Journal of Orthopaedic Science 24 (2019) 142e146

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Journal of Orthopaedic Science

journal homepage: http://www.elsevier.com/locate/jos

Original Article

A clinical comparison study of three different methods for treatment

of transverse patellar fractures
Depeng Meng a, 1, Peng Xu a, 1, Di Shen a, Yu Chen a, Chengdong Zhu a, b, Chunlin Hou a,
Haodong Lin a, *, Yueping Ouyang a, **
a
Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, PR China
b
Department of Orthopedics, The People's Hospital of Yizheng City, Jiangsu, PR China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Tension bands structures are widely used to treat transverse patellar fractures. However,
Received 28 June 2018 many implants-related complications have been reported. The purpose of this study is to evaluate effects
Received in revised form and compare complications of three methods used to treat transverse patellar fractures, including tita-
16 August 2018
nium cable tension bands, compression screws with titanium cable cerclage, and X-shaped plating
Accepted 19 August 2018
technique.
Available online 11 October 2018
Methods: From January 2010 to March 2016, 120 cases of transverse patellar fracture received open
reduction and internal fixation with one of three methods: titanium cable tension band (group A),
compression screws with titanium cable cerclage (group B), and X-shaped plating technique (group C). Of
these, 108 cases were followed for >2 years. Clinical and radiographic data were retrospectively collected
and statistically compared.
Results: Final analysis included 108 patients (n ¼ 38 in group A, 36 in B, and 34 in C). Reduction was
satisfactory in all patients after surgery. No significant differences were noted in age, gender, time from
injury to surgery, postoperative articular step-off, Lysholm score, and range of motion at 24 months
among all groups. At final follow-up, 12 (31.6%) symptomatic implant complications were encountered in
group A, along with 6 (16.7%) and 2 (5.9%) in groups B and C, respectively (p < 0.05).
Conclusion: All three methods could achieve the goal of rigid fixation and early functional rehabilitation.
However, the X-plate technique had the lowest risk of symptomatic implant complications and could
thus be a safe and effective alternative for internal fixation of transverse patellar fractures.
© 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

1. Introduction reported with this method, including breakage or migration of

Transverse patellar fractures are the most common type of
patellar fractures. Displaced fractures affecting the extension
apparatus often require surgical treatment [1,2]. Tension bands and
other modified structures are mostly used to treat transverse
patellar fractures and are regarded as the gold standard [3e5].
However, lots of implants-related complications have been
* Corresponding author. Department of Orthopedics, Changzheng Hospital, Sec-
ond Military Medical University, Shanghai, 200003, PR China.
** Corresponding author. Department of Orthopedics, Changzheng Hospital, Sec-
ond Military Medical University, Shanghai, 200003, PR China.
E-mail addresses: linhaodong1978@smmu.edu.cn (H. Lin), Oyaopin@aliyun.com
(Y. Ouyang).
1
These authors contributed equally to this work and should share the first
authorship.
wire, hardware prominence and subsequent fragment displace-
ment, loss of reduction, and pain in the knee [6e8].
Anatomically, the patella lies just beneath the skin, making
complications such as pain from implant or soft-tissue irritation
likely to occur. The therapeutic principle of rigid fixation and
anatomical feature has provoked researchers to develop ideal im-
plants with characteristics of adequate strength and thin configu-
ration. To date, new techniques including titanium cables, low-
profile locking plates, and modification of the tension band wire
construct using cannulated screws have been described [9e13].
However, only few clinical comparisons of these trending methods
in treating patellar transverse fractures have been reported.
Based on these, we retrospectively collected clinical data to
further evaluate effects and compare complications of three
methods used to treat transverse patellar fractures, including

