Accepted Manuscript

Title: Biomechanical evaluation of the tension band wiring

principle. A comparison between two different techniques for
transverse patella fracture fixation

Authors: Ivan Zderic, Karl Stoffel, Christoph Sommer,

Dankward Höntzsch, Boyko Gueorguiev

PII: S0020-1383(17)30362-5
DOI: http://dx.doi.org/doi:10.1016/j.injury.2017.05.037
Reference: JINJ 7263

To appear in: Injury, Int. J. Care Injured

Accepted date: 27-5-2017

Please cite this article as: Zderic Ivan, Stoffel Karl, Sommer Christoph, Höntzsch
Dankward, Gueorguiev Boyko.Biomechanical evaluation of the tension band wiring
principle.A comparison between two different techniques for transverse patella fracture
fixation.Injury http://dx.doi.org/10.1016/j.injury.2017.05.037

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Biomechanical evaluation of the tension band wiring principle. A comparison between two different

techniques for transverse patella fracture fixation.

Ivan Zderica, MSc, Karl Stoffelb, c, PhD, Christoph Sommerd, MD, Dankward Höntzsche, MD, Boyko

Gueorguieva, PhD

a
AO Research Institute Davos, Davos, Switzerland
b
Cantonal Hospital Baselland, Bruderholz, Switzerland
c
University of Basel, Basel, Switzerland
d
Cantonal Hospital Graubuenden, Chur, Switzerland
e
BG Klinik Tübingen, Tübingen, Germany

Corresponding author:

Ivan Zderic

AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland

E-Mail: ivan.zderic@aofoundation.org 

Abstract

Purpose: The aim of this study was to investigate the validity of the dynamic compression principle of tension

band wiring in two techniques for patella fracture treatment.

Methods: Twelve human cadaveric knees with simulated transverse patella fractures were assigned to two

groups for treatment with tension band wiring using Kirschner (K-) wires or cannulated screws. Biomechanical

testing was performed over three knee movement cycles between 90° flexion and 0° extension. Pressure

distribution in the fracture gap and fracture site displacement was evaluated at the 3rd cycle in 15° steps,  namely

90º-75º-60º-45º-30º-15º-0º extension and 0°-15º-30º-45º-60º-75º-90º flexion phase.

Results: Mean anterior and posterior interfragmentary pressure in group with K-wires ranged within 0.16 – 0.40

MPa/0.12 – 0.35 MPa, and 0.37 – 0.59 MPa/0.10 – 0.30 MPa with cannulated screws. These changes remained

non-significant in both groups and loading phases (P≥0.171). Mean anterior and posterior fracture site

displacement in group with K-wires ranged within -0.01 – 0.53 mm/0.11 – 0.74 mm, and 0.11 – 0.55 mm/-0.10 –
1 
 
0.50 mm with cannulated screws. Anterior displacement remained without significant changes in both groups

and loading phases (P≥0.112). However, posterior displacement underwent a significant increase in this regard

for K-wires (P≤0.047), but not for cannulated screws (P≥0.202), in the course of knee extension. Significantly

smaller displacement at the posterior fracture site was detected in group using cannulated screws compared to K-

wires at 60° and 75° extension phase (P≤0.017), as well as at 45°, 60° and 75° flexion phase (P≤0.018). The

critical value of 2 mm displacement at the posterior fracture site was not reached for any specimen and fixation

technique. Knee extension was accompanied by synchronous increase in quadriceps pulling force.

Conclusions:

Tension band wiring fulfills from a biomechanical point of view the requirements for sufficient fixation stability

in transverse patella fracture fixation. It should, however, rather be considered as a static fixation principle than a

dynamic one. Tension band wiring with cannulated screws was found advantageous over Kirschner wires with

regard to interfragmentary movements at the posterior fracture site.

