CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 446, pp. 161–166
Periprosthetic Patellar Fractures
Javad Parvizi, MD, FRCS*; Kang-Il Kim, MD*; Ali Oliashirazi, MD†; Alvin Ong, MD*; and
Peter F. Sharkey, MD*
Patellar fracture after total knee arthroplasty is a rare yet
challenging complication. Patellar fracture can occur as a
result of trauma or it may be atraumatic. A multitude of
factors can lead to periprosthetic patellar fracture including
patient related factors, surgical technique related factors,
and implant specific factors. Understanding the etiologic fac-
tors leading to atraumatic patellar fractures could result in
minimizing complications. We present the results of peri-
prosthetic patellar fractures in 12 patients. All type I non-
displaced fractures (7 cases) were treated nonoperatively.
Surgical treatment was selected for the remaining 5 cases
which included resection arthroplasty combined with open
reduction and internal fixation of the fracture (3 knees), par-
tial patellectomy (1 knee), and total patellectomy (1 knee).
The outcome was excellent in 1 knee, good in 8 knees, and
fair in the remaining 3 knees at the latest follow-up. There
were 2 reoperations; 1 for disruption of the extensor mecha-
nism and 1 for refracture. One patient developed a superfi-
cial wound infection. We reviewed the available literature
regarding the etiology, surgical strategies, and outcomes for
periprosthetic patellar fracture.
Level of Evidence: Therapeutic studies, level IV (case series).
See the Guidelines for Authors for a complete description of
levels of evidence.
Complications related to extensor mechanism is the most
common problem after total knee arthroplasty
(TKA).1,6,18,26,35,41,44 Over the last two decades, a better
understanding of knee biomechanics has led to refine-
ments in surgical technique and implant design, resulting
in a dramatic decline in extensor mechanism complica-
From the *Rothman Institute of Orthopedics at Thomas Jefferson University,
Philadelphia, PA; and †Marshall University, Huntington, WV.
One of the coauthors (PFS) is a consultant to Stryker Orthopedics. The
institution of the authors has received funding from Stryker Orthopedics.
Each author certifies that his or her institution has approved the reporting of
this case report, that all investigations were conducted in conformity with
ethical principles of research, and that informed consent was obtained.
Correspondence to: Javad Parvizi, MD, FRCS, Rothman Institute of Ortho-
pedics at Jefferson Hospital, 925 Chestnut Street, Philadelphia PA 19107.
Phone: 267-399-3617; Fax: 215-503-0580, E-Mail: parvj@aol.com.
DOI: 10.1097/01.blo.0000218722.83601.18
161
© 2006 Lippincott Williams & Wilkins
tions associated with TKA.14,25 However, patellar frac-
tures after TKA continue to occur.8,22,27
Patellar fractures can occur in an unresurfaced or resur-
faced patella.4,5,13,37 These fractures can result in loosen-
ing of the patellar component.27 The treatment strategy for
loosening depends on numerous factors including fracture
morphology, the presence of a patellar prosthesis, the type
of patellar component (metal backed versus all polyethyl-
ene), and the fixation status of the component.4,27
This article discusses the prevalence, etiology, and the
available treatment strategy for periprosthetic fracture of
the patella. We reviewed all published articles dealing
with these issues and a synopsis of the findings is pre-
sented. In addition, the article reports our institutional ex-
perience in a cohort of 12 patients.
MATERIALS AND METHODS
We identified all patients having treatment for periprosthetic
patella fracture from 2000 to 2005. We then reviewed the clinical
and radiographic records of these patients. There were eight men
and four women with a mean age of 67.2 years (range, 42–78
years). The patella fracture occurred at a mean of 3.5 years
(range, 0.5 to 12 years) after the index arthroplasty.
Different classifications for periprosthetic patellar fracture
have been proposed.11,15,27,41 The most commonly used classi-
fication system categorizes the fractures based on the integrity of
the extensor mechanism and the fixation status of the patellar
component. Type I fractures have a stable implant and the ex-
tensor mechanism is intact. Type II fractures have a disruption of
the extensor mechanism, with or without the implant in place.
