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Tomasz Poboży

Patellar fractures: locking plate fixation or tension-band wiring?

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Tomasz Poboży

Polish version: Złamanie rzepki — płytka blokowana czy klasyczny popręg napięciowy?

Choosing between conventional tension-band wiring (TBW) and plating remains a practical issue in surgically treated patellar fractures. A multicentre randomized trial of 122 adults, published in The Bone & Joint Journal on 1 September 2026, provides substantial clinical support for locking plates. Its predefined superiority criterion required both statistical significance and a minimum clinically important difference (MCID).

Why this study matters

TBW is familiar, but symptomatic implants, implant removal and fixation failure remain concerns. Dedicated patellar plates offer biomechanical advantages, while much of the previous clinical evidence was observational. This trial provides a prospective randomized comparison.

Study design

The trial enrolled 122 adults with displaced patellar fractures requiring surgery and allocated them 1:1 to locking plate fixation or TBW. Patients and assessors were blinded, and analysis followed the intention-to-treat principle.

  • Locking plate fixation: 63 patients.
  • TBW: 59 patients.
  • Follow-up at 12 months was completed by 57/63 (90.5%) and 52/59 (88.1%), respectively.
  • The primary outcome comprised the five KOOS subscales at 12 months.

Superiority was predefined as statistically significant differences in at least three KOOS subscales, together with differences exceeding their prespecified MCIDs.

Main results

Locking plate fixation met the superiority criterion in three of five KOOS domains: symptoms, sport/recreation and quality of life. The abstract reported these mean differences:

  • KOOS Symptoms: −10.4 points (95% CI −16.4 to −4.4).
  • KOOS Sport/Recreation: −14.1 points (95% CI −24.7 to −3.4).
  • KOOS Quality of Life: −10.9 points (95% CI −19.0 to −2.7).

The negative signs reflect the direction in which the comparison was defined; the authors interpret all three results as favouring plates. Implant removal, fixation failure and reoperation were more frequent after TBW. Exact event rates were not provided in the public abstract and should not be estimated from it.

Clinical interpretation for an orthopaedic surgeon

The advantage concerned patient-reported outcomes and exceeded predefined thresholds for clinical importance in three domains, rather than being limited to radiographic or biomechanical measures. The adverse-event pattern also fits the familiar problems of symptomatic TBW hardware and further surgery. Confirmation through longer follow-up and other centres could strengthen the role of locking plates where suitable implants and expertise are available.

Limitations

  • The primary endpoint was assessed at 12 months; persistence of the advantage is unknown from the abstract.
  • The findings apply to displaced fractures requiring surgery, not every patellar fracture or those managed nonoperatively.
  • Exact rates of implant removal, fixation failure and reoperation are unavailable in the public abstract.
  • Results for this plate system and operative protocol do not establish superiority of every plate over every TBW variant.
  • This was not a cost-effectiveness study; the abstract cannot establish whether fewer reoperations offset higher implant costs.

Implications for practice

The trial may lower the threshold for choosing a plate in an operatively treated displaced patellar fracture, on the basis of clinical rather than purely biomechanical evidence. It does not imply that every patellar fracture needs surgery, that all locking plates are equivalent, or that every patient will benefit. Fracture pattern, bone quality, soft tissues and technical feasibility still require individual assessment, and the 12-month advantage cannot be assumed to persist for years.

References

Larsen P. et al. Locking plate fixation compared with tension-band wiring for patellar fractures: a multicentre randomized controlled trial. The Bone & Joint Journal. 2026;108-B(9):1182–1189. Published: 1 September 2026.

The NCT04891549 registry lists six participating centres in Denmark: Aalborg, Aarhus, Hjørring, Kolding, Randers and Viborg. This summary relies solely on publicly available metadata, the abstract and the trial registry.

Related resources

For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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