fractures of the patella? What are these conditions? How are they best treated?

All permanent upward or downward displacements of the patella as a whole, if dependent upon rupture of the quadriceps extensor femoris tendon, or of the ligamentum patella, will cause symptoms somewhat analogous to those which are caused by complete transverse, oblique, stellate or comminuted fractures of the patella. Violence of the same nature can determine a solution of continuity of either the tendon, the patella or the ligament. The force that indirectly produces the solution of continuity is obviously exerted equally on the quadriceps tendon, on the ligamentum patellæ, on the tuberosity of the tibia and on the patella; but fracture of the patella is by far the most common result of such indirect violence.

Traumatic or pathological, open or subcutaneous ruptures of the quadriceps extensor femoris tendon or of the ligamentum patellæ, may, like fractures of the patella, be simple or complicated, be complete or incomplete, be unilateral or bilateral. They may be associated with, precede, or follow a fracture of the patella.

The quadriceps extensor femoris muscle, the patella and the ligamentum patellæ are the main structures by which extension of the leg on the thigh is effected. The integrity of each of the main component parts of this extensor apparatus is indispensable for the proper performance of the functions of the knee-joint. The restoration of the continuity of a completely fractured patellæ is just as essential for anatomical and functional recovery of the affected extremity as is that of a completely divided quadriceps extensor femoris tendon or that of a completely torn ligamentum patellæ. The careful approximation of the divided ends of the quadriceps extensor femoris tendon, the exact coaptation of the separated ends of the torn ligamentum patellæ can be done effectively only by the aid of sight, that is, through an open operation. The same applies to the fractured patella, the exact apposition of whose fractured surfaces is frequently prevented by obstacles removable, only by an open operation. The ideal function only exists when each and all of the aforementioned elements are anatomically and functionally absolutely normal. The study of the subject conclusively demonstrates that the absence of any single one of these elements (patella, ligamentum patellæ or quadriceps extensor femoris tendon) or the presence of a pathological state of any single one of them, manifests itself by impairment of function. It leads to the conclusion that perfect function presupposes and demands anatomical integrity.

Treatment.

The following indications have to be met in fractures of the patellæ:

I. The fracture must be reduced.

2. The bony fragments must be maintained in intimate apposition until organic union has been effected.

3. The continuity of the overlying and contiguous soft tissues must be re-established.

4. The functional integrity of the knee-joint must be restored. 5. The value of any form of treatment is dependent upon its ability to meet the above indications. All forms of treatment can be classified into one or the other of two main classes: the nonoperative and the operative. The latter admits of further subdivision into the subcutaneous and into the open methods. Each method has advantages and disadvantages, indications and limitations.

The numerous non-operative methods of treatment that have been employed, the large number of percutaneous and subcutaneous operations for approximation of the fragments that have been proposed, lauded, tried and then abandoned, the comparatively great number of patients, who, having been subjected to non-operative treatment, of themselves seek operative treatment in order to lessen or entirely overcome their disability, all these are proofs that all the non-operative, and the subcutaneous operative methods as well, have deficiencies which debar them from ever being elective methods of treatment.

In the literature of the subject, occasional cases are to be found in which, though the operator succeeded in restoring to the patella its normal anatomical contour, functional integrity of the knee-joint was not secured. Our explanation for these cases is that some essential step in the operation has either been completely overlooked or unskillfully performed, or that the postoperative treatment has been injudicious. The extravasated blood may not have been removed from the synovial cavity; the lacerations of the soft tissue may not have been repaired, etc.

A distinction must be made between the short-comings of the operator and the short-comings of an operative procedure, as such. A few, a very few cases, such as the following, can be found in the literature.

Sonnenberg showed two patients, who, despite a separation of from 3 to 4 inches between the fragments of their fractured patellæ and noticeable atrophy of the quadriceps extensor femoris, had fairly good function. In one of these the bone was in three fragments owing to a twice fractured patella. An explanation of these exceptional cases is to be found in the fact that the reserve extensor apparatus of the leg either was not injured, or if injured, that its integrity was restored and thereby the loss of continuity of the patella is fairly well compensated. Though in isolated cases good functional results may follow non-operative treatment, as a rule, its employment in fractures of the patella is followed by very unsatisfactory results. Facts confirm what logic had led us to expect. Anatomical and functional integrity go hand in hand. In the treatment of fractures of the patella we have come to discard

all the subcutaneous and percutaneous operations. In scientific conception and in the practical results obtained by their employment the inferiority of the various subcutaneous methods to the various open operations is manifest. We acknowledge that under exceptional circumstances the operator may feel compelled to resort to them.

Why do we advise the abandonment of the various subcutaneous and percutaneous operations? Because: I. They do not enable the surgeon to accurately coapt the fractured fragments. After an arthrotomy, either by bone suturing, or by circumferential looping or ligaturing, or by careful sewing of the torn soft tissues, the fragments can be closely apposed and held immovably together. This intimate apposition of the fractured surfaces lessens the liability to an excess, either in length or in width, of callus formation. Any change in the contour of the patella is liable to interfere with the normal adaption of its articular surface to the femoral articular surface.

2. They do not enable the operator to freshen the fractured surfaces. In the repair of old fractures the resection of the interfragmentary fibrous bond of union and the freshening of the fractured surfaces are among the essential steps of the operation.

3. They do insure against union of the bony fragments in a faulty position. Impaired function results from union in a faulty position. The open operation enables the surgeon to overcome any tilting of the fragments, as well as any tendency to union in faulty position.

