Description, Causes and Risk Factors:
The patella is a small bone located in front of your knee joint — where the thighbone (femur) and shinbone (tibia) meet. It protects your knee and connects the muscles in the front of your thigh to your tibia.
The ends of the femur and the undersides of the patella are covered with a slippery substance called articular cartilage. This helps the bones glide smoothly along each other as you move your leg.
A bipartite patella is found in roughly 1% of the population. For most people, the bipartite patella functions fine and there is no pain or other symptoms. However, in some people with a bipartite patella, the synchondrosis (fibrous tissue between the two parts) can become injured in a fall or other injury to the knee. Or, it can become inflamed and irritated due to repetitive activity. Symptoms often start after a minor injury, but the pain persists.
Several factors can cause Bipartite patella. The most of anterior knee pain disorders are result from patellofemoral joint abnormalities however, other pathologic conditions including injury of intraarticular structures (anterior and posterior cruciate ligaments, meniscal lesions etc.). Osteoarthritis, osteochondritis dissecans, Osgood-Schlatter disease, Sinding-Larsen-Johanson disease, synovial plica, iliotibial band syndrome, medial collateral bursitis and prepatellar bursitis, inflammatory rheumatic diseases (juvenile rheumatiod arthritis, seronegative spondiloarthropathies, etc.), neoplasms and infections may also cause Bipartite patella.
Most bipartite patellae are asymptomatic and observed only as an incidental finding when the knee is radiographed for other reasons. The natural history of painful bipartite patella is as follows: the patella normally begins primary ossification at about 5 to 6 years. Patellar primary ossification occurs centrifugally in a mass of epiphyseal cartilage. Some patellar accessory foci may present developmental variations and a superolateral accessory center is usually evident by 12 years of age. Most secondary ossification centers fuse with the patella during adolescence and some may persist into adult years. It was suggested that a painful bipartite patella might be symptomatic if non-union induced by excess tensile force applied to the superolateral patellar pole and the accessory ossification center could not be fused between the main ossification centres. With rare exceptions this anomaly occurs at the superolateral aspect of the patella. The lesion is usually asymptomatic, but can be associated with localized anterior knee pain.
Common symptoms of an inflamed bipartite patella include:
Swelling at the synchondrosis.
Painful range of motion of the knee.
Pain directly over the kneecap.
Soft tissue tenderness might be present over the location of the bipartite patella, (commonly the superolateral pole of the patella).
Standing or jumping may cause pain.
A bipartite patella is most commonly diagnosed as an incidentalfinding. This means that most often an X-ray was obtained toevaluate the knee for another reason, and the bipartite patellawas seen on the X-ray. A bipartite patella is only concerning ifit is symptomatic. Common symptoms of an inflamed bipartitepatella include pain directly over the kneecap and swelling overthe fibrous part. X-rays will show the bipartite patella. Physicalexamination of the knee will also look for other sources of painwithin the knee. An MRI may be done to evaluate the otherstructures in the knee.
Most of the patients with painful bipartite patella respond relatively well to nonsurgical treatment including rest, stretching exercises of the quadriceps and hamstring muscles, strengthening exercises of the quadriceps muscle and bracing to support the patella. However, long-term success is questionable because recurrence rates are fairly high. In the few patients who develop persistent symptoms as a result of their bipartite patella, there are surgical treatment options. The surgery usually consists of removing the smaller fragment of bone or detaching the muscle that inserts on the smaller piece of bone. The majority of patients do well without treatment. Some patients require surgery. If needed, surgery leads to improvement in most patients.
Surgical Treatment Options:
The second surgical treatment is a lateral retinacular release. The surgeon cuts the connective tissue holding the quadriceps to the outer edge of the kneecap. This releases the traction force put on the patella by the vastus lateralis muscle. The vastus lateralis is the outer most tendon of the four tendons that make up the quadriceps muscle.
In some cases, a lateral release allows the two bone fragments to join together and heal. Pain is relieved within four weeks. Athletes are able to return to their pre-injury level of sports participation. This procedure can be done arthroscopically, thus avoiding an open incision. Studies show that results are improved with this technique. There is less swelling after surgery and faster recovery of muscle strength postoperatively.
A third surgical technique is the subperiosteal detachment of the vastus lateralis insertion. This method accomplishes the same thing as a lateral release but without weakening the vastus lateralis muscle. By just releasing the tendon from the fragment and from under the first layer of bone, the action of the muscle is not altered. The fragment may or may not be removed. This depends on how severe the condition is. In some patients, the fragment can and does join with the rest of the patella.
And finally, there is a more invasive approach, called open reduction and internal fixation (ORIF). An open incision is made. The fragment is attached to the main patella with wires or screws. This procedure is used when the fragment is large and removing it would cause patellofemoral arthritis later.
The first is an open incision and removal of the bone fragment. There are many studies using this method and reporting good-to-excellent responses. The procedure is invasive. The surgeon cuts down to the quadriceps tendon. Removing a large fragment this way can cause problems later with the patellofemoral joint. This is where the patella moves up and down over the femur. The two surfaces no longer match up for smooth tracking.
NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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