What is the treatment for a transverse fracture of the patella?

Treatment of Transverse Patella Fracture

Transverse patellar fractures with displacement and disruption of the extensor mechanism require surgical fixation, with modified tension band wiring (with or without cannulated screws) being the treatment of choice for non-comminuted fractures. 1, 2

Initial Assessment and Indications for Surgery

• Evaluate extensor mechanism integrity by assessing the patient's ability to perform straight leg raise against gravity—inability indicates disruption requiring operative intervention 3
• Obtain anteroposterior and lateral radiographs to assess fracture displacement and articular congruity 1, 4
• Consider CT imaging when radiographs are inconclusive or to better characterize fracture pattern 1, 4
• Transverse fractures are often associated with patellar maltracking and typically require surgical intervention 1

Treatment Algorithm

Non-Displaced Fractures

• Non-displaced fractures with intact extensor mechanism can be managed conservatively with immobilization 2
• Early rehabilitation is recommended to avoid knee joint contractures and cartilage degeneration 2

Displaced Transverse Fractures (Most Common Scenario)

Modified tension band wiring is the treatment of choice and can be combined with cannulated screw fixation due to its biomechanical superiority 2

Surgical Technique Options:

1. Modified tension band wiring alone 2, 5

   • Standard approach for most displaced transverse fractures
   • Provides adequate stability for fracture healing

2. Cannulated compression screws with tensioned high-resistance suture tape (FiberTape) as tension band 6

   • Minimizes symptomatic hardware complications compared to traditional metal implants
   • Provides effective, reproducible fracture fixation with lower reoperation rates

3. Modified tension band wiring combined with cannulated screws 2

   • Biomechanically superior to tension band wiring alone
   • Recommended for optimal stability

Important Technical Considerations:

• Proper K-wire placement is critical—superficial positioning of K-wires increases fixation failure risk (OR = 6.3) 5
• Augmented circumferential cerclage wiring (ACCW) is NOT recommended as concurrent application with modified tension band wiring shows no benefit in reducing fixation failure, nonunion, or revision surgery rates 5
• However, circular cerclage wiring using resorbable PDS or non-resorbable FiberWires can increase fixation stability when used appropriately 2

Comminuted Fractures

• Open reduction and fixation with small fragment screws or angular stable plates for anatomic restoration of the retropatellar surface 2
• Stabilize all displaced fragments whenever possible 1
• Circular cerclage wiring may be added to increase stability and decrease re-dislocation risk 2

Minimally Invasive Approaches

Minimally invasive techniques achieve improved knee joint mobility, shorter hospitalization, and more favorable outcomes compared to conventional open reduction 7

Options include:

• Kirschner wires with cerclage 7
• Cannulated screws with supplementary cerclage tension banding 7
• Combined tension-band braided polyester with suture button 7
• Arthroscopically assisted techniques to improve control of patellar articular surfaces and reduce malreduction 7

Common Pitfalls to Avoid

• Superficial K-wire placement significantly increases fixation failure risk, particularly when combined with ACCW (OR = 18.6) 5
• Failure to secure both ends of K-wires properly 5
• Unnecessary use of augmented circumferential cerclage wiring with tension band constructs 5
• Delayed rehabilitation leading to knee joint contractures 2

Special Populations

• Elderly patients (>60-70 years) show a trend toward higher fixation failure rates (though not statistically significant), requiring careful surgical technique 5
• Partial or complete patellectomy should be regarded only as a rare salvage operation due to severe functional impairment 2

Postoperative Management

• Early mobilization is essential to prevent contractures and cartilage degeneration 2
• Appropriate pain management 8
• Wound assessment and care 8
• Monitor for complications including symptomatic hardware, which is very common with traditional metal implants 6

Long-Term Considerations

• Patellofemoral joint arthrosis is very common after healing of patella fractures 3
• Substantial functional deficits may persist long after fracture healing 3
• Patients aged 50 years and over should be evaluated systematically for osteoporosis and risk of subsequent fractures 8