International Journal of Surgery Case Reports 114 (2024) 109165

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International Journal of Surgery Case Reports

Case report

Painful knee
Sarah Magdy Abdelmohsen a, *, Marwa T. Hussien b
a
Aswan University Hospital, Aswan University, Egypt
b
South Egypt Cancer Institute, Assiut University, Egypt

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: A bipartite patella is a rare anatomical variant of the patella. A patella bipartite is often asymp­
Bipartite patella tomatic and is often an incidental finding on radiological imaging. The patella remains bipartite when secondary
Arthroscopy ossification centers fail to fuse. Herein, a case of bipartite patella improved after knee arthroscopy and surgical
Knee joint
removal.
Anatomical variant of the patella
Presentation of the case: A 57-year-old male with a history of polytrauma. He complained of progressive pain in
Quadriceps muscle
the right knee area. A radiological investigation reported a right bipartite patella. The condition improved after
the open removal of the accessory patella.
Discussion: This case is considered type III according to Saupe's classification. Due to its location and radiological
appearance, it is a painful synchondrosis of a bipartite patella.
Conclusion: After the failure of conservative management, the removal of the bipartite patella was necessary and
unavoidable to restore everyday activities.

1. Introduction 2. Presentation of the case

The patella is the largest sesamoid bone within the human body. It is A 57-year-old male bakery worker presented with pain in his right
located longitudinally within the quadriceps muscle fascia, among the knee. The patient had a history of polytrauma (a fall from 5 m) 10 years
quadriceps and patellar tendons. It is important for the extensor mech­ ago. For five months, he had complained of progressively increased knee
anism of the knee [1–3]. pain, especially when climbing stairs.
A bipartite patella (BP) is an anatomical variant of the patella. It is Physical examination demonstrated a slightly limping gait, tender­
caused by different ossification development. It is usually asymptomatic ness over the superolateral pole of the right patella, and quadriceps
and rare. It was discovered incidentally by plain X-rays. It affects 2 %–6 muscle atrophy. There were no signs of local infection, such as redness,
% of the population. Only 2 % of people experience symptoms after swelling, or hotness. Stable collateral and cruciate ligaments. There is no
trauma or high-stress activities. It occurs bilaterally in 50 % of patients. pressure or pain in the joint space. Range of knee joint mobility
It is more common in men than in women [3–10]. (extension/flexion range 125◦ -0◦ -0◦ passive) (normal range 135◦ -0◦ -0◦ )
Herein, we describe a case of a male patient who complained of right The Oxford knee score was rated as moderate (29) [12].
knee pain because of BP. He did not respond to conservative treatment A plain X-ray of the right knee (anterior-posterior and lateral views)
and physiotherapy. After the knee arthroscopy and surgical removal of revealed a gap in the superior-lateral aspect of the right patella (BP),
accessory bone, the symptoms improved, and he was able to return to his type III according to Saupe's classification (Fig. 1). The CT examination
usual life activities. The case is unique and could be a good lesson for reported a right BP with evidence of degenerative changes between the
other healthcare professionals. This work has been reported in line with ossicles and in the superior-lateral aspect of the femoropatellar joint.
the SCARE criteria [11]. There is no evidence of a fracture. The other knee radiological exami­
nation was free.
Following the failure of conservative physiotherapy, the managing
orthopaedic surgeon recommended a knee joint arthroscopy and

Abbreviation: BP, bipartite patella.

https://doi.org/10.1016/j.ijscr.2023.109165
Received 9 November 2023; Received in revised form 7 December 2023; Accepted 8 December 2023
Available online 20 December 2023
2210-2612/© 2023 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S.M. Abdelmohsen and M.T. Hussien International Journal of Surgery Case Reports 114 (2024) 109165

Fig. 1. A plain X-ray anterior-posterior and lateral view revealed a fracture in the superior-lateral aspect of the right patella (bipartite patella), type III according to
Saupe's classification.

Fig. 2. Arthroscopy showed a normal anterior cruciate ligament and a normal medial meniscus.

