Tension-band wiring has been the default for displaced patellar fractures for decades despite well-documented complication rates and frequent hardware removal. Locking plates are biomechanically more stable, but until now the clinical comparison rested on small series. This patient- and assessor-blinded multicentre randomised trial assigned 122 adults with displaced patellar fractures 1:1 to locking plate fixation or tension-band wiring, with the five KOOS sub-scales at 12 months as the primary outcome and superiority defined in advance as a significant difference on at least three sub-scales, each exceeding the minimal clinically important difference.
It met that bar. Locking plates were superior on symptoms (mean difference 10.4 points, 95% CI 4.4 to 16.4), sport and recreation (14.1, 3.4 to 24.7) and quality of life (10.9, 2.7 to 19.0), against minimal clinically important differences of 9, 10 and 10 respectively. Hardware removal, fixation failure and reoperation all occurred more frequently after tension-band wiring. Follow-up was complete in 57 of 63 (90.5%) and 52 of 59 (88.1%).
What makes this convincing is the design rather than the size. Blinding both the patient and the outcome assessor in a fracture trial is difficult and is exactly what is usually missing from surgical comparisons — and the prespecified requirement for three sub-scales to clear their clinical thresholds is a much harder test than a single significant p value.
The practical consequence is a change to a default technique. For a displaced patellar fracture in an adult, plate fixation is now the better-evidenced choice, and the argument is strengthened by the reoperation data: much of the misery of tension-band wiring comes from prominent hardware that has to come out in a second operation.
The counterweight in Indian practice is implant cost. Tension-band wiring uses K-wires and cerclage wire and costs almost nothing; a patellar locking plate does not, and in a self-funding patient that difference is real. The honest framing is that the plate costs more up front and appears to save a second operation, and that the functional difference is genuine but concentrated in sport, recreation and quality of life rather than in basic activities of daily living. For a manual worker or an active adult, the case is strong; for a low-demand elderly patient it is less compelling.
- Make locking plate fixation the default for displaced patellar fractures in active adults.
- Quote the benefit accurately: symptoms, sport and recreation, and quality of life — not activities of daily living.
- Factor in reduced hardware removal and reoperation when discussing implant cost with a self-funding patient.
- The trial blinded both patients and assessors, which is unusual and strengthens the result considerably.
- In low-demand elderly patients the functional advantage matters less; cost may reasonably decide.
The statistics, in plain English
The prespecified superiority rule is what gives this weight. Requiring at least three of five sub-scales to be both statistically significant and above their minimal clinically important difference guards against two common problems at once: finding significance on one outcome out of five by chance, and finding a real but trivially small difference. The intervals are wide — sport and recreation runs from 3.4 to 24.7 points — because 122 patients is a modest trial, so the size of the benefit is uncertain even though its existence is well supported. About one in ten patients was lost to follow-up in each arm, which is good for a fracture trial.
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