Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 20  |  Issue : 1  |  Page : 74-77

Patella gigantism following traditional bonesetter treatment


Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Date of Web Publication29-May-2018

Correspondence Address:
Dr. Somiari L Harcourt
Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_3_18

Rights and Permissions
  Abstract 


The patella is the largest human sesamoid bone, lies within, and is an important component of the knee extensor mechanism. Tumors and tumor-like lesions of the patella are rare. Fractures of the patella are relatively uncommon and account for 1% of all musculoskeletal system fractures. These fractures can be managed by traditional bonesetters with attendant complications. To report a case of patella gigantism following a patella fracture which was treated by a traditional bonesetter. An 18-year-old male Nigerian presented with a 2-year history of anterior left knee swelling following a motorcycle accident. A diagnosis of closed patella fracture was made, but he declined orthodox treatment. Treatment had been from traditional bonesetters who were massaging the knee regularly for about 2 years. Clinical and radiographic examinations revealed an enlarged patella. He had patellectomy and reconstruction of the extensor mechanism of the left knee. The patella measured 22 cm × 18 cm and weighed 0.5 kg, which was regarded as a giant patella. Histopathological report of the excised patella revealed patella sclerosis. He made an uneventful recovery and presently walks about unaided. Patella gigantism can occur following treatment of patella fracture by traditional bonesetters. We recommend patellectomy and reconstruction of the extensor mechanism, whenever a giant patella is encountered.

Keywords: Fracture, gigantism, patella, traditional bonesetter


How to cite this article:
Harcourt SL, Echem RC. Patella gigantism following traditional bonesetter treatment. J Med Trop 2018;20:74-7

How to cite this URL:
Harcourt SL, Echem RC. Patella gigantism following traditional bonesetter treatment. J Med Trop [serial online] 2018 [cited 2018 Dec 15];20:74-7. Available from: http://www.jmedtropics.org/text.asp?2018/20/1/74/233424




  Introduction Top


The patella is the largest human sesamoid bone, lies within and is an important component of the knee extensor mechanism.[1],[2],[3] It serves to protect the front of the knee and increases the lever arm of the quadriceps.[1],[4],[5]

Tumors and tumor-like lesions of the patella are rare,[6],[7],[8],[9],[10],[11] with benign lesions occurring more frequently than malignant lesions. Fractures of the patella are relatively uncommon and account for 1% of all musculoskeletal system fractures.[12],[13],[14],[15] These fractures can be managed by traditional bonesetters with attendant complications, as a number of those who sustain these injuries resort to them.

Traditional bonesetters are commonly found in most developing nations,[16] and they play a significant role in the treatment of fractures in these nations.

The aim of this paper is to report a case of patella gigantism following a patella fracture, which was treated by a traditional bonesetter.


  Case report Top


An 18-year-old male Nigerian presented to a Nigerian hospital in March 2006 with a 2-year history of anterior left knee swelling following a motorcycle accident. He had sustained closed injury to his left knee with a loss of active extension, associated with acute swelling. A diagnosis of patella fracture had been made radiologically, immediately following his injury, but he declined orthodox treatment and went home. Thereafter, treatment had been from traditional bonesetters, who were massaging the knee regularly using native concoctions/pastes for about 2 years. He had no constitutional symptoms.

Physical examination revealed some wasting of the left lower limb with a grossly enlarged left knee. The anterior swelling, which was bony and mobile (patella), measured 32 and 22 cm in the vertical and transverse diameters, respectively [Figure 1]. There was some effusion, and the range of motion in the knee joint was 10–75° of flexion.
Figure 1: Photograph of the lower limb showing the anterior knee swelling (enlarged patella)

Click here to view


Radiograph of the affected knee showed an enlarged patella with granular opacities. His chest radiograph was within normal limits. His genotype was AS, and the full blood count, blood chemistry and urinalysis were within normal.

He underwent patellectomy and reconstruction of the extensor mechanism of the left knee. Operative findings included a patella measuring 22 cm × 18 cm [[Figure 2] and [Figure 3]], adherent to the overlying fascia and weighing 0.5 kg with gross thickening of the knee joint capsule and synovium. One hundred milliliters of amber-colored synovial fluid was evacuated from the knee. [Figure 4] shows the immediate postoperative photograph.
Figure 2: Anterior surface of the excised patella

Click here to view
Figure 3: Under surface of the excised patella

Click here to view
Figure 4: Postoperative photograph

Click here to view


Histopathological report of the excised patella revealed patella sclerosis. No cysts were found. There was no cortical disruption, and no evidence of malignancy was found. The patient made an uneventful recovery and presently walks about unaided.


