treatment of an avul-
sion fracture of the inferior pa-
tellar pole between 1990 and
continued
 
THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S M ARCH 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 1 · JBJS . ORG

ABSTRACT | continued

1997. Fourteen patients had

had internal fixation with a bas-
ket plate, and fourteen had had
pole resection with patellar liga-
ment repair. Eleven patients
who had had internal fixation
(Group A) and thirteen patients
who had had pole resection
(Group B) were followed for an
average of 4.6 years. The final
evaluation was based on the
patellofemoral score, and the
patellar height was measured
radiographically.
FIG. 2

The patient is placed in the supine position. The knee is supported in a semiflexed posi-
RESULTS:
tion with use of a bolster. A tourniquet is used.
The average patellofemoral
score (maximum, 100 points)
was 94.1 points in Group A and
81.2 points in Group B. Signifi-
cant differences between the FIG. 3
groups were noted with regard to
The straight midline
knee pain, level of activity, and
skin incision starts
range of motion. Normal patellar approximately two
height was found in ten of fingerbreadths proxi-
eleven patients in Group A and mal to the displaced
in three of thirteen patients in proximal fragment
Group B. Patella baja was signifi- of the patella and
cantly associated with a poor runs distally to the
functional outcome. tibial tuberosity.

CONCLUSIONS:
In patients who have sustained
an avulsion fracture of the infe-
rior patellar pole, the normal
height of the patella can be
maintained by preserving the pa-
tellar pole. In contrast with pole
resection, which requires post-
operative immobilization, inter-
nal fixation with a basket plate
allows for immediate mobiliza-
tion and early weight-bearing.
The present study indicates that
internal fixation with use of a
basket plate can provide better
clinical results.
 
THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S M ARCH 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 1 · JBJS . ORG

combined with patellar tendon

repair. In the present report, we
describe a new technique of fixa-
tion with a basket plate that pro-
vides stable fixation and
preserves the patellar pole even
in patients with comminuted
avulsion fractures.

SURGICAL TECHNIQUE
The procedure is performed with
the patient under spinal block or
general anesthesia. The patient is
placed in the supine position. A
thigh tourniquet is applied. The
leg is draped in a manner that
will allow free movement of the
knee. The knee is supported in a
FIG. 4
slightly flexed position with use
of a bolster (Fig. 2).
The ruptured retinaculum on either side of the fracture, both fragments, and the patellar
A straight midline incision,
tendon are exposed.
approximately 12 cm in length, is

FIG. 5

Schematic representation of the interwoven suture placed transversely through the patellar tendon just distal to the pole fragments and the
basket plate.
 
THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S M ARCH 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 1 · JBJS . ORG

CRITICAL CONCEPTS

INDICATIONS:
• Avulsion fractures of the apex
of the patella, including com-
minuted fractures

CONTRAINDICATIONS:
• Open fractures
• Active infection at or near the
operative site
• Sleeve avulsions
• Pathologic fractures
• Severely osteopenic bone
• An unreliable, noncompliant
patient
continued

made in the skin. It starts about FIG. 6

two fingerbreadths proximal to
Intraoperative photograph demonstrating placement of the interwoven suture.
the displaced proximal fragment
of the patella and runs distally
over the pole fragment to the tib-
ial tuberosity (Fig. 3). Full-thick-
ness skin flaps are raised medially
and laterally to expose the trans-
versely ruptured retinaculum on
either side of the fracture, both
fragments, and the patellar ten-
don (Fig. 4).
The blood clot is removed,
the knee joint is irrigated, and
the fracture fragments are
cleaned of debris to allow exact
reconstruction. The articular
surface of the femoral condyles is
examined to identify any carti-
lage lesions. The distal fragment
or fragments are prepared for
fixation with the basket plate de-
signed by Smiljani1. The plate has
the shape of a basket with four FIG. 7
posterior and three anterior The four posterior hooks of the basket plate are thrust through the patellar tendon, just
hooks that can be bent to fit the distal to the suture line, so that the fragments are embraced by the basket.
shape of the inferior patellar
 
THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S M ARCH 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 1 · JBJS . ORG

CRITICAL CONCEPTS | continued

FIG. 8

A 2.0-mm Kirsch- PITFALLS:

ner wire is drilled
through one of the
central plate
holes and through
the patellar pole
as posteriorly as
possible.
• An anteriorly tilted plate
leads to a less-than-optimal
direction of the pulling force
on the four posterior hooks.
These hooks can bend, allow-
ing the distal fragments to
displace.