https://doi.org/10.1016/j.jos.2018.08.026
0949-2658/© 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
 D. Meng et al. / Journal of Orthopaedic Science 24 (2019) 142e146
titanium cable tension band, compression screws with titanium
cable cerclage, and X-shaped plating technique.
2. Materials and methods
2.1. Population
From January 2010 to March 2016, 243 patients with patellar
fractures admitted to our hospital received open reduction and
internal fixation (ORIF) surgery. Before surgery, the surgeons
informed the patients different implant options as well as their
medical cost, potential risk and general prognosis. The final choice
was made by the patients themselves.
Patients were screened by the following criteria: (i) fresh
transverse patellar fractures classified as 34-A (extra-articular) or
34-C1 (intra-articular) according to the AO/OTA classification sys-
tem (within 21 days) [14]; (ii) no history of previous injury or
surgery in the knee joint involved; (iii) closed fracture with soft
tissue injury less severe than Tscherne type I [15]; (iv) patient was
treated with either of the three aforementioned methods. Exclu-
sion criteria were (i) incomplete clinical data and follow-up of <2
years and (ii) patients with pre-operative severe osteoarthritis that
would bias results.
In total, 120 patients met the inclusion criteria. After exclusion,
108 cases and equal number of fractures meeting inclusion criteria
were included and divided into three groups based on treatment
received. Group A patients were treated using the titanium cable
tension band method (n ¼ 38). Group B patients received fixation
with combination of cannulated double-threaded compression
screws and titanium cable cerclage (n ¼ 36). Group C patients
received fixation with only X-plates (n ¼ 34). Study design and data
collection were approved by the institutional review board of the
“Human Experimental and Ethics Committee” in our hospital. The
patients and/or their families were informed that data from the
case would be submitted for publication, and gave their consent.
2.2. Surgical procedures
After spinal or general anesthesia, patients were placed in the
supine position on a radiolucent operating table. A tourniquet was
used to minimize blood loss and improve fracture visualization. The
knee was flexed at 30 and a longitudinal middle incision was
made, centered over the fracture line. The hematoma was removed
Fig. 1. Follow-up data of a 46-year-old female. The fracture was treated with titanium cable tension band technique. a Lateral image of a transverse patellar fracture with
displacement. b Postoperative anteroposterior image at 1-year follow-up. c Postoperative lateral image at 1-year follow-up.
143
with clearance of the periosteum inserted in the fracture line.
Manual reduction was performed with the help of clamps, and
Kirschner (K)-wires were used to maintain temporary fixation.
In Group A, the fracture was fixed with traditional tension band
technique, by alternating stainless wires with titanium cables
(Atlas, Medtronic, USA). Titanium cables were gradually tightened
until a tension of 30 lbs. was achieved and then secured using an
affiliated device (Fig. 1aec).
In Group B, two longitudinal cannulated double-threaded
compression screws (Bold, Newdeal, France) were used to fix
fragments under guidance of K-wires. In order to augment stability,
an additional titanium cable (Atlas, Medtronic, USA) was passed
circumferentially around the patella and a loop was formed. Sub-
sequently, the titanium cables were tightened as mentioned earlier
(Fig. 2aec).
In Group C, a variable angle-locking X-shaped plate (VLP * FOOT,
Smith & Nephew, USA) in a suitable length (range: 24e36 mm) was
used, and four separate 2.7 mm locking screws were placed to lock
the plate with the fragment. Preferably, the X-plate was bent to
serve as a claw with poly-axial locking screws to fix upper and
inferior fragments. Screw placement was performed cautiously,
particularly when targeted toward the articular surface (Fig. 3aed).
The correct length of the screws could be checked by a parapatellar
articular palpation or axial view fluoroscopy methods.
Lateral fluoroscopy was regularly performed to confirm fixation
with the knee range of motion (ROM) up to 90 . After sufficient
wash with saline solution, the wound was closed in layers. Passive
knee ROM could reach >90 immediately after surgery in all pa-
tients. Weight bearing was allowed under protection of a hinge
brace locked in full extension.
2.3. Clinical and radiographic evaluation
We retrospectively reviewed radiographic and clinical data of all
patients. Postoperative clinical and radiographic data were recor-
ded immediately after surgery, at 1, 3, and 6 months, and yearly
thereafter. Clinical evaluation parameters included hospital stay
(HS), time from injury to surgery (TS), operation time (OT), ROM,
Lysholm score [16], complications, and time of union. Complica-
tions such as symptomatic implant events (which required revision
surgery, e.g., unbearable hardware prominence, wire breakage, and
deep infections), re-displacement, knee contraction, weakening of
extensor muscles, bone nonunion, and osteoarthritis were
144 D. Meng et al. / Journal of Orthopaedic Science 24 (2019) 142e146
