Superior Outcomes After Operative Fixation of Patella Fractures Using A Novel Plating Technique - A Prospective Cohort Study

Journal of Orthopaedic Trauma Publish Ahead of Print
DOI: 10.1097/BOT.0000000000000787
Superior Outcomes after Operative Fixation of Patella Fractures using a
Novel Plating Technique: a Prospective Cohort Study
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Dean G. Lorich MD
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Associate Director, Orthopaedic Trauma Service
Hospital for Special Surgery and Weill Cornell Medical College, New York Presbyterian
Hospital
New York, NY
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Peter D. Fabricant MD, MPH
Pediatric Orthopaedic Service

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Hospital for Special Surgery
New York, NY
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Gina Sauro PT, DPT

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Department of Physical Therapy
New York Presbyterian Hospital
New York, NY
Lionel E. Lazaro MD
Orthopaedic Trauma Service
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
New York, NY
Ryan R. Thacher BA
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New York, NY
Matthew R. Garner MD
Harborview Medical Center

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Seattle, WA
Stephen J. Warner MD, PhD

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New York, NY
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Correspondence:
Stephen J. Warner MD, PhD
535 East 70th Street
New York, NY 10021
Phone: (314)779-4409
Fax: (212)606-1477
Email: stephen.warner@gmail.com
Conflicts of Interest: No conflicts of interest declared for all authors regarding this
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manuscript.
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Presented in part at the Annual Meeting of the Orthopaedic Trauma Association, San
Diego, CA, October 9, 2015.

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Patella Plate Outcomes
1 ABSTRACT
2 Objective: The purpose of this prospective cohort study was to determine if a new patella
3 fracture fixation construct resulted in improved outcomes compared to traditional tension band
4 techniques.
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6 Design: Comparative cohort study.
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8 Setting: Academic level I trauma center.
10 Patients/Participants: Patients with isolated, unilateral patellar fractures were enrolled
11 prospectively. From 2012-2014, 33 patients underwent fixation with a novel plate construct that
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12 spans half of the patella circumference laterally and provides multiplanar fixation through a low
13 profile plate. A comparison cohort was drawn from 25 patients treated from 2008-2012, where
14 treatment consisted of traditional tension band fixation techniques.

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16 Intervention: Surgical fixation of patella fractures was performed with either a tension band or
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17 novel plate construct.
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19 Main Outcome Measurements: Subjective postoperative clinical outcomes and objective
20 functional and strength measurements were subsequently collected.
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22 Results: The two cohorts had similar baseline characteristics. Patients with the plate construct
23 had clinically and statistically significantly superior Knee Outcome Survey Activities of Daily
24 Living Scale (KOS-ADLS) scores throughout the study period (p<0.001). Functional testing also
25 demonstrated significant improvements in patients with plate constructs compared to tension
26 band constructs at twelve months. Patients in the plate cohort had significantly increased thigh
27 circumferences (p=0.003) and decreased anterior knee pain (p<0.0001) compared to the tension
28 band cohort.
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30 Conclusions: In this prospective cohort study, the use of a novel fixation construct with
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31 multiplanar and interfragmentary fixation and minimal disruption of patellar vascularity enables
32 improved clinical outcomes and functional performance.
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34 Key Words: Patella fracture;outcomes;plate;tension band

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36 Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description
37 of levels of evidence.
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38 INTRODUCTION
39 Displaced patella fractures (OTA 341) frequently require surgical treatment to achieve
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40 anatomic reduction of the articular surface and restoration of extensor mechanism function.
41 Operative fixation of patella fractures can be challenging due to its subcutaneous location, its
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42 role in knee extensor mechanism function, and the inferior pole comminution often seen with
43 these injuries2–10. Techniques for fixation of patella fractures have traditionally involved anterior
44 tension band constructs using Kirschner wires surrounded by a figure-of-eight wire11–14. These
45 anterior tension band constructs have been evolved to designs with improved biomechanical
46 profiles using partially threaded cannulated screws, non-absorbable sutures, and cerclage
47 wires12,14–17.
48 Despite advances using anterior tension band constructs and low rates of nonunions,
49 malunions, and implant failures, outcomes following operative treatment of patella fractures
50 have remained unsatisfactory13,18–20. Prominent and painful implants and residual knee
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51 discomfort continue to be concerns for patients and surgeons. The comminution of the inferior
52 pole frequently associated with these injuries is difficult to appropriately address with tension
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53 band constructs10,21–23.
54 Attempts to address these issues with operative fixation of patella fractures have included
55 the development of new fixation techniques and devices. Several patella plating constructs have
56 been shown to have favorable biomechanical properties24–30. In addition, case series with various
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57 patella plating techniques have shown promise in potentially improving clinical outcomes21,31,32.
58 We have developed a novel surgical technique for treating patella fractures that provides
59 multiplanar and interfragmentary fixation, addresses inferior pole comminution, and minimizes
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60 disruption to patellar vascularity using a low-profile mesh plate (Figure 1)33,34. The purpose of
61 this prospective cohort study was to determine if the new fixation construct resulted in improved
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62 outcomes compared to traditional tension band techniques for the treatment of displaced patella
63 fractures, as measured by knee-specific patient-reported outcome scores (KOS-ADLS) and

