Compliments of the Author. 
THE MODERN TREATMENT OF FRACTURE OF 
THE PATELLA. 
BY 
JOHN S. MILLER, M.D., 
SURGEON TO ST. JOSEPH'S HOSPITAL, PHILADELPHIA. 
REPRINTED FROM THE TRANSACTIONS 
OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
1893. THE MODERN TREATMENT OF FRACTURE OF 
THE PATELLA. 
By JOHN S. MILLER, M.D., 
SURGEON TO ST. JOSEPH'S HOSPITAL, PHILADELPHIA. 
[Read February 22, 1893.] 
The uncertainty in the results of treatment of fracture of tiie 
patella, and the values that are placed by operators upon the various 
methods applied for the fulfilment of the indications in the treat- 
ment of this injury, as well as a desire to learn what the members 
of this Society have experienced in their practice, has induced me to 
submit this subject for discussion. It is not my desire to speak at 
length of the various older methods of treatment, but I shall more 
fully emphasize those operations which have been brought before the 
profession in later years. The treatment of simple fracture of the 
patella may be divided into the operative and the non-operative. 
The one involves no mortality, whereas the other may be attended 
by great risk to life and limb if antisepsis is not carried out in its 
fullest sense. 
It is an undisputed surgical principle that when osseous union is 
obtained in a fracture, this result is certainly more desirable than 
ligamentous union. It has been claimed, and notably by Konig, 
Levis, and Dennis, that bony union may take place in simple frac- 
ture of the patella treated by the older methods, such specimens 
having been found in anatomical rooms. 
Such results can only be possible where the separation of the 
fragments is very slight, and where there is no injury to the liga- 
ments and aponeurotic tissues adjacent. At best, the chances are 
greatly in favor of ligamentous union in a greater or lesser degree. 
Experience has taught us that ligamentous union, however short, 
does not always restore the function of the limb to its former use- 
fulness. 2 
MILLER, 
The most obvious causes which prevent union of the fragments 
are: 
1. Inability to maintain steady and accurate apposition of the 
fragments due to imperfect apparatus. 
2. Extreme separation of the fragments by the powerful retraction 
of the quadriceps extensor muscles dragging upon the upper frag- 
ment. 
3. - Interposition of aponeurotic and bursal structures between the 
fragments. 
While consideration must be given to the action of the quadriceps 
muscle as well as to the occurrence of blood-clot in the joint, the 
true cause probably is the intervention of the lacerated patellar tissue 
(Macewen). 
Malgaigne?s hooks, or the same as modified by Levis, are very 
efficient for approximating the fragments and retaining them in an 
accurate position. They are useful in such cases where there is no 
interposition of soft tissue. Malgaigne's hooks have fallen some- 
what into disuse, as I have learned from instrument-makers and 
surgeons in this country aud abroad. It is quite likely that the com- 
plications which followed their application were largely due to the 
introduction of septic matter. In the days when this method was 
more popular, antiseptic surgery was unknown or perhaps in its 
infancy. 
Agnew regarded the use of this instrument as " infernal and bar- 
barous." Roberts still advocates the use of Levis's modification of 
Malgaigne's hooks. I believe that in suitable cases, and under strict 
asepsis, they fulfil the indication, and are worthy of being restored 
to the surgical armamentarium of to-day. 
Treatment by the metallic suture. According to Dennis this oper- 
ation was first performed in this country by Rhea Barton in 1834, 
and in 1838 by McClellan. To avoid inflammatory action the 
operation should not be performed under forty-eight hours after the 
accident. The limb is to be placed at rest, and cold affusions are to 
be applied. The transverse incision is preferable, the clots should 
be carefully washed away, and any fringes of aponeurotic or lacer- 
ated tissues should lie removed with scissors. The ends of the 
fragments should be curetted to remove any of the soft tissues which 
may have become impaled or crowded into the fractured surfaces. 
The fragments are accurately brought together, and usually four 
drill-holes are made for the two heavy silver wires which are to lie 
inserted. The ends of the wires may be cut off and hammered down, TREATMENT OF FRACTURE OF THE PATELLA. 
3 
or they may be allowed to protrude from the wound. Ordinarily 
there is no difficulty in removing them, as they cut their way out 
and are found lying loose in the dressing. The aponeurosis is next 
united with eatgut, short drainage-tubes are introduced at the most 
dependent part of the wound, and the skin wound is closed, prefer- 
ably with silkworm-gut. 
The limb may be treated in a fracture-box, in which case the 
wound is under constant observation. Or a plaster-of-Paris dress- 
ing may be applied after the soiled dressing and the drainage-tubes 
are removed, which is on the third day. 
