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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Treating patella fractures with a fixed-angle patella plate—A

prospective observational study
Michael Wilda,* , Kai Fischera , Florian Hilsenbecka , Mohssen Hakimib , Marcel Betschc
a
Klinikum Darmstadt, Department of Orthopedics, Trauma and Hand Surgery, Grafenstr. 9, D-64283 Darmstadt, Germany
b
Vivantes Klinikum Am Urban, Department of Trauma, Orthopedic and Hand Surgery, Dieffenbachstr. 1, D-10967 Berlin, Germany
c
University of Aachen, Department of Orthopedic Surgery, Pauwelsstraße 30, D-52074 Aachen, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Anterior tension wiring using Kirschner wires (K-wires) is still considered the standard
Received 17 April 2016 treatment for patella fractures, despite its high complication rate. The objective of this prospective
Received in revised form 26 May 2016 clinical study was to evaluate intra- and perioperative complications as well as the clinical outcome of
Accepted 9 June 2016
patients with patella fracture treated with a new developed bilateral, polyaxial, fixed-angle 2.7 mm
patella plate.
Keywords: Patients and methods: Between 2011 and 2014 all patients with a patella fracture were included in this
Fixed-angle patella plate
prospective study and treated with a fixed-angle patella plate. Avulsion fractures of the inferior or
Patella fracture
Outcome
superior pole of the patella were excluded. All fractures were classified according to the AO/OTA fracture
Results classification. During a twelve-month follow up period all intra- and postoperative complications were
Prospective observational study recorded as well as the time until fracture healing. One year postoperatively the Lysholm Score, the pre-
and postoperative Tegner Score, the Hospital for Special Surgery Knee Score (HSS), the Turba Score, the
Oxford Knee Score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the Bostman Score and the
Iowa Knee Score were surveyed. Altogether, 20 patella fractures in 19 patients were included in this
prospective study. The most frequent type of fracture, n = 10, was a simple transverse patella fracture
(C1), followed by 7 comminuted patella fractures (C3) and 3 T-shaped patella fractures (C2).
Results: During the 12-month follow up period two patients treated with the patella plate had a
complication. In one patient a superficial wound infection occurred, which was treated successfully with
hardware removal and in one patient a fracture dislocation due to an implant failure occurred. X-rays
demonstrated complete bony healing in all fractures on average 3.2 months postoperatively. All knee
scores showed good to excellent clinical results one year postoperatively.
Conclusion: The results of this first clinical study indicate that the fixed-angle patella plate is an effective
and safe treatment option for patella fractures with a short operative learning curve. The treatment of
communited patella fractures (C3) with a fixed-angle patella plate should be well-considered to avoid
distending the indication and biomechanical properties.
ã 2016 Elsevier Ltd. All rights reserved.

Introduction fractures [2,3]. However, despite several technical modifications of

With a prevalence rate of just 1% patella fractures are not among
the most common skeletal injuries in humans [1]. Approximately
one-third of all patella fractures require a surgical intervention,
either when the fracture gap exceeds 2–3 mm or in case of joint
incongruence [1]. Modified anterior tension wiring is still the most
widely used and advocated surgical treatment option for patella
* Corresponding author.
E-mail addresses: post@michaelwild.de (M. Wild), kai_fischer83@yahoo.de
(K. Fischer), florian.hilsenbeck@mail.klinikum-darmstadt.de (F. Hilsenbeck),
mohssen.hakimi@vivantes.de (M. Hakimi).
anterior tension wiring, typical complications, such as failure of
fixation with early fracture dislocation occur in up to 22–30% of all
cases [4,5]. Furthermore, migration of K-wires, postoperative pain
and high rates of revision surgery can be observed with this
technique leading to unsatisfactory long-term results in clinical
studies [3,6,7]. Postoperative pain due to skin irritation caused by
the K-wires is also a common problem when using modified
anterior tension wiring [8]. Thus, revision surgery with K-wire
removal becomes necessary in up to 65% of all cases [8].
Encouraged by the improved primary stability of fixed-angle
plates in fracture treatment, a fixed-angle patella plate was
developed by the author of this manuscript (Fig. 1). Biomechanical

http://dx.doi.org/10.1016/j.injury.2016.06.018
0020-1383/ã 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: M. Wild, et al., Treating patella fractures with a fixed-angle patella plate—A prospective observational study,
Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.06.018
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2 M. Wild et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx

studies showed a superior and significant higher stability of this

bilateral fixed-angle patella plate compared to the two currently
most common used surgical techniques for patella fractures:
modified anterior tension wiring with K-wires and cannulated lag
screws with anterior tension wiring [9,10].
Goal of this first prospective clinical study was to evaluate the
safety, efficiency and outcome in patients with patella fractures
treated with this novel fixed-angle patella plate. A special focus
was set on intra- and postoperative complications and hardware
failure.

