Case report Staged treatment of a chronic patellar sleeve fracture using the Taylor spatial frame Vishnu C. Potini ⁎, Mark C. Reilly, Robin M. Gehrmann Department of Orthopaedic Surgery, Rutgers University–New Jersey Medical School, Newark, NJ, United States abstract article info Article history: Received 11 November 2014 Received in revised form 20 February 2015 Accepted 15 April 2015 Available online xxxx Keywords: Taylor frame Patellar sleeve fracture Patella Patellar sleeve fractures are easily missed injuries since plain radiographs may not show a bony fragment at the time of injury. Failure to diagnose these injuries can result in patellar instability, extensor lag, and anterior knee pain. We report a novel treatment using a Taylor spatial frame as part of a staged reconstruction to regain length of the extensor mechanism and maintain knee motion prior to performing primary repair of the avulsed patellar sleeve fragment. In our case, an 11-year-old male presented to our institution six months after sustaining a pa- tellar sleeve fracture. Radiographic examination with the knee in extension revealed a 23-mm gap between the inferior patellar pole fragment and the remaining patella. The patient was ultimately taken to the operating room twelve months after the initial injury for placement of a Taylor spatial frame to regain length of the extensor mechanism. The patient began immediate knee range-of-motion exercises, and performed daily soft tissue lengthening of two millimeters. After four weeks of treatment the patient underwent removal of the fixator and primary repair of the patella. At final follow up six years after patellar reconstruction, the patient had an ac- tive knee range-of-motion from five degrees of hyperextension to 140° of flexion. Where current literature re- ports suboptimal results even when treatment is delayed for two months, in our case the patient was able to obtain a high level of function after treatment with a two-stage reconstruction using a Taylor spatial frame. © 2015 Elsevier B.V. All rights reserved. 1. Introduction Patellar fractures are rare in children because the patella is largely cartilaginous and has greater mobility compared to the patella of an adult [1]. Of all patellar fractures, less than two percent occur in the skel- etally immature. However, in patients younger than 16 the most com- mon fracture pattern is that of a patellar sleeve fracture [2]. The fracture is named due to the sleeve, or cuff, of cartilage that is pulled from the patella in addition to an avulsion of a small osseous fragment from the pole of the patella [3]. The patella begins to ossify at age three, and patellar sleeve fractures generally occur in patients between eight and 12 years of age, before ossification is complete. These injuries are often the result of an indirect force on the patella, such as rapid contraction of the quadriceps on a flexed knee [3,4]. Ap- propriate diagnosis and treatment of these injuries are important to maintain length of the patellar tendon, the function of the extensor mechanism, and to restore the articular surface of the patella [3,5]. The diagnosis may be difficult at initial presentation, because plain ra- diographs may not show a visible bony fragment at the time of injury. In these instances where clinical suspicion remains high, advanced imaging studies such as ultrasound or magnetic resonance imaging (MRI) are needed to prevent a missed or delayed diagnosis [6]. Failure to diagnose these injuries can result in a myriad of complica- tions including patella alta or instability, extensor lag, quadriceps wasting, anterior knee pain from patellar osteochondral damage, as well as ossification of the patellar tendon or duplication of the patella [3,7]. There are very few cases in the literature documenting treatment of chronic, displaced patellar sleeve fractures [8–10]. The treatments de- scribed for these patients ranged from continuing non-operative treat- ment to resection of the ossified fragment and reconstruction of the patellar tendon [8]. In our case, an 11-year-old male underwent surgical fixation one year after sustaining a patellar sleeve fracture. We describe a novel technique for the treatment of a chronic patellar sleeve fracture using the Taylor spatial frame (TSF) as part of a staged reconstruction to regain length of the extensor mechanism prior to performing a primary repair of the avulsed and ossified patellar sleeve fragment. 2. Case report An 11-year-old boy presented to our facility six months after landing on his left leg with knee in the flexed position. The patient's family re- ported that at the time of injury, the initial treatment prescribed by the outside institution was to place him into a knee immobilizer with in- structions that he had no fracture and did not require any treatment. At time of presentation to our hospital, the patient was unable to actively The Knee xxx (2015) xxx–xxx ⁎ Corresponding author at: Rutgers University–New Jersey Medical School, Department of Orthopaedics, 140 Bergen Street, ACC D1768, Newark, NJ 07103, United States. Tel.: +1 973 972 8240; fax: +1 973 972 1080. E-mail address: potinivc@njms.rutgers.edu (V.C. Potini). THEKNE-02079; No of Pages 5 Contents lists available at ScienceDirect The Knee Please cite this article as: Potini VC, et al, Staged treatment of a chronic patellar sleeve fracture using the Taylor spatial frame, Knee (2015), http:// dx.doi.org/10.1016/j.knee.2015.04.010 http://dx.doi.org/10.1016/j.knee.2015.04.010 0968-0160/© 2015 Elsevier B.V. All rights reserved.