Type III fractures refer to loosening of the patellar component
and an intact extensor mechanism. Type III fractures may be
further subdivided based on the patellar bone stock. Though not
included in the classification system, the anatomic location of the
fracture also influences treatment. Our fractures were classified
as Type I (7 knees), Type II (2 knees), and Type III (3 knees)
(Table 1). The patients were followed a mean of 1.8 years (range,
0.6 to 4.3 years)
All patients presented with pain. The fractures had occurred
secondary to trauma in five knees and were atraumatic in nature
in seven knees.
 Clinical Orthopaedics
162 Parvizi et al and Related Research

TABLE 1. Details of Patients Treated for Periprosthetic Patellar Fracture at Our Institution
Mechanism of Fracture
Patient Injury Type Treatment Outcome Complications
1 Fall I Bracing Excellent None
2 Fall I Bracing Good None
3 Fall I Bracing Good None
4 Motor vehicle I Bracing Good None
Accident
5 Direct impact I Bracing Good None
6 Atraumatic I Bracing Good None
7 Atraumatic I Cylinder cast Fair Superficial wound infection
8 Motor vehicle II ORIF and repair of extensor Good Patella alta
accident mechanism (Achilles
reinforcement)
9 Stepping onto stool II ORIF (allograft tissue Good None
reinforcement)
10 Atraumatic III Resection arthroplasty and ORIF Good Refracture and reoperation
11 Atraumatic III Partial patellectomy Fair None
12 Atraumatic III Total patellectomy Fair Extensor mechanism disruption
reoperation

ORIF = open reduction and internal fixation

All Type I nondisplaced fractures (seven cases) were treated
nonoperatively. Surgical treatment was selected for the remain-
ing five cases which included resection arthroplasty combined
with open reduction and internal fixation of the fracture (three
knees), partial patellectomy (1 knee), and total patellectomy (1
knee). Achilles tendon reinforcement of the extensor mechanism
was performed at the time of resection arthroplasty and fixation
of the fracture.
The outcome was determined based on the presence of pain,
extensor lag, arc of motion, and functional ability. Excellent
outcome constituted arc of motion greater than 110°, extension
lag of less than 5°, and absence of anterior knee pain. Arc of
motion between 80 to 110°, extension lag of up to 10°, and mild
anterior knee pain was deemed to represent good outcome. Any
other was considered as fair or poor outcome.
RESULTS
The outcome was considered excellent in one knee, good
in eight knees, and fair in the remaining three knees at
follow-up. All seven nondisplaced fractures were treated
nonoperatively with good to excellent outcomes. Surgical
treatment for repair of the extensor mechanism (2 pa-
tients), removal of loose implant and fixation of the frac-
ture (2 patients), or patellectomy (1 patient) had fair to
good outcomes. (Table 1).
There were two reoperations; one for disruption of the
extensor mechanism and one for refracture. One patient
developed a superficial wound infection.
Literature Review
The prevalence of patellar fracture after TKA is between
0.2–21% in resurfaced patellae2,11,13,41,44 to 0.05% in un-
resurfaced patellae.11 In one of the largest series on patel-
lar fracture after TKA from the Mayo Clinic,27 the re-
ported incidence of patellar fracture was 0.68%. The inci-
dence of patellar fracture after revision TKA (0.61%) has
been reported as nearly six-fold higher than primary TKA
(0.12%).13 The variation in incidence rate is understand-
able as there are a number of factors that impact the preva-
lence of patellar fracture after TKA. A considerable num-
ber of patellar fractures (44%) may be asymptomatic.27 In
general, patellar fracture is more common after patellar
resurfacing,5,35,37,44 revision surgery,13 lateral release,34
and with specific prosthesis design.1,14,41 Although patel-
lar fracture after TKA can ensue at any time, most frac-
tures occur within 1–2 years after the index arthroplasty.
In a report from the Mayo Clinic, 2⁄3 of the fractures oc-
curred within 2 years of the index arthroplasty.27
A multitude of factors influence the incidence of patella
fracture after TKA. These can be categorized under pa-
tient, implant, and technical factors (Table 2). Understand-
ing the etiological factors resulting in patellar fracture is
critical in preventing this challenging complication.
Several patient related factors impacting the incidence
of periprosthetic patellar fracture have been identified.