Patients and methods

This study was approved by the local ethics board of our

institution. All patients gave their oral and written consent and
were given the option to discontinue participation at any time.
Between 2011 and 2014 patients with a patella fracture and a
fracture displacement or articular incongruity > 2–3 mm were
Fig. 1. Titanium 3.5 variable angle-stable bilateral patella-plate (manufacturer:
included in this prospective study and treated with a fixed-angle
Königsee Implantate1, Allendorf, Germany).
stable patella plate (Koenigsee Implantate1, Allendorf, Germany)
at the author’s institution (Figs. 1 and 2). Avulsion fractures of the

Fig. 2. X-rays of a 74-year old male patient suffering a 34-C1.1 fracture and treated with an angle-stable patella plate. (a) lateral view preoperatively; (b) lateral view
postoperatively; (c) a.p. view postoperatively; (d) tangential view postoperatively.

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M. Wild et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx 3

inferior or superior pole of the patella were excluded. The
postoperative treatment protocol was defined individually
depending on the type of fracture. With the exception of
comminuted patella fractures (type C3 according to the AO/OTA
fracture classification) all patients were treated without a cast or
knee brace. Patients with simple two-part transverse and three-
part T-shaped patella fractures were allowed immediate full
weight bearing in case that each fragment was secured with at
least one screw. Due to the high loads reacting on the patella stair
climbing was forbidden independent of the fracture type.
Postoperative treatment included physical therapy without
limitations for knee flexion or extension.
Altogether 27 patella fractures in 26 patients were treated with
a fixed-angle stable patella plate between 2011 and 2014. Two
patients did not give their written consent and 5 patients decided
not to continue the study after discharged from the hospital.
Therefore 19 patients with 20 patella fractures who gave their
written consent and completed the follow up period were included
in this prospective study.
Mean age of the patients was 64.5  23.56 years, with the
majority of the patients being women (n = 14). The most frequent
type of fracture with a total of number of 10 was a simple
transverse patella fracture (Type C1 fracture; AO/OTA classifica-
tion), followed by 7 comminuted patella fractures (Type C3
fracture), and 3 T-shaped patella fractures (Type C2 fracture)
(Table 1). All patients were treated operatively on average 5.6 days
(range: 0–29 days) after suffering the fracture. One patient was
treated after 29 days due to a secondary fracture dislocation after
he was initially treated with modified anterior tension wiring in
another hospital. One poly-traumatized woman with bilateral
patella fractures underwent surgery 12 days after her condition
was stabilized. The majority of the patients had an isolated patella
fracture (16 cases), only 4 patients were multiple injured.
All patella fractures were classified according to the AO/OTA
fracture classification [11]. Knee x-rays with special patella views
were assessed one day after the surgical treatment, and 6, 12, 26
and 52 weeks postoperatively. Healing of the bone, cutting out of
the implant, implant failure, secondary dislocation or intraarticu-
lar gaps in all fractures were determined.
In all patients, age, gender, duration of the surgical procedure,
any kind of complication, time till bony healing, implant removal
when necessary and knee range of motion were recorded.
Operative technique
All patients were operated in supine position. Starting 1 cm
proximal to the patella a longitudinal anterior skin incision of
10–12 cm length was performed up to the insertion of the patella
tendon. After surgical preparation of the medial and lateral
retinaculum a lateral arthrotomy for digital palpation and
inspection of the retropatellar joint surface was carried out. Using
a reduction forceps the dislocated patella fracture was reduced and
the anatomical reduction was checked radiologically by flouro-
scopy and by manual palpation. Both small inferior hooks of the
patella plate were carefully bended posteriorly. At the inferior pole
of the patella two small 5 mm longitudinal incisions parallel the
origin of the patella tendon were done. Through these two
incisions the previously bended small hooks of the patella plate
were placed around the cartilage free inferior patella pole. The
patella plate was then flipped posteriorly on the medial and lateral
margin of the patella. Both branches of the patella plate were
approximated to the upper pole of the patella and temporarily
fixed with two K-wires which were drilled through the small
eyelets located at the tip of both plate branches into the proximal
patella pole. In all screw holes an angle stable screw was placed
starting distally with the surgeon’s finger at the retropatellar joint
surface avoiding an accidentially intraarticular drilling. The amont
of screws used was determined by the type of fracture. One or two
screws crossed the fracture line to further improve stability. Even
in three or four part fractures screws were placed in each fragment,
if the fragments were large enough to be fixed by at least one screw.
Finally, the K-wires which stabilized the positioning of the plate on
the patella were removed. Reduction and fixation was then one
more time checked by flouroscopy before the wound was closed.
To be able to compare our results with the results of other
studies, we also included comminuted patella fractures in our
study. So far there does not exist a validated patella specific
fracture score to report outcomes following operative treatment of
patella fractures. Therefore and to be able to better compare our

