European Journal of Cardiovascular Medicine

Patellar fractures account for ~1% of all fractures, more common in males ¹. Open injuries make up 6–9%, often with associated major bone trauma. Bipartite patella, a congenital condition due to failed secondary ossification (commonly at the superolateral edge), can mimic fractures on X-rays. ² Fractures occur from direct or indirect trauma. Indirect forces, especially from the extensor mechanism, typically cause transverse fractures. Direct trauma (e.g., falls or dashboard injuries) may cause comminution. Patellar fractures are classified as undisplaced , transverse with displacement, inferior pole, comminuted (with/without displacement), vertical, or osteochondral.³ Minimally displaced fractures (<2–3 mm step-off) with intact extensor mechanism can be treated conservatively using a cylindrical slab and physiotherapy.^4,5 Displaced fractures often require surgical fixation—methods include tension band wiring (TBW), plating, screws, and cerclage wiring. Conventional TBW using a single figure-of-eight wire, though widely used, is associated with complications like wire breakage, migration, and non-union.⁶ A modified TBW technique using double stainless-steel wires in a reinforced figure-of-eight has shown improved outcomes and fewer complications.⁷

This prospective observational study (single cohort) was conducted in the Department of Orthopaedics, Maharaja Agrasen Medical College, Agroha (Hisar), from May 2023 to August 2024 included 35 patients, aged 18 years and above, presenting with patellar fractures to the outpatient or emergency department. Ethical approval for the study was obtained from Institutional ethical Committee.Inclusion criteria for the study included patients with closed, displaced two-part patellar fractures (injury duration < 2 weeks), open (Gustilo-Anderson Type I), displaced two-part patellar fractures (injury duration < 2 weeks), closed or open (Gustilo-Anderson Type I) displaced three-part patellar fractures that could be reduced to two-part fractures. All participants underwent a thorough clinical evaluation, followed by radiological assessment using standard anteroposterior and lateral X-ray views of the knee.  Fractures were classified based on the descriptive classification of patellar fractures. The surgery was performed using standard AO technique. Two cerclage wires of size 20G intertwined with each other before making a figure of 8 loop around k wires. All patients received broad-spectrum intravenous antibiotics for a minimum of 3 days. Patients were followed up at the 4th week, 12th week, and 24th week post-operatively. Clinical and functional outcomes were evaluated using the Reich and Rosenberg scoring system.Serial radiographs were also done to evaluate union & implant status.

In this study, the majority of patients (28.6%) were in the 18–30 years age group, followed by 25.7% in the 31–39 years age group.Out of the 35 patients, 26  were male and 9  female.The most common mode of injury was road traffic accident (RTA), seen in 80% of cases.According to the descriptive classification of patellar fractures, 25 patients  had transverse fractures and rest 10 patients had constructable two part fractures. Right -sided involvement was seen in 23 patients, while 12 patients had left-sided patellar fractures.Most patients (80%) had no associated injuries. In the initial 7 cases, two cerclage wires were passed individually & separately without intertwining. This led to uneven tension, with one wire often becoming loose. In the remaining 28 cases, the wires were intertwined prior to insertion, resulting in uniform tension, better fixation, and increased mechanical stability.At 24 weeks follow-up, all patients had achieved union, with the average time to union being 12.74 weeks

. Table 1: Time for Union (In weeks)

There was a statistically significant improvement in functional outcomes, as assessed by the Reich and Rosenberg scale.

Table 2: Reich and Rosenberg Scale

Extension lag, showing progressive recovery during follow up as shown in table 3.

Table 3: Extension lags at follow-up

 The incidence of complications in this study was low, with one patient experiencing superficial surgical site infection which resolved after serial dressing and i.v. antibiotics and one patient having cerclage knot impingement which was corrected by readjustment of knot with no cases having cerclage wire breakage, k wire migration, no flexion limitation and no extension lag and no nonunion.  There were only few complications as listed below in table 4.

Table 4: Complication status at follow-up

Fig 1.  Showing  x rays Pre op ,  immediate post op & x rays after union at follow up.

Fig 2. Showing functional outcome

A total of 35 patients having patella fractures, with results demonstrating significant improvements in functional recovery, fracture union, and minimal postoperative complications.The technique was designed by Yu et al⁵ (2020) where double bundle wire stiching was done. Exact union time was not published They had treated 20 patients with this technique without any adverse effect. In our study we had treated 35 patients with double cerclage wire TBW with no implant failure & yielded excellent outcomes.

The predominance of younger patients (18~30 years, 28.6%) in the current cohort aligns with observations by Hanumantharya et al⁷(2017), Samiullah et al¹⁰ (2022) and Rathi et al¹² (2012).

Additionally, the male preponderance (74.3%) reflects findings by Hanumantharya et al⁷ 2017), Asimuddin et al⁸(2021) and Choudri et al⁹(2022) who attributed similar trends to greater involvement of men in high-risk activities.

The high proportion of transverse fractures (71.4%) is consistent with the findings of Assumudin et al⁸ (2021) . 

In initial seven cases both the cerclage wires of TBW were passed individually & separately. It was observed that both the wires got different tension while tightening and one wire was relatively loose than the other and didn’t supplement the other wire practically. So, in rest of 28 cases both the wires were intertwined priorly and then passed for TBW. Now both wires act as single strong wire getting equal tension & adding to strength of wires & fixation.

Radiological assessments revealed complete fracture union in all patients by the 24week follow-up. The majority of patients 25 ( 71.4%) had achieved fracture union by 12 weeks and 8( 22.8%)  patients achieved fracture union between 12-18 weeks and 2(5.7%) patients achieved union at 19 weeks .The high union rate of 100% observed in this study is similar with findings of Asimuddin et al.⁸ (2021), Samiullah et al¹⁰(2022), Choudri et al ⁹(2022) and Hanumantharya et al⁷ (2017) Patil et al¹³ (2014)  Murlidhar et al¹⁴ (2017) Meng et al ¹⁵(2019) reported a similar union timeframe of 12 weeks  in a cohort treated with conventional TBW technique.            

The clinical outcomes of this study, evaluated using the Reich and Rosenberg classification, revealed a significant improvement over the 24-week follow-up period. By the final follow-up, 80% of patients achieved excellent outcomes, with a marked reduction in extension lag, reflecting the effectiveness of MTBW in restoring knee function and 20% had good outcomes. These findings better than those of Asimuddin et al⁸(2021), where 62.5% had excellent results, 20%of patients reported goodresults 10% fair and 7.5% poor results. The better functional outcome focuses on rigid and stable fixation and immediate post op knee mobilisation without any fear of implant failure.

The limitation of present study includes small sample size & restricted follow up to 24 weeks, sufficient for assessing fracture union and short-term complications. Though long follow up is required for delayed implant failure or long-term outcomes such as the development of patellofemoral arthritis or chronic knee pain.

MTBW had found to be a robust fixation in our study with no implant related complications. It is cost effective.It shows excellent clinical and radiological outcomes.The study provides infect to advocate for its continued use and broader adoption in orthopaedic practice.

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