KNEE

A 12TO

FUNCTION
48-YEAR

AFTER
FOLLOW-UP

PATELLECTOMY

I. A.

C.

LENNOX,

A.

G. COBB,

J. KNOWLES,

G.

BENTLEY

From

the Royal

National

Orthopaedic

Hospital,

Stanmore,

England

We describe 83 knees (69 patients) which had had patellectomy for anterior knee pain (52), patellofemoral osteoarthritis (25) or comminuted fractures (6) between 1942 and 1978. The patients were questioned about their symptoms and the function of the operated knee 14 to 50 years after operation. In the group with anterior knee pain, 76% achieved good results and were satisfied with the operation. Only 54% of the osteoarthritis group had satisfactory relief of pain and most had progressive deterioration of function. Sixteen patients who had had unilateral patellectomy were assessed by dynamometry, ultrasound and radiography. The average quadriceps muscle power was 60% of that on the normal side although two patients had stronger muscles in their operated than in their unoperated legs.
J BoneJoint Received Surg 20 May [Br] 1993; 1994; Accepted 76-B:485-7. after revision 26 October 1993

tory in the series of 81 patients reported by Ackroyd and Polyzoides (1978); only 53% of their patients had a good result at a mean of 6.5 years after operation and 50% had
weakness of extension of the knee. The senior author of con-

this

paper

(Bentley
treatments

1970,
for

1978)

in his

review
patellae, or

of four

surgical

chondromalacia grade III of choice.

cluded that patellectomy animal studies

in adults with was the treatment (Bruce and

IV changes, Evidence from that degener-

Walmsley

1942)

ative change sulcus after

results may

occurs in the articular cartilage patellectomy, suggests that

be less than satisfactory.

ofthe femoral the long-term morbidity

Our aim was to investigate

of patellectomy.

the long-term

PATIENTS

AND

METhODS
showed that for anterior 130 knee patients pain, had osteo-

Our hospital records undergone patellectomy

arthritis After anatomical, on patients who

fracture,

or comminuted
and

fracture

of the patella

between

dissection

and

dynamometric

studies

had
(1937)

been
function

treated

by patellectomy
that, in man, knee by Hey performs

for

the years 1942 since undergone known to have

1978. All were traced; an arthrodesis of the died, and of the remaining

one patient had knee, 3 1 were 98 patients, 69

Brooke

concluded

the patella

(70%)
Table

responded
I. Details

to a questionnaire
of the 69 patients Anterior knee pain who

(Table
answered

I).

subserves

no useful This

and thatthe

better
and

without
power.

it, both
work

as regards
was

rapidity

of movement
Groves

the questionnaire

confirmed

(1937). patients
reported

Scott (1949), however, after reviewing 101 who had undergone patellectomy for fracture, that only 5% of patients considered that they had
knee function, and Wilkinson (1977), who for 61%. 31 patients found good 4 to 13 years or excellent after patellectomy results in only

Osteoarthritis 22 75 (58 to 88) 19(12 32 56 to 31)

Fracture 6 59 (36 to 81)

20(15 to 23)

Number

of patients (yr)

41 48 (31 to 88) 24 (12 to 48) 29

normal
examined fracture,

Age at follow-up Length Male Right

offollow-up(yr)
(per

Patellectomy

for osteoarthritis

seemed

even

less satisfac-

cent) cent)

67 50

side (per

58

I. A. C. Lennox, FRCS Ed, Senior Registrar Western Infirmary, Glasgow Gl 1 6NT, UK. A. G. Cobb, BSc, FRCS, Senior Lecturer in Orthopaedic Surgery J. Knowles, MCSP, Physiotherapist G. Bentley, ChM, FRCS, Professor of Orthopaedic Surgery The Institute of Orthopaedics, Royal National Orthopaedic Hospital Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.
Correspondence should be sent to Mr I. A. C. Lennox

Sixteen clinical, both Their knees. mean

of the 69 patients and had was

were

able

to attend assessment

for full of

radiological

biomechanical unilateral (3 1 to 78)

All
age

NHS Way,

undergone 49 years

patellectomy. and the mean

at 8 Moorfoot

time since patellectomy was operation had been performed

1 1, for osteoarthritis in three

17 years (12 to 39). The for anterior knee pain in

and for fracture in two. The

Bearsden,

Glasgow

G61

4RL,

UK. of Bone and Joint Surgery

1994 British 0301-620X/94/3725

Editorial

Society $2.00

maximum eccentrically

power of the quadriceps muscle (paying out) and concentrically

was measured (shortening),

485

VOL

76-B, No. 3. MAY

1994

486

I. A. C. LENNOX,

A. G. COBB,

J. KNOWLES,

G.

