Tension-band wiring is the default for displaced patellar fractures and everyone who does it knows its problems: prominent hardware, wire migration, loss of fixation, and a high rate of removal. Locking plates are biomechanically stronger but have had almost no clinical outcome data behind them.
This multicentre randomised trial, blinded to both patient and assessor, assigned 122 adults with displaced patellar fractures 1:1 to locking plate fixation or tension-band wiring. The primary outcome was patient-reported knee function across all five KOOS sub-scales at 12 months, and superiority was defined in advance as a statistically significant difference exceeding the minimal clinically important difference on at least three sub-scales. Follow-up was completed by 90.5% and 88.1% of the two groups.
The threshold was met. Locking plates produced clinically meaningful improvements in 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, failure of fixation and reoperation were all more frequent after wiring.
What makes this convincing is the prespecification. Studies reporting multiple sub-scales can find a positive result by chance; defining in advance that three of five must exceed a stated clinical threshold removes that.
The consideration this trial does not address is cost. A locking plate costs substantially more than wire and a tension band, which in Indian practice is often paid directly by the patient. The counterargument is the reoperation rate: hardware removal is a second anaesthetic, a second admission and a second period off work, and that is where the wiring saving disappears.
- Prefer locking plate fixation to tension-band wiring for displaced patellar fractures requiring surgery
- Expect less hardware removal, less fixation failure and fewer reoperations
- Quote the functional difference honestly: about 10 to 14 KOOS points on symptoms, sport and quality of life
- Factor the reoperation rate into the cost conversation, not just the implant price
- Note this covers displaced fractures needing surgical fixation, not undisplaced fractures managed conservatively
The statistics, in plain English
The design feature that carries this result is the prespecified superiority rule. With five sub-scales tested, one significant difference would be unremarkable — the trial required three, each exceeding a stated minimal clinically important difference, and got exactly three. That is a demanding bar honestly met. The intervals are wide, particularly for sport and recreation at -24.7 to -3.4, reflecting 122 patients, so the size of the benefit is imprecise even though its existence is not. The complication differences are reported without confidence intervals and should be read as a consistent direction rather than a quantified effect.
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