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Inferior pole fractures of the patella (IPFP) pose a significant surgical challenge due to the small size and comminution of the distal fragments, as well as disruption of the extensor mechanism. There is currently no consensus in the literature on the optimal surgical approach for managing these injuries. We report the case of a young male presenting with chronic knee pain and difficulty walking, secondary to a neglected avulsion fracture of the inferior pole of the patella. The patient was managed successfully using transosseous Ethibond sutures combined with ipsilateral semitendinosus autograft augmentation to restore extensor mechanism integrity. This report highlights the clinical, radiological, and functional outcomes of this technique, suggesting it as a viable option in managing chronic IPFP cases.
Inferior pole fractures of the patella (IPFP) commonly occur in younger males due to eccentric quadriceps contraction or direct trauma [1,2]. These extra-articular injuries are often displaced and associated with loss of active knee extension due to retinacular disruption [2]. Surgical management is typically required to restore extensor mechanism integrity, rather than achieve anatomical reduction [3]. Historically, partial patellectomy with patellar tendon repair was standard but led to complications such as patellar shortening and tendon ossification, impairing patellofemoral function [4,5]. Alternative techniques, including suture repair, tension band wiring, and basket plating, often involve hardware and are associated with stiffness and anterior knee pain [6,7]. A novel technique of IPFP management with transosseous suture repair with ethibond and ipsilateral semitendinosus autograft augmentation of the extensor mechanism is being tried nowadays as it avoids implant-related complications and allows for early postoperative mobilization with good functional outcomes [8,9].
A 30-year-old previously healthy male presented with refractory right knee pain and difficulty walking for five months. The symptoms began after a fall while carrying heavy objects, but he did not seek immediate medical attention. He reported a pain score of 7/10 on the Visual Analogue Scale (VAS) and had no comorbidities.
PREOPERATIVE
On examination, the patient had a palpable defect below the proximal patellar fragment of the right knee. The straight leg raise test was positive, and active extension was absent. On full passive extension, the patella was abnormally elevated to the distal one-fourth of the femur (Figure 2). At 30° of knee flexion, a distinctive ‘Camelback sign’ was observed, characterized by two visible soft-tissue mounds.
Radiological evaluation included bilateral knee radiographs and magnetic resonance imaging (MRI) to assess fracture configuration, patellar height, and extensor mechanism integrity. Lateral radiographs revealed an inferior pole fracture with a high-riding patella (Figure 3). MRI confirmed an old avulsion fracture of the lower pole of the patella, with the bony fragment displaced into Hoffa’s fat pad. Retraction of the patellar tendon had resulted in superior and medial migration of the patella, located above the trochlear groove (Figure 4). The distance between displaced patella and the avulsed lower pole (fracture gap) was 4.7 cm.. No significant intra-articular abnormalities were noted.
A diagnosis of inferior pole fracture of the right patella with disruption of extensor mechanism was made. Given the chronicity and functional impairment, surgical repair was planned using transosseous Ethibond sutures along with ipsilateral semitendinosus tendon autograft augmentation to restore the extensor mechanism.
INTRAOPERATIVE – Surgical technique
After obtaining informed written consent, the patient underwent surgery under spinal anaesthesia in a sterile operating room. The patient was supine and the affected limb was rightly identified and prepared for the surgery with a tourniquet in place. When inflating the tourniquet, the knee was flexed and the patella was pushed inferiorly till the tourniquet was inflated. . Intraoperative imaging (C-arm fluoroscopy) was used to assess patellar positioning.
A midline longitudinal skin incision on the right knee was given. The distal pole patella fragment was identified, and soft tissue from the fracture site was removed. The proximal patellar edge was irrigated and debrided. Quadriceps lengthening was performed using a V–Y plasty technique
Transosseous Tunnel Repair:
The first half of the surgical repair of IPFP by transosseous (TO) suture technique was done in a standard fashion as described by Swenson S et al [7]. A total of three transpatellar tunnels were drilled inferior to superior direction, horizontal to the plane of bone using a 2.5-mm drill bit or pin at the central, medial, and lateral proximal patellar sites. Next #5 Ethibond sutures were placed through the patellar tendon inferiorly and tied to the superior pole in extension
Ipsilateral Semitendinosus-Gracilis Tendon Autograft Augmentation:
After TO suture repair was done, the ipsilateral STG tendon was harvested using an open tenotome while preserving its distal tibial insertion. A horizontal tibial tunnel was created medially at the tuberosity, and the graft was passed through this and a transverse tunnel in the patella. It was then looped and secured to itself using two Ethibond sutures. Medial and lateral retinacula were repaired using 2–0 non-absorbable sutures, and the wound was closed in layers.