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S.M. Abdelmohsen and M.T. Hussien International Journal of Surgery Case Reports 114 (2024) 109165

Fig. 3. Intra-operative CT radiography showed the shadow of the patella without its superior-lateral fragment (crescent in shape, the orange arrow).

surgical open removal of the BP. After extensive sterilization, antero­ small number of patients [1]. The fibrous zone between the patella and
lateral arthroscopic access to the right knee joint was created. There was the accessory fragment is called the synchondrosis. The intervening
no effusion. A diagnosis of type III superior-lateral BP was confirmed. tissue between the two cartilage surfaces may be fibrous, fibrocartila­
Other structures were normal and age-appropriate, such as the medial ginous, or hyaline cartilage [18]. Canizares and Selesnick reported
and lateral menisci as well as the anterior cruciate ligament (Fig. 2). An reactive and degenerative changes within this fibrocartilaginous struc­
open procedure allowed direct access to the detached fragment (Fig. 3). ture that resulted in anterior knee pain [4]. Although the precise cause
The separated fragment measured 2 × 1.5 × 2 cm. The reticulum, sub­ of these degenerative changes is unknown, it has been suggested that
cutaneous, and skin layers were sutured after irrigation and drainage. disruption of the diffusion of nutrient fluid through the fibrocartilagi­
The histopathology examination revealed that the composition of the nous structure has been implicated [16,18]. Also, vascular insufficiency
interposed tissue was fibrous, hyaline and fibrocartilage. In the inter­ can contribute to the pain. Scapinelli believed that the patella's
posed tissue, there was focal necrosis in the fibrocartilage with lacked superolateral pole was particularly vulnerable because of its constrained
blood vessels (Fig. 4). vascular supply [4].
Postoperatively, the patient was maintained in a Mecron splint for Particularly in active individuals, constant distraction and friction
knee immobilization in the extension position for 2 weeks. The post­ along the patellar synchondrosis can lead to inflammation and anterior
operative period passed smoothly without any complications (Fig. 5). knee pain. An MRI scan can show bone marrow edema [18,19]. The
For quadriceps muscle strengthening, the physiotherapy started after clinical picture of “painful synchondrosis” is a diagnosis of exclusion and
two weeks and continued for one year. The rate of physiotherapy ses­ should be considered in patients with anterior knee pain with otherwise
sions was twice weekly. The preoperative pain completely resolved after normal examination and x-ray findings [18].
three weeks, and the patient returned to his normal activities. After According to Saupe's classification, there are three types of BP: Type
three months, the patient had achieved the full normal range of knee I, which is positioned at the inferior patellar pole (5 %); Type II, which is
joint movement; the extension and flexion ranges became 135◦ –0◦ –0◦ located at the lateral border of the patella (20 %); and Type III, which is
passive. After one year of follow-up, the patient remains asymptomatic, found at the superolateral pole (75 %) [1]. This case is considered type
and his grading for the Oxford knee score improved to an excellent 38 III according to Saupe's classification. Although the patient had a history
[13,14]. of trauma, it is a congenital BP and not a patellar fracture because of its
location in the radiological appearance. Because the patient was an
3. Discussion active physical worker at a bakery, this may be considered a triggering
factor for the development of BP. In addition to overuse, direct trauma is
Wenzel Gruber discovered the BP for the first time in 1883 in St. a risk factor for congenitally susceptible individuals, because it causes
Petersburg, Russia, while performing an autopsy on a 21-year-old disruption to the fibrocartilaginous zone between the primary and
farmer who had a tiny bone fragment attached superolaterally to the accessory patellar fragments [20]. The patient's knee function and pre­
patella [9,15]. Kempson described it as emargination and an accessory operative symptoms improved after the removal of the accessory patella,
patella in 1902 [16]. as documented by the Oxford knee score questionnaire. The combined
Normally, 77 % of patellas ossify from one center, and 23 % ossify long-term physiotherapy, in addition to the surgery, is responsible for
from two or three centers. The BP is a developmental variation that the improvement of the score. The postoperative complications of BP, if
represents a secondary patellar ossification center that does not fuse the patient wasn't managed well, are malalignment of the patellofemoral
with the primary patella. Direct force or excessive traction applied to the joint and osteoarthritis [20].
patella can result in the separation of an incompletely developed carti­
lage segment prior to ossification and result in BP [3–5,17].
This gap between the two bony fragments is the source of pain for a

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S.M. Abdelmohsen and M.T. Hussien International Journal of Surgery Case Reports 114 (2024) 109165

Fig. 4. Bipartite patellae fibrous tissue: (A) Fibrocartilage and hyaline cartilage are present (x10). (B) The interposed tissue is fibrous tissue and focal necrosis of the
fibrocartilage (×40).

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S.M. Abdelmohsen and M.T. Hussien International Journal of Surgery Case Reports 114 (2024) 109165

Fig. 5. A plain X-ray of the anterior-posterior and lateral views revealed the absence of the superior-lateral fragment in the right patella.

4. Conclusion Declaration of competing interest

After failure of conservative treatment and physiotherapy, surgical There are no conflicts of interest to declare by all the authors.
removal of the accessory patella is important in restoring normal quality
of life. Combined long-term physiotherapy and surgical removal of BP References
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