reprinted from 
ANNALS 
SURGERY 
A MONTHLY REVIEW OF SURGICAL SCIENCE AND PRACTICE 
EDITED BY 
L S PILCHER AM. M D. J. WILLIAM WRITE. M D 
FREDERICK TREVES. F.R.CS., WILLIAM MACEWEN. M.D. 
TABLE OF CONTENTS 
ORIGINAL MEMOIRS 
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TRANSACTIONS OF THE NEW YORK 
SURGICAL SOCIETY 
KOITOKIAL AKTIC2X 
INDEX or 3OROICAL PROGRESS 
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BOOK REVIEWS 
ANNOUNCEMENTS 
UNIVERSITY UF PENNSYLVANIA PRESS. 
PHILADELPHIA. PA 
Great Britain; Cassell and Company. London. 
rtamnlt Number, so Csatt. 
NOVEMBER, 1895 
Single Copies, Two Shillings. 
THREE CASES OE WIRING OE THE PATELLA FOR OLD 
FRACTURE WITH DIVISION OF THE QUADRICEPS 
MUSCLE, AND CHISELLING LOOSE THE TUBER- 
CLE OF THE TIBIA IN TWO OF THE CASES. 
By WILLIAM W. KEEN, M.D., 
OF PHILADELPHIA, 
Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College. THREE CASES OF WIRING OF THE PATELLA FOR 
OLD FRACTURE WITH DIVISION OF THE QUAD- 
RICEPS MUSCLE, AND CHISELLING LOOSE THE 
TUBERCLE OF THE TIBIA IN TWO OF THE 
CASES.1 
By WILLIAM W. KEEN, M.D, 
OF PHILADELPHIA, 
PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY, 
JEFFERSON MEDICAL COLLEGE. 
CASE I.-H. K., aged thirty years; weight, 240 pounds; six 
feet two inches high. First consulted me at the Jefferson Col- 
lege Hospital, February 14, 1894, at the instance of Dr. T. 
H. White, of Connellsville, Pa. Dr. White gave me the following 
history : that the patient was the superintendent of a lumber establish- 
ment, and on October 9, 1892, fractured his right patella by a fall. 
Dr. White treated him by means of adhesive strips, and a posterior 
splint with a very satisfactory result, there being merely a narrow 
seam between the two fragments. On February 14, 1893, he slipped 
on a wet board and fell with his whole weight on the injured knee in 
a flexed position, rupturing the ligamentous union which had been 
secured. He returned to Dr. White, w'ho treated him with a full 
length leather splint, in which tongues were cut above and below the 
knee to receive the adhesive strips and bandages used in bringing the 
fragments together. This was worn for several weeks after leaving 
the hospital. The space between the fragments was about one-half 
inch. May 24, 1893, he again fell, stretching the union still farther. 
He was treated as before, and when discharged the separation of the 
fragments had increased to one and a half inches. On December 
27, 1893, he fell for the fourth time and still farther separated the 
fragments, which now amount to three and a half inches in extension 
and five inches in flexion. Even with this wide separation he has 
1 Read before the Surgical Section of the College of Physicians of Philadelphia. 2 
WILLIAM W. KEEN, 
fair use of the leg when he is walking on an even surface, but over 
rough ground or over logs, as he is compelled to walk over by his 
occupation, the leg is unstable. 
Operation, February 19, 1894. A vertical incision was made in 
the axis of the limb, which was finally extended to about twelve 
inches, for reasons which will appear later. The knee-joint was 
opened, and cultures made from the fluid in the interior, the result 
being negative. It was found filled with synovial fluid, mixed with 
the remains of blood-clots. The anterior surface of the femur was 
very red, presumably, however, rather from staining of the blood 
than from inflammation. The two fragments of the patella were 
separated three and a half inches, the upper fragment (about three- 
fourths of the whole bone) being an inch in thickness antero-pos- 
teriorly. The lower fragment was split off from the upper obliquely, 
from above downward and backward, making its upper edge, or that 
which presented towards the other fragment, but little over a quarter 
of an inch in thickness. 
After sawing off the fractured surfaces, by which about half of 
the lower fragment was removed, the two fragments were drilled 
and an attempt made to join them by means of silver wire (diameter 
No. 3, French catheter scale), but the fragments could only be brought 
to a distance of two and a half inches. Therefore, having prolonged 
the incision, as before stated, upward, I divided the tendon of the 
rectus about two and a half inches above the patella completely 
down to the bone, together with two incisions from the end of this 
transverse one, respectively outward and inward thus / When 
this division was effected, I was able to get the two fragments within 
about an inch and a half of each other, but by no possibility would 
traction effect their approximation any further. Accordingly I 
chiselled away the tubercle of the tibia, together with a considerable 
portion of the thickness of the bone in a V-shaped fragment. This 
loosened the lower piece so that I could just get the fragments to 
touch when the leg was in extension. Each fragment of the patella 
was held chiefly by lateral fibrous attachments. The lower end of 
the piece chiselled from the tibia tilted so much upward when 
traction was made that I wired transversely through the edges of the 
tibia, passing the wire in front of the lower end of the fragment, in 
which I sawed a slight groove in order to hold the wire. The ends 
of both wires were cut off and gently hammered into the bone. The 
soft parts on the outer 1 order of the two fragments of the patella WIRING THE PATELLA FOR OLD FRACTURE. 