Table 1
Demographic data.

No. Age (yrs.) Gender Fracture Isolated/ Operation time (min) Implant Implant
Type (AO/OTA) Multiple failure removal
Injured
1 71 F 34-C1.1 I 70 Yes No
2 58 F 34-C3.2 I 107 No No
3 41 M 34-C3.2 I 37 No No
4 54 M 34-C1.1 I 59 No No
5 87 F 34-C1.1 I 67 No No
6 88 F 34-C1.1 M 62 No No
7 88 M 34-C1.2 I 95 No No
8 68 F 34-C2.2 I 54 No Yesa
9 41 M 34-C1.1 I 71 No No
10 76 F 34-C3.2 I 77 No No
11 93 F 34-C1.1 I 85 No No
12 87 F 34-C1.1 I 70 No No
13 27 F 34-C2.3 M 64 No Yes
14 27 F 34-C3.2 M 63 No Yes
15 71 F 34-C1.1 M 76 No Yes
16 74 M 34-C1.1 I 77 No Yes
17 18 M 34-C3.2 I 116 No No
18 65 F 34-C2.2 I 100 No No
19 77 F 34-C3.1 I 54 No No
20 79 F 34-C3.2 I 90 No No
a
Due an infection.

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results with the results of other studies we used the most common
clinical knee scores such as the Lysholm Score [12], the pre- and
postperative Tegner Score [13], the Hospital for Special Surgery
Knee Score (HSS) [14], the Turba Score [15], the Oxford Knee Score
[16,17], the Knee injury and Osteoarthritis Outcome Score (KOOS)
[18], the Bostman Score [6] and the Iowa Knee Score [19].
Additionally, the patients were asked to subjectively rate their pain
during walking using the visual analogue scale (VAS) and judge
their outcome on the basis of school marks from 1 to 6 (excellent–
poor).
A descriptive statistical analysis was performed using Excel1
(Version 14.0, Microsoft, USA).
Results
The duration of the surgical procedure was on average 74 min
(range: 37–116 min) and no intraoperative complications could be
observed.
During the 12-month follow up period, two patients treated
with the patella plate had a complication. A 68-year-old woman
developed a superficial wound infection, which healed immedi-
ately after removal of the patella plate, and one 71-year-old woman
showed a secondary fracture dislocation with an intrarticular gap
of more than 2 mm. Due to this dislocation, revision surgery was
indicated, however the patient refused to undergo another surgery.
Fracture healing, as documented on x-rays, was achieved on
average after 3.2 months (range: 3–6 months). In 4 patients a
hardware removal was performed on average 18.75 months
(range: 11–24 months) after the initial surgery. Altogether, just
in one case a superficial wound infection was noted, as mentioned
above.
The range of motion one year postoperatively was on average
125  17.79 (range: 80–145 ), only in one case an extension deficit
of 10 degree compared to the opposite knee was found (patient
with implant failure). At the 12-month follow up period, pain
during walking averaged at 0.7  7.71 (range: 0–5) as measured by
visual analogue scale (VAS) and the average subjective rating on
the basis of school marks from 1 to 6 (excellent–poor) was
1.7  0.65 (range: 1–3), which correlates to an excellent to good
result.
All surveyed objective knee scores showed one year postoper-
atively excellent to good results (Table 2). In the Lysholm score an
average of 89.5  8.5 of 100 points (range: 71–100) could be
reached which is categorized as good. The mean preoperative
Tegner score was 3.4  1.79 and at the 12-month follow up
3.2  1.80. Comparing the pre- and postperative level of work- and
sports-activity, which is measured by the Tegner score, only a
slight impairment of 0.2  0.52 (range: 0–2) could be shown. On
average 92  12.5 points (range: 62–100) were recorded for the
Hospital for Special Surgery Knee Score (HSS) which is categorized
as excellent, whereas the results in the Turba score were rated as
good, showing 2  1.41 points on average (range: 0–5). In our series
the patients reached 41.5  5.1 points on average (range: 28–48) in
the modified Oxford Knee Score System corresponding with an
excellent result.
The Knee injury and Osteoarthritis Outcome Score (KOOS),
transformed to a 0–100 scale representing the percentage of total
possible score achieved, reached on average in the subscale pain a
score of 86.7  0.12% (range: 60–100%), in the subscale symptoms
of 94.4  0.11% (range: 55–100%), for activities of daily living of
90.7  0.09% (range: 69–100%), for sport and recreation function of
60  0.66% (range: 20–100%) and for the knee-related quality of life
of 78.7  0.18% (range: 50–100%). Altogether the patients had a
total score of 86.3  0.09% (range: 70–99%) on average in the KOOS.
The average in the Bostman Score was 27.4  3.77 points (range:
19–30 points) representing also a good result after open reduction