These include obesity,36 high activity level,9,18,19 exces-
sive flexion of the knee,1,37 and possibly an underlying
diagnosis of rheumatoid arthritis (RA).25 It is not known
how these factors affect the incidence of periprosthetic
patella fractures, but interplay among these factors may be
in effect. For example, young patients usually have a high
degree of activity and may have a higher body mass index
(BMI). Patients with higher activity level could plausibly
be at higher risk for a traumatic event. Traumatic events
Number 446
May 2006
TABLE 2. Etiological Factors Influencing the
Incidence of Patellar Fracture after Total
Knee Arthroplasty
Factors Criteria
35,40
Patient related factors Obesity
High activity8,17,18
Excessive flexion of knee1,36
Thin patella5,12,34
Osteopenia24
Previous surgeries12
Male gender26,34
Implant related factors Resurfaced patella4,12,36
Central single peg implant5,11,22,34,36,40
Inset patella component34
Uncemented fixation10,34
Metal backing13,39
Technical factors Patellar maltracking10,41
Inappropriate thickness5,12,34
Thermal necrosis5,12
Devascularization (lateral release,
aggressive excision of fat pad)5,13,34
Femoral component
malpositioning9,10,30,34,39
Extensor mechanism malalignment19
Excessive (quadriceps) release3
account for nearly 1⁄2 of periprosthetic patellar fractures.27
Patients with RA are more likely to have osteopenia. A
combination of these factors may explain the higher inci-
dence of periprosthetic patellar fractures observed in pa-
tients with RA.25 It is plausible that the reaction forces in
the patellofemoral joint may be the most important factor
influencing extensor mechanism related complications in
general and patellar fracture in particular.32,35 Body
weight, high activity level, and increased ROM all influ-
ence joint reaction forces.
Although fractures of unresurfaced patellae have been
observed, patellar fractures (particularly stress fractures)
are much more likely to occur after resurfacing of the
patella during TKA.6,13,35 Some patellar component de-
signs, mostly metal backed uncemented patella11,14,35,40 or
large central pegs,6,12,23,35,37 have been associated with
increased patellar fractures.
Appropriate component positioning and alignment on
the incidence of extensor mechanism are of critical impor-
tance. Prior studies have observed that more severe patel-
lar fractures and the worst outcomes were associated with
component malpositioning.10,11 Studies have shown that
use of a large anteroposterior (AP) diameter femoral com-
ponent or positioning of the femoral component in flexed
position can increase patellofemoral joint reaction forces,
predisposing the patella to fracture.31,40
Patellar thickness has a profound effect on extensor
mechanism mechanics.33,39 Most surgeons believe that
Periprosthetic Patellar Fractures 163
restoration of the original patellar thickness during TKA is
most desirable. A cadaveric study showed that a thicker or
thinner patella resulted in a smaller contact area and con-
siderably increased joint reaction forces.16 Other studies
have confirmed that underresection of patella can result in
patellofemoral joint overload and tension within the quad-
riceps tendon.33,39 Overresection of the patella with thin
residual bone compromises the mechanical strength of the
patella and possibly increases the risk of fracture.6,7,37
Reuben et al33 showed that patellar thickness of less than
15 mm substantially increased strain in the anterior patella
region and increased the risk for fracture. Asymmetric
patellar resection, particularly with excessive resection of
the lateral facet, can result in compromised mechanical
strength of the patella.25,37
The manner in which the patella is treated during TKA
is also a very important factor influencing the outcome.
Heat necrosis and devascularization of the patella, possi-
bly during lateral release, and excessive fat pad excision
that could result in sacrifice of the lateral superior genicu-
lar artery, increase the incidence of periprosthetic patella
fracture.24 The latter has been cited as the most important
reason why some surgeons refrain from routine patellar
resurfacing during TKA.3,21
Extensor mechanism malalignment is another important
factor that can affect patellar function and possible inci-
dence of patellar fracture. Biomechanical stud-
ies10,12,16,17,20,32 have shown a substantially increased
contact force with patellofemoral malalignment. The ec-
centricity and the magnitude of load in the patellofemoral
joint increase with patellar subluxation.17
The literature suggests a number of treatment strategies
for periprosthetic patellar fracture. Some periprosthetic pa-
tellar fractures may be treated nonoperatively.44 A number
of factors must be considered during planning a treatment
strategy. Unresurfaced patellae are usually treated like any
traumatic patella fracture. As long as the extensor mecha-
nism is intact then more articular surface disruption may
be accepted, as the patella may be resurfaced later should
posttraumatic osteoarthritis (OA) ensue. The treatment of
resurfaced patellae is individualized based on fracture dis-
placement, comminution, and component fixation.