Fig. 2. Follow-up data of a 57-year-old male. The fracture was fixed with titanium cable cerclage and cannulated double-headed compression screws. a Lateral image of displaced
transverse patellar fracture. b Postoperative anteroposterior image at 1-year follow-up. c Postoperative lateral image at 1-year follow-up.
recorded. Radiographic evaluation included migration of hardware
and articular step-off or gap reduction. Re-displacement was
considered as an articular step-off of >2 mm or a gap of >3 mm in
comparison with immediate postoperative radiography.
2.4. Statistical analysis
Results were expressed as mean ± standard deviation (SD). Data
were independently collected by two reviewers who were blinded
to the study design and were entered into the SPSS (version 19.0;
SPSS Inc., IBM, USA) software. Chi-square or Fisher exact tests were
used for categorical variables (e.g., gender, complications). One-
way analysis of variance (ANOVA) and Tukey's multiple compari-
son test were used for normally distributed continuous variables
(e.g., age, OT, ROM, Lysholm score, HS, and time of union). p
values < 0.05 were considered statistically significant.
3. Results
3.1. Characteristics evaluated immediately after surgery
The mean articular step-off or gap was 0.38 ± 0.66, 0.34 ± 0.54,
and 0.43 ± 0.56 mm in Groups A, B, and C, respectively, immediately
after surgery. Reduction was satisfactory in all patients. No signif-
icant differences were noted in age, gender, TS, rate of 34-C1 frac-
ture pattern (intra-articular fracture), and postoperative articular
step-off (p > 0.05).
Baseline and operative characteristics of patients are presented
in Table 1.
3.2. Clinical outcomes at 2-year follow-up
At the 2-year follow-up, the mean Lysholm scores were
92.14 ± 3.13 (Group A), 91.44 ± 3.25 (Group B), and 93.13 ± 2.66
(Group C). ROM was 129.6 ±13.22 (Group A), 131.9 ±6.80 (Group
B), and 133.3 ±6.73 (Group C). Fracture union was observed at a
mean postoperative time of 3.13 ± 0.58 (Group A), 3.12 ± 0.34
(Group B), and 3.07 ± 0.26 (Group C) months. No significant dif-
ferences were observed in average Lysholm scores and ROM across
the three groups at the 2-year follow-up (Table 2 and Fig. 4).
3.3. Complications until final follow-up
As shown in Table 2, the mean follow-up period was
32.07 ± 7.26 (range: 24e46), 30.94 ± 7.47 (24e48), and 29.80 ± 6.38
(24e45) months, with no significant intergroup differences. At the
final follow-up, a total of 12 (31.6%) symptomatic implant compli-
cations (which needed revision surgery, e.g., unbearable hardware
prominence, wire breakage, and deep infections) were encountered
in Group A, while 6 (16.7%) and 2 (5.9%) such cases were noted in
Groups B and C, respectively, with significant intergroup differ-
ences (p ¼ 0.019). The most common complication in Group A was
migration of hardware, noted in 15 (39.5%) cases, but no such
complication was noted in Groups B and C; intergroup differences
were significant (p < 0.001). One (2.6%) case of superficial infection
was encountered in Group A as was noted in Groups B (2.8%) and C
(2.9%); intergroup differences were nonsignificant (p > 0.05). There
were no cases of subsequent fragment displacement, loss of
reduction and knee contraction, weakening of extensor, and bone
nonunion in any group. No osteoarthritis was observed in any case.
4. Discussion
Patellar fractures account for approximately 1% of all skeletal
fractures. Displaced transverse patellar fractures are best treated by
ORIF. The goal of therapy is to restore anatomy of the articular
surface and provide stable fixation, thus allowing restoration of
knee motion and rapid rehabilitation. Tension band constructs is
the most widely used treatment [5,17]. However, the incidence of
implant-related complications is high [6], including early fracture
dislocation or soft-tissue irritation due to failure or migration of the
implant, and therefore, revision surgery is often required [8,18].
Moreover, evidently, the “figure 8” tension-band configuration was
not the most rigid construct for fixing transverse patellar fractures
[19]. Thus, several authors have advocated new methods for
treating transverse patellar fractures in recent years.
Studies in biomechanics have demonstrated that use of lag
screws alone provide superior stability at a high load compared
with the standard tension band wiring [13]. When used in combi-
nation, with tension band wiring through cannulated screws, this
modified construct provided the most efficient stabilization than
the other methods used separately [19]. Clinical studies have
shown that the method of using tension band wiring through
cannulated screws can reduce the rate of implant removal and
achieve acceptable clinical results when compared with the tradi-
tional K-wire tension band technique [20,21]. This technique is
currently preferred by many clinicians in simple transverse frac-
tures, but it has the risk of cutting the “Fig. 8” wire if the screw tip
penetrates the cortex of the patellar pole [2].
Another trend is the usage of locking plates, which are designed
according to the concept of internal fixator with screws locked in
the plate [10,11,22]. With the development of more sophisticated
 D. Meng et al. / Journal of Orthopaedic Science 24 (2019) 142e146 145