Table 2
Clinical scores.

No. VAS Lysholm Tegner HSS Turba Oxford Bostmann (max. Iowa KOOS (%)
(0 10) (max. (Pre-and (max. (max. (max. 30 P.) (max. Totala
100 P.) postoperatively) 100 P.) 28 P.) 48 P.) 100 P.) (Pain/Symptoms/ADL/Sports/QoL)
(sub./
obj.)
1 0 76 2/2 68 2 (2/0) 37 20 74 126 (18/36/52/8/12)
2 0 91 3/3 100 1 (1/0) 45 30 97 161 (28/36/64/19/14)
3 0 96 4/4 100 2 (1/1) 48 24 99 163 (25/36/67/19/16)
4 0 84 5/3 76 2 (2/0) 37 21 82 134 (22/34/60/10/8)
5 0 87 1/1 98 1 (1/0) 35 30 87 127 (28/36/47/4/12)
6 5 72 3/3 73 5 (3/2) 36 30 86 120 (22/25/54/8/11)
7 0 85 2/2 82 2 (1/1) 28 23 65 138 (24/36/55/7/16)
8 0 100 2/2 91 2 (1/1) 44 28 84 148 (28/34/62/12/12)
9 0 94 3/3 100 1 (1/0) 45 30 97 159 (26/36/68/15/14)
10 0 91 3/2 99 2 (2/0) 41 30 90 148 (26/36/62/11/13)
11 0 100 3/3 99 2 (1/1) 46 28 89 163 (28/36/66/18/15)
12 0 93 3/2 100 1 (1/0) 41 28 76 136 (23/34/61/9/9)
13 0 95 5/5 100 1 (1/0) 44 30 98 151 (20/36/68/14/13)
14 0 89 5/5 100 3 (3/0) 44 29 96 148 (17/36/68/14/13)
15 5 71 4/4 62 5 (2/3) 38 19 74 118 (23/20/53/13/9)
16 4 95 3/3 100 0 (0/0) 48 30 95 161 (28/36/68/14/15)
17 0 99 9/9 100 0 (0/0) 44 30 99 167 (28/36/68/20/15)
18 0 87 2/2 93 4 (3/1) 41 29 88 137 (21/36/63/6/11)
19 0 90 3/3 100 3 (3/0) 40 30 85 130 (20/31/61/9/9)
20 0 95 4/4 100 1 (1/0) 47 30 94 166 (24/35/68/20/15)
range 0–5 71–100 1–9/1–9 62–100 0–5 28–48 19-30 65-99 70-99 (60–100/55–100/69–100/20–100/
Difference 0–2 50–100)b
mean 0.7 89.5 3.4/3.2 92 2 (1.5/ 41.5 27.4 87.7 86.3 (86.7/94.4/90.7/60/78.7)b
0.5)
STD (+/ ) 1.71 8.5 0.52 12.5 1.41 5.1 3.77 9.7 not presented in this table
average n/a good n/a excellent good excellent good excellent n/a
rating
a
Total not validated.
b
Normalized values in%; n/a not applicable; ADL Activity of daily living;QoL Knee-related Quality of Life.