Treatment of Type I fractures is generally nonoperative,
and almost all Type III fractures require surgical interven-
tion to remove the loose implant and perform fixation.22,27
Complete extensor mechanism disruption also necessitates
surgical treatment. Some surgeons will accept a large de-
gree of extensor mechanism lag8 in lieu of operative treat-
ment. Nonoperative treatment may be instituted with the
use of a brace locked in extension. If patient noncompli-
ance is suspected, the extremity may be placed in a cyl-
inder cast until the fracture heals. The type of surgical
treatment selected depends on a combination of all the

164 Parvizi et al
aforementioned factors and includes open reduction and
internal fixation (ORIF) with or without component revi-
sion, partial patellectomy with tendon repair, patellar re-
section arthroplasty and fixation,30 or total patellectomy.
Patella resurfacing may be performed in patients with
loose patellar component and adequate bone stock (>13
mm).28,30
There are numerous reports pertinent to management of
periprosthetic patellar fractures.1,6,15,18,26,35,41,44 In gen-
eral, the studies report that patients with stable implants
and an intact extensor mechanism can be successfully
treated nonoperatively with good results.22,37 The main
problem after nonoperative treatment relates to extensor
lag.27,37 Nonoperative treatment of patients with Type III
fractures is likely to result in a poor outcome.27 Surgical
treatment of the Type III fractures provides a good out-
come but is associated with more surgical complica-
tions.11,15,27 In one study, four of nine patients treated with
excision of an extruded patella button developed a deep
infection.22 Two patients treated with ORIF had non-
union.22 The authors reported that surgery on patients with
patellar fractures had a high complication rate and should
be avoided if possible.22
Ortiguera and Berry,27 in the largest series reported to
date, suggested the outcome of treatment of patients with
periprosthetic patella fracture depended upon type of frac-
ture and that when performed operative treatment was as-
sociated with a high rate of complications. Thirty-eight of
78 patients had Type I fractures, 12 patients had Type II
fractures, and 28 had Type III had fractures.27 All but one
patient with a Type I fracture received nonoperative treat-
ment. Radiographic analysis revealed osseous union in six
patients, fibrous union in 16 patients, and asymptomatic
nonunion in 15 patients. The authors considered the out-
come of nonoperative treatment successful in 31 (82%)
patients who exhibited no pain, and no patellar or extensor
mechanism instability or weakness. Nonoperative man-
agement failed in one patient who required excision of
nonunion. Eleven of the 12 patients with Type II fractures
were treated surgically. Six of 12 patients with Type II
fractures developed complications; five patients required
reoperation. The outcome of operative (20 patients) and
nonoperative (8 patients) treatment for the 28 patients with
Type III fractures was modest. Nine knees had complica-
tions and four patients required reoperation. Another
study15 in a cohort of 21 patients15 suggested that nondis-
placed fractures of the patella after TKA can be success-
fully treated nonoperatively. Surgical treatment of dis-
placed fractures with extensor mechanism had a poor out-
come. Those authors concluded fragment excision should
be considered for displaced distal pole fractures with pa-
tellar tendon disruption, and patellectomy should be con-
sidered for failures of all other treatments.
Clinical Orthopaedics
and Related Research
Every attempt should be made to preserve the patella to
increase the mechanical advantage of the quadriceps
mechanism. Patellectomy reduces the quadriceps lever
arm and can result in marked quadriceps weakness. Pat-
ellectomy should be reserved for patients with extremely
poor bone stock and a fracture with high degree of com-
minution. Partial patellectomy with insertion of smaller
component may on occasions be preferable to complete
patellectomy.
DISCUSSION
Periprosthetic patella fracture is an infrequent complica-
tion of TKA. The management of patellar fracture after
TKA is challenging with modest outcome.11,15,22,27 Un-
derstanding the etiology of periprosthetic patellar fractures
should help reconstructive surgeons with prevention.
We note several limitations of our study. The series is
small and cannot be used to identify any factors predicting
success. However, we judged the outcome generally fa-
vorable. The followup was short in some patients (6
months minimum) and might not reflect longer term prob-
lems. Only records were reviewed and any major problems
not noted in the charts would be underreported.
The influence of numerous technical factors that could
potentially increase the incidence of patellar fracture after
TKA has been mentioned. Following basic principles of
knee arthroplasty in obtaining extensor mechanism align-
ment, soft tissue balancing, and performing accurate bony
cuts are crucial to for successful outcome and preventing
patellar fracture. Accurate symmetrical patellar osteotomy
to obtain the appropriate thickness for implantation during
TKA is particularly critical. Histological analyses of frac-
tured patellae after TKA have confirmed the presence of
osteonecrosis.19,37 The reconstructive surgeon should ex-
ercise diligent care in preserving the blood supply to the
patella during reconstruction to avoid osteonecrosis and
potential fractures. An elaborate system of intraosseous
and extraosseous vasculature provides blood supply to the
patella.3,21 A peripatellar anastomotic ring consisting of
six main arteries forms the extraosseous blood supply. The
superior part of the ring passes anterior to the quadriceps
tendon and the inferior portion passes posterior to the pa-
tellar tendon through the substance of the fat pad. The
intraosseous system is comprised of midpatellar, polar,
and quadriceps tendon blood supply. A considerable dis-
ruption of the blood supply to patella occurs during routine
medial parapatellar approach to the knee.6,7,10,11,21,37 The
medial superior and inferior genicular arteries are usually
divided during the medial arthrotomy. The excision of the
fat pad and aggressive lateral meniscectomy may compro-
mise the lateral inferior genicular artery. Lateral release
results in a reduction of blood flow to the patella,38,43 so it
Number 446
May 2006
is incumbent to perform as minimal soft tissue dissection
as needed for good visualization.
The blood supply to patella is likely to be compromised
further during preparation of the patella for resurfacing,
especially when using a single large central peg compo-
nent that can disrupt the intraosseous vascular supply. The
fear of patellar fracture and other related complications
prevents some surgeons from performing routine patella
resurfacing. The influence of resurfacing the patella on the
outcome of TKA continues to be debated.4,42 The advo-
cates of resurfacing cite higher incidence of anterior knee
pain and need for reoperation as the reason to perform
patellar resurfacing during TKA.4,7,29,42 Two metaanaly-
ses on randomized prospective studies related to patellar
resurfacing detected a higher incidence of anterior knee
pain and reoperation in nonresurfaced patellae.29,30 No
increase in patella related complications was observed in
the resurfaced group. However, resurfaced patellae are
more prone to fracture compared with nonresurfaced pa-
tellae. If patellar resurfacing must be performed, irrigation
of the patella during osteotomy to minimize heat necrosis
avoiding a single large central peg components, and gentle
minimal soft tissue dissection should be exercised.6,37
Total knee arthroplasty, similar to any operative proce-
dure, should be performed based on principles of provid-
ing the best possible outcome and avoiding complications.
Critical factors influencing the outcome and complication
rate after TKA are the accuracy of soft tissue balancing
and extensor mechanism alignment. The appropriate posi-
tioning of the components during TKA directly impacts
patellar tracking and the overall extensor mechanism
alignment. All efforts should be made to achieve sym-
metrical seating of the patella in the groove of the femoral
component and appropriate patellar tracking. The latter
may occasionally necessitate the use of lateral release to
balance the extensor mechanism. Although some studies
have refuted the direct influence of lateral release on the
incidence of patellar complication,34 many others have
demonstrated a higher incidence of patellar fracture after
TKA during which lateral release was performed.6,22,34,38
Lateral release should be avoided if possible, and the lat-
eral superior genicular artery should be preserved during
the necessary times when performing the release.
Periprosthetic patella fracture is a challenging compli-
cation after TKA. Nonoperative management should be
elected for patients with an intact extensor mechanism and
fixed components. Surgical intervention has a modest out-
come with a complication high rate. Understanding the
etiology of patellar fractures and using preventative mea-
sures are the most effective management techniques.
Based on our institutional experience and the reports in the
literature, we advocate nonoperative treatment for peri-
prosthetic patellar fracture when possible. Patients should
Periprosthetic Patellar Fractures 165
be warned about the possible poor outcome when opera-
tive management is selected for more severe fractures.
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