Locking plates beat tension-band wiring for displaced patellar fractures

The edition in brief

Tension-band wiring for patellar fractures has persisted despite well-known complication rates because nothing had been shown to be better. 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 predefined as significant differences exceeding the minimal clinically important difference on at least three sub-scales. Locking plates achieved exactly that: symptoms (mean difference -10.4, 95% CI -16.4 to -4.4), sport and recreation (-14.1, -24.7 to -3.4) and quality of life (-10.9, -19.0 to -2.7). Hardware removal, fixation failure and reoperation were all more frequent after wiring. A dose-response meta-analysis of 20 randomised trials in 791 people with knee osteoarthritis modelled resistance exercise volume against outcome using restricted cubic splines. Pain reduction peaked around 6,000 total repetitions, functional improvement around 2,600 repetitions at moderate intensity, and strength gain around 1,600. Certainty was low to very low. An interim analysis of 107 patients randomised to robotic-assisted or jig-based medial unicompartmental knee arthroplasty found better component positioning, less inpatient pain and opioid use and shorter stay with the robot, but no difference in Oxford Knee Score, KOOS or WOMAC at two years. A meta-analysis of 12 randomised trials in 1,327 patients found adding a lateral extra-articular procedure to primary ACL reconstruction reduced graft failure and positive pivot shift.