  Discussion Top


The patella is roughly triangular in shape with the base proximal and the apex distal.[2],[17] The patella in an adult measures 5 cm in diameter,[2] although limits of length varying from 47 to 58 mm (4.7–5.8 cm) and width from 51 to 57 mm (5.1–5.7 cm) have been described.[17] The weight of normal dry human patellae was reported by two studies, one among those of Iraqi ethnicity[18] and the other among those of Japanese ethnicity.[19] In the Iraqi study,[18] the mean weight of dry human right patella was 7.06 g (range = 4.21–11.07 g), and that of the left was 7.04 g (range = 3.28–12.91 g). In the Japanese study,[19] the combined mean weight of the right and left patellae was 7.178 g. The range for the right patellae was 4.281–10.832 g, and that for the left was 4.240–13.195 g. The index patient had a patella, which measured 22 cm × 18 cm, which is almost four times the measurement cited in the literature and it weighed 0.5 kg. The weight of the excised patella is about 70 times the mean weight of dry human patella. We propose that any patella, which weighs this much (0.5 kg) and above should be regarded as a giant patella.

The giant patella that was encountered in this patient may have been due to the treatment by the traditional bonesetter. The treatment consisted of massaging the knee regularly. Regular massage of an injured part is a common form of treatment by traditional bonesetters in this environment. With the patella fracture that had occurred in the patient, the massaging may have stimulated more vascularization of the patella. The patella has a rich blood supply,[20],[21] which in the face of fracture may lead to hyperplasia as the callus forms. Hyperplasia of the patella has been associated with infection and trauma of the patella, with or without fracture.[22],[23] However, in the present report, the hyperplasia is extensive giving rise to the giant patella. This is a unique sequela of massaging as a form of treatment by traditional bonesetters.

Patella enlargements have been reported in both benign and malignant tumors.[6],[7],[8],[9],[10],[11] The most frequent benign lesions are giant cell tumor, chondroblastoma, and aneurysmal bone cysts. The more frequent primary malignant lesions are osteosarcoma, hemangioendothelioma, and malignant fibrous histiocytoma.[6],[7],[8],[9] The malignant lesions could be metastatic.[6],[7],[8],[9] The possibility of later malignant transformation of the patella in the index patient had the patellectomy not been conducted could have been borne in mind given the size of the patella. It has been documented that some initially benign patellar tumors have been reported to have the potential for malignant transformation over time.[6],[7],[8],[9]

Patellectomy together with reconstruction of the extensor mechanism is a recommended treatment option for patella tumors.[6],[7],[8] The index patient had this form of treatment and did well. Reasonable knee function has been reported after patellectomy,[24],[25] especially when formal rehabilitation is instituted. Hence, patellectomy will, therefore, be advantageous in the long term.


  Conclusion Top


Patella gigantism can occur following treatment of patella fracture by traditional bonesetters. We recommend patellectomy and reconstruction of the extensor mechanism, whenever a giant patella is encountered.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carpenter JE, Kasman R, Matthews LS. Fractures of the patella. J Bone Joint Surg Am 1993;75:1550-61.  Back to cited text no. 1
    
2.
Clemente CD, editor. Osteology: The Patella. Gray’s Anatomy of the Human Body. 30th American ed. Philadelphia: Lea & Febiger 1984. p. 282-4.  Back to cited text no. 2
    
3.
Snoeckx A, Vanhoenacker FM, Gielen JL, Van Dyck P, Parizel PM. Magnetic resonance imaging of variants of the knee. Singap Med J 2008;49:734-44.  Back to cited text no. 3
    
4.
Kaufer H. Mechanical function of the patella. J Bone Joint Surg Am 1971;53:1551-60.  Back to cited text no. 4
[PUBMED]    
5.
Grelsamer RP, Weinstein CH. Applied biomechanics of the patella. Clin Orthop Relat Res 2001;(389):9-14.  Back to cited text no. 5
    
6.
Mercuri M, Casadei R. Patellar tumors. Clin Orthop Relat Res 2001;(389):35-46.  Back to cited text no. 6
    
7.
Ferguson PC, Griffin AM, Bell RS. Primary patellar tumors. Clin Orthop Relat Res 1997;(336):199-204.  Back to cited text no. 7
    