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64 functional strength measurements.
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68 PATIENTS AND METHODS
69 Selection Criteria
70 This study was approved by our institutional review board prior to data collection.
71 Patients were recruited to participate in the study if they were at least eighteen years old and
72 underwent open reduction and internal fixation of an isolated, unilateral patella fracture.
73 Additional inclusion criteria consisted of completion of outcome scores twelve months after
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74 surgery. Exclusion criteria consisted of inability to walk without assistance at three months after
75 surgery and contralateral lower extremity dysfunction. Demographic and clinical data were
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76 retrieved from patients’ medical records. Radiographic analysis was used to determine fracture
77 healing by the treating surgeon during routine follow-up intervals.
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79 Surgical Treatment
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80 Indications for surgical treatment included an articular step-off of 3mm or more and/or
81 fragment distraction of 5mm or more. All patients were surgically treated by a single, senior
82 surgeon (DGL) with the goals of anatomic reduction of the articular surface, achieving stable
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83 fixation, and restoring extensor mechanism function. A lateral parapatellar approach was used
84 for direct visualization of the articular surface as previously described35. Standard fracture
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85 reduction techniques were performed and provisional fixation achieved with fully threaded
86 Kirschner wires (K-wires). From 2008-2012, the fixation construct consisted of retrograde K-
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87 wires or cannulated screws and wiring or suturing in a figure-of-eight and/or cerclage fashion
88 (Figure 2). During the study period from 2012-2014, the novel fixation construct using a low-
89 profile mesh plate with multiplanar fixation was used (Figures 1 and 3). The plate configuration
90 can be fashioned depending on the fracture pattern using a 1.25mm wire cutter and contoured to
91 the patient’s patella anatomy33,34.
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93 Rehabilitation Protocol
94 Patients in both cohorts were subject to the same postoperative protocol, which included
95 immediate weight bearing as tolerated in a knee brace locked in extension. At 2 weeks
96 postoperatively, patients were allowed to perform isometric quadriceps contraction and straight
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97 leg raises. Range of motion exercises and low resistance stationary biking began 4 weeks
98 postoperatively. A chondromalacia patella strengthening protocol with quadriceps, VMO,
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99 hamstrings, and gastrocnemius-soleus resistance exercises were initiated at 2 months after
100 surgery.
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102 Clinical and Function Outcome Assessments