• Positioning the parallel

screws too far anteriorly
prevents positioning of the
oblique screws.

• If the proximal fragment is

less than half of the patellar
length, the fixation may be
insufficient.

• Not placing the interwoven

suture during the treatment
of a comminuted fracture,
or piercing the patellar ten-
don with the hooks of the
basket plate proximal to the
suture, may lead to slippage
of the fragments between the
hooks of the plate and redis-
placement.

• Excessively aggressive
rehabilitation in the first
three weeks postoperatively
may lead to mechanical
failure.
continued

pole. The four posterior hooks

are thrust through the patellar
tendon to embrace the posterior
surface of the patellar pole while
the anterior hooks embrace the
patellar pole ventrally (Fig. 5).
In patients with commi-
FIG. 9
nution of the patellar pole, a
The pole fragments within the plate are reduced and fixed with two large, pointed reduc- number-1 absorbable interwo-
tion forceps to the main fragment, and the Kirschner wire is drilled across the fracture
into the proximal fragment.
ven suture is placed transversely
through the patellar tendon and
 
THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S M ARCH 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 1 · JBJS . ORG

aspect of the main fragment,

parallel with the articular sur-
face (Fig. 8).
The pole fragments within
the plate are then reduced and
temporarily held to the main
fragment with two large, pointed
reduction forceps. The Kirsch-
ner wire is then drilled across
the fracture line into the proxi-
mal fragment (Fig. 9). One of
the large, pointed reduction for-
ceps is then removed from the
plate hole distally and is placed
around the apex of the metal
basket to compress the plate to
the main proximal fragment
(Fig. 10). The three anterior
plate hooks are then curved to
fit the shape of the anterior pa-
tellar surface. Correct position-
ing of the Kirschner wire must
FIG. 10 be checked on the image inten-
One of the large, pointed reduction forceps, previously repositioned around the apex of sifier at this point.
the plate, compresses the plate and the pole fragments against the main fragment. A The plate is then fixed to
4.0-mm cancellous-bone screw is placed in the right central plate hole. The screwdriver
the main patellar fragment with
is in place, indicating the direction of the screw, so that the second hole can be drilled
parallel to the first.
two 4.0-mm cancellous-bone
screws. The first is placed through
the free central hole of the plate,
circumferentially just distal to hooks of the plate are thrust and then the second is placed
the pole fragments and is used through the tendon just distal after the Kirschner wire has been
to tie the fragments into a bun- to the fragment. The hooks are removed (Fig. 10). These two lag
dle2 (Figs. 5 and 6). This suture curved to fit the shape of the screws must be parallel to pro-
prevents slippage of the multiple posterior surface of the patella vide interfragmentary compres-
tiny fragments between the so that the pole fragments are sion, and they should be placed
hooks of the basket plate. The embraced by the basket (Fig. 7). as posteriorly as possible to
four posterior hooks of the It is acceptable for the tips of the provide the optimal position
basket plate are then thrust posterior hooks to touch the ar- of the reduced patellar tendon
through the patellar tendon, just ticular surface of the posterior with its pole fragments (Figs.
distal to the suture line, so that surface of the patella. 11-A and 11-B). Another two
the pulling force of the extensor A 2.0-mm Kirschner wire is small cancellous-bone screws
mechanism is transferred to the then drilled through one of the are then positioned obliquely
patellar pole fragments mainly central plate holes and through and ventrally into the proximal
by the interwoven suture. In pa- the patellar pole as posteriorly patellar fragment to increase
tients with one solid fragment, as possible so that, after reduc- resistance against distraction
the suture is not needed and the tion, it will lie in the posterior forces (Fig. 12).
 
THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S M ARCH 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 1 · JBJS . ORG

FIGS. 11-A AND 11-B

Fig. 11-A Intraoperative fluoroscopic image showing the position of the first two screws, which must be placed parallel to each other and
parallel to the articular surface of the patella. Fig. 11-B Intraoperative posteroanterior fluoroscopic image.

The prominence of the tips

of the four posterior hooks that
might impinge against the ar-
ticular surface of the femoral
groove should be identified by
palpation with the tip of the fin-
ger through the retinacular gap
on either side of the patella. If
they are prominent, they should
be bent further toward the patel-
lar surface. A suction drain is
placed into the joint, and the
retinaculum is repaired with use
of number-0 absorbable sutures
(Fig. 13). At the end of the pro-
cedure, the knee is fully flexed
to test the stability of the fixa-
tion (Fig. 14). Postoperative ra-
diographs are made routinely to FIG. 12
check the reduction of the frac-
Fluoroscopic image showing the final position of the basket plate after fixation to the
ture and the position of the pa- main fragment with four screws.
tella (Fig. 15).
 
THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S M ARCH 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 1 · JBJS . ORG

FIG. 13

Intraoperative photograph showing

the final position of the basket
plate after coverage with soft tis-
sue. The retinaculum on the medial
side has been sutured. Before the
gap is closed completely, it is im-
portant to check for impingement of
the hooks against the patellar
groove and to bend them further
against the patellar surface if
needed.

CRITICAL CONCEPTS | continued

AUTHOR UPDATE:
• Although severely osteopenic
bone is still regarded as a
relative contraindication, the
age of the patient is not a lim-
itation of the procedure.

• The indications of the tech-

nique have been extended
to include comminuted frac-
tures of the distal pole of the
patella, provided that the
proximal, solid fragment con-
stitutes more than half of the
patellar length.

FIG. 14

The stability of fixation is checked by flexing the knee into full flexion before the wound is
closed.
 
THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S M ARCH 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 1 · JBJS . ORG

cises of the knee in the prone

position. Active extension exer-
cises are allowed after the third
postoperative week. Patients
are encouraged to start bearing
weight during level walking on
the second postoperative day
and full weight-bearing without
limitation is encouraged at six
weeks.

Matjaz Veselko, MD, PhD

Matej Kastelec, MD, MSc
Department of Traumatology, University Medical
Centre Ljubljana, Zaloška 7, SI-1525 Ljubljana,
Slovenia. E-mail address for M. Veselko:
matjaz.veselko@kclj.si

The authors did not receive grants or outside

funding in support of their research or prepara-
tion of this manuscript. They did not receive
payments or other benefits or a commitment
or agreement to provide such benefits from a
commercial entity. No commercial entity paid
or directed, or agreed to pay or direct, any
benefits to any research fund, foundation,
educational institution, or other charitable or
nonprofit organization with which the authors
are affiliated or associated.

The line drawings in this article are the work

FIG. 15 of Joanne Haderer Müller of Haderer & Müller
(biomedart@haderermuller.com).
Postoperative lateral radiograph demonstrating anatomic reduction of the fracture and a
reduced position of the patella.
doi:10.2106/JBJS.D.02631

A standard wound clo- Postoperatively, knee im-

sure is performed in layers with mobilization is not necessary. REFERENCES
use of number-2 absorbable Patients start passive motion 1. Smiljani B. Stabilna osteosinteza patele
košarastom ploicom po Smiljaniu. Acta Clinica
sutures for the subcutaneous exercises on the first postopera- Croatica. 1991;30:5-17.
tissue and a subcuticular stitch tive day and are encouraged 2. Veselko M, Smrkolj V, Tonin M. Comminuted
avulsion fractures of the inferior pole of the patella.
for the skin. to perform active flexion exer- Unfallchirurg. 1996;99:71-2.