ORIGINAL ARTICLE
Biomechanical Assessment of Locked Plating for the
Fixation of Patella Fractures
Simone Wurm, MD,* Peter Augat, PhD,†‡ and Volker Bühren, MD*
Objective: To analyze the mechanical stability of locked plating in
comparison with tension-band wiring for the fixation of fractures of
the patella.
Methods: Biomechanical tests were performed on artificial foam
patella specimens comparing an angular stable plate and mono-
cortical screws with tension-band wiring. Tests were performed
under combined tension and bending until failure simulating
physiological loading of the tibia during walking.
Results: Tension-band wiring failed at 66% of the failure load of
plating (1052 N, P = 0.002) and had 5 times larger fracture gap
displacements (P = 0.002).
Conclusions: Based on the biomechanical advantages, locked
plating of the patella may constitute a reasonable alternative in the
treatment of patella fractures.
Key Words: patella plate, locking, patella fracture, osteosynthesis,
comminuted fracture
(J Orthop Trauma 2015;29:e305–e308)
INTRODUCTION
The patella is the largest sesamoid bone in the human
body. It increases the effectiveness of the quadriceps muscle
and enables flexion of the knee, which requires substantial
forces in load-bearing situations such as squatting or
kneeling.1–3 Patella fractures are not unusual, accounting for
0.5%–1.5% of all skeletal injuries.4 Because of the functional
importance of the patella, a patella fracture requires an accu-
rate reduction and rigid fixation. Only nondisplaced fractures
without retinacular disruption should be treated nonopera-
tively. Fracture gaps of more than 2 mm and/or comminuted
fractures are considered indications for operative treatment.3,5
Tension-band wiring has long been the standard treatment
for displaced patella fractures. This technique includes the use of
2 parallel Kirschner wires over the anterior aspect of the patella
acting as a tension band. The principle of tension-band wiring is
Accepted for publication February 2, 2015.
From the *Department of Traumatology, BG Trauma Center Murnau, Murnau,
Germany; †Institute of Biomechanics, BG Trauma Center Murnau, Murnau,
Germany; and ‡Institute of Biomechanics, Paracelsus Medical University
Salzburg, Austria.
Presented in part at the ESTES Annual Meeting, April 29, 2011, Milan, Italy.
The patella plates used in the biomechanical test setup were provided by
Arthrex. The authors report no conflict of interest.
Reprints: Simone Wurm, MD, BG-Unfallklinik Murnau, Prof. Küntscher-Str
8, 82418 Murnau, Germany (e-mail: Simone.Wurm@bgu-murnau.de).
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J Orthop Trauma  Volume 29, Number 9, September 2015
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the transformation of tension into compressive forces; however,
under cyclic loading particularly in knee extension, fragmentary
compression is neutralized and the fracture might gap.6 In addi-
tion, tension-band wiring often leads to loosening of the wires,
dislocation of the fracture, and failure of the osteosynthesis re-
sulting in knee stiffness and posttraumatic osteoarthritis.4,7,8
Transverse patella fractures have recently been treated with in-
terfragmentary screw fixation alone or in combination with a wire
looped over the screws. Although these techniques create a stable
osteosynthesis, the anatomic reduction of the fracture is often
problematic, especially with comminuted fractures. Therefore,
complications like knee stiffness and posttraumatic osteoarthritis
remain still a problem after patella fractures.3,7
An alternative approach is the application of bone
plating for patella fractures. Plating of the patella became
feasible with the development of the locked plating technique.
In 2006, Matejcic et al9 evaluated a basket plate in the treat-
ment of comminuted fractures of the distal pole of the patella
and showed good results. Recently, biomechanical studies
have demonstrated the feasibility of using locked plating for
the fixation of certain types of patella fractures with or with-
out the additional use of cable wires.10,11 We hypothesized
that the biomechanical stability of patella fracture fixation will
be improved by using an anatomic locking plate as compared
with tension-band wiring. We specifically addressed the load
to failure and the dislocation after loading.
MATERIALS AND METHODS
The study was conducted with the arrow plate design of
the patella plating system by Arthrex (Arthrex, Karlsfeld,
Germany, Fig. 1). This device has recently been approved for
the treatment of patella fracture in Europe and is under con-
