Patellar reconstruction following previous patellectomy: a review of the literature and a case series using distal femoral autograft during total knee arthroplasty

Abstract

During total knee arthroplasty, the reconstruction of the patella following a previous patellectomy is challenging, and is undertaken to improve functional outcomes and patient satisfaction. In this case series, we have reconstructed the patella using a femoral condyle resected during total knee arthroplasty. The resected femoral condyle with best available bone stock is selected and secured to the extensor mechanism. We reviewed the preoperative indications and postoperative outcomes of two patients who underwent the above procedure at our Institute, and compared this to the literature. The cases include a 68-year old male (6 months follow-up) who sustained a multi-fragmentary fracture of his right patella and underwent a patellectomy 30 years previously, and a 45-year old female (4 years follow-up) who underwent a left-sided patellectomy 15 years previously following polytrauma. As a result of progressive osteoarthritis they required total knee arthroplasty, and simultaneous patella reconstruction with a femoral condyle autograft. Compared to their preoperative range of motion, both patients demonstrated an improvement post-operatively with successful pain-free knee function, with no radiological signs of graft resorption. In this limited, small series we have reported two patients who are clinically and functionally satisfied by the outcome of surgery, with comparable outcomes to alternative methods. We believe the use of a femoral condyle autograft for patellar reconstruction is a safe and simple technique that optimises knee kinematics, without associated donor morbidity.

Patellar reconstruction in primary total knee arthroplasty using bone chips from routine cuts: A case report and review of literature

“…Autograft bone can be harvested from the medial femoral condyle or tibial plateau through distal cutting[ 21 , 23 - 25 ]. While both techniques are generally reliable, our case presented challenges due to the size due to the size of the medial femoral condyle, particularly in cases of severe valgus knee osteoarthritis.…”

“…We attribute our success to the meticulous placement of the fragmented autograft bone in a press-fit manner within the intra-tendon pocket, facilitating optimal patellar tracking, and securing closure with strong sutures to prevent graft migration. Despite the potentially compromised vascularity of the extensor mechanism due to prior surgeries, our patellar reconstructions have maintained bone integrity on radiographs two years post-operation, showing no signs of resorption[ 21 , 37 ]. Though the long-term viability of the bone graft remains uncertain, our hypothesis asserts that maintaining the occupied space through patella reconstruction, whether by original bone or fibrous tissue replacement, may suffice to preserve the mechanical integrity of the patella and yield satisfactory outcomes.…”

“…Given these considerations, surgeons must evaluate how to reconstruct the patella, considering the need to preserve biomechanical properties. Patellar reconstruction might be performed using various methods, including autologous bone grafts, allogeneic extensor or bone grafts, and, less commonly, metal augmentations[ 6 , 10 , 21 - 29 ]. Additionally, alternative techniques involving soft tissue have been described[ 30 ].…”

A New Procedure for Reconstructing the Knee Extension Mechanism After Resection of the Knee Joint and Patella

“…These methods can be divided into 2 types: with and without patellar reconstruction. Approaches with patellar reconstruction reconstruct the patella using autologous distal femur 8 or iliac bone graft 9 or allograft 10 while approaches without patellar reconstruction repair the extensor mechanism with tubeplasty 11 . Leopold et al 12 reported that allograft reconstruction of the extensor mechanism after total knee arthroplasty according to the procedure described by Emerson et al 10 showed a mean extension lag of 59° after a mean follow-up of 39 months and resulted in 4 revision surgeries in 7 cases.…”