Patellar distal pole fracture treatment with transosseous sutures vs vertical cerclage wire techniques: a comparative retrospective cohort study

Patellar distal pole fracture treatment with transosseous sutures vs vertical cerclage wire techniques: a comparative retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patellar distal pole fracture treatment with transosseous sutures vs vertical cerclage wire techniques: a comparative retrospective cohort study Jose Ignacio Laso, Jose Tomas Muñoz, Sebastian Bianchi, Diego Martínez, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8695399/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Purpose To compare transosseous sutures (TOS) and vertical wire cerclage (VCW) for treating distal pole patellar fractures and evaluate their equivalence in terms of clinical outcomes, patient reported outcome measures (PROMs), radiographic outcomes and complications. Methods We conducted a non-concurrent cohort study retrospectively reviewing all patients surgically treated for patellar distal pole fractures (AO/OTA 34A1b) with either TOS or VCW between 2015 and 2023. Patient characteristics, surgical technique and postoperative follow-up data, patellar height and complications were recorded. Functional outcomes were evaluated at least 12 months postoperatively using PROMs (Kujala, Lysholm and Bostman scores). Internal approval of the Institutional Ethics Committee was gained, and informed consent was obtained from all patients. Results A total of 46 patellar distal pole fractures were included; 30 TOS and 16 VCW. Baseline characteristics were comparable between groups. No significant differences were found between groups regarding clinical nor functional outcomes or complications. No significant differences were found respecting patellar height. However, significant length variation was found in the TOS group, with a mean elongation of 3.77 mm (p 0.001). Conclusion Both Transosseous sutures and vertical cerclage wires reinsertion techniques achieve good clinical and radiographic outcomes. Nonetheless, the finding of patellar elongation warrants further investigation to elucidate its etiology and potential clinical relevance. Patellar fractures Distal Pole Inferior Pole Extensor mechanism injury Patellar trauma Figures Figure 1 Figure 2 Figure 3 Introduction Patellar fractures constitute approximately 0.5% to 2% of all fracture cases, with an estimated incidence of 13.1 per 100,000 individuals annually [ 1 , 2 ]. These fractures exhibit a characteristic bimodal distribution, affecting younger individuals typically involved in high-energy incidents or sports activities, and older adults—predominantly women—who sustain low-energy injuries, such as ground level falls resulting in direct impact to the knee[ 3 ]. Effective management of these fractures demands the restoration of the articular anatomy, and recovery of the knee's extensor mechanism, promoting early mobilization [ 2 , 4 ]. Fractures of the inferior pole of the patella are relatively uncommon, accounting for approximately 5% to 22.4% of all patellar fractures [ 5 ]. These fractures are often complex, characterized by significant comminution and displacement, which complicates their reduction and fixation. Additionally, the distal fragments tend to be small, and the cancellous bone is typically weak, posing a challenge for stabilization using conventional techniques [ 3 , 6 , 7 ]. Since most of these injuries are extraarticular, the main goal of surgical treatment is to restore the knee's extensor mechanism rather than to precisely align the articular surface [ 8 – 10 ]. Moreover, these fractures are susceptible to complications, particularly implant-related issues such as fixation failure and symptomatic osteosynthesis [ 5 , 6 , 11 , 12 ]. Various surgical techniques have been proposed, yet there is no current consensus on which one is the best [ 4 , 5 , 7 , 9 ]. The traditional approach involves performing a distal partial patellectomy combined with patellar tendon reinsertion using sutures and transosseous tunnels [ 11 – 13 ]. Alternatively, in order to preserve bone tissue, distal pole fixation with vertical cerclage wire loops has been proposed [ 5 ]. Over time, several modifications of this technique have been introduced, contributing to its widespread adoption [ 6 , 9 , 10 , 14 ]. To date, however, no comparative studies between these two techniques have been published. This study aims to compare two surgical techniques for treating distal pole patellar fractures and evaluate their equivalence in terms of patient reported outcome measures (PROM), radiographic outcomes and complications. Materials & methods Ethics Committee Approval The study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki and Resolution 008430 of 1993. It was approved by the Institutional Ethics Committee, and informed consent was obtained from all patients participating in the study. Study Design A retrospective cohort study was conducted by analyzing records of patients with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 34 A1b fracture type surgically managed with transosseous suture fixation (TOS) or vertical cerclage wire fixation (VCW) at a single trauma center that primarily treats conditions secondary to occupational accidents. Surgical indications for fracture fixation were based on previously described by Harget et al [ 15 ], Posner et al [ 16 ] and Kakazu et al [ 17 ], and included: 1) fractures that affects de extensor mechanism; 2) > 3 mm of fracture displacement; 3) open fractures. The choice of surgical technique was determined according to each patient's surgeon's criteria. The aforementioned trauma center treats patients under an occupational insurance that covers all aspects of the injury, including but not limited to: primary consult at the emergency department; all imaging studies including preoperative and postoperative follow ups; surgical treatment; postoperative rehabilitation; surgical and non surgical complications and their diagnosis and treatment; injury and complication related sick days; diagnosis and treatment of sequelae. The institutional electronic medical record database was retrospectively reviewed for patients who underwent TOS or VCW between January 2015 and June 2023, w-ith a minimum follow-up of 12months. Exclusion criteria included: 1) prior fractures in the currently fractured patella; 2) bilateral patellar fractures; 3) concurrent lower limb injuries; 4) neurological injuries preventing early mobilization; and 5) insufficient follow-up. Infection was prevented according to the institutional protocol. After surgery for closed fractures, patients received intravenous cefazolin 2 g as a single dose (not weight-adjusted) or vancomycin for patients allergic to beta-lactams, which was adjusted by weight (1 g for less than 70 kg, 1.5 g for 70–100 kg, and 2 g for > 100 kg). In the case of open fractures, Gustilo & Anderson I-II, the same antibiotics are used but administered for 24 h after surgical debridement (one dose every 8 h for cefazolin and one dose every 12 hours for vancomycin). In the case of open fractures, Gustilo & Anderson III added gentamicin, adjusted by weight (4 mg/kg/day, with a maximum daily dose of 560 mg), and the treatment regimen was maintained for 72 hours after cleaning if there was bone coverage. In cases of wounds exposed to fresh or saltwater, ciprofloxacin 400 mg/day intravenously every 12 h was added to the usual regimen. If contamination with anaerobic microorganisms is suspected, metronidazole (500 mg intravenously every 8 hours) is added to the usual regime. The characteristics of the patients included in the study are summarized in Fig. 1 . Surgical