sideration by the FDA. The plate is anatomically shaped and
provides unidirectional angular stability and suture holes for
the fixation of soft tissue to the plate. Twelve dome-shaped
test specimens were custom-made from Sawbone foam blocks
with a density of 30 pound per cubic foot (pcf) (Sawbones,
Malmoe, Sweden). The test specimens were cylindrically
shaped with a diameter of 76 mm and a height of 38 mm.
The top of the cylinders had a curvature according to that of
a human patella. To fix the simulated patella, the cylinders
were trimmed off with a turning lathe. The upper area imi-
tated the human patella. With a diameter of 50 mm, it had the
dimensions of an average human patella.12 The lower area
served as fastening for mechanical fixture of the testing setup.
After preparing the Sawbone dome, a transverse
osteotomy was performed in the middle of the cylinders using
a bandsaw with a width of 1 mm. Then, the 12 cylinders were
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 Wurm et al
FIGURE 1. Anatomically shaped locking plate with mono-
cortical screws for the fixation of patella fractures.
divided into 2 groups. One group was equipped with the patella
plate. The plate was fixed with 3 monocortical locking screws
(3.5 mm diameter, 16 mm length) per bone fragment. The other
group was equipped with a tension-band wiring using K-wires of
2 mm diameter (Aesculap, Germany). Two Kirschner wires were
inserted just under the cupola of the upper area of the Sawbone
dome with a space of 2.8 mm. A steel cable with a diameter of 2
mm was tightened around the K-wires with 222 N (50 lbs).
The biomechanical test setup combined tension and
bending to simulate the physiological load of the patella
(Fig. 2). Stretching the leg, the patella is exposed to tension
caused by the quadriceps and patellar tendon. During flexion,
an additional bending moment is generated by the fulcrum
caused by the femoral condyles. This bending moment was
simulated by a plastic pulley moving on the foam cylinder
with mounting. Tension was simulated by the use of 2 rods
adjusted to an angle of 45 degrees. The angle of 45 degrees
was chosen because Burvant et al13 demonstrated the
FIGURE 2. Biomechanical testing
device: a view from anterior with
patella plate (A) and from lateral (B).
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J Orthop Trauma  Volume 29, Number 9, September 2015
maximum fracture separation after patella osteosynthesis
was observed from 60 degrees to 30 degrees of flexion.
The lower area of the foam block was inserted in the
fixture with steel pins so that the upper area representing the
patella did not have to be clamped. The patella fixture was
adjusted to the load cell and the movable adapter to the base
plate. The adapters and the patella attachment were connected
with flat rods. A rounded plastic pulley was used to imitate the
femoral condyle pushing on the back of the patella at the level
of the osteotomy. This allowed the fracture gap to open without
interference from the fixture. The tests were performed on an
electromechanical testing machine (Z010; Zwick, Einsingen,
Germany). Movements between the fracture fragments were
recorded with an optoelectronic movement tracking system
(Pontos, Braunschweig, Germany), providing an accuracy of
0.01 mm. Opening of the fracture gap was measured at the
center of the patella at the anterior aspect.
Tension was applied until failure of the osteosynthesis.
Load was applied in displacement-control at a velocity of 1 mm/
min. Failure of the osteosynthesis was defined as a sudden
decrease in load. The biomechanical performance was assessed
by the relative fracture gap movement and the force at failure.
Statistical comparisons between both techniques were performed
with SPSS Statistics 18.0 using a Wilcoxon signed-rank test.
RESULTS
The failure mechanism in the biomechanical test was
always failure of the bone substitute, which occurred on
average at 627 N (SD: 231 N) using the tension-band wiring
and at 1052 N (SD: 32 N) using the patella plate (P = 0.002)
(Figs. 3, 4).
Because the patella Sawbones with tension-band wiring
started to show failure at 370 N, we compared fracture gap
displacements between the 2 groups at a load of 350 N at
which all specimens were still intact. With tension-band
wiring, the fracture gap at 350 N load level was more than
5 times larger than with plate fixation (Table 1, P = 0.002).
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 J Orthop Trauma  Volume 29, Number 9, September 2015 Plate Fixation of Patella Fractures

