What is the next step after confirming a bipartite patella on a patellar skyline view?

Management of Confirmed Bipartite Patella

The next step after confirming a bipartite patella on patellar skyline view is to determine if the patient is symptomatic—if asymptomatic, no treatment is needed; if symptomatic with anterior knee pain, initiate conservative management for at least 6 months before considering surgical options.

Initial Clinical Assessment

The critical distinction is whether the bipartite patella is causing symptoms, as approximately 98% of cases are asymptomatic incidental findings 1, 2.

Key Clinical Features to Evaluate:

• Pain pattern: Determine if anterior knee pain is present and whether it's exacerbated by sporting activities, work demands, or specific loading activities 1, 3
• Activity level: Document sports participation (basketball, football, soccer, track-and-field) or occupational demands (laborer, manufacturing work) that may stress the patellofemoral joint 1, 3
• Trauma or overuse history: Identify if symptoms began after trauma or developed from strenuous sports activity, which commonly triggers symptomatic bipartite patella in adolescents and young adults 2, 4
• Physical examination findings: Assess for localized tenderness over the fragment, pain with resisted knee extension, and evaluate patellofemoral tracking 1

Asymptomatic Bipartite Patella

• No treatment is required for asymptomatic cases discovered incidentally on imaging 2
• Reassure the patient that this is a normal anatomical variant present in 1-2% of the population 4

Symptomatic Bipartite Patella Management

Conservative Treatment (First-Line for Minimum 6 Months)

All symptomatic patients should undergo conservative management before surgical consideration, as most patients improve with nonsurgical treatment 2, 5.

• Activity modification: Reduce or temporarily cease aggravating sports or work activities 4, 3
• Physical therapy: Implement knee-targeted exercise therapy focusing on quadriceps strengthening and patellofemoral joint rehabilitation 6, 4
• Adjunctive modalities: Consider extracorporeal shock wave therapy (ESWT) and viscosupplementation, which have shown success in reducing pain from VAS 5/10 to 0-1/10 4
• Duration: Conservative treatment should be attempted for at least 6 months before considering surgical intervention 1, 3

Surgical Intervention (When Conservative Treatment Fails)

Surgery should only be considered after failure of >6 months of conservative treatment 1, 3.

Surgical Options Based on Fragment Characteristics:

• Fragment excision (most popular option): Indicated when the fragment represents <12% of the total patella, with excellent outcomes in 84.1% achieving pain relief and 98.3% returning to preoperative activity levels 1, 5

• Fragment excision with lateral release: Recommended for superolateral (Saupe type III) fragments, which represent the majority of symptomatic cases 1, 3

• Lateral retinacular release alone: Alternative when the fragment is large with an articular surface, as excision may lead to patellofemoral incongruity and compromise quadriceps strength 2

• Internal fixation: Has limited support in the literature and is generally not recommended 2

Surgical Approach:

• Arthroscopic-assisted open excision is the preferred technique, allowing visualization of the joint and precise fragment removal 1, 3
• Average return to full sporting activity occurs at 9.8 weeks (range 6-13 weeks) postoperatively 3

Common Pitfalls to Avoid

• Do not operate prematurely: Ensure adequate trial of conservative management (minimum 6 months) as most cases resolve without surgery 1, 2, 3
• Avoid excising large fragments: When the fragment exceeds 12% of the patella or has significant articular surface, excision may cause patellofemoral incongruity—consider lateral release instead 1, 2
• Do not confuse with patellar fracture: Bipartite patella has smooth, sclerotic margins on radiographs, unlike acute fractures with irregular edges 2
• Weight-bearing views are essential: Standard radiographs may underestimate functional malalignment; weight-bearing axial views provide superior assessment of patellofemoral kinematics 7, 8