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Quantitative and Qualitative Assessment of Bone Perfusion and Arterial Contributions in a Patellar Fracture Model Using Gadolinium-Enhanced Magnetic Resonance ImagingA Cadaveric Study
Lionel E. Lazaro, MD1; David S. Wellman, MD1; Craig E. Klinger, BS1; Jonathan P. Dyke, PhD2; Nadine C. Pardee, BA1; Peter K. Sculco, MD1; Marschall B. Berkes, MD1; David L. Helfet, MD1; Dean G. Lorich, MD1
1 Orthopedic Trauma Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for L.E. Lazaro: lionellazaro@gmail.com
2 Citigroup Biomedical Imaging Center, Weill Medical College of Cornell University, 1300 York Avenue, Box 234, New York, NY 10021
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Investigation performed at the Hospital for Special Surgery, New York, NY



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 02;95(19):e140 1-7. doi: 10.2106/JBJS.L.00401
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Abstract

Background: 

The purpose of the present study was to evaluate the anatomy and contribution of the patellar vascular supply and to quantify the effect of a transverse fracture on patellar perfusion.

Methods: 

In twenty matched pairs of fresh-frozen cadaveric knees, the superficial femoral artery, anterior tibialis artery, and posterior tibialis artery were cannulated. One side of each matched pair was randomly selected to undergo one of two osteotomies: (1) midpatellar osteotomy or (2) distal-pole osteotomy. For volumetric analysis, comparisons were performed between contrast-enhanced magnetic resonance images and precontrast magnetic resonance images as well as between osteotomized patellar bone fragments and the corresponding intact areas on the control side. We then injected a urethane polymer compound and dissected all specimens to examine extraosseous vascularity.

Results: 

Magnetic resonance imaging demonstrated that the largest arterial contribution to the patella entered at the inferior pole in 100% of the specimens; in 80% of these specimens, the artery entered inferomedially. It also revealed an overall decrease in contrast enhancement in both transverse osteotomy groups, with an average reduction in enhancement in the proximal fragment of 36%.

Conclusions: 

If possible, surgical interventions about the knee should be carefully planned to preserve the peripatellar ring (the source of the entire patellar blood supply), especially the inferior patellar network. Distal-pole patellectomy should be avoided to retain vascularized bone at the reduced fracture site.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Philip Hardy, MD
    Posted on October 10, 2013
    A question about the diagrams
    Jacksonville Orthopaedic Institute, Jacksonville, FL, USA

    The second diagram in this article (Figure 2), depicting the blood supply of the patella, shows two medial superior geniculate arteries, and is inconsistent with the first diagram (Figure 1). 

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