Tension-band wiring remains the standard for displaced patellar fractures despite high rates of hardware irritation, migration and reoperation. Locking plates are biomechanically superior in the laboratory, but clinical evidence has been thin. This patient- and assessor-blinded multicentre randomised trial enrolled 122 adults with displaced patellar fractures, assigning them 1:1, with a demanding superiority definition set in advance: statistically significant differences exceeding the minimal clinically important difference on at least three of the five KOOS sub-scales at twelve months.
That threshold was met. Locking plate fixation was 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). Follow-up was 90.5% and 88.1% in the two arms. Hardware removal, failure of fixation and reoperation all occurred more often after tension-band wiring.
The pre-specified superiority definition is what makes this convincing. Requiring three sub-scales to clear the minimal clinically important difference is a much harder test than finding one significant p-value among five, and it was set before the data were seen. Cost and implant availability remain real constraints, and plates are more expensive. But on outcomes, this is high-level evidence that the default technique should change where plates are available.
- Superior on three KOOS sub-scales: symptoms, sport and recreation, quality of life
- All three differences exceeded the minimal clinically important difference
- More hardware removal, fixation failure and reoperation after wiring
- Superiority criteria set in advance, requiring three of five sub-scales
The statistics, in plain English
The value of this trial is in its pre-specified threshold. Testing five sub-scales without one would risk a chance finding — with five outcomes, one significant result is likely by luck alone. Demanding three, each exceeding the minimal clinically important difference, makes an accidental positive very improbable. The intervals are wide, particularly for sport and recreation at 3.4 to 24.7, so the size of the benefit is uncertain even though its existence is well supported.
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