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and internal fixation of the patella fractures with the patella plate. often reported [30]. Sorensen [5] found a rate for patella-femoral
At last, the Iowa knee score showed with 87.7  9.7 points on osteoarthritis of more than 70%, which was significantly higher
average (range: 65–99 points) a good result. than on the uninjured opposite side (31%). Although, the clinical
outcome after joint injuries is difficult to assess, many studies have
shown that the best clinical results can be expected when the best
Discussion
possible reduction of a patella fracture was performed [1,31].
Therefore, the goal of treatment is to restore the articular
In 2012 Dy et al. [20] published a meta-analysis to evaluate the
surface of the patella and to achieve a strong stabilization, which
re-operation, non-union, and infection rate following open
allows early mobilization of the knee joint and to avoid subsequent
reduction and internal-fixation of patella fractures. Analyzing 24
secondary fracture dislocation.
studies with a total of 737 patella fractures treated with tension
The newly developed angle-stable patella plate showed
band wiring or other surgical techniques they found a re-operation
biomechanically a significant increased stability and lower
rate of 33.6%. The authors conclude that although the non-union
deformation under load, compared to the currently most
and infection rates of these techniques are fair, the re-operation
frequently used techniques like modified anterior tension wiring
rate of these techniques is substantially to high.
or cannulated lag screws with anterior tension wiring [10]. We
Despite the high re-operation rate, modified anterior tension
were able to demonstrate that the use of two polyaxial fixed-angle
wiring is still worldwide the most commonly used technique to
plates, attached to the medial and lateral border of the patella, lead
treat patella fractures [2,3]. Another frequently used alternative is
to a significant increase in stability (mean tensile strength: 2396 N)
internal fixation with cannulated lag screws in combination with
compared to the use of cannulated lag screws with tension band
anterior tension band wiring [2]. The combination of lag screws
(mean tensile strength: 1015 N). Compared to fixation with a
with a tension band promises greater stability with fewer
modified tension band with Kirschner wires (mean tensile
dislocations and higher biomechanical failure loads [21,22] .In
strength: 625 N) a four-fold greater stability was shown [10].
biomechanical studies the advantages of this technique were
Encouraged by these very promising biomechanical results, we
shown, however the clinical outcome after this procedure was only
decided to conduct a prospective clinical study. During a 4-year
evaluated in a small number of case series. Berg et al. [2] presented
period, 27 patella fractures were treated consecutively with a
in 1997 a small series of 10 patients. In a recently published
fixed-angle patella plate. In consideration of the low prevalence of
retrospective study comparing modified anterior tension wiring
patella fractures all types of patella fractures with the exception of
with titanium cable-cannulated screws in patella fractures no
superior or inferior patella avulsion fractures were treated with
complications were found in the group (n = 49) treated with
this implant by 5 senior surgeons of our institution. Even
titanium cable-cannulated screws whereas 30% complications in
communited patella fractures, which are an exclusion criteria by
52 patients were reported with modified anterior tension wiring
the manufacturer of the patella plate, were treated as an off label
even though communited fractures were excluded [23]. These
use with this plate. This was done to avoid a possible indication
findings are in accordance with Qi [24] who published in 2011 a
bias in this study. Altogether 27 patella fractures were treated
series of 15 patients treated with bioabsorbable cannulated lag