Key words: Transverse patella fracture, Tension band wiring, Kirschner wire, Cannulated screw, Biomechanics,

Interfragmentary pressure

2 
 
Introduction

The incidence of patella fractures, usually caused by direct trauma of the anterior knee surface, is approximately

0.5-1.5% of all fractures [1]. Among them, most common are the transverse patella fractures [2]. Operative

treatment is indicated for displaced fractures with a disrupted extensor mechanism [1]. High contact forces

acting between the patella and the femur require restoration and preservation of a smooth articular surface in

order to prevent posttraumatic osteoarthritis [3]. This can only be achieved if the two fragments are anatomically

reduced and subsequently firmly fixed.

Tension band wiring is one of the most common treatment methods for transverse patella fracture fixation [3]. Its

main principle in all modifications is to counteract muscle traction, maintain the fracture reduced and possibly

transform the tensile forces between the quadriceps muscle and the anterior tibia tuberosity into compression at

the articular patella cortex during knee flexion [4]. The latter should stabilize the fracture and enhance bone

healing in an environment of large distraction forces by closing the fracture gap and maintaining the

interfragmentary contact [5]. Similar techniques are applied for olecranon and malleolus fracture fixation [6].

Although tension band wiring is currently one of the most frequently used fixation techniques for patella fracture

fixation, poor clinical outcomes have been reported in up to 55% of the cases [1]. Moreover, lots of previous

studies are not in favor of this principle by stating that other implants, such as compression screws (single or in

combination with tension band wiring), perform better in terms of fixation stability, complication rates or

functional outcomes [2, 3, 7-25]. Currently, there is no existing evidence yet, based on pressure assessment in

the patella fracture gap and/or interfragmentary movements, that this principle is valid in the surgical practice.

Specifically, there are no existing studies on pressure distribution in the patellar fracture gap, displacement and

rotational movement at the fracture site, related to knee flexion and extension during the early mobilization

phase, proving that tension band wiring by using Kirschner (K-) wires or cannulated screws is a effective

surgical treatment.

Therefore, the aim of the present study was to investigate whether the principle of tension band wiring applies

for transverse patella fracture fixation during the extension and flexion phase of knee movement. Referring to

previous findings on tension band wiring of the olecranon [25], we examined the following hypotheses for the

tension band wiring of the knee in the acute postoperative phase of knee movement:

3 
 
 1) Tension band wiring using K-wires and cannulated screws does not induce a significant change upon

knee motion in terms of interfragmentary pressure and movement;

2) Interfragmentary displacements do not exceed the 2 mm-threshold upon knee motion with these two

fixation techniques, satisfying the requirements for primary stability;

3) There are no significant differences between the two techniques in terms of interfragmentary pressure

and movement.

4 
 
Materials and Methods

Specimens and preparation

Twelve fresh-frozen (-20°C) human cadaveric knees (5 left and 7 right) with distal femur and proximal tibia

parts, including soft tissue, were used in this study. The sample size was determined based on a priori power

analysis for seven-step repeated measures test using GLIMMPSE web-based power and sample size program

(http://glimmpse.samplesizeshop.org). Presuming 0.1 MPa initial (90° knee flexion angle) posterior pressure

continuously increasing by 0.1 MPa until 0° full knee extension for tension band wiring using K-wires, and 0.3

MPa posterior pressure continuously increasing by 0.3 MPa using cannulated screws, an initial inter-

measurement correlation of 0.6 with 0.1 decay rate, a sample size of n = 5 would be required to detect a

significant response of the posterior pressure upon knee movement under a power of 0.839 and level of

significance 0.05. To account for unexpected irregularities during testing, a sample size of n = 6 was chosen for

each group. All donors gave their informed consent within the donation of anatomical gift statement during their

lifetime. The specimens were randomly assigned to two study groups with six specimens each for treatment with

tension band wiring techniques using either K-wires or cannulated screws. Radiographic assessment assured

intact knee joints without any pathology in all specimens. A physiological range of motion between 130° flexion

and full knee extension was proven by physical examination. The specimens were thawed at room temperature

prior to preparation and biomechanical testing.

