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IntroductionWe present the surgical technique of rim-plate-augmented separate vertical wiring for comminuted inferior pole fracture of the patella and report the clinical outcomes.Materials and methodsBetween July 2013 and January 2016, 13 patients (7 male and 6 female) who were diagnosed with comminuted inferior pole fracture of the patella in preoperative computed tomography and underwent a minimum of 1 year of follow-up were enrolled in this study. Mean patient age was 57.7 years (range 28–72 years). All patients underwent open reduction and internal fixation by rim-plate-augmented separate vertical wiring. Bony union, complications, range of motion and Bostman score were the clinical outcomes.ResultsBony union was achieved in all cases at an average of 10 weeks after surgery (range 8–12). There was no loss of reduction and fixative failure during follow-up. The average range of motion was 127° (range 120°–130°). The mean Bostman score at last follow-up was 29.6 points (range 27–30) and graded excellent in 12 patients.ConclusionRim-plate-augmented separate vertical wiring demonstrated secure fixation and favorable clinical outcomes. This study provides evidence for its effectiveness as a fixation method for treating displaced, comminuted inferior pole fracture of the patella.

PurposeComminuted inferior pole fractures of the patella are notorious fractures where it is difficult to obtain rigid internal fixation by conventional tension band wiring. The purpose of this study is to evaluate the clinical and radiological outcomes of the suture bridge anchor fixation for these comminuted inferior pole fractures of the patella.MethodsFrom March 2012 to December 2018, suture bridge anchor fixation for the inferior pole comminuted fracture of the patella was performed in 22 patients. There were 21 patients of inferior pole comminuted fracture and 1 patient of lower periosteal sleeve avulsion fracture. Clinical outcomes including SF-36 score, Knee injury and osteoarthritis outcome score (KOOS) and post-operative range of motion were evaluated. In all patients, suture bridge anchor fixation was performed and, tension band wiring with K wire was added for large fragment fixation in two patients. We evaluated bony union, the patellar height using Insall–Salvati ratio and its complications.ResultsMean age was 46 ± 20 (15–82) years. Mean follow-up period was 25 ± 18 (11–74) months. In all patients, bony union was achieved at postoperative 4 months. At final follow-up, mean SF-36 score was 72 ± 15 (30–91) points and KOOS score was 66.7 ± 16 (43–97). The average range of motion was 134 ± 5 (125–140) degrees. As a complication, one patient developed a wound infection and subsequent osteomyelitis of inferior pole fracture fragment. Compared to the normal knee, the Insall–Salvati ratio of the injured knee averages 0.73 and this smaller ratio less than 0.8 meant patella baja.ConclusionsIn the comminuted inferior pole fractures of the patella, suture bridge anchor fixation showed good bony union and satisfactory clinical outcomes at the short-term follow-up and could be a satisfactory alternative treatment option. Even though suture bridge anchor fixation in these fractures caused decreased Insall–Salvati ratio (patella height), any patellofemoral pain and limited range of motion was not developed.Level of evidenceLevel IV

IntroductionInferior pole fracture of the patella (IPFP) is difficult to repair and stabilize clinically. Although various fixation techniques have been developed, fixation strength and mobility remain daunting challenges to orthopedic surgeons. The goal of this research is to evaluate the biomechanical strength and clinical outcomes of a novel “fishing net” suture fixation procedure.Materials and methodsFour finite element models, modified tension-band wiring fixation, anchor suture fixation, basket plate fixation and “fishing net” suture fixation were built to compare the fixing efficacy of “fishing net” suture fixation with three other fixation methods during IPFP fixation. From January 2018 to February 2019, 17 patients who suffered IPFP and treated by “fishing net” suture (FNS) fixation were compared with 20 patients treated by tension-band wiring (TBW) fixation in database and the two groups were evaluated postoperatively using the modified Cincinnati knee rating system.ResultsBiomechanical evaluation showed that the relative displacement values of proximal patella measured by three pairs of points on both sides of the fracture line were the lowest using the “fishing net” suture fixation, while fixation using tension-band wiring and basket plate showed similar levels of stability that were less desirable than the “fishing net” method. As to clinical outcomes, there were 17 (100%) patients exhibited excellent or good results with no internal fixation failures in the FNS group compared to three internal fixation failures in the TBW group.ConclusionThe biomechanical and clinical results suggest that the “fishing net” suture fixation is a viable candidate for fixation of IPFP.