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103 Patient-reported, disease-specific clinical outcomes were prospectively collected at
104 predetermined intervals of three, six, and twelve months postoperatively, and objective
105 functional and strength outcomes were prospectively collected at twelve months
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106 postoperatively13. Subjective clinical outcomes were measured using the Knee Outcome Survey
107 Activities of Daily Living Scale (KOS-ADLS), which has been validated as a responsive
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108 measure for patients with patellofemoral symptoms undergoing physical therapy36–38. The
109 minimal clinical important difference for the KOS-ADLS is 7.138. Objective functional and
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110 strength outcomes were all performed by a single senior physical therapist, and all tests were
111 performed using the uninjured lower extremity as a control. Functional outcomes were grouped
112 into closed and open kinetic chain tests. Closed kinetic chain tests consisted of sit-to-stand,
113 forward lunge, and step-up-and-over13. Open kinetic chain tests evaluated quadriceps and
114 hamstring muscle functions using isometric knee flexion and extension, dynamic power flexion
115 and extension, and dynamic endurance flexion and extension as previously described13.
116 Comparisons between each cohort were performed using a percentage difference in the outcome
117 measurement between the operative and contralateral lower extremity; a lower percentage
118 difference represents improved function of the operative side. The sit-to-stand rising index was
119 measured as a percentage bodyweight as opposed to percentage difference between sides, and a
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120 higher rising index represents improved function. Thigh circumference of both extremities was
121 measured as a surrogate for muscle mass39 in a standardized fashion by the same physical
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122 therapist. The presence or absence of anterior knee pain at final follow up was also recorded for
123 each patient.
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125 Statistics
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126 Independent samples Student t-tests and chi squared tests were used to compare
127 demographic variables between cohorts for continuous and count variables, respectively. To
128 evaluate the primary outcome measure of KOS-ADLS scores over the entire study period, a
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129 mixed model repeated measures analysis was selected as it is able to determine between-subject
130 and within-subject effects over the study period while taking into account the longitudinal nature
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131 of the collected data. Demographic variables with differences that neared statistical significance
132 with regard to difference between groups (P<0.1) were loaded into the mixed model repeated
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133 measures analysis in order to eliminate the potential for confounding. With regard to secondary
134 outcomes, each functional outcome test was evaluated using Independent samples Student t-tests
135 to compare between groups. Levene’s test for equality of variances was used for each outcome to
136 determine whether to assume equal or unequal variances. A threshold for statistical significance
137 was set at P≤0.05.
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139 RESULTS
140 Thirty-three patients treated with a tension band construct (Figure 2) and twenty-five
141 patients treated with the novel plate construct (Figure 3) were included in the study. The two
142 cohorts had similar baseline characteristics, including mean age (60.0 years and 67.0 years,
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143 respectively), gender distribution (82% female and 92% female, respectively), dominant leg
144 involvement (67% and 56%, respectively), body mass index (24.1 and 23.6, respectively), and
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145 medical comorbities (Supplemental Digital Content 1 http://links.lww.com/BOT/A847) (P>0.05
146 for all).
147 For both groups, the patient-reported, disease-specific KOS-ADLS scores increased
148 significantly over the study period (P=0.035), indicating a consistent progress toward recovery
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149 regardless of implant construct (Supplemental Digital Content 2
150 http://links.lww.com/BOT/A848). The plate construct group, however, had statistically and
151 clinically significantly elevated KOS-ADLS scores throughout the study period compared to the
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152 tension band group (P<0.001), a finding that remained significant when controlling for age
153 (P=0.002) (Supplemental Digital Content 2).