Each knee was prepared following a procedure as previously described by Schnabel et al. The femur was

transected 12 cm proximally and the tibia 15 cm distally to the knee joint by using a handsaw. The fibula was

removed and soft tissue was stripped off preserving the joint capsule, ligaments and the extensor mechanism

intact. The proximal 6 cm of the femur and the distal 6 cm of the tibia were embedded in

polymethylmethacrylate (PMMA, Suter Kunststoffe AG, Fraubrunnen, Switzerland). A steel rod was secured

into the tibia canal during embedding. With the knee in full extended position, a transverse patella fracture was

simulated via an osteotomy between the superior and inferior poles of the patella using an oscillating saw. The

extensor retinaculum was divided in line with the transverse cut.

An electronic pressure sensor with thickness of 0.1 mm, spatial resolution of 0.695 mm2 and a total matrix area

of 1023 mm2 (Tekscan 5033, 46 x 32 sensels, 38.3 mm x 26.7 mm, Tekscan Inc., South Boston, USA) was

inserted into the osteotomy gap from anterior to posterior direction. Two 0.5 mm thick rubber foils were attached

on both sides of the sensor to prevent uneven stress distribution over the sensing area. Prior to insertion, each
5 
 
sensor was calibrated on a calibration device (trublu Eichgerät, novel GmbH, Munich, Germany) applying a two-

point power law calibration at 0.3 MPa and 0.6 MPa pressure with Mid-2 sensitivity (I-Scan, Tekscan Inc., South

Boston, USA). The calibration succeeded prior to foil attachment and resulted in an approximate saturation

pressure of 112 MPa. One sensor was used per specimen.

Surgical technique

Prior to instrumentation the created osteotomy gap was anatomically reduced and stabilized using two pointed

forceps.

For the tension band wiring technique using K-wires two 1.8 mm K-wires were inserted through the osteotomy

from the proximal to the distal pole. A 1.0 mm cerclage was then placed in a figure-of-eight pattern through the

ligamentous structures and around the K-wires close to the patella surface. Two twisted knots, dividing the

cerclage wire in two sections of equal length, were tightened with surgical pliers. The distal ends of both K-wires

were bent over towards the patella to prevent slipping of the cerclage. A specimen instrumented with tension

band wiring using K-wires is shown in Figure 1a.

The tension band wiring technique with cannulated screws was performed by inserting two 1.2 mm K-wires

through the osteotomy from the proximal to the distal pole. A 2.7 mm cannulated drill bit was then inserted over

the K-wires to drill out the pilot holes. A short-threaded self-drilling 4.0 mm titanium alloy (TAN) cannulated

screw was inserted in antegrade direction over each K-wire using a cannulated screw driver. Optimal screw

length was measured individually for each specimen, taking into account that the screw tip should remain

completely intraosseous. A 1.0 mm cerclage wire was inserted into the cannula of the screws and fixed in a

similar way as with tension band wiring using K-wires. A specimen instrumented with tension band wiring using

cannulated screws is shown in Figure 1b.

In both groups the K-wires were inserted after positioning of the electronic sensor in the fracture gap, ensuring

hereby its stable trans-fixation via perforation at the entry points. Proper instrumentation was checked via

radiographic examination of all specimens as shown in Figure 1c-d. All instrumentation procedures were

performed by a single surgeon according to the surgical techniques as prescribed by the manufacturer. All

implants were provided by the same manufacturer (DePuy Synthes, Zuchwil, Switzerland). Finally, three retro-

reflective marker sets were attached to the proximal patella fragment, distal patella fragment and proximal tibia

for optical motion tracking during biomechanical testing.

6 
 
Biomechanical Testing

Biomechanical testing was performed on a servohydraulic test system (Bionix 858.20; MTS Systems, Eden

Prairie, MN, USA) in a test setup similar to Schnabel et al., as shown in Figure 2. Each femur was fixed

proximally to the base of the testing frame in horizontal position. Pulling force was introduced to the quadriceps

tendon via an inextensible steel cable, attached via a pulley to a 25 kN load cell being interconnected to the

machine actuator. The quadriceps tendon was sutured between two custom steel plates, connected to the steel

cable with a Ti-Cron 5 suture (Covidien plc, Dublin, Ireland). Weight of the lower leg was simulated attaching a

disc of 3.1 kg load to the steel rod, fixed in the tibia canal during specimen's embedding, at a distance of 25 cm

distally to the knee joint, establishing same moment arm around the knee for each specimen equivalent to that of

an average person weighing 70 kg [15].