3 
were drawn together, where they gaped considerably, by means of a 
double silkworm-gut suture, which was buried. All the soft parts that 
were incised bled profusely, a number of small arteries close to the 
bone spurting freely. They were controlled, however, by hot water 
and pressure and haemostatic forceps without any ligatures. The 
incision was now sutured and the leg placed on a Macewen splint. 
On February 20, the day after the operation, an incision was 
made at the inner and lower part of the wound and a drainage-tube 
inserted. On the 22d the drainage-tube was removed, the wound 
being in excellent condition. 
He made an uninterrupted recovery, and was discharged in eight 
weeks, walking with a cane. After five weeks, active and passive 
movements were begun. 
April, 1895. After fifteen months the result is excellent, flexion 
to ninety degrees being easily attained. The fragments are slightly 
movable on each other. The wire has never given any trouble. 
Case II.-Mrs. M. E., Glencarbon, Pa., aged forty-three years, 
was admitted to the Jefferson College Hospital March 3, 1894. In 
August, 1893, she fell while descending a flight of steps and hurt her 
knee. It was not seen by a physician until the following day, when 
the swelling was so great that he could not tell what was the trouble ; 
when the swelling finally subsided a fracture of the patella was dis- 
covered, but the fragments were so far separated that union was im- 
possible. She is in good health, bowels constipated, urine acid, 
cloudy, sp. gr. 1020, neither albumen nor sugar. 
Operation, March 7, 1894. The knee was opened by a vertical 
incision, the intervening fibrous tissue removed, and the bones brought 
together by force, and wired with No. 3 silver wire (French catheter 
scale) and the wire hammered into the bone; dressed on a Macewen 
splint. The external sutures were removed on the eighth day. A 
small abscess formed on the inner aspect of the knee, and another 
abscess in front of the knee, during the treatment. The highest 
temperature was ioo° F. 
March 4, 1894, the splint was removed and passive motion was 
begun. She could walk without aid. The leg could be bent to a 
right angle and was still improving, when she was discharged March 
14, 1894. 
Case HI.-S. J. DeH., Meyerstown, Pa., aged forty-two years, 
was sent to the Jefferson Hospital by Dr. Krum, of Lebanon, Janu- 
ary 8, 1895. 4 
WILLIAM W. KEEN. 
Six months previously, by an accident on the railway, he struck 
his right knee and fractured the patella transversely. The fracture was 
treated with adhesive strips and a posterior splint, and he recovered 
with an interval of one and a half inches between.the fragments. 
Last September, by a misstep, the fragments were dragged farther apart, 
so that they are now separated two and a half inches in extension and 
five inches when the leg is flexed. The function of the joint is very 
much impaired. 
Operation, January 9, 1895. I exposed the patella by a vertical 
incision in the axis of the leg, dissected away the tissue between the 
two fragments, and sawed off a portion of each. With all the traction 
I could make upon the fragments they were still separated two and a 
half inches. Accordingly I prolonged the incision upward and down- 
ward, and repeated the operation described in Case I. Cultures 
made at the time gave a negative result. I was now able to bring 
the fragments into very satisfactory apposition. The twisted end of 
the wire I hammered into the bone. The ligamentum patellae was 
firmly attached to the tibia by lateral fibrous tissue. The point of 
the V was so tilted forward that I removed it with bone pliers. The 
wound was then closed by interrupted sutures. 
His temperature after the operation rose to nearly ioo° and 102° 
F. for about a week. This was due to the accumulation of blood at 
the site of the cross-section of the muscles. Some stitches were re- 
moved and the wound irrigated two days after the operation, when his 
temperature gradually fell to the normal. After five weeks of exten- 
sion and elevation of the leg by a posterior splint passive motion was 
begun, and when he left the hospital on March 6 (eight weeks after the 
operation) he was able to bend the leg over one-third of the full flexion. 
The fragments were very slightly movable upon each other. 
Remarks. 
My experience in these cases is very favorable to the com- 
bined triple operation of wiring the fragments of the patella, 
section of the quadriceps muscle, and chiselling loose the tibial 
attachment of the ligamentum patellae when the two fragments can- 
not otherwise be brought into apposition. No reaction followed 
the larger violence, and the only unfavorable point was in con- 
nection with the section of the quadriceps at the upper end of WIRING THE PATELLA FOR OLD FRACTURE. 
5 
the incision. This leads me to suggest the following modification 
of the technique : 
First, I shall hereafter make an anterior flap of skin begin- 
ning on a level with the upper border of the patella and extend- 
ing downward an inch below the tubercle of the tibia. When 
this is dissected up, the operative procedures in wiring the patella 
and, if need be, chiselling loose the tubercle could be undertaken 
as usual, and then the line of union of the patella and the wire 
and the point at which the tubercle is chiselled loose will not be 
exposed to possible infection or other accident by lying imme- 
diately behind the line of incision, but will be entirely covered 
by a solid flap. If it is necessary to divide the tendon of the 
quadriceps or of the rectus alone above the patella, this can be 
done by an entirely independent incision, which could be drained, 
if need be, and the possibility of contamination of the knee- 
joint by accumulation of blood-clot through the long incision be 
avoided.