Background Maintaining effective reduction and firm fixation in inferior pole patellar fractures is a highly challenging task. There are various treatment methods available; although tension-band wiring combined with cerclage wiring (TBWC) is the mainstream approach, its effectiveness is limited. Herein, we propose and evaluate a new technique called candy box (CB), based on separate vertical wiring (SVW), for the treatment of inferior pole patellar fractures. Specifically, we provide biomechanical evidence for its clinical application. Methods Five fixation models were built: SVW combined with cerclage wiring (SVWC); TBWC; modified SVW with the middle (MSVW-A) or upper (MSVW-B) 1/3 of the steel wire reserved, and CB. A finite element analysis was performed to compare the displacement and stress under 100-N, 200-N, 300-N, 400-N and 500-N force loads. Three-dimensional printing technology was utilized to create fracture models, and the average displacement of each model group was compared under a 500-N force. Results The results of the finite element analysis indicate that CB technology exhibits significantly lower maximum displacement, bone stress, and wire stress compared to that with other technologies under different loads. Additionally, in biomechanical experiments, the average force displacement in the CB group was significantly smaller than that with other methods under a 500-N force (P < 0.05). Conclusions CB technology has the potential to overcome the limitations of current techniques due to its superior biomechanical characteristics. By incorporating early functional exercise and ensuring strong internal fixation, patient prognosis could be enhanced. However, further clinical trials are needed to fully evaluate the therapeutic effects of CB technology.

PurposeComminuted inferior patellar pole fractures are challenging injuries and require effective treatment due to the extension mechanism of the knee. This study aims to evaluate the outcome of above fractures treated with a modified technique of cerclage-wire-augmented separate vertical wiring (SVW) with cerclage wiring passed through the proximal patella.MethodsRetrospective analysis (1/2017–1/2020) were performed for patients that were treated with three SVWs through the posterior margin of proximal fragment and directly to the anterosuperior border of patella, combined with a cerclage wiring passed through the proximal patella. Patients who experienced comminuted inferior patellar pole fractures within 3 weeks were included, and the outcome was evaluated radiologically and clinically by Bostman score after a minimum of 12 months following surgery. Further evaluation included the operation time and complication rate.ResultsA total of 20 patients (10 males, 10 females) with a mean age of 54 ± 14.5 years (26–83 years) and a follow-up of 18.9 ± 6.6 months (12–36 months) were evaluated. The average operation time was 45.7 ± 8.8 min (30–60 min). At final follow-up, the average range of motion was 131.3° ± 3.5° (125°–135°), and the mean Bostman score was 29.4 ± 0.7 points (28–30) and graded excellent in all cases. Two patients experienced occasional giving way of the knee. Radiologically no loss of reduction, implant breakage, nonunion or skin irritation was observed.ConclusionsThe cerclage-wire-augmented SVW with cerclage wiring passed through the proximal patella appears to be a safe and simple technique which can effectively treat the comminuted inferior patellar pole fractures.

Purpose This study aimed to comprehensively review the existing evidence concerning surgical treatment of inferior pole fractures of the patella and to report the outcomes and complications of different fixation techniques. Method This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches of PubMed, Scopus, and Web of Science were conducted in March 2023. Studies were screened against predecided inclusion and exclusion criteria. The extracted data included fracture characteristics, surgical techniques, and radiographic and functional outcomes. The Methodological Index for Non-Randomized Studies (MINORS) quality assessment tool was used to assess the eligible literature. The primary outcome was postoperative range of motion of different surgical methods, and the secondary outcomes were other clinical results and complications. Results A total of 42 studies satisfied all the inclusion criteria and were deemed suitable for review. Fourteen case–control studies and 28 case series were selected, for a total of 1382 patients with a mean age of 51.0 years (range = 11–90). The follow-up period ranged from 6 to 300 months. The surgical techniques were categorized based on the device used as follows: (1) rigid fixation device; (2) tensile fixation device; (3) mixed device; and (4) extra-patella device. Conclusion Regarding the outcomes following surgical treatment of inferior pole fractures of the patella, the postoperative range of motion (ROM) of each technique ranged from 120° to 135°, with the exception of that involving the patellotibial wire which had poorer outcomes. The lowest functional score was also found in those using the patellotibial wire. Complications after surgery are rare, but approximately half of the patients required additional surgery for implant removal, particularly those whose initial surgery involved rigid fixation devices. It's worth noting that bony fragment excision is no longer recommended, and the combined use of multiple surgical devices is now more common.