8.
Saglik Y, Yildiz Y, Basarir K, Tezen E, Guner D. Tumors and tumor-like lesions of the patella: A report of eight cases. Acta Orthop Belg 2008;74:391-6.  Back to cited text no. 8
    
9.
Singh J, James SL, Kroon HM, Woertler K, Anderson SE, Davies AM. Tumor and tumor-like lesions of the patella − A multicentre experience. Eur Radiol 2009;19:701-12.  Back to cited text no. 9
[PUBMED]    
10.
Gottschalk FA, Solomon L, Isaacson C, Schmaman A. Aneurysmal bone cysts of the patella secondary to chondroblastoma. Case reports. S Afr Med J 1985;67:105-6.  Back to cited text no. 10
[PUBMED]    
11.
Ozan F, Toker G. Secondary aneurysmal bone cyst of the patella. Acta Orthop Traumatol Turc 2010;44:246-9.  Back to cited text no. 11
[PUBMED]    
12.
Luna-Pizarro D, Amato D, Arellano F, Hernandez A, Lopez-Rojas P. Comparison of a technique using a new percutaneous osteosynthesis device with conventional open surgery for displaced patella fractures in a randomized controlled trial. J Orthop Trauma 2006;20:529-35.  Back to cited text no. 12
    
13.
Uvaraj NR, Mayil Vahanan N, Sivaseelam A, Mohd Sameer M, Basha IM. Surgical treatment of neglected fractures of the patella. Injury 2007;38:979-83.  Back to cited text no. 13
[PUBMED]    
14.
Carpenter JE, Kasman RA, Patel N, Lee ML, Goldstein SA. Biomechanical evaluation of current patella fracture fixation techniques. J Orthop Trauma 1997;11:351-6.  Back to cited text no. 14
[PUBMED]    
15.
Levack B, Flannagan JP, Hobbs S. Results of surgical treatment of patellar fractures. J Bone Joint Surg Br 1985;67:416-9.  Back to cited text no. 15
[PUBMED]    
16.
Onuminya JE. Performance of a trained traditional bonesetter in primary fracture care. S Afr Med J 2006;96:320-2.  Back to cited text no. 16
[PUBMED]    
17.
Fulkerson JP. Normal anatomy. In: Fulkerson JP, editor. Disorders of the Patellofemoral Joint. 4th ed. Philadelphia: Lippincott Williams & Wilkins 2004. p. 1-23.  Back to cited text no. 17
    
18.
Al-Imam A, Al-Zamili Z, Omar R. Surface area of patellar facets: Inferential statistics in the Iraqi population. Anat Res Int 2017;2017:2685159.  Back to cited text no. 18
[PUBMED]    
19.
Al-Imam A, Al-Imam ML. Human patella morphometry and volumetry, an osteology-based study in the Japanese ethnicity. Eur J Pharm Med Res 2016;3:388-96.  Back to cited text no. 19
    
20.
Scapinelli R. Blood supply of the human patella. Its relation to ischaemic necrosis after fracture. J Bone Joint Surg Br 1967;49:563-70.  Back to cited text no. 20
[PUBMED]    
21.
Shim SS, Leung G. Blood supply of the knee joint. A microangiographic study in children and adults. Clin Orthop Relat Res 1986;(208):119-25.  Back to cited text no. 21
    
22.
Roy DR. Osteomyelitis of the patella. Clin Orthop Relat Res 2001;(389):30-4.  Back to cited text no. 22
    
23.
Fulkerson JP. Dysplasias: Hyperplasia or patella magna. In: Fulkerson JP, editor. Disorders of the Patellofemoral Joint. 4th ed. Philadelphia: Lippincott Williams & Wilkins 2004. p. 137.  Back to cited text no. 23
    
24.
Lennox IA, Cobb AG, Knowles J, Bentley G. Knee function after patellectomy. A 12- to 48-year follow up. J Bone Joint Surg Br 1994;76:485-7.  Back to cited text no. 24
[PUBMED]    
25.
Gunal I, Taymaz A, Kose N, Gokturk E, Seber S. Patellectomy with vastus medialis obliquus advancement for comminuted patellar fractures: A prospective randomised trial. J Bone Joint Surg Br 1997;79:13-6.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed230    
    Printed14    
    Emailed0    
    PDF Downloaded36    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]