Anatomy

The patella is the largest sesamoid bone in the body. Its superior pole
is the major site of attachment of the quadriceps aponeurosis, which
is also known as the trilaminar quadriceps tendon. The trilaminar
quadriceps tendon consists of the superficial rectus femoris muscle
and tendon, the vastus intermedius muscle and tendon, and portions
of the muscles and tendons of the vastus medialis and the vastus
lateralis.
The inferior pole of the patella is the major site of attachment for the
patellar ligament or tendon, which inserts distally onto the anterior lip
of the tibia and the tibial tubercle. A portion of the patellar ligament is
composed of fibers of the rectus femoris that course over the surface
of the patella. Medially, the patellar attachment is formed by the
medial retinaculum, which is a confluence of the tendons of the vastus
medialis and the rectus femoris. These tendons attach to the
superomedial border of the patella and the medial condyle of the tibia.
The lateral retinaculum of the patella is composed of the tendon of the
vastus lateralis, which inserts into the superolateral border of the
patella and the lateral tibial condyle. Anteriorly, only a thin layer of
skin, subcutaneous tissue, and the prepatellar bursa cover the patella;
posteriorly, it is lined by thick articular cartilage.
The patella's primary functional role is knee extension, in which
tensile forces from the quadriceps muscles are transferred to the
proximal patella and then distally via the patellar ligament's
attachment to the tibia. Posteriorly, contact stresses develop when
the patella articulates with the femur. This 3-point bending stress is
concentrated in the anterior patella and involves both tension and
compressive forces. The stress is maximal at 45° of flexion (2-10
N/mm2).
Ossification of the patella occurs between the ages of 2 and 6 years;
however, the patella may be congenitally absent or hypoplastic, as in
nail-patella syndrome (Fong disease). In 77% of persons, only a single
center of ossification exists. In the remaining 23% of patients, 2-3
separate centers of ossification may exist. These secondary centers
typically coalesce by the time children reach age 12 years, but the
centers may remain separate in 2% of children. Radiographically, the
ossification centers that do not fuse with the major primary portion
remain visible, as in bipartite patellae.
Of the 2% of the population with an un-united bipartite patella, only 2%
are symptomatic. Bipartite patella occurs unilaterally in 57% of these
individuals and bilaterally in 43%. A fracture or fibrous nonunion of a
bipartite patella may be acute or a result of chronic stress.
The Saupe classification for partitioned patella includes the following:
1. Inferior pole (5% of patients)
2. Lateral or vertical (20% of patients)
3. Superolateral (most common type; 75% of patients)