Objective The treatment of comminuted inferior pole patellar fractures has long posed a challenge for orthopedic surgeons. This study aims to compare the biomechanical stability and clinical efficacy of Kirschner wire tension band combined with anchor cross-suture fixation versus traditional partial patellectomy in the treatment of comminuted inferior pole patellar fractures. Methods A retrospective analysis was conducted on 14 patients who underwent Kirschner wire tension band combined with anchor cross-suture fixation (Group A) in our department of orthopedics from September 2020 to April 2022. Additionally, we matched 14 patients with similar baseline characteristics who received inferior pole patellectomy combined with patellar tendon repair (Group B). The two groups were compared in terms of operative time, intraoperative blood loss, postoperative complications, and at the final follow-up, knee range of motion (ROM), visual analogue scale (VAS) score, Bostman knee function score, peak knee torque, and Insall-Salvati (IS) ratio. Results All patients were followed up for more than 12 months. At the final follow-up, Group A showed significantly better outcomes than Group B in terms of knee range of motion (ROM), Bostman knee function score, knee VAS score, and average peak knee torque, with statistically significant differences ( P  < 0.05), indicating faster postoperative recovery and better clinical results in Group A. The IS ratio of the injured knee in Group B was 0.71 ± 0.66, less than 0.8, suggesting a decrease in patellar height. There were no significant differences between the two groups in terms of operative time, intraoperative blood loss, or incision length ( P  > 0.05). In Group A, one patient experienced complications from hardware irritation, while in Group B, one patient had postoperative knee pain, and two patients experienced knee extension weakness after cast removal and rehabilitation. Conclusion Kirschner wire tension band combined with anchor cross-suture fixation for the treatment of inferior pole patellar fractures yields satisfactory results. This technique provides reliable fixation, restores the original extensor mechanism, promotes early postoperative rehabilitation, and reduces the incidence of complications, making it suitable for clinical application and widespread use. Evidence level Level III (retrospective comparative study)

Background The optimal surgical technique for the fixation of inferior pole patellar fracture remains controversial. The aims of this study were (1) to compare clinical and radiological outcomes following fixation of inferior pole patellar fracture by using tension band wire (TBW) and transosseous reattachment (TOR) without excision of the bony fragment and (2) to determine the risk factors for postoperative radiological loss of reduction. Methods For this retrospective cohort study, consecutive patients with inferior pole patellar fracture between January 2010 and December 2017 were recruited. The patients were grouped according to their fixation method (TBW or TOR), and demographic data, clinical outcomes, and postoperative Insall–Salvati (IS) ratio were analyzed. Then, the patients were grouped according to radiological loss of reduction, the possible risk factors for loss of reduction were identified, and odds ratios were calculated. Result This study included 55 patients with inferior pole patellar fracture; 30 patients were treated using TBW and 25 were treated using TOR. Clinical failure occurred in two patients in the TBW group (7%) and three in the TOR group (12%). The rate of radiological loss of reduction was significant higher in the TOR group, whereas removal of implants was significantly more common in the TBW group. Patella baja was noted immediately after surgery in the TOR group, but the IS ratios of the two groups were similar after 3 months. Fracture displacement of more than 30 mm was the only independent risk factor for postoperative radiological loss of reduction. Conclusion For treating inferior pole patellar fracture, both TWB and TOR were effective and had a low clinical failure rate. In 60% of patients undergoing TBW fixation, however, additional surgery was required to remove the implants. Patella baja occurred immediately following TOR, but the patellar height was similar to that in the TBW group after 3 months. Surgeons should be aware of the high risk of postoperative radiological loss of reduction, especially when the fracture displacement is more than 30 mm.

