Seventy-nine open patella fractures in 76 patients were treated between 1986 through 1994, with an 80% incidence of multiple injuries. All were treated with irrigation and debridement, open reduction, internal fixation, and reconstruction of the extensor mechanism. In no case was a primary patellectomy performed, even with severe comminution. There were three failures of initial fixation and one asymptomatic nonunion. Average range of motion for all groups was 112 degrees, at an average follow-up of 21 months. Secondary surgical procedures were performed in 65% of knees, the majority for symptomatic hardware. To determine long-term functional outcome, a modified Hospital for Special Surgery knee score was used. At an average of 36 months, good to excellent knee scores were observed in 17 of 22 patients. We conclude that all attempts for preservation of bone substance and precise reconstruction of the extensor should be attempted, reserving total patellectomy as a salvage procedure.