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MARCH, IMHW 
'•UKI TECHNIQUE OF SUTURING OF THE PATELLA 
AFTER FRACTURE. 
CHARLES GREENE CUMSTON, M.D., 
A"ialam IWr<i>or of Surgical Pathology in the Faculty .>( Me.licinr of Tnfta College. 
OF BOSTON, THE TECHNIQUE OF SUTURING OF THE PA- 
TELLA AFTER FRACTURE. 
Hv CHARLES GREENE CUMSTON, M.D., 
OF BOSTON, 
ASSISTANT PROFESSOR OF SURGICAL PATHOLOGY IN THE FACULTY Ol MEDICINE 
OF TUFTS COLLEGE. 
Although I am not, at the present time, prepared to 
say that 1 would advocate suture of the patella after fracture 
in each and every case, still results, especially those recently 
published by Dr. Charles Phelps, tend to lead me rather to 
this practice. This short note, however, will be entirely con- 
fined to a few remarks on the technicjue of the operation. 
This may be divided into three steps, the first of which is the 
opening1 of the joint and freeing the fragments of bone by 
cutting through all adhesions about, and these may be well 
developed and numerous if the case is of long standing. 
The incision dividing the integuments and underlying 
tissues is made on the anterior aspect of the knee, but there 
arc various ways of making it. Kbnig, for example, makes 
a transversal incision over the space formed by the separa- 
tion of the fragments, so that the resulting cicatrix may be 
opened afterwards by movements of flexion of the knee. And 
what is of still greater importance, the cutaneous cicatrix may 
unite with that of the bone, so that if another fracture should 
occur the skin will naturally open with the fracture, resulting 
in an open wound, with all its serious consequences. 
Other operators make a median longitudinal incision 
about five or six centimetres long: but if drainage is em- 
ployed. and, 1 may say, it is desirable in many instances, two 
small lateral incisions must be made for the passage of the 
drain. A curved incision, similar to that employed for resec- 
tion of the knee, extending from one condyle to the other CHARLES GREENE CUMSTON. 
and passing over the space between the fragments of the bone, 
does not entail other incisions for drainage, as the wicks can 
be placed in the angles of the wound. This incision can be 
made with its convexity above or downward. 
Now, the points on which I desire to lay particular stress 
in making the incision are as follows: In the first place, the 
incision should be made so as to give plenty of room and freely 
expose the joint, especially so when the fracture is of long 
standing. The flap should be well supplied with blood at its 
base, and the latter should be cpiitc broad in proportion to 
the size of the flap. 
The flaps used by Trendelenburg and Lucas-Champion- 
niere are poorly nourished, because the important vessels of 
the internal aspect of the knee are cut. 
Fig. i. 
Fig. 2. 
Fio. 3. 
The third condition of a good 
ous cicatrix should be as distant as 
incision is that the cutanc- 
possiblc from the cicatrix of 
the bone. In order to fulfil these requirements I make a horse- 
shoe-shaped incision, keeping at least four or five centimetres 
away from the borders of the patella. (Fig. 1.) 
It is commenced above the internal angle of the upper 
fragment and carried outward, then brought down almost 
vertically along the external aspect of the knee, and then, 
when it has been carried below the lower fragment, it is car- 
ried nearly to the anterior tuberosity of the tibia. This inci- SUTURING OF THE PATELLA AFTER LRACTURE. 
3 
sion has been in my hands most useful when there is a con- 
siderable separation of the fragments, but when the fracture 
is recent or the separation slight a horseshoe flap with its base 
down is perhaps better, (Fig. 2.) 
When the parts have been freely exposed, all fragments 
of bone and blood-clot should be cleaned out. Especial care 
must he taken to rid the parts of all clots, because the latter 
are often mixed with bits of periosteum and shreds of aponeu- 
rosis, forming quite a solid mass, filling the joint and the 
space between the fractured ends. 
In cases of old fracture this part of the operation is always 
more complicated and often quite difficult, because the fibrous 
adhesions must be cut and the bony surfaces freshened with 
hammer and chisel. It occasionally is necessary to incise the 
aponeurosis and triceps in order to bring the fragments into 
contact, but before doing this they may be made to come to- 
gether if the thigh and leg be elevated. 
To suture the bone strong silver wire appears to me the 
only satisfactory material to use. and by drilling a triangle in 
each fragment with the apices directed towards each other, 
the wire may be entirely buried in the bone, excepting the 
point where the ends come out and are twisted. This manner 
of suturing will give the greatest amount of solidity, and has 
been entirely satisfactory. (Fig. 3.) 
When one of the fragments is small and the other one 
large the above method of suturing cannot be applied, and 
in this case the wire should he passed through the ligament of 
the patella or through the tendon of the triceps.