Case Reports

Arthroscopic Excision of Bipartite Patella With Preservation of Lateral Retinaculum in an Adolescent Ice Hockey Player

Am J Orthop. 2017 May;46(3):135-138

References

1. Atesok K, Doral MN, Lowe J, Finsterbush A. Symptomatic bipartite patella: treatment alternatives. J Am Acad Orthop Surg. 2008;16(8):455-461.

2. Insall J. Current concepts review: patellar pain. J Bone Joint Surg Am. 1982;64(1):147-152.

3. Bourne MH, Bianco AJ Jr. Bipartite patella in the adolescent: results of surgical excision. J Pediatr Orthop. 1990;10(1):69-73.

4. Oohashi Y, Koshino T, Oohashi Y. Clinical features and classification of bipartite or tripartite patella. Knee Surg Sports Traumatol Arthrosc. 2010;18(11):1465-1469.

5. Okuno H, Sugita T, Kawamata T, Ohnuma M, Yamada N, Yoshizumi Y. Traumatic separation of a type I bipartite patella: a report of four knees. Clin Orthop Relat Res. 2004;(420):257-260.

6. Yoo JH, Kim EH, Ryu HK. Arthroscopic removal of separated bipartite patella causing snapping knee syndrome. Orthopedics. 2008;31(7):717.

7. Felli L, Fiore M, Biglieni L. Arthroscopic treatment of symptomatic bipartite patella. Knee Surg Sports Traumatol Arthrosc. 2011;19(3):398-399.

8. Green WT Jr. Painful bipartite patellae. A report of three cases. Clin Orthop Relat Res. 1975;(110):197-200.

9. Ishikawa H, Sakurai A, Hirata S, et al. Painful bipartite patella in young athletes. The diagnostic value of skyline views taken in squatting position and the results of surgical excision. Clin Orthop Relat Res. 1994;(305):223-228.

10. Stocker RL, van Laer L. Injury of a bipartite patella in a young upcoming sportsman. Arch Orthop Trauma Surg. 2011;131(1):75-78.

11. Wong CK. Bipartite patella in a young athlete. J Orthop Sports Phys Ther. 2009;39(7):560.

12. Weckström M, Parviainen M, Pihlajamäki HK. Excision of painful bipartite patella: good long-term outcome in young adults. Clin Orthop Relat Res. 2008;466(11):2848-2855.

13. Kumahashi N, Uchio Y, Iwasa J, Kawasaki K, Adachi N, Ochi M. Bone union of painful bipartite patella after treatment with low-intensity pulsed ultrasound: report of two cases. Knee. 2008;15(1):50-53.

14. Azarbod P, Agar G, Patel V. Arthroscopic excision of a painful bipartite patella fragment. Arthroscopy. 2005;21(8):1006.

15. Carney J, Thompson D, O’Daniel J, Cassidy J. Arthroscopic excision of a painful bipartite patella fragment. Am J Orthop. 2010;39(1):40-43.

16. Tauber M, Matis N, Resch H. Traumatic separation of an uncommon bipartite patella type: a case report. Knee Surg Sports Traumatol Arthrosc. 2007;15(1):83-87.

17. Werner S, Durkan M, Jones J, Quilici S, Crawford D. Symptomatic bipartite patella: three subtypes, three representative cases. J Knee Surg. 2013;26(suppl 1):S72-S76.

18. Adachi N, Ochi M, Yamaguchi H, Uchio Y, Kuriwaka M. Vastus lateralis release for painful bipartite patella. Arthroscopy. 2002;18(4):404-411.

19. Maeno S, Hashimoto D, Otani T, Masumoto K, Hui C. The “coiling-up procedure”: a novel technique for extra-articular arthroscopy. Arthroscopy. 2010;26(11):1551-1555.

20. Ogata K. Painful bipartite patella. A new approach to operative treatment. J Bone Joint Surg Am. 1994;76(4):573-578.

21. Mori Y, Okumo H, Iketani H, Kuroki Y. Efficacy of lateral retinacular release for painful bipartite patella. Am J Sports Med. 1995;23(1):13-18.

22. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154

23. Grevnerts HT, Terwee CB, Kvist J. The measurement properties of the IKDC-subjective knee form. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3698-3706.

Postoperative Rehabilitation

Rehabilitation focused on protection of the healing patella and accelerated rehabilitation for early return to play. Range-of-motion exercises and stationary bicycling were initiated on postoperative day 1. Weight-bearing was allowed as tolerated. Quadriceps sets, straight-leg raises, and ankle pumps were performed 5 times daily for 6 weeks. Six weeks after surgery, the patient was cleared, and he returned to full on-ice activities.

Outcomes

This study was approved by an Institutional Review Board. Preoperative and postoperative outcomes were obtained and stored in a data registry. The patient’s Lysholm score²² improved from 71 before surgery to 100 at 31-month follow-up. In addition, his subjective International Knee Documentation Committee score²³ improved from 65.5 before surgery to 72.4 after surgery. At follow-up, patient satisfaction with outcome was 10/10. In addition, the patient had returned to playing hockey at a higher national level without functional limitation.

Discussion

The most important finding in this case is that arthroscopic excision of a bipartite patella with preservation of the lateral retinaculum in an elite adolescent hockey player resulted in improved subjective clinical outcomes scores and early return to competition. Arthroscopic excision was favored over open excision in this patient because of potential quicker recovery,¹⁴ less pain, and expedited return to competition. In addition, previous arthroscopic techniques were modified to shorten postoperative rehabilitation. The modified technique included preservation of the lateral retinaculum and total arthroscopic excision of the accessory bipartite patella fragment.

Although results of open techniques have been favorable,^3,8,9 these procedures are far more invasive than arthroscopic techniques and may result in loss of quadriceps strength and prolonged rehabilitation.¹⁸ Weckström and colleagues¹² followed 25 male military recruits for a minimum of 10 years after open excision of symptomatic bipartite patella. Mean Kujala score was 95 (range, 75-100), and median visual analog scale score for knee pain was 1.0 (range, 0.0-6.0). In a study by Bourne and Bianco,³ 13 of 16 patients who were followed for an average of 7 years experienced complete pain relief with an average recovery time of 2 months.

Other studies have described the arthroscopic excision technique for symptomatic bipartite patella,^7,14,15 but outcomes are underreported, especially for follow-ups longer than 2 years. Felli and colleagues⁷ described a case of arthroscopic excision and lateral release in a 23-year-old female professional volleyball player; at 1-year follow-up, the patient was symptom-free and back to full athletic participation. Azarbod and colleagues¹⁴ also reported on a patient who was symptom-free, 6 weeks after arthroscopic excision of bipartite patella. Carney and colleagues¹⁵ indicated that successful excision of bipartite patella was evident on 6-month radiographic follow-up. Our 31-month follow-up is the longest of any study on arthroscopic excision of bipartite patella. Clinical outcomes were excellent both in our patient’s case and in the earlier studies.

Our patient was a high-level hockey player who wanted to return to competition as quickly as possible. Conservative management, including physical therapy, initially resolved his symptoms and allowed him to resume on-ice activities after 6 weeks. In time, however, his symptoms returned and began limiting his on-ice performance. Arthroscopic removal of the bipartite patella accessory fragment allowed him to return to full on-ice activities after 6 weeks. His case provides evidence that arthroscopic management of bipartite patella with preservation of the vastus lateralis and lateral retinaculum may be an excellent treatment option for patients who want to return to athletics as quickly as possible.

Our technique of arthroscopic excision with preservation of lateral retinaculum is an excellent treatment option for symptomatic bipartite patella. This option, combined with an aggressive rehabilitation protocol, allows for pain relief and expedited return to competition.

References

1. Atesok K, Doral MN, Lowe J, Finsterbush A. Symptomatic bipartite patella: treatment alternatives. J Am Acad Orthop Surg. 2008;16(8):455-461.

