How is a bipartite patella managed?

Management of Bipartite Patella

Bipartite patella should be managed with an initial trial of conservative treatment for at least 3 months, followed by surgical intervention only for cases with persistent symptoms that fail to respond to non-operative measures. 1

Initial Diagnosis and Evaluation

• Imaging:

  • Standard radiographs (including axial views) are usually sufficient for diagnosis and assessment 2
  • Weight-bearing axial radiographs provide better assessment of patellofemoral kinematics 2
  • CT or MRI with metal artifact reduction techniques may be used for complex cases 2

• Clinical Assessment:

  • Evaluate pain severity and location (typically anterior knee pain)
  • Assess aggravating factors (sports activities, squatting, climbing stairs)
  • Determine functional limitations and impact on quality of life

Conservative Management (First-Line Treatment)

Conservative management should be attempted for at least 3 months and includes:

1. Activity Modification:

   • Temporary reduction in aggravating activities
   • Avoidance of high-impact exercises during acute phase

2. Physical Therapy:

   • Knee-targeted exercise therapy focusing on quadriceps strengthening 2
   • Hip strengthening exercises if indicated by assessment 2
   • Progressive loading based on symptom severity and irritability

3. Pain Management:

   • NSAIDs for pain control
   • Ice application after activity

4. Supportive Measures:

   • Patellofemoral bracing to resist lateral displacement of the patella 2
     • Off-the-shelf versions are suitable for most patients
     • More active individuals may benefit from braces with lateral hinges and adjustable patellar buttresses
   • Patellar taping for symptom relief during rehabilitation 2

5. Education:

   • Explanation of condition and expected recovery timeline
   • Guidance on activity modification and self-management

Surgical Management (For Refractory Cases)

If symptoms persist despite 3-6 months of well-managed conservative treatment, surgical intervention may be considered. Surgical options include:

1. Fragment Excision:

   • Most common surgical approach for symptomatic bipartite patella 3
   • Appropriate for smaller fragments (<12% of patellar size) 3
   • Can be performed open or arthroscopic-assisted
   • Excellent outcomes reported in majority of cases 3

2. Lateral Retinacular Release:

   • Can be performed alone or in combination with fragment excision 3, 4
   • Reduces traction force of vastus lateralis on the loose fragment 4
   • May be particularly beneficial for superolateral fragments (Saupe type III)

3. Fragment Fixation:

   • Consider for larger fragments with articular surface involvement 4
   • Preserves patellofemoral congruity
   • Limited support in literature compared to excision 4

4. Synchondrosis Drilling:

   • Less commonly performed procedure 1
   • May be considered in specific cases

Treatment Algorithm

1. Initial Presentation:

   • Begin with conservative management for all patients

2. At 6-12 weeks:

   • Reassess symptoms and function
   • Continue conservative management if improving

3. At 3-6 months:

   • If symptoms persist despite adequate conservative management, consider surgical consultation
   • Select surgical technique based on:
     • Fragment size (excision for small, fixation for large)
     • Location (lateral release more beneficial for superolateral fragments)
     • Presence of articular surface involvement

4. Post-surgical Rehabilitation:

   • Structured rehabilitation program
   • Gradual return to activities over 2-3 months 3, 5

Outcomes and Prognosis

• Approximately 76% of patients (particularly younger patients) achieve full resolution with conservative management alone 1
• Surgical intervention has high success rates (90.8%) for patients who fail conservative management 1
• Potential complications after surgery include:
  • Residual pain (9.2%) 1
  • Need for reoperation (5.3%) 1
  • Hardware complications if fixation was performed

Special Considerations

• Adolescent athletes may require more aggressive management due to higher activity demands 5
• Larger fragments with articular surface involvement may benefit from fixation rather than excision to preserve patellofemoral congruity 4
• Female competitive athletes with prolonged symptoms may be more likely to require surgical intervention 5