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154 Several objective functional testing outcomes demonstrated modest superiority in the
155 plate cohort. Closed kinetic chain functional testing demonstrated mean improvements in the
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156 plate cohort using sit-to-stand (P=0.029-0.93), step up-and-over (P=0.028-0.931), and forward
157 lunge (P=0.028-0.067) exercises, with significant improvements in four measurements
158 (Supplemental Digital Content 3 http://links.lww.com/BOT/A849). Similarly, open chain
159 strength testing revealed significant improvements in the plate cohort during static and dynamic
160 open chain exercises, including isometric knee flexion (P= 0.001), endurance knee flexion (P=
161 0.007), and power knee extension (P=0.006) and flexion (P= 0.011) (Table 1).
162 Thigh circumference difference was significantly better at 12 months in the plate cohort
163 (0.38cm versus 1.28cm, p = 0.003), indicating more symmetric muscle bulk (Table 1). Lastly,
164 anterior knee pain at 12 months was reported in significantly more patients with tension band
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165 constructs (27/33, 82%) than with the plate construct (3/25, 12%) (p<0.0001) (Table 2).
166 There was one complication in the tension band cohort due to a wound dehiscence that
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167 required a gastrocnemius rotational flap. Otherwise, there were no other complications in either
168 group during the study period, including no infections, nonunions, or implant failures.
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170 DISCUSSION
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171 Operative treatment of patella fractures using traditional tension band constructs have
172 resulted in impaired functional outcomes overall despite anatomic reductions and low rates of
173 complications, nonunion, and malunion13,18,19. Patients treated with tension band constructs
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174 report a high prevalence of knee pain up to a year from surgery. The etiology of their pain is
175 likely multifactorial resulting from soft tissue irritation from the implants, chondral damage from
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176 the initial injury, and patella maltracking and subsequent loading of the patella during
177 rehabilitation due to weakened quadriceps. Knee pain in these patients likely limits their ability
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178 to perform effective physical therapy and their subsequent functional outcome is compromised.
179 When appropriate rehabilitation is inhibited by knee pain, the quadriceps atrophies and causes
180 patella maltracking, increased stress on the articular surfaces, and further knee pain. In this
181 prospective cohort study, the use of a novel low-profile patella plating construct with multiplanar
182 and interfragmentary fixation has led to decreased anterior knee pain and improved clinical and
183 functional outcomes over traditional tension band constructs.
184 Others have investigated the use of alternative means of patella fracture fixation. Through
185 biomechanical models, Thelen et al. demonstrated improved fracture fixation with decreased
186 fracture gapping and increased failure loads using fixed-angle plating compared to anterior
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187 tension band constructs26–28. A similar result was recently reported by Wurm et al25. Limited
188 clinical studies using case series have suggested favorable outcomes in patients treated with
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189 various patella plate constructs31,32. However, these studies lack comparisons to traditional
190 fixation techniques and include different types of plating constructs that varied based on the
191 fracture characteristics.
192 In an attempt to improve postoperative outcomes following open reduction and internal
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193 fixation of patella fractures, we have developed a novel construct to provide stable fracture
194 fixation with a low-profile implant construct. The new constructs provides improvements in
195 patella fracture fixation with the ability to place the plate circumferentially around the lateral half
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196 of the patella and to transfix the plate with multiple bicortical interfragmentary compression
197 screws from lateral to medial, proximal to distal, and distal to proximal. Unicortical locking
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198 screws are placed from anterior to posterior for augmentation with fixed-angle stability. With the
199 anterior screws locking into the plate and the ability to contour the plate in situ, the construct
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200 remains low profile with minimal soft tissue irritation. The plate design also allows for secure
201 reinforcement of inferior pole comminution with the use of a Krackow stitch through the patella
202 tendon that is tied through the plate. Also, the surgical approach and plate position protect the
203 vascularity of the patella, which is predominantly inferomedial40. While removal of implants for
204 patella fractures is common with tension band constructs19, we did not have any patients treated
205 with the novel plate construct that required implant removal for pain relief.
206 The prospective cohort design of this study has several strengths. All cases were
207 performed by a single senior surgeon using the same surgical approach, and all functional
208 outcome evaluations were completed by a single senior physical therapist for improved
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209 precision. Patients in each cohort underwent the same rehabilitation protocol postoperatively.
210 The outcomes for functional evaluations were calculated using patients’ contralateral lower
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211 extremities as controls. In addition, complications in both groups were minimal. Three time
212 points for the patient-reported outcomes and the one time point for functional outcomes were
213 used for each patient to optimize our ability to compare the two cohorts.
214 Limitations of this study include only twelve months of outcomes postoperatively; and
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215 while the current study has shed light on postoperative recovery and early outcome differences
216 following these fixation techniques, further studies will be needed to determine whether the
217 differences observed here are sustainable. The patients and physical therapist evaluator were not
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218 blinded to their treatment construct; although, the majority of outcomes were objective
219 measurements controlled against the contralateral lower extremity which are unlikely affected by
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220 observer bias. In addition, while the list price of the plate construct ($2,000) is higher than the
221 cannulated screw tension band construct ($1,000), a comprehensive cost analysis that accounts
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222 for the improved clinical outcomes with the plate construct is beyond the scope of this work.
223 This study suggests that the use of a novel fixation construct for patella fractures
224 improves patient outcomes postoperatively. We believe this new construct improves fracture
225 stability, decreases soft tissue irritation, and minimizes disruption to patellar vascularity all of
226 which may contribute to decreased anterior knee pain. Furthermore, by treating patellar fractures
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227 as patellofemoral periarticular fractures with anatomic articular surface reduction and rigid
228 fixation rather than merely restoring extensor mechanism continuity using a tension band
229 technique, subsequent shear stress to the patellofemoral articular cartilage is minimized. This is
230 important given the magnification of the effect of residual articular stepoff via patellofemoral
231 joint reactive forces of up to 3.1x body weight during ADLs41–43 and up to 11x body weight
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232 during physical activity44. With decreased knee pain, patients are able to perform more effective
233 physical therapy and improve their quadriceps strength and gait mechanics, further facilitating
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234 restoration of patients’ knee function to pre-injury levels.
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343
344 FIGURE LEGENDS
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346 Figure 1. Demonstrations of the novel patella fracture fixation construct. A mesh plate cut to a
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347 typical pattern used prior to contouring, and a contoured plate fixed to a patella model
348 demonstrating the plate’s ability to wrap circumferentially along the lateral half of the patella (a).
349 Anterior-posterior (AP) and lateral post-operative radiographs of a patella following fixation
350
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with the novel construct (b).
351
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352 Figure 2. Case example using a tension band construct. Anterior-posterior (AP) and lateral injury
353 radiographs of a transverse patella fracture (a). Three-dimensional computed tomography of the
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354 fracture pattern (b). AP and lateral intra-operative fluoroscopic images and 6-month
355 postoperative radiographs demonstrating appropriate implant position and fracture reduction (c).
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357 Figure 3. Case example using a novel fixation construct. Anterior-posterior (AP) and lateral
358 injury radiographs of a transverse patella fracture with inferior pole comminution (a). Three-
359 dimensional computed tomography of the fracture pattern (a). AP, medial facet, and lateral facet
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360 intra-operative fluoroscopic images and 6-month postoperative AP and lateral radiographs
361 demonstrating appropriate implant position and fracture reduction demonstrating appropriate
362 implant position and fracture reduction (c).
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364 Supplemental Digital Content 2. Comparisons of KOS-ADLS scores between patients with
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365 tension band and plate constructs over the study period. * P<0.001 using mixed model repeated
366 measures analysis comparing the plate and tension band cohorts.
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Table 1. Objective strength outcomes using open chain static and dynamic exercises
measurements in the in the two treatment cohorts.
Tension Band Plate Mean