The mortality, according to the statistics collected by Dennis, is 
four out of one hundred and thirty-seven cases. These statistics 
are based upon cases occurring during the infancy of the wiring 
method. He believes that it will be less than 3 per cent, in the 
future. This question largely depends upon the strictness with 
which surgeons carry out antiseptic precautions. 
I have had no experience with Schede's method, which has been 
denounced by Kbnig (incision and washing out of clots). Cecci's as 
well as Barker's operations are among the more recent procedures, 
but they have not been performed often enough to form a basis upon 
which to estimate their practical value. 
The following cases serve to illustrate three of the methods in 
general use at this time : 
Case I.-C. M., aged thirty-one years, milkman. On going down stairs 
June 27, 1885, patient missed the bottom step and fell on his buttocks in a 
squatting posture. The left leg was forced into extreme flexion, and simulta- 
neously it struck the wall. He thinks that the fracture occurred during the 
flexion of the leg upon the thigh. The blow against the wall caused a lacer- 
ation of the soft parts communicating with the joint. Separation of the 
fragments was very marked, and the subsequent effusion with the blood-clots 
escaped through the wound. The joint was not irrigated, but the parts were 
cleansed, and an antiseptic dressing was applied. The limb was placed on an 
Agnew splint, and a figure-of-8 bandage applied. The wound closed without 
any complication. In six weeks he was allowed to go about with a cane. 
Ankylosis was overcome by passive motion and massage. 
Result, eight years later: The union is osseous. Use of limb perfect. 
Case II.-Mrs. S. E. M., forty-four years old, seamstress. On June 13, 
1888, while stepping off backward from a chair with the right foot first, she 
felt something break in the knee of the same leg. She fell to the floor in 
great pain, and it was found that she had sustained a transverse fracture of 
the patella. The effusion and swelling were at once so great that it was im- 
possible to elicit crepitus. Separation of fragments about two inches. Ice- 
cold applications were made for sixty hours, when I suggested opening the 4 
MILLER, 
joint and suturing the fragments. This suggestion was not accepted. I then 
decided to use Levis's modified Malgaigne hooks. The limb was cleansed and 
sterilized, and hypodermatic injections of cocaine so benumbed the parts that 
the hooks were applied without inflicting pain Great difficulty was expe- 
rienced in maintaining the apparatus in position, and it had to be handled 
frequently, thereby causing pain and irritation. The slipping was due to a 
peculiar pointed condition of the upper fragment, and also to the tilting of 
the fragments from the pressure of the serum and blood clots in the joint. 
To maintain antisepsis, bichloride of mercury irrigation and gauze of 1 to 
1000 was applied. The corrosive action of the solution upon the screws was 
so rapid that they became immovable. The joint was highly inflamed, and I 
feared that suppuration might ensue. About five days later I removed the 
hooks and placed the limb upon a Hamilton splint (inclined plane) with 
figure-of-8 adhesive strips. She remained in bed five weeks. Massage of the 
quadriceps extensor muscles was now made daily, as the circumference of the 
thigh rapidly diminished. Passive motion of the joint was made for two 
weeks longer, when she was allowed to walk about with a cane. At this time 
the fragments were separated about three-quarters of an inch by ligamentous 
union. 
Result, five and a half years later: Excellent use of limb. Ligamentous 
union about one-half inch long. 
Case III.-Same patient. On August 30, 1889, about fourteen months 
after the above accident, she fell in her yard and sustained a multiple fracture 
of the patella of the left leg. The preliminary treatment was the same as in 
the first accident. Three days after the injury I had the affected limb shaved 
and scrubbed from the middle of the thigh to the calf of the leg, and thor- 
oughly sterilized with a mercurial solution of 1 to 1000. A transverse incision 
was made over the middle of the knee, when a copious discharge of bloody 
serum took place. Large blood-clots filled the posterior portion of the joint. 
The three fragments were widely separated, and the floor of the patellar 
bursa had been pinched, and shreds thereof were impaled, as it were, by the 
serrated or tooth-like fractured surfaces. So firm was this impaction that it 
was necessary to use a sharp curette. The joint was irrigated thoroughly with 
a 1 to 2000 corrosive sublimate solution, and all lacerated tissues removed with 
scissors. Short drainage-tubes were inserted on either side of the joint. The 
fragments were drilled and brought together with heavy silver wires, the ends 
of which were left long. The aponeurosis over the patella was brought 
together with catgut sutures. The skin wound was united with heavy silk 
sutures. Iodoform gauze and a bandage completed the dressing. The limb 
was laid upon a long bolster, and sand-bags were placed on either side of the 
limb. 
By this procedure the wound was under constant surveillance. On the 
tenth day the drainage-tubes were removed and a plaster of-Paris dressing 
was applied, reaching from the upper third of the thigh to the ankle. No 
elevation of temperature occurred throughout the case. The plaster dressing 
was removed in six weeks. Ankylosis was quite firm, but daily passive motion 
soon made the knee-joint flexible. The wires were easily removed. 