BENTLEY

using
Chattecx meter (Farrell

a kinetic
Corp, had and been

communicator
Chattanooga, tested for 1986). its The

apparatus
Tennessee). reliability tests were

(KIN/COM,
The and dynamovalidity out carried

Richards

between quadriceps
of three

10#{176} and 90#{176} of knee flexion lag. After several practice

measurements was recorded against

to allow attempts,
for each knee;

for any the best

a rest

was
graph

allowed

before

recording
power

the opposite
angle

leg.
of knee

From
flexion,

of quadriceps

the maximum was achieved

were used calculated.

torque, the angle at which and the work done during

Ultrasound scans, above

maximum torque each contraction

plane,
Ultrasound

in the transverse

of both
to quadriceps sectional

thighs

5, 10, 15 and 20 cm measure the anteroposterior muscle at each area of the muscle level was

the knee, were diameter of the

scan

of anterior

thighs

to measure

quadriceps

thickness

(x-x).

(Fig. 1) and the crosscalculated as Hr2. The

volume of a 15 cm portion of each quadriceps was then estimated and the two sides compared. Anteroposterior, lateral and 30#{176} tangential radiographs were taken of both

knees of degenerative

all

16 patients change.

to

compare

the

degree

of

RESULTS Degenerative arthritis. The radiographs ofthe 16 patients with unilateral patellectomy showed Ahlb#{228}ck (1968) grades of tibiofemoral osteoarthritis in both knees which ranged between 2 and 5 (mean 2.4) but in no case was
there knee. femoral
in
,-

------Fig. Degenerative change in the femoral 2 sulcus 16 years after patellectomy.

a difference between the operated Seven of the 16 operated had sulcus evidence (Fig.

and the unoperated knees which were change some in the calcification which were still

radiographed

of degenerative most had

2) and

Table II. Number perienced symptoms

(percentage)

at follow-up

of patients who after patellectomy

ex-

the patellar tendon. Subjective observations.

had causing treated undergone patellectomy severe pain for anterior

Twelve
for

of the 25 knees
osteoarthritis but were only still

Anterior knee pain (n=52) Severe Crepitus Swelling Giving way pain 4 (8) 15 (29) 29 (56) 34 (65)

Osteoarthntis
(n=25) 12 (48)

Fracture (n=6) 0(0) 1 (17) 1 (17)

3 (50)

at follow-up knee pain

four of the 52 painful. This

5 (20)
14 (56) 12 (48)

difference is significant (p < 0.001, chi-squared test). None of the six knees which had undergone patellectomy for fracture In all reported was painful. three groups of giving
>

a large way

proportion (Table

of

patients was no
Table flexion
HI. Number (percentage)

episodes

II). There

significant
way

difference

between

the

incidence

of giving

in the three groups (p In the 55 patients who tomy, the range of extension

0.05, chi-squared test). underwent unilateral patelleccompared with the normal

and

full extension Anterior knee pain (n=30)

after

of patients with full unilateral patellectomy

side was limited in 14 and the range of flexion was limited in 15. There was no significant difference in the limitation of flexion or extension between the three groups (Table III; p > 0.05).
with and Activity levels reported the patients recollections one year after patellectomy. at follow-up of their This were compared activities before comparison sug-

Osteoarthritis (n=19) 13 (68) 1 1 (58)

Fracture (n=6)
5 (83) 5 (83)

Full extension Full flexion

23 (77) 24 (80)

deteriorated

after patellectomy
treated despite for level

for osteoarthritis.
fracture had remained

Function
at the

in the patients
same high

gested
after bilateral) 24 years

that

function
for

at follow-up
anterior knee

was
pain

generally
(unilateral

better
or

the patellectomy.

patellectomy

despite the fact that the patients older at follow-up. In contrast,

were on average knee function had

The level of patient satisfaction reflected these results. Of those treated for anterior knee pain, 31 (76%) thought that the operation had been helpful and 4 (10%)
THE

JOURNAL

OF BONE

AND JOINT

SURGERY

KNEE

FUNCTION

AFTER

PATELLECTOMY

487

thought
osteoarthritis,

that it had made

12 (54%)

them
thought

worse.
that difference

Of those
the

treated

for
had

operation in the levels

Table LV. The mean (sD) strengths of the quadriceps mean (sD) angles at which the strength was maximal who had had unilateral patellectomy

muscles and in 16 patients

been
worse.