The loading protocol was adapted from previously published work [25, 26]. One test with three ramped,

continuous load cycles, ranging from 90º knee flexion to full knee extension was performed in displacement

control of the machine actuator at 1/6 Hz for each specimen and stabilization technique to simulate active knee

extension and passive knee flexion of a sitting patient. After each cycle the actuator was paused for 5 seconds,

keeping the knee at 90° flexion. The range for actuator displacement required to reach these extreme positions

was assessed by extending and flexing the knee in a manually controlled actuator displacement one-cycle test

prior to main test start.

Data acquisition and analysis

Machine data in terms of force (equivalent to pulling tendon force, N) and actuator displacement (proportional to

knee angle, °), as well as pressure sensor output signals (MPa) were continuously recorded during each

biomechanical test at 64 Hz and 30 Hz, respectively.

For pressure distribution analysis, the area of each pressure sensor was divided in one posterior and one anterior

region, defined as the areas of the osteotomy plane closer or more distant to the knee joint surface, respectively

(Figure 3). Posterior and anterior pressure was calculated by dividing the force acting upon the respective region

to its area by using software package I-Scan (Tekscan Inc., South Boston, MA, USA). While performing the first

two loading cycles for preconditioning purposes, the third cycle was considered for evaluation and investigated

during both extension and flexion phases of knee movement in 15° steps as follows: 90º - 75º - 60º - 45º - 30º -

7 
 
15º - 0º extension phase and 0° - 15º - 30º - 45º - 60º - 75º - 90º flexion phase. Begin and end of a loading cycle

were characterized by an acute pressure change in the continuous time-pressure graph. Considering the temporal

distance between these two points as the duration of one full loading cycle, and the linear relationship between

time and knee angle based on the ramped (not sinusoidal) nature of each cycle, the time scale was converted into

a continuous knee angle scale using trivial linear conversion formula. Consequently, the distances between the

13 knee angle positions were characterized by 12 sections of equal length. Finally, maximum anterior and

posterior pressure was determined for each specimen and loading phase together with the respective knee angle

at which maximum pressure was reached.

A three-dimensional optical Motion Tracking system with five Qualisys ProReflex MCU cameras (Qualisys AB,

Gothenburg, Sweden) was used to capture movements of the marker sets, attached to the patella fragments and

the proximal tibia at 100 Hz throughout the test. The system was found to operate at a resolution of 10 µm, an

accuracy of 1.39%-2.37%, and a precision of 1.9-3.9 µm [27].

Fracture site displacements (mm) at the most anterior (ventral) and posterior (dorsal) aspects of the patella along

the tibia axis, as well as interfragmentary rotation around the mediolateral axis were calculated from the motion

tracking data in the same fashion (knee angles, loading phases and cycles) as for pressure distribution analysis.

Software packages Qualisys Track Manager (v.1.10.282, Qualisys AB) and Matlab (v.2015a, The MathWorks,

Natick, MA, USA) were used for this purpose. A value of 2 mm posterior displacement was defined as failure

criterion in accordance with previous studies [3, 8, 25].

Statistical analysis was carried out using SPSS software package (v.21, IBM SPSS, Armonk, NY, USA). Data

was screened for normality of distribution with Shapiro-Wilk test. General Linear Model Repeated Measures test

was applied to assess influence of knee motion on posterior and anterior pressure, as well as on the posterior and

anterior fracture site displacements and interfragmentary rotation. It was employed for each loading mode

separately with each loading mode comprising seven repeated measurements (90º - 75º - 60º - 45º - 30º - 15º - 0º

extension phase and 0° - 15º - 30º - 45º - 60º - 75º - 90º flexion phase). Independent samples t-test was conducted

to detect significant differences between the fixation techniques. Differences between anterior and posterior

pressure, as well as between anterior and posterior fracture site displacements were explored with paired samples

t-tests. Level of significance was set to 0.05 for all statistical tests.