Result, four and one-half years later: Bony union, and a useful limb, 
This case is of interest owing to the fracture of the opposite patella within TREATMENT OF FRACTURE OF THE PATELLA. 
5 
a short time. She is undecided as to which knee is the better, and can run 
and go up stairs without difficulty. She only experiences some inconvenience 
on going down stairs. 
Case IV.-Daniel J., aged twenty-three years. On June 6, 1889, while 
vaulting into the rear of a wagon, which was going at a rapid rate, he felt a 
stinging pain in the left knee. He was disabled at once, and noticed a de- 
formity. The joint soon began to swell. Was taken to a hospital, where the 
injury was pronounced a contusion of the knee-joint. He was then taken 
home in a carriage, and the attending physician accepted the diagnosis made 
at the hospital and treated the case accordingly. The joint became very stiff, 
and passive motion was frequently made. The case not improving under this 
treatment, another physician was called, who pronounced the case "white 
swelling." This physician was dismissed, and another called in, who pro- 
nounced it "housemaid's knee." About four months after the accident I 
saw the case for the first time, and discovered a transverse fracture of the 
lower fifth of the patella. The limb was shaved and sterilized in the usual way. 
A transverse incision was made. The diagnosis was now fully confirmed, the 
lower fragment being very small. The joint contained only a small quantity 
of synovial fluid. 
The fragments at the fractured points were covered by a dense cartilaginous 
tissue, but no ligamentous union had formed. This was removed with diffi- 
culty with a cartilage knife. A thin slice of bone was removed from each 
fragment with a surgical engine. The separation of the fragments was fully 
three inches, and it was impossible to make them meet. A subcutaneous 
division of the quadriceps extensor tendon was then made, which permitted 
the upper fragment to be drawn down. The lower fragment was so small that 
the gold-plated copper wire had to be inserted into the ligamentum patellae, as 
there was not enough bone left to hold. Two wires were placed and twisted, 
and the after-treatment was substantially the same as in Case III. It can be 
readily understood why the surgeons who had seen the case in the early stage 
were deceived. On palpation the patella probably seemed to be of normal 
size, and the lower fragment being so exceedingly small, accompanied by 
effusion and swelling, certainly made an accurate diagnosis very difficult. 
The gap in the ligament of the quadriceps extensor muscie is now entirely 
filled in. The knee was stiff for a long time. Under massage and passive 
motion the ankylosis was soon relieved. 
Result, three years and nine months since accident: Perfect use of limb. 
Absolute bony union. 
The failure of the Malgaigue hooks in Case II. can be easily 
explained. Although the limb had been thoroughly cleansed and 
sterilized, I erred in using a cocaine solution which was not sterile, 
and thereby defeated my efforts at antisepsis. In the future I shall 
prefer ether or chloroform anaesthesia when the patient cannot bear 
the pain inflicted by the application of the hooks. The corrosive 
effect upon the screws of the hooks might have been avoided by 
using iodoform-gauze dressing or baked aseptic gauze. 6 
TREATMENT OF FRACTURE OF THE PATELLA. 
In the operation of suturing the patella, to my mind the joint 
should be treated precisely like the peritoneal cavity. Corrosive 
solutions should be avoided. We should aim at a strictly aseptic 
operation, and the wound and surrounding parts should be constantly 
irrigated throughout the operation with hot distilled water. Catgut 
and other animal sutures have been used and recommended for 
suturing the fragments, but several unpleasant experiences with this 
ligature in ununited fracture of other parts of the body have de- 
terred me from using it in fractures of the patella. 
Although it is hardly proper to make deductions from such a 
small number of cases, yet it appears that excellent results can be 
obtained with the ordinary postural treatment in cases of slight 
displacement. 
It is claimed by some authorities (Von Bergmann, Hamilton, and 
others) that a short ligamentous union is as serviceable as a bony 
one. This is diametrically opposed by authorities of equal prominence. 
In my practice I should only resort to the suturing of an old or 
neglected fracture, where the ligamentous union is so long as to 
greatly impair the usefulness of the limb, in which case it also 
endangers the patella of the opposite side; in compound fracture; 
and in cases where crepitus cannot be felt owing to the interposition 
of soft tissues. 
The suturing method is not indicated in all cases. The cases 
should be carefully selected and are not to be attempted by one who 
does not possess the utmost tact and confidence in maintaining asepsis. 
It seems as though the knee-joint is less tolerant of surgical manipu- 
lation than the peritoneal cavity, and more sensitive than the latter 
in that the synovial membrane has not the same power to dispose of 
infective germs. Even with a mortality of only 3 per cent., we are 
obliged to regard this procedure as one demanding serious consider- 
ation, as to whether the risk balances the advantages to be gained.