Fig. 3. Follow-up data of a 48-year-old female. The fracture was treated with X-plate technique. a Lateral image of a transverse patellar fracture with extensor mechanism abruption.
b Postoperative anteroposterior image at 1-year follow-up. c Postoperative lateral image at 1-year follow-up. d Postoperative axial image at 1-year follow-up.

implants, Taylor et al. [10] successfully used a 2.4/2.7-mm variable
angle-locking plate and four unicortical 2.4/2.7-mm locking screws
to treat transverse patellar fractures and achieved satisfactory
clinical outcomes. The variable angle-locking plate could better fit
the irregular anatomical nature of the patella, and no implant
prominence requiring removal was observed during a short follow-
up period of 1 year. However, outcomes of this study were limited
by the small sample size (n ¼ 5) and lack of controls.
Based on this available information, we conducted this retro-
spective comparison study to verify effects and compare compli-
cations of three methods used to treat transverse patellar fractures:
titanium cable tension-band, four-hole-locking X-plate, cannulated
double-threaded compression screws with titanium cable cerclage.
Results suggested that all three methods could achieve the goal of
rigid fixation and allow early functional rehabilitation. However,
the X-shaped locking plate technique had the lowest risk of
symptomatic implant complications and could thus be a safe and
effective alternative for internal fixation of transverse patellar

Table 1
Baseline and operative characteristics of patients. Table 2
Clinical outcomes at 2-year follow-up.
Group Age (year) Time to Articular Number of Number of
surgery (day) Step-off male/total 34-C1 Group ROM at 2-year Lysholm score Union (month) Follow-up (month)
(mm) fractures/ follow-up at 2-year
total follow-up

A 55.93 ± 11.96 2.143 ± 1.167 0.38 ± 0.66 20/38 26/38 A 129.6 ± 13.22 92.14 ± 3.13 3.13 ± 0.58 32.07 ± 7.259
B 56.06 ± 15.71 2.5 ± 1.095 0.34 ± 0.54 19/36 20/36 B 131.9 ± 6.80 91.44 ± 3.25 3.12 ± 0.34 30.94 ± 7.47
C 57.40 ± 16.30 2.333 ± 1.291 0.43 ± 0.56 16/34 22/34 C 133.3 ± 6.73 93.13 ± 2.66 3.07 ± 0.26 29.80 ± 6.383

No significant difference was found among these groups (p > 0.05). No significant difference was found among these groups (p > 0.05).
146 D. Meng et al. / Journal of Orthopaedic Science 24 (2019) 142e146
Fig. 4. Range of motion and Lysholm score comparison at 2-year follow-up. No sig-
nificant difference was found among groups. Ns ¼ no significant difference.
fractures. Our study responses well with the results reported pre-
viously [10].
The study outcomes indicate that all three methods could gain
favorable functional outcomes at the 2-year follow-up. Neverthe-
less, there are several technical issues that should be discussed.
First, we preferably used hollow double-threaded compression
screws instead of traditional lag screws in Group B in order to
reduce the incidence of implant displacement. Second, combina-
tion of cable cerclage method rather than tension-band wire
through cannulated screws could provide sufficient stability for
functional exercise and prevent the screw tip from cutting the ca-
ble. Third, the titanium-braided cable and its tension-locking de-
vice used in Groups A and B could provide greater resistance than
traditional stainless steel wires and the simplistic wire twisting.
Fourth, in Group C, the parapatellar articular palpation or axial view
fluoroscopy should be effective methods for intra-operative screws
length measuring. Preferably, the X-plate was bent to serve as a
claw with long screws to fix upper and inferior fragments, which is
supposed to be more rigid than bridging plate method. Finally, in all
groups, before the suture of superficial fascia and skin, we regularly
transfer the surrounding soft tissue (e.g. fascia, periosteum) as flap
to cover the prominence of the tips of implants. It would help to
reduce the risk of complications of implants irritation.
Our study also has certain limitations. This was not a prospective
randomized controlled trial. Implants used in our series are more
expensive than the common tension band wire. We lacked the
biomechanical evidence to define which one could provide the
most rigid stiffness among these three methods. Additional pro-
spective and biomechanics studies should be conducted to confirm
these outcomes in future.
5. Conclusion
All three methods could achieve the goal of rigid fixation and
allowed early functional rehabilitation. However, the X-plate
technique had the lowest risk of symptomatic implant complica-
tions and could be a safe and effective alternative for internal fix-
ation of transverse patellar fractures.
Funding
This work was supported by the Project of Special Research on
Battle Injury and Trauma of Changzheng Hospital [grant number
201709]. The sponsor had no role in the design or conduct of this
research.
Conflicts of interest
None declared.
Acknowledgements
We would like to thank the native English speaking scientists of
Elixigen Company (Huntington Beach, California) for editing our
manuscript.
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