operatively with this patella plate and 7 patella fractures were lost
screws and braided polyester suture bands. He found no
during the follow up period. To the best knowledge of the author
complications using this technique. However, this technique can
these lost patients had no implant related complications when
only be applied for simple central transverse fractures with good
contacted on the phone.
bone quality.
In 20 operatively treated patella fractures, we found one
The patella withstands significant axial forces produced by the
implant-related complication due to implant failure with second-
quadriceps muscle during everyday activities. Walking generates a
ary fracture dislocation in a 71-year-old woman with a comm-
patello-femoral load amounting for about half of the body weight,
united patella fracture (off label use of the fixed-angle plate). This
which further increases by a factor of 3.3 when climbing stairs and
complication results in a total complication rate of 5% in our study.
even further by a factor of 7.6 when taking a crouching position
In the current literature a complication rate of 20–30% is found for
[25]. Given the fact that every internal fixation of the patella is
modified anterior tension wiring [4,29]. Also Gosal et al. [32] found
exposed to such high tensile forces, a discussion over the
in 21 cases a re-operation rate of 38% due to wire complications
appropriate fixation method was unavoidable from the beginning
and a re-operation rate of 6% in his non-absorbable polyester group
[26]. Using anterior tension wiring in the treatment of patella
within 16 cases.
fractures tensile forces can be transformed into compression forces
In one case a superficial infection occurred, which was treated
making it possible to withstand high tension loads. However, in
with implant removal and antibiotics. Hereby, the infection could
biomechanical studies it was shown that the principle of tension
be healed without any further complications. Due to the small
wiring only works during knee flexion, while knee extension may
number of patients, the infection rate was 5% in our series and
lead to a fracture gap [27,28]. This biomechanical misbehavior and
therefore higher than in a multicentre study of Dy et al. [20], who
soft tissue complications as well as elongation of the tension band
found an infection rate of 3.2% in a meta-analysis of 18 studies with
may predispose this technique to hardware loosening leading to
522 patella fractures. However, not every study was included in
early secondary fracture dislocation, which could be observed in
this meta-analysis due to missing data about postoperative
20–30% [4,29].
infections. On the other hand all patella fractures treated with a
In a study of 50 patients with patella fracture who were treated
patella plate healed and a non-union could not be observed while
surgically using a modified tension band wiring, a secondary
Dy et al. [20] found a non-union rate of 1.3% in 15 studies with 464
fracture dislocation of less than 2 mm became apparent in 50% and
patella fractures.
a dislocation or step in the articular surface of > 2 mm appeared in
Many validated scores exist to assess the postoperative
20% of all patients [29]. Although a dislocation or step of the
outcome after knee surgery. However no validated patella fracture
fracture gap of 2 mm may not affect the outcome after surgical
specific score is yet established. Furthermore the comparability of
treatment of patellar fractures in the literature, the anatomical
different studies about patella fractures is difficult because each
reduction of articular fractures should be the aim of any surgical
author uses his preferred scoring system. Therefore, we decided to
treatment, especially in the heavily loaded patella-femoral joint
use more than one established knee score to allow a better
[1,7]. Post-traumatic osteoarthritis following patellar fracture is
comparability of the results of our study with other studies.