Objective Most inferior pole fractures of the patella are comminuted. Therefore, an ideal treatment method has not been determined. We have presented a modified tension band fixation technique—the Krachow suturing, Nice knot combined with tension band fixation—and reported the results of the procedure. Methods A total of 16 inferior patellar pole fractures were treated at our institution between January 2019 and October 2020, 15 of which underwent treatment with the modified tension band fixation technique consisting of Krachow suturing with Nice knots combined with tension band fixation. The primary measures: knee motion, Bostman score, anterior knee pain, fixation failure. Results Bone union occurred at a mean of 9 weeks postoperatively (range: 8–13). There were no cases of postoperative anterior knee pain, refracture of the inferior patellar pole or wire breakage. The patients regained full ROM of the knee joint without functional deficits during follow‐up; the mean ROM was 128.46° ± 7.07° (range: 113.4°–137.8°). At the last follow‐up, all patients had a mean Bostman score of 28.40 ± 1.29 (range: 26–30), with an excellent score in 11 patients and a good score in four patients. Conclusion The modified tension band fixation technique for the treatment of inferior patellar pole fractures is a simple and easy‐to‐perform surgical technique that provides stable fixation and good functional results. Most inferior patellar pole fractures are comminuted, so it is difficult to achieve anatomical reduction and strong fixation. As a result, many investigators have proposed different surgical techniques and devices to treat inferior patellar pole fractures, such as partial patellectomy, screw fixation with a titanium cable or steel wire, interwoven sutures and basket plates, mesh plates, angle‐stable locking plates, wire interwoven sutures and Krachow sutures, and separate vertical wiring (SVW). The modified tension band fixation technique (Krachow suturing with Nice knots combined with tension band fixation) for the treatment of inferior patellar pole fractures is a simple and easy‐to‐perform surgical technique that provides stable fixation and good functional results.

Objective Inferior pole fracture of the patella (IPFP) is notoriously difficult to manage. Although multiple surgical options are available, the percutaneous cannulated-screw tension-band (PCST) technique remains the conventional choice, despite its high complication rate. The recently introduced technique of tension-band wiring through a cannulated screw with suture anchors (TACS-SA) offers a promising alternative, though its efficacy requires further validation. This study was conceived to compare the biomechanical behaviour and early clinical results of the TACS-SA construct with PCST fixation. Methods This study comprises a finite-element analysis (FEA) and clinical investigation. In the FEA, a knee flexion of 45° under 200 N contact stress was simulated. Three fracture models were constructed for the TACS-SA, PCST with a figure-of-eight tension band (EPCST), and PCST with a figure-of-zero tension band (ZPCST). Fracture fragment stability was assessed by measuring mean displacement (MD-FF) and mean stress (MS-FF). The biomechanical strength of the fixation device was evaluated via its mean displacement (MD-IF) and mean stress (MS-IF). The clinical cohort included 43 patients, with 25 undergoing TACS-SA and 18 undergoing EPCST. Recorded parameters included bone union time, radiographic union time, range of motion (ROM), and follow-up duration. At the final follow-up, functional outcomes were evaluated with the Böstman score, KOOS score, and extension lag. Results In the FEA, the TACS-SA models consistently showed lower MD-FF, MS-FF, and MD-IF across all three fragment conditions ( p  < 0.05), with the MS-IF of TACS-SA being moderate but not significant in the one-fragment condition ( p  > 0.05). In the retrospective cohort, the TACS-SA group achieved radiographic union earlier than the EPCST group ( P  < 0.05). Similar results were observed in the KOOS score, bone union period, ROM, Böstman score, and extension lag between the groups ( P  > 0.05). Conclusion The TACS-SA technique exhibits superior biomechanical properties and clinical outcomes to the conventional PCST technique when treating IPFP.