THE PATELLA OF LONG STANDING 475 



dealt with by a single operation, though not without much traction, this defect 

 of the continued suture might be readily got over by introducing a superficial 

 central stitch of comparatively thin wire to ensure coaptation of the anterior 

 margins of the fragments. 



The effect of the second operation in the above case was such as would 

 have surprised me if I had not seen in other cases how substantial and strong 

 a patella may result from wiring after thorough paring of the surfaces, even when 

 one of the fragments is of quite insignificant size. Without my notes I cannot 

 say how long it is since the case was treated, but I think it must be about four 

 years. And I lately had the satisfaction of hearing from the patient that she 

 could walk well, with strong and supple knee-joints. 



Fig 5. 



In Miss 's case I would suggest that you should, in the first instance, 



before making any incision, but after she has been placed under an anaesthetic, 

 apply the strong sharp hook to the border of the upper fragment through the 

 skin, and, with the limb vertical, ascertain to what extent the quadriceps will 

 yield immediately. If the upper fragment came pretty well down, you would 

 proceed to do all by one operation, but if there were the slightest doubt as to 

 the feasibility of this, you would adopt the preliminary procedure as in tlie 

 above case. 



Supposing you to be doing all by one operation, and that it seems desirable 

 to employ Cameron's continued suture, as the wire will be left in permanently, 

 it would be better to introduce its ends first into the lower fragment and fix them 

 over the upper one, where the fixed ends could not cause inconvenience in kneeling. 

 The strong hook would keep the upper fragment well down during the fixing 

 process. If I had published this case, as I ought perhaps to have done, 1 should 

 not have had to inflict upon you so large an amount of manuscript. 



I remain, 



Ever truly yours, 

 (Signed) Joseph Listkr. 



II 2 



