EC Orthopaedics

Background: Tension band wiring (TBW) remains the standard fixation technique for patella fractures, particularly in simple transverse patterns. However, its effectiveness in comminuted fractures is limited due to dependence on an intact cortical buttress and susceptibility to implant-related complications. Recent biomechanical studies have demonstrated superior stability of locking plate constructs, with reduced interfragmentary displacement and higher resistance to cyclic loading compared to TBW [3-5]. This study evaluates functional outcomes and failure patterns in a large cohort of patients undergoing operative fixation of patella fractures.

Methods: A retro-prospective comparative cohort study was conducted on approximately 250 patients treated between January 2017 and December 2023. Patients underwent operative fixation with either tension band wiring (TBW) or locking plate constructs, with near-equal distribution between groups. Fractures were classified according to the AO/OTA classification system, and a predefined subgroup analysis was performed for AO 34-C3 comminuted fractures.

Functional outcomes were evaluated using validated scoring systems (Böstman and/or Lysholm scores), in addition to objective assessment of range of motion (ROM) and extensor lag. Patients were followed at standardized intervals of 3, 6, 12, and 18 months.

A dedicated failure pattern analysis was performed, including assessment of loss of reduction, implant-related complications such as K-wire migration, and need for reoperation. Statistical analysis was conducted using appropriate parametric and non-parametric tests, with a p-value < 0.05 considered statistically significant.

Results: Locking plate fixation demonstrated superior maintenance of fracture reduction and more consistent functional recovery, particularly in comminuted fractures. TBW provided satisfactory outcomes in simple fracture patterns; however, in comminuted fractures, patients treated with TBW more frequently reported pain during range of motion and demonstrated higher rates of implant-related mechanical issues. K-wire migration and loss of reduction were predominantly observed in the TBW group, consistent with previously reported complication profiles [16,17]. In contrast, such complications were minimal in the plating group. Overall complication rates were low, with no major adverse events or non-unions observed across the cohort.

Conclusion: While TBW remains an effective technique for simple patella fractures, its limitations are evident in comminuted patterns. Locking plate fixation provides superior mechanical stability, fewer implant-related complications, and improved functional outcomes in AO 34-C3 fractures. These findings support a shift in surgical preference toward plate fixation in complex patella fractures, in line with emerging biomechanical and clinical evidence [6,8].

Keywords: Tension Band Wiring (TBW); Patella Fractures; AO 34-C3 Fractures; Range of Motion (ROM)

1. Boström A. “Fracture of the patella: a study of 422 patellar fractures”. Acta Orthopaedica Scandinavica, Supplementum 143 (1972): 1-80.
2. Melvin JS and Mehta S. “Patellar fractures in adults”. Journal of the American Academy of Orthopaedic Surgeons 4 (2011): 198-207.
3. Stoffel K., et al. “Anterior variable-angle locked plating versus tension band wiring of simple and complex patella fractures - a biomechanical investigation”. BMC Musculoskeletal Disorders 1 (2023): 279.
4. Kim S., et al. “Comparative study of locking neutralization plate construct versus tension band wiring for patella fractures: experimental and finite element analysis”. Journal of Orthopaedic Surgery and Research 1 (2024): 77.
5. Garner MR., et al. “Transverse patella fracture fixation: a cadaveric biomechanical comparison of cannulated screws and anterior tension band versus multiplanar mesh plating”. Injury 6 (2024): 111574.
6. Bickel S., et al. “Clinical and functional outcomes of locked plating vs. cerclage compression wiring for AO type C patellar fractures”. European Journal of Trauma and Emergency Surgery 6 (2024): 2975-2985.
7. Yiu CBB., et al. “Clinical and functional outcomes of locking plate versus cerclage compression wiring for comminuted patella fractures”. Journal of Orthopaedics, Trauma and Rehabilitation (2025).
8. Tsotsolis S., et al. “To plate, or not to plate? A systematic review of functional outcomes and complications of plate fixation in patellar fractures”. European Journal of Orthopaedic Surgery and Traumatology 8 (2023): 3287-3297.
9. Elsoe R., et al. “Tension band versus locking plate fixation for patella fractures - protocol of a randomized controlled trial”. Danish Medical Journal 5 (2024): A12230753.
10. Kazemi SM., et al. “Patella fractures outcome after tension band wiring: a cross-sectional study”. Journal of Pioneering Medical Sciences 1 (2024).
11. Carpenter JE., et al. “Fractures of the patella”. Journal of Bone and Joint Surgery. American Volume 10 (1993): 1550-1561.
12. Berg EE. “Open reduction internal fixation of displaced transverse patella fractures with figure-of-eight wiring through parallel cannulated screws”. Journal of Orthopaedic Trauma 8 (1997): 573-576.
13. LeBrun CT., et al. “Functional outcomes after operatively treated patella fractures”. Journal of Orthopaedic Trauma 7 (2012): 422-426.
14. Wild M., et al. “Fixed-angle plates in patella fractures: clinical and radiological results”. Archives of Orthopaedic and Trauma Surgery 130 (2010): 147-152.
15. Taylor BC., et al. “Plating of patella fractures: techniques and outcomes”. Journal of Orthopaedic Trauma 9 (2014): e231-e235.
16. Hoshino CM., et al. “Complications following tension band fixation of patella fractures”. Journal of Orthopaedic Trauma 27 (2013): e93-e98.
17. Smith ST., et al. “Early complications in the operative treatment of patella fractures”. Journal of Orthopaedic Trauma 11 (1997): 183-187.
18. Lorich DG., et al. “Superior outcomes after operative fixation of patella fractures using novel plating techniques”. Journal of Orthopaedic Trauma 5 (2016): 241-247.
19. Thelen S., et al. “Biomechanical cadaver testing of a fixed-angle plate in comparison to tension wiring and screw fixation in transverse patella fractures”. Injury8 (2012): 1290-1295.
20. Bedi A and Karunakar MA. “Patella fractures and extensor mechanism injuries”. Journal of Knee Surgery (2006).