Figure 8. Intraoperative image showing transosseous suture repair augmented with semitendinosus tendon and quadriceps lengthening
POSTOPERATIVE / FOLLOW UP
The patient’s intraoperative and immediate postoperative course was uneventful, with no complications such as bleeding, infection, or repair failure.
Postoperatively, the knee was immobilised in full extension (0°) using a cylindrical slab for six weeks to facilitate healing of the repaired extensor mechanism and retinacula. Partial weight-bearing (50%) was initiated at six weeks, progressing to full weight-bearing without immobilisation by week eight. Passive and active range-of-motion (ROM) exercises were introduced in the sixth week, aiming for 90° knee flexion within two weeks, followed by full ROM from the eighth week onward.
At 12-week follow-up, the patient demonstrated pain-free active knee flexion of 95° (Figure 8), full extension (0°), and no extensor lag. He ambulated independently without assistive devices. By 16 weeks, ROM had improved to 0–100°, with only mild discomfort (2/10 on the Visual Analogue Scale), which was easily managed with intermittent acetaminophen. Functionally, he had resumed daily activities without difficulty.
Plain radiographs of the right knee anteroposterior and lateral views were taken during each follow-up visit.
Patellar fractures account for approximately 1% of all skeletal injuries, with inferior pole fractures (IPFPs) comprising 5%–22.4% of these [10,11]. Typically resulting from avulsion of the distal patella and patellar tendon due to direct trauma or eccentric quadriceps contraction, IPFPs are particularly common in males under 40 years [2]. These injuries often present late with chronic symptoms, including pain and impaired knee extension. Our case mirrored this pattern—a young male with chronic, neglected IPFP and functional impairment.
Chronic comminuted IPFPs are challenging to manage due to proximal patellar migration, muscle contractures, and adhesions, which compromise the extensor mechanism [12]. While minimally displaced fractures (<4 mm gap) may be managed conservatively, significantly displaced fractures (as in our case, 4.7 cm) typically require surgical intervention [13].
Partial patellectomy (PP) with transosseous suturing has historically been the mainstay for irreparable fragments [14]. However, it sacrifices patellar length, lacks bone-to-bone healing, and reduces range of motion [7,15]. Techniques such as tension band wiring, vertical wiring, cerclage, and basket plate fixation aim to preserve patellar anatomy but often result in implant-related complications, extended immobilisation, and higher reoperation rates [16–19].
Transosseous (TO) suture repair using Ethibond sutures is now considered a gold standard for IPFP, offering better healing outcomes and earlier mobilisation in both young and elderly patients [8,20]. Anchor suturing (AS) has also shown promise. A systematic review by Ibergamo et al. found no significant differences between TO and AS in reoperation or infection rates, though TO had a lower re-rupture rate, supporting our decision to use TO repair in this case [11,21].
However, TO repair alone may not provide sufficient stability in chronic or severely displaced cases, prompting the need for augmentation techniques. Traditional methods such as cerclage or buttress plates may cause soft tissue irritation due to the subcutaneous nature of the extensor mechanism [19,22]. Alternatives such as autografts (ipsilateral/contralateral semitendinosus, patellar tendon), Achilles tendon, or allografts have shown better outcomes [23,24].
In our case, augmentation with ipsilateral semitendinosus-gracilis (STG) autograft, preserving the distal insertion, was chosen for its cost-effectiveness and biomechanical advantages. The graft offers excellent tensile strength and retains vascularity, enhancing healing and facilitating early rehabilitation [25].
At final follow-up, our patient achieved full extension (0°) and 100° of pain-free flexion, without extensor lag—outcomes consistent with those reported by Strother et al. in patients undergoing similar techniques [23]. Although mild pain persisted, it was manageable, and the patient had resumed normal function.
The major assets of our technique were cost effective, good functional outcome, and reduced re-rupture rate. [26]. Although there is a risk of potential morbidity due to hamstring autograft harvest, it is minute when compared to the benefits [27].
Given the absence of a universally accepted surgical approach for inferior pole fractures of the patella (IPFP), transosseous (TO) suture repair with Ethibond combined with ipsilateral semitendinosus autograft augmentation appears to be a safe and effective alternative—particularly in chronic cases or those with extensor mechanism disruption. This technique offers strong fixation, avoids implant-related complications, and facilitates early rehabilitation with satisfactory functional outcomes. However, larger prospective studies and randomized controlled trials are needed to validate its superiority over conventional methods.
COMPLIANCE WITH ETHICAL STANDARDS
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