helpful
There

and

6 (27%)
statistical

thought between maximum

that it had made the two groups. torque achieved

and IV).

them
of
Operated
Concentric torque (Nm) 81 (55)

is no

knee

Normal 1 18 (60)

knee

Percentage difference
30 35 38 37

satisfaction or dissatisfaction Muscle power. The mean

the mean work done

and the

during

eccentric

concentric

Eccentric Concentric Eccentric Concentric Eccentric

torque work work angle angle

(Nm) (J) (J) (degrees) (degrees)

107 (58) 156 (122) 212 (107) 60 (19) 54 (17)

164 (85)
253 (159) 339 (233) 60 (13) 54 (15)

contractions
operated than

were

found

to
legs

be

one-third
(Table

less

in

in the normal

The mean concentric torque was 1 18 Nm (SD 60) in the normal knee and 81 Nm (SD 55) in the operated knees. The difference between these groups was significant (p = 0.0078, paired t-test). The mean eccentric torque was 164 Nm (SD 84.5) in the normal knee and 107 Nm (SD 58) in the operated knee. The difference between these two groups was significant (j = 0.021, paired t-test).
The mean angle of flexion at which the quadriceps

the

opposite

quadriceps,

we

deduce

that living,

quadriceps

strength
performing

does
the

not recover
normal

after
activities

patellectomy,
of daily

by virtue
but

of
that

it may

be restored,

as in two

of our patients,

by formal

exerted altered

maximum concentric or eccentric power was not by patellectomy (Table IV). Six of the 16 operated knees regularly experienced
ofgiving way; their quadriceps strength averaged

rehabilitation.

Conclusion.

The results

of patellectomy
patients with While

are not univerthey 76% of the knee

episodes

sally unfavourable. For are poor, but in patients reported a good of follow-up, result. that

with osteoarthritis anterior knee pain the activity with level anterior

only

3 1 % of that

on the

normal

side.

Four

knees

had

occasional episodes of giving way; their strength averaged 60% of the normal side. Six knees did not give way; they averaged 81% of the strength of the other side. There was

osteoarthritic
years

patients doubled

had declined
of the patients

by 25% during of follow-up,

the 19 both in

pain

had

in the 24 years

in the strength of the quadriceps gave way compared with those which did not (j < 0.001, Wilcoxon rank-sum test). Two patients who had had vigorous rehabilitation postoperatively, a former professional footballer (male aged 44
years) and a former body-builder had more power in the operated (female aged 68 years), than in the normal knee.

a significant difference in those knees which

those with unilateral and those with bilateral patellectomies. If patients with normal tibiofemoral joints are selected and sufficient rehabilitation is provided, the success operation anterior
No benefits commercial

rate should a sensible knee pain.

in any form party related

be even option

higher. This for patients

would with

make the intractable

The average
operated legs was

volume
15% less

of the quadriceps
than

muscle
side.

of the

have been received directly or indirectly

or will be received from to the subject of this article.

on the normal

REFERENCES
Ackroyd

DISCUSSION The results

the

CE, Polyzoides AJ. Patellectomy eighty-one patients followed from two JointSurg[Br] 1978; 60-B:353-7. of the 277:7-72. knee:

for osteoarthritis: a study of to twenty-two years. J Bone investigation. Acta

of patellectomy
diagnosis.

seem
As

to depend
a treatment

very
for

much
painful

on

Ahlb#{228}ck S. Osteoarthrosis Radio! 1968; Suppl Bentley G. Chondromalacia A:221-32.

a radiographic

preoperative

osteoarthritis of the patellofemoral joint the operation is most disappointing. The results of patellectomy for idiopathic anterior knee pain, however, were as good as those of patellectomy for comminuted fracture. Levack, Flannagan and Hobbs (1985) have already shown that the long-term results in the latter case are better than after the preservation of a malunited patella. The most common symptom in all three groups was giving way and we have shown that weakness of knee
extension is probably the instability. Since patellectomy flexion at which concentric greatest the weakness must reason for this feeling of did not alter the angle of and eccentric strength was be due to loss of muscle bulk

patellae.

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of

rather

than

to mechanical

disadvantage.

In most

patients,

Scott

iC
81.

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a long

term

VOL

76-B, No. 3, MAY

1994