p-Value
Mean (SD) (SD)
Isometric Knee Extension
38.69 (28.78) 21.68 (31.36) 0.075
(% difference)
Static
Isometric Knee Flexion
17.04 (18.67) -0.75 (15.36) 0.001*
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(% difference)
Endurance Knee Extension
30.57 (34.29) 26.67 (39.58) 0.74
(% difference)
Endurance Knee Flexion
24.31 (30.34) -1.04 (28.50) 0.007*
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(% difference)
Dynamic
Power Knee Extension
44.57 (38.67) 16.33 (27.18) 0.006*
(% difference)
Power Knee Flexion
18.71 (16.13) 5.29 (16.60) 0.011*
(% difference)
*P≤0.05
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Table 2. Thigh circumference measurements and anterior knee pain in the two treatment cohorts.
Tension Band Plate Mean

p-Value Test
Mean (SD) (SD)
Thigh Circumference t-test
*
(Uninjured cm- 1.28 (0.99) 0.38 (0.91) 0.003
Injured cm)
% Anterior Knee Chi
82% 12% <0.0001*
D
Pain Squared
*P≤0.05
TE
EP
C
C
A
D
TE
EP
C
C
A
D
TE
EP
C
C
A
D
TE
EP
C
C
A

Superior Outcomes After Operative Fixation of Patella Fractures Using A Novel Plating Technique - A Prospective Cohort Study

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Superior Outcomes After Operative Fixation of Patella Fractures Using A Novel Plating Technique - A Prospective Cohort Study

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Superior Outcomes After Operative Fixation of Patella Fractures Using A Novel Plating Technique - A Prospective Cohort Study

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Journal of Orthopaedic Trauma Publish Ahead of Print

Superior Outcomes after Operative Fixation of Patella Fractures using a

Novel Plating Technique: a Prospective Cohort Study

Pediatric Orthopaedic Service

Hospital for Special Surgery

Gina Sauro PT, DPT

Department of Physical Therapy

New York Presbyterian Hospital

Orthopaedic Trauma Service

Orthopaedic Trauma Service

Orthopaedic Trauma Service

Harborview Medical Center

Stephen J. Warner MD, PhD

Orthopaedic Trauma Service

Hospital for Special Surgery

Stephen J. Warner MD, PhD

Hospital for Special Surgery

535 East 70th Street

New York, NY 10021

Diego, CA, October 9, 2015.

10 Patients/Participants: Patients with isolated, unilateral patellar fractures were enrolled

14 treatment consisted of traditional tension band fixation techniques.

17 novel plate construct.

19 Main Outcome Measurements: Subjective postoperative clinical outcomes and objective

20 functional and strength measurements were subsequently collected.

25 demonstrated significant improvements in patients with plate constructs compared to tension

32 improved clinical outcomes and functional performance.

34 Key Words: Patella fracture;outcomes;plate;tension band

63 fractures, as measured by knee-specific patient-reported outcome scores (KOS-ADLS) and

64 functional strength measurements.

68 PATIENTS AND METHODS

77 healing by the treating surgeon during routine follow-up intervals.

91 the patient’s patella anatomy33,34.

95 immediate weight bearing as tolerated in a knee brace locked in extension. At 2 weeks

98 postoperatively. A chondromalacia patella strengthening protocol with quadriceps, VMO,

102 Clinical and Function Outcome Assessments

123 each patient.

137 was set at P≤0.05.

146 for all).

153 (P=0.002) (Supplemental Digital Content 2).

157 lunge (P=0.028-0.067) exercises, with significant improvements in four measurements

158 (Supplemental Digital Content 3 http://links.lww.com/BOT/A849). Similarly, open chain

183 functional outcomes over traditional tension band constructs.

191 fracture characteristics.

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