FIGURE 3. Loads to failure (median,

interquartile range, minimum, and
maximum) of patella plating com-
pared with the tension-band wiring.
The tension-band wiring failed at
significantly lower loads (P = 0.001).

The measured displacement at the load level before failure
of the fracture fixation construct was almost 3 times larger
for tension-band wiring compared with plate fixation
(Table 1, P = 0.002).
DISCUSSION
The findings of our study suggest that osteosynthesis of
patella fractures with this particular locked plate design
provides sufficient mechanical stability to prevent fracture
separation with postoperative functional loading. The
biomechanical assessment of locked plates under challenging
conditions of knee flexion demonstrated less interfragmentary
gap movement and increased failure strength compared with
tension-band wiring, which is the current gold standard for
the fixation of patella fractures. Compared with tension-band
wiring, locked plating resulted in increased fixation strength
and reduced distraction of the fracture gap. The tension-band
wiring failed at significantly lower loads than the patella plate
with some failures occurring at load levels below 400 N. These
values are in accordance with the results by Carpenter et al,7
who biomechanically tested tension-band wiring with screw

FIGURE 4. Displacement of the fracture

gap at the maximal load after plate osteo-
synthesis (A) and tension-band wiring (B).

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 Wurm et al
TABLE 1. Displacement of Fracture Gap at 350 N Load Level
and Immediately Before Failure
Displacement, Arrow Plate Tension-Band Wiring
mm (Mean 6 SD) (Mean 6 SD) P
Displacement at 0.5 6 0.1 2.4 6 1.1 0.01
350 N
Displacement 1.8 6 0.3 5.1 6 1.8 0.01
before failure
fixation in human patellae and found failure at a load level of
395 N, at a knee flexion of 45 degrees. Although screw fixation
alone failed at 554 N, screw fixation in combination with a wire
placed through the cannulated screws failed at significantly
higher loads of 732 N. Together with our findings, this would
suggest that failure loads with plate fixation are nearly twice
those observed with tension-band wiring.
In our study, the failure mechanism in both groups was
failure of the bone substitute. The patella Sawbones fractured at
the screw–sawbone interface, or at the K-wire–sawbone inter-
face. That failure mechanism could be explained by the mate-
rial properties of the bone substitute. We used a Sawbones
model with a density of 30 pcf because this most closely
represents the characteristics of the cancellous nature of the
human patella. Cancellous bone has a compressive strength
between 3 and 30 MPa and a tensile strength of 2–20 MPa.
The compressive strength of a 30 pcf Sawbone is 18 MPa, and
its tensile strength is 12 MPa as defined by the manufacturer.
Contrary to our expectations, the foam was more brittle than
the human bone, which led to specimen fracture instead of
cutting through the specimen with cables or screws.
Probably, more important than the increase in fixation
strength was the reduction of fracture gapping by the locked
plate. Retention of fracture reduction under load is an important
requirement for successful fracture repair. With the use of
patella plating, fracture gap widening under loading was always
,2 mm, even at maximum load levels before construct failure.
In contrast, using tension-band wiring, fracture gapping ex-
ceeded 2 mm at load levels of 350 N and was almost 5 times
larger compared with the locked plate construct. Load levels of
350 N are likely to occur with partial weight-bearing, whereas
full load-bearing during level walking generates loads in excess
of 850 N.14 Fracture gapping .2 mm during loading is likely to
negatively affect fracture healing and may to a certain extent
explain the clinical observations of wire loosening, fracture dis-
location, and healing delays after tension-band wiring of patella
fractures.4,7,8 The reduced amount of deformation under loading
may result in faster consolidation of the fracture and earlier
return to function.15 Our findings therefore suggest that gapping
of the fracture under load-bearing is more likely to occur with
tension-band wiring as compared with locked plating.
This study not only has several strengths, but also
limitations. One important strength of our study was the
custom-designed testing device, which combined tension and
bending in a physiological way. Furthermore, this testing
device and the use of Sawbones instead of human cadavers led
to a high reproducibility. The fracture gap could be measured
with a high degree of accuracy by using a 3-dimensional
image–based movement analysis. Finally, to our knowledge,
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J Orthop Trauma  Volume 29, Number 9, September 2015
this was the first study that assessed the biomechanical prop-
erties of a locking patella plate in comparison with tension-
band wiring for the fixation of patella fractures.
One of our limitations was the use of Sawbones, which
were too brittle. If we had used less brittle bone substitutes, we
could probably have observed the cutting through of the screws
or steel cables. That would have been a more physiologically
failure mechanism. In addition, using a bone substitute with
a dense cortical layer might have been improved the results of
tension-band wiring. However, the observed failure forces in our
foam model were in agreement with previous biomechanical
studies in human cadaveric patellae.7 Another limitation was
that our tests were performed at 1 fixed angle of knee flexion.
We chose the flexion angle at which the maximum fracture
separation was observed in previous studies.13 Furthermore,
we inserted the K-wires just under the cupola of the upper area
of the Sawbone dome. We chose this position because the inser-
tion depth corresponded best to an in vivo situation. Because of
the fact that we tested only 1-layered bone substitutes without
a cortical layer, the K-wires presumably broke out earlier.
In conclusion, locked plating of patella fractures with an
anatomically contoured plate provides a biomechanical stable
fixation. Compared with tension-band wiring, locked plating
resulted in higher mechanical strength and reduced fragment
dislocation under loading. Based on our biomechanical findings,
locked plating may constitute a reasonable alternative to tension-
band wiring in the treatment of patella fractures in the future.
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