2. Insall J. Current concepts review: patellar pain. J Bone Joint Surg Am. 1982;64(1):147-152.

3. Bourne MH, Bianco AJ Jr. Bipartite patella in the adolescent: results of surgical excision. J Pediatr Orthop. 1990;10(1):69-73.

4. Oohashi Y, Koshino T, Oohashi Y. Clinical features and classification of bipartite or tripartite patella. Knee Surg Sports Traumatol Arthrosc. 2010;18(11):1465-1469.

5. Okuno H, Sugita T, Kawamata T, Ohnuma M, Yamada N, Yoshizumi Y. Traumatic separation of a type I bipartite patella: a report of four knees. Clin Orthop Relat Res. 2004;(420):257-260.

6. Yoo JH, Kim EH, Ryu HK. Arthroscopic removal of separated bipartite patella causing snapping knee syndrome. Orthopedics. 2008;31(7):717.

7. Felli L, Fiore M, Biglieni L. Arthroscopic treatment of symptomatic bipartite patella. Knee Surg Sports Traumatol Arthrosc. 2011;19(3):398-399.

8. Green WT Jr. Painful bipartite patellae. A report of three cases. Clin Orthop Relat Res. 1975;(110):197-200.

9. Ishikawa H, Sakurai A, Hirata S, et al. Painful bipartite patella in young athletes. The diagnostic value of skyline views taken in squatting position and the results of surgical excision. Clin Orthop Relat Res. 1994;(305):223-228.

10. Stocker RL, van Laer L. Injury of a bipartite patella in a young upcoming sportsman. Arch Orthop Trauma Surg. 2011;131(1):75-78.

11. Wong CK. Bipartite patella in a young athlete. J Orthop Sports Phys Ther. 2009;39(7):560.

12. Weckström M, Parviainen M, Pihlajamäki HK. Excision of painful bipartite patella: good long-term outcome in young adults. Clin Orthop Relat Res. 2008;466(11):2848-2855.

13. Kumahashi N, Uchio Y, Iwasa J, Kawasaki K, Adachi N, Ochi M. Bone union of painful bipartite patella after treatment with low-intensity pulsed ultrasound: report of two cases. Knee. 2008;15(1):50-53.

14. Azarbod P, Agar G, Patel V. Arthroscopic excision of a painful bipartite patella fragment. Arthroscopy. 2005;21(8):1006.

15. Carney J, Thompson D, O’Daniel J, Cassidy J. Arthroscopic excision of a painful bipartite patella fragment. Am J Orthop. 2010;39(1):40-43.

16. Tauber M, Matis N, Resch H. Traumatic separation of an uncommon bipartite patella type: a case report. Knee Surg Sports Traumatol Arthrosc. 2007;15(1):83-87.

17. Werner S, Durkan M, Jones J, Quilici S, Crawford D. Symptomatic bipartite patella: three subtypes, three representative cases. J Knee Surg. 2013;26(suppl 1):S72-S76.

18. Adachi N, Ochi M, Yamaguchi H, Uchio Y, Kuriwaka M. Vastus lateralis release for painful bipartite patella. Arthroscopy. 2002;18(4):404-411.

19. Maeno S, Hashimoto D, Otani T, Masumoto K, Hui C. The “coiling-up procedure”: a novel technique for extra-articular arthroscopy. Arthroscopy. 2010;26(11):1551-1555.

20. Ogata K. Painful bipartite patella. A new approach to operative treatment. J Bone Joint Surg Am. 1994;76(4):573-578.

21. Mori Y, Okumo H, Iketani H, Kuroki Y. Efficacy of lateral retinacular release for painful bipartite patella. Am J Sports Med. 1995;23(1):13-18.

22. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154

23. Grevnerts HT, Terwee CB, Kvist J. The measurement properties of the IKDC-subjective knee form. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3698-3706.

Arthroscopic Excision of Bipartite Patella With Preservation of Lateral Retinaculum in an Adolescent Ice Hockey Player

References

Postoperative Rehabilitation

Outcomes

Discussion

Pages

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