Surgical Repair of Patellar Fractures
For displaced patellar fractures requiring surgery, modified tension band wiring provides the best functional outcomes, while non-displaced or minimally displaced fractures can be effectively managed with cast immobilization. 1, 2
Treatment Algorithm Based on Fracture Pattern
Non-Displaced or Minimally Displaced Fractures
- Cast immobilization is the preferred treatment approach for stable, non-displaced patellar fractures, avoiding surgical risks while achieving good functional outcomes 1
- Rigid immobilization should be maintained until fracture healing is confirmed radiographically 1
Displaced Fractures Requiring Surgery
Transverse Fractures (Most Common Pattern)
- Modified tension band wiring technique delivers superior results compared to other fixation methods, with 55% good outcomes in surgical series 2
- This technique provides stable fixation allowing early mobilization while maintaining fracture reduction 2
Vertical/Longitudinal Fractures
- Mini cancellous screws or lag-screw fixation are appropriate for vertically oriented fracture patterns 2
- These provide interfragmentary compression perpendicular to the fracture line 2
Comminuted Fractures
- Combination of K-wire and circumferential cerclage wire fixation can be used for multi-fragmentary patterns 2
- In severely comminuted fractures where no major articular fragments exist, patellectomy may be necessary to restore extensor mechanism function 2
Patient-Specific Considerations
Age and Activity Level
- Elderly patients (>50 years) with fragility fractures require systematic evaluation for osteoporosis and secondary fracture prevention 3, 1
- Higher-demand patients benefit more from anatomic restoration and stable fixation to enable return to activities 2
Hemodynamic Status
- In polytrauma patients with hemodynamic instability, damage control principles apply with temporary stabilization preferred over definitive fixation 3
- Definitive osteosynthesis should be performed within 24-36 hours once clinical stability is achieved 3
Critical Postoperative Management
Essential postoperative care includes: 3
- Appropriate pain management tailored to patient needs
- Antibiotic prophylaxis per institutional protocols
- Early mobilization to prevent stiffness (most common complication)
- Regular assessment of wound healing and hardware position
- Correction of postoperative anemia if present
Common Pitfalls to Avoid
- Delayed mobilization leads to significant loss of knee flexion - rehabilitation should begin as soon as fracture stability permits 2
- Inadequate fixation in comminuted patterns results in loss of reduction and poor outcomes 2
- Failure to address underlying bone quality in elderly patients increases risk of subsequent fractures 3
- The type of fracture pattern, surgical technique selection, and postoperative rehabilitation all significantly impact final functional results 2
Evidence Quality Note
The available evidence consists primarily of small retrospective series and very low-quality trials with significant design flaws 4. A 2021 Cochrane review found insufficient evidence to definitively recommend specific surgical techniques over others, though clinical series consistently show modified tension band wiring performs well for transverse fractures 2, 4. The recommendation prioritizes the most consistent clinical outcomes data available while acknowledging evidence limitations. 2