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Patients treated with the patella plate reached high values in all
scores corresponding to an excellent or good result.
Using his own clinical score Levack et al. [31] found in 14
patients treated with modified anterior tension wiring in half of
the cases a good result while the other half had a fair or poor result.
These results are inferior to our findings using a fixed-angle patella
plate.
Comparing the one-year results of Mao et al. [33] who treated
31 simple transverse patella fractures by a cable pin system in a
minimally invasive technique the Bostman score in our group (27.4
on average) was a little bit lower than in his series where an
average Bostman score of 29.1 was reached. This maybe based on
the fact that Mao et al. treated only simple transverse patella
fractures in younger patients (35 years on average), whereas in our
series communited and T-shaped fractures were also included and
the average age in our study group was significantly higher (64.5
years on average).
Tian et al. [23] reported retrospectively about 101 patients
treated with modified K-wire tension band or titanium cable-
cannulated screw tension band technique. Using the Iowa score as
an outcome assessment they found in the titanium cable-
cannulated screw tension group (n = 49) 92% excellent and 8%
good results and in the modified K-wire tension band group
(n = 52) 69% excellent, 17% good, 8% fair and 6% poor results. The
patella plate showed in the Iowa score in 70% excellent, in 25% good
and in 5% fair results. Compared to Tian et al. the results of our
series are superior to modified anterior tension wiring and inferior
to titanium cable-cannulated screw tension. However, these
results have to be interpreted carefully because of the retrospective
study design of Tian et al. and the exclusion of AO/OTA 34-C3
fractures, which are included in our study.
Qi et al. [24] treated in a prospective study 15 patients with
transverse and comminuted patella fractures using bioabsorbable
cannulated lag screws and braided polyester suture bands. Severe
communited fractures were excluded due lag screws could not be
used. He had no complications and found 12 months postopera-
tively a Lysholm Score of 95.7 and a VAS score of 0.7 on average. The
VAS score in our series matches the same value, but the Lysholm
score of 89.5 on average is a little bit lower compared to Qi et al.
However, the patients in our series were almost 20 years older
(64.5 vs. 46.2 years) and severe communited fractures were also
included in our study.
Le Brun et al. [34] followed 15 patients, which were treated with
modified anterior tension wiring and 10 patients, which were
treated with cannulated screws and tension band after suffering a
patella fracture. The clinical outcome was surveyed with the KOOS
score. In the modified anterior tension wiring group he found the
following values: pain 62%, symptoms 65%, activity of daily living
(ADL) 67%, Sport 44% and knee-related quality of life (QoL) 44%.
These findings are inferior to our findings, which were higher in
every subscale (pain 86.7%, symptoms 94.4%, ADL 90.7%, sport 60%
and QoL 78.7%). Our results were also superior compared to the
results in the cannulated screw and tension band group (pain 79%,
symptoms 72%, ADL 77%, Sport 55% and QoL 60%).
In 14 patients with patella fracture Bostman et al. [7] found 9
(64%) excellent, 3 (22%) good and 2 (14%) fair results after modified
anterior tension wiring. Using the same score the outcome with
the patella plate was better due to 15 (75%) excellent, 4 (20%) good
and 1(5%) poor results.
Interestingly, four of our patients wished a removal of the
implant although none had any hardware associated problems.
Only in one case with a superficial infection the implant removal
was medically indicated. This may be the result of the medical care
system in Germany, where also implant removals are paid if they
are not mandatory.
Please cite this article in press as: M. Wild, et al., Treating patella fractures with a fixed-angle patella plate—A prospective observational study,
Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.06.018
Compared with anterior tension wiring the costs using a patella
plate are higher. However, in modified anterior tension wiring a
high complication rate and high numbers of implant removals due
to implant related complications or implant-associated pain are
described. The use of the patella plate may reduce the number of
implant removals necessary compared to modified anterior
tension wiring, which will have to be shown in future studies.
The longer mean surgical time in our series is based on the fact that
we decided to also include a patient that was treated with an iliac
crest bone graft due a bone defect after BTB ACL reconstruction and
one patient who suffered bilateral patella fractures. Additionally,
the implant was used by all surgeons of our department. However,
after a learning curve the operation time using a patella plate will
be shorter. Even if later a removal of the plate should be necessary
the operation time might be less compared to modified anterior
tension wiring since the plate is placed on the soft tissue directly
beneath the subcutis. Therefore the soft tissue does not have to be
dissected for searching the implant.
Based on our experience we see the best indications for the
angle stable patella plate in simple transverse and T-shaped
fractures because the implant was biomechanically tested in these
type of fractures which account for 50–60% of all patella fractures
[1]. Even in these types of patella fractures modified anterior
tension wiring or cannulated screws with anterior tension wiring is
also easy applicable the patella plate showed in recently published
biomechanically studies a superior stability. This allows a more
aggressive postoperative treatment protocol compared to modi-
fied anterior tension wiring or cannulated screws plus anterior
tension wiring. We see also good indications for the fixed angle
patella plate in three or four part fractures if the fragments are
large enough to be fixed stable by at least one screw. We don’t
recommend the patella plate in comminuted fractures or avulsion
fractures. In our opinion this is a clear contraindication.
With the exception of a few retrospective studies including
different kinds of operative treatment methods and collecting
patients over a long time period the majority of recent studies
introducing new operative techniques for patella fractures have
only small numbers of patients due the low prevalence of patella
fractures [24,34,35]. This is also a limitation of our study, which has
to be taken in concern when interpreting our results. On the other
hand we used a prospective approach and we will continue our
study to collect more patients treated with the fixed-angle patella
plate. Another limitation of our study design is the missing
comparability with other surgical treatment options since we
decided to forego a control group. But using different and common
in literature used outcome scores should allow a better compara-
bility with other studies. This study may also encourage other
study groups to prove our results in further studies to avoid a
developer bias.
Conclusions
The operative treatment of patella fractures is still a challenge
even for an experienced surgeon. The results of our study show
that the fixed-angle patella plate is a good and safe option treating
different kind of patella fractures with a short learning curve and
promising first results. However, the treatment of communited
patella fractures (C3) with a fixed-angle patella plate should be
well considered to avoid distending the indication and biomechan-
ical properties.
Conflict of interest
The first author receive as developer of the implant a passive
income from turnover sharing as well as reimbursements for
lectures.
G Model
JINJ 6777 No. of Pages 7
M. Wild et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
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