8 
 
Results

All biomechanical tests were absolved without catastrophic failure of the specimens and with a normal

distribution of the data for all parameters of interest. The critical value of 2 mm displacement at the posterior

fracture site was not reached within the performed three test cycles for any specimen and fixation technique.

Interfragmentary pressure

Mean anterior and posterior pressure in group using K-wires was within the range 0.16 – 0.40 MPa/0.12 – 0.35

MPa, and 0.37 – 0.59 MPa/0.10 – 0.30 MPa in group using cannulated screws, respectively. The course of

pressure in both sites is shown in Figure 4 for each fixation technique and loading phase of the knee separately.

Maximum pressures and corresponding knee angles, at which these maxima were reached, are shown in Table 1.

Both anterior and posterior pressure, measured at the predefined knee angles, did not change significantly in the

course of each loading phase (P ≥ 0.171) for each fixation technique. Furthermore, no significant differences in

anterior and posterior pressure were detected between the two fixation techniques for each knee angle and

loading phase (P ≥ 0.102), with one exception showing a trend for higher anterior pressure with cannulated

screws than K-wires at 45° extension phase (P = 0.053). Finally, the comparison between anterior and posterior

pressure of each specimen revealed no significant differences within each group, knee angle and loading phase

(P ≥ 0.102).

Fracture site displacements

Mean anterior and posterior fracture site displacement in group using K-wires was within the range -0.01 – 0.53

mm/0.11 – 0.74 mm, and 0.11 – 0.55 mm/-0.10 – 0.50 mm in group using cannulated screws, respectively. The

course of fracture site displacement in both sites is shown in Figure 5 for each fixation technique and loading

phase of the knee separately. Anterior fracture site displacement in each group did not change significantly in the

course of each loading phase and cycle (P ≥ 0.112). However, posterior fracture site displacement underwent a

significant change in this regard in group using K-wires (P ≤ 0.047) but not cannulated screws (P ≥ 0.202).

Displacement at the anterior fracture site revealed no significant differences between the two fixation techniques

for each knee angle and loading phase (P ≥ 0.09). On the contrary, significantly smaller displacement at the

posterior fracture site was detected in group using cannulated screws compared to K-wires at 60° and 75°

extension phase (P ≤ 0.017), as well as at 45°, 60° and 75° flexion phase (P ≤ 0.018). Finally, the comparison

between the displacements at the anterior and posterior fracture cites of each specimen resulted in significantly

9 
 
higher values of the former in group using K-wires at 15° extension phase, at full knee extension and at 15°

flexion phase (P ≤ 0.037).

Interfragmentary rotation

Mean interfragmentary rotation in group using K-wires was within the range -2.14 – 0.56°, and 0.16 – 1.03°

using cannulated screws. The course of this rotation in both groups is shown in Figure 6a-b) for each loading

phase of the knee separately. It changed significantly in the course of each loading phase in group using K-wires

(P ≤ 0.030), but not cannulated screws, the latter showing only a trend for change in flexion phase (P ≥ 0.062).

Finally, significantly higher rotation in terms of gap opening at the posterior fracture site was registered in group

using K-wires compared to cannulated screws at 0° and 15° extension phase and at 15° flexion phase (P ≤

0.047).

Quadriceps pulling force

Mean quadriceps pulling force in group using K-wires was within the range 3 – 389 N, and 6 – 384 N using

cannulated screws. The course of this force in both groups is shown in Figure 6c-d) for each loading phase of the

knee separately.

Discussion

The present study investigated biomechanically the validity of the tension band wiring principle for transverse

patella fracture fixation by means of pressure measurements in the fracture gap and interfragmentary movement

analysis. Fixation strength of two state-of-the-art tension band wiring techniques with the use of K-wires or

cannulated screws was quantified.

The first (null-) hypothesis that tension band wiring would not induce significant changes upon knee motion was

partially rejected, namely for posterior displacement and interfragmentary rotation in the group using K-wires.

On the other hand, neither anterior nor posterior pressure change significantly responded to the course of cyclic

knee motion.

