What is the appropriate approach for management for a neglected patella fracture of over a year with the proximal fragment at the region of the mid thigh with weakness in the extensor mechanism.
As you know if it was a two-part fractures, the treatment are most often fixed in place using pins and wires and a "figure-of-eight" configuration tension band in order to get the compression or use cannulated screws. If the fragment is too small to be fixed back into place you should consider to remove it.
In this case we have more than one year untreated fracture patella, so this is patellar nonunion with proximal pole migration by the pull of the quadriceps muscle. I expect bone resorption at the fracture site and some difficulties in achieving reduction. The surgical approach is longitudinal midline exposure from site of fracture down to tibial tuberosity. Quadriceps release may be needed to achieve reduction and fixation of the fracture by tension band wiring. If the fragment is too small or massively deformed by malunited comminution, excision with restoration and repair of extensor mechanism is all what is needed, protected by cerclage wire in the tibial tuberosity or above the knee plaster cast for 6 weeks.
I agree with Dr. Farouk. This injury lies back more than a year and the fragments are severely dislocated. The fragments are osteoporotic. One can try to mobilise the quadriceps muscle in an attempt to reduce the non-united fragments and fix them but in my opinon this should be difficult if possible at all.
One should then consider patellectomy, quadriceps plasty and transposition of part of the ischiocrural muscles to enhance the extension mechanism. In my practice this prosedure has worked satisfactorally.
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