4. The subcutaneous methods make no provision for the toilet of the synovial cavity. The open operation allows of the early and complete removal of all articular effusions, of all extravasated blood. intra or extra-articular, liquid or clotted, of all completely detached bone fragments.

5. The tears in the capsule, the lacerations in the aponeurotic expansions of the vasti, demand repair. Only by means of an open operation can they be repaired. The extensor apparatus of the leg must be considered as one organ. Structural impairment of any of its constituent parts entails a corresponding impairment of function. The insertion of the vastus externus and of the vastus internus into the capsule of the knee-joint and the lateral prolongations of their insertions down upon the head of the tibia and fibula are of assistance in the extension of the leg on the thigh. Solutions of continuity in these tissues must be repaired.

6. None of the subcutaneous operations allow of the removal of the fibro-periosteal shreds which so frequently overlap the fractured surfaces and which in some cases have been found to adhere so tightly to bony projections that for their liberation it was necessary to use forceps and curette. These fibro-periosteal shreds are an obstacle to osseous union; they can be removed by an open operation.

7. The subcutaneous and percutaneous operations create

openings which are inadequate for the escape of intra-articular and extra-articular extravasates and exudates, but which are ample for the introduction of infection.

Before proceeding, let us determine the dangers, their nature and their gravity, to which patients are exposed by the employment of the open operative treatment.

The probability of ankylosis, joint suppuration or pyæmia following an aseptic arthrotomy, for practical purposes, can almost be disregarded. We concede that the general dangers inherent to other major operative procedures are also present in these cases. These dangers, anesthesia, shock and suppuration, are common to all operations. Shock can be minimized by rapid operating. The time consumed in the performance of any operation should be the shortest consistent with the careful and complete execution of the different steps of the operation. We will not at this time. discuss the other two dangers.

We believe we are fully justified in stating that the dangers of the open operation, if it be performed with due precaution by careful and skillful hands, are practically nil. There is always plenty of time to reach hands well able to perform the operation. What are some of the advantages of the open operative method?

1. Refracture of the patella is more common after massage and other forms of non-operative treatment than after the open operative treatment. Refracture is more frequent in the patella than in any other bone. By more closely restoring the bone to anatomical perfection, the open operative treatment lessens to a considerable degree the tendency to refracture.

2. In any fracture, the union between the fractured fragments which is considered the most desirable is osseous union. Modern surgeons do not expect to obtain osseous union in fractures of the patella which are treated non-operatively. Its occurrence under such conditions, though possible, is so rare that it is considered a pathological curiosity. One of the main justifications of the open operative treatment is the frequency with which osseous union follows its employment.

It being a demonstrated fact that osseous union can be obtained, it behooves us to employ that method of treatment which most frequently secures it.

It cannot be contested that the solidity of the patella contributes, in a great measure, to the stability of the knee-joint. Fibrous union of the fractured bone imparts to the articulation a weakness, an uncertainty, an instability, as a result of which patients with fibrously united patella, frequently fall. This lack of stability, this impairment of control predisposes to refracture of the fibrously united patella. It is exceptional for fibrous union to be associated with absolute functional recovery. A fibrous bond of union has a tendency to elongate under use.

3. The open operations enable us to obtain a more rapid, a

more complete recovery. The more active the patient is the more his occupation involves work on different levels, the more is operative treatment indicated.

4. The open operation enables the operator to mitigate all and to remove most of the conditions that tend to cause imperfect union and its consequence, impaired functional integrity. Let us enumerate and briefly discuss the most important of these unfavorable conditions.

a. Separation of the fragments.

b. Tilting of the fragments. Either or both fragments, often, are or may be, everted or inverted. In the presence of tilting the fragments can never be maintained with the fractured surfaces exactly towards each other either by bandages or by retentive appliances, or by any subcutaneous operative method.

c. Rupture of the tendinous expansions of the vasti and of the lateral portions of the capsule of the joint.

d. Prolapse of the prepatellar tissues into the breach caused by the separation of the fractured fragments.

e. Atrophy of the quadriceps femoris due to disuse, arthritis, marked contusions of the muscle, extravasated blood from the joint through the rent in the upper part of the capsule, etc.

f. Arthritis of the knee-joint.

g. Adhesions of the patella. The upper fragment has been found adherent to the femoral condyles.

h. Union of the fragments in bad position, mechanically interfering with proper function of joint.

The open operation enables the operator to void inflammatory exudates, to make the toilet of the synovial cavity. If a loose spicule of bone be found between the fragments, its removal is easily effected. The open operative method allows us to completely overcome the tilting of the fragments and to coapt them with a nicety attainable by any other method.

If, shortly after a fracture of the patella, the knee-joint is opened, it will be found that the articulation contains blood. The quantity of the extravasated blood is not the same in all cases. In some cases it is small; in others, considerable, filling the joint to distention. The blood may be liquid, clotted or semi-organized. Not infrequently it originates intra-articular adhesions or loose foreign joint bodies. It is easy to conceive how a large intraarticular liquid collection, can, in transverse or oblique fractures, rotate the upper or lower fragments, or both, about a transverse axis.

Rupture of the Tendinous Expansion of the Vasti and of the
Lateral Portions of the Capsule of the Joint.

In fractures of the patella, as in other fractures, in addition to the bone-lesion, we have co-existing injuries of the contiguous soft tissues.

When one recalls the intimate relations with the patella, of the fascia, muscles and ligaments which surround it, no stretch of