The highest interfragmentary posterior pressure is theoretically expected when the highest distraction forces act

upon the anterior site of the patella. Taking into account diverse parameters influencing fragment stability, such
10 
 
as lever arm between patella and tibio-femoral joint, patellofemoral joint reaction forces as well as quadriceps

muscle forces, the highest distraction forces can be expected for movements in the range between approximately

30° knee flexion and full knee extension [28]. Considering both fixaton techniques, loading phases and evaluated

cycles, the maximum posterior pressure was realized at knee angles between 8° and 49°. This is approximately

the knee angle with highest lever arm between the patella and the tibio-femoral joint [29], as well as with highest

expected patellofemoral joint reaction forces [30]. From this point of view, our findings are in agreement with

the principle of tension band wiring. However, the changes in posterior pressure between the predefined knee

angles, observed within a loading phase for both fixation techniques failed to statistically substantiate this theory.

Based on motion tracking data the measured posterior fracture site displacement continuously increased from

90° flexion to full knee extension in both groups, thereby significantly changing in group using K-wires. Similar

progression was observed for quadriceps pulling forces reaching a peak at full knee extension in each group.

This synchronous increase in fragment distraction and pulling force seems to be contradictory to the principle of

tension band wiring, but is in agreement with the majority of previously published work [7, 10, 13, 25].

Although interfragmentary pressure did not change considerably upon knee movement, it was present for both

the anterior and posterior fracture regions in the groups, indicating maintained stability of the fixed fragments.

Moreover, both anterior and posterior regions revealed comparable pressure, which is an indication for

homogeneous pressure distribution over the whole fracture site. Preserved sufficient stability was also reflected

by the motion tracking data, showing that critical values defining loss of reduction, reported to be between 2 mm

[3, 8, 25] and 3 mm [31] displacement at the posterior fracture site, have not been reached in any of the groups,

accepting hereby the second hypothesis of this study. Although, or precisely because this stability remained to

the biggest part indifferent in the course of knee movement and between anterior and posterior sites, or even

decreased with acting pulling forces, as found and reported above, we anticipate considering tension band wiring

rather as a static than a dynamic fixation technique. However, it was shown to fulfill the requirements for

adequate fracture stabilization, which is in contrast to reported findings of some previous studies claiming the

opposite [8, 9, 11]. However, a direct comparison to other published work is infeasible due to different study

design and evaluated parameters.

Tension band wiring with use of cannulated screws showed significantly less posterior fracture site displacement

than with K-wires for some knee angles. The latter can be considered as the method of preferable choice if

additional stabilization is required, which is not surprising, considering the additional compressive strength that

11 
 
short-threaded screws provide. Their use has been favored in previous publications [15, 18]. Surprisingly, there

were no significant differences between the two techniques with regard to anterior fracture site displacement.

Furthermore, no clear advantage could be ascribed to any of the two fixation methods with respect to

interfragmentary pressure, which remained at the same level. This fact could be referred to distraction forces

acting on the patella, being potentially high enough to destroy the interface between the trabecular structures and

the threaded part of the screw, and herewith its anchorage. Furthermore, the screw heads could have migrated, at

least on a microscopic scale, into the bony structures. In both cases an abrupt loss of compression would have

occurred.

There was a distinct difference in interfragmentary rotations around the mediolateral axis between the two

fixation techniques. Whereas during knee extension the fragments in group using K-wires rotated predominantly

toward posterior site opening, the predominant rotation in group using cannulated screws was toward anterior

site opening. Posterior site opening in group using K-wires could have been facilitated by the cerclage, inducing

anterior bending of the K-wires. Its highest values were detected at full knee extension, the state with highest

pulling forces. In group using cannulated screws the rigid screws seemed to have withstood the bending

moments during tightening of the cerclages, thus resulting in cerclage-bone interface as the weakest link and

leading to predominant anterior wedge opening, which was maximal at 45° knee flexion phase.

The limitations of the present work were similar to those inherent to all cadaveric biomechanical studies with

first and most important a limited number of tested specimens and scattering of the measured data, rendering

statistical power possibly lower than initially predicted. Second, non-paired cadaveric knees were used, disabling

a pairwise and thus more meaningful comparison. Third, each pressure sensor had to be perforated with K-wires

or two cannulated screws, both differing in diameter and potentially unevenly affecting the measurements. The

humidity-sensitive sensors were harmed by exposing them to a cadaveric environment. In addition, rubber foils

that were attached to the sensors may have influenced the results. Some negative values indicated bone

compaction, but this may in fact be the result of foil deformation. Forth, the setup used in this study could have

been too aggressive, simulating exercising forces during active knee extension. Clinically, patients would usually

not undergo such extreme movements immediately after surgery. However, the aim was to investigate the

validity of the tension band principle, and therefore the use of higher forces was justified. Fifth, the performed

three loading cycles deem at a first glance not enough to investigate fixation stability of these two techniques.

However, we focused on the investigation of the dynamic principle, which is basically applicable to all

12 
 
subsequent loading cycles. In addition, in a similar biomechanical study performed by Patel et al. [26], the

authors reported no significant decrease in quality of fixation after loading three knees in a long-term cyclic test.

Relying on these findings the consideration of the third loading cycle for evaluation of fixation stability is

justified. Finally, knots of the cerclage wire were twisted according to surgeon's feeling for each specimen

individually, making the instrumentation less standardized and comparable.

The validity of the tension band was directly assessed in the fracture gap by using calibrated pressure sensors. In

addition, a motion tracking system, capable to detect interfragmentary movements at high resolution, was used.

These two approaches represented a methodological strength of this study.

Conclusions

Tension band wiring fulfills from a biomechanical point of view the requirements for sufficient fixation stability

in transverse patella fracture fixation. It should, however, rather be considered as a static fixation principle than a

dynamic one. Tension band wiring with cannulated screws was found advantageous over Kirschner wires with

regard to interfragmentary movements at the posterior fracture site.

Conflict of Interest

The authors are not compensated and there are no other institutional subsidies, corporate affiliations, or funding
sources supporting this work unless clearly documented and disclosed. 

Acknowledgments

DePuy Synthes is acknowledged for providing all implants. We thank very much Dr. Tomas Nicolino for the

instrumentation of all specimens.

Funding

This investigation was performed with the assistance of the AO Foundation via the AOTK System. 

13 
 
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Figure captions

Fig. 1 Photographs (a, b) and radiographic images (c, d) of two exemplified specimens instrumented with tension

band wiring using K-wires (a, c) and cannulated screws (b, d)

Fig. 2 Test setup with an instrumented specimen mounted for mechanical testing

Fig. 3 a) Evaluation principle showing the division of the sensing area in an anterior (green bordered) and a

posterior (red bordered) region; b) Retrograde view on the fracture gap with the sensor schematically divided in

two halves

Fig. 4 Course of anterior (green) and posterior (red) pressure in the fracture gap for tension band wiring using K-

wires (a-b) and cannulated screws (c-d), shown separately for extension (a, c) and flexion (b, d) phase in terms of

mean and standard deviation (dashed lines) values

Fig. 5 Course of anterior (green) and posterior (red) fracture site displacement for tension band wiring using K-

wires (a-b) and cannulated screws (c-d), shown separately for extension (a, c) and flexion (b, d) phase in terms of

mean and standard deviation (dashed lines) values

Fig. 6 Course of interfragmentary rotation (a, b) and quadriceps pulling force (c, d) for tension band wiring using

K-wires (green) and cannulated screws (red), shown separately for extension (a, c) and flexion (b, d) phase in

terms of mean and standard deviation (dashed lines) values

   

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Table 1: Maximum anterior and posterior pressure and angle at maximum pressure shown in terms of mean and
standard deviation values for each fixation technique and loading phase.

Extension phase Flexion phase

Anterior Posterior Anterior Posterior
0.40 0.38 0.40 0.40
K-wires
Maximum pressure (0.41) (0.27) (0.41) (0.20)
(MPa) Cann. 0.79 0.32 0.71 0.33
Screws (0.43) (0.38) (0.34) (0.37)
K-wires 15 (30) 45 (19) 8 (15) 35 (24)
Angle at maximum
pressure (°) Cann.
49 (41) 23 (29) 45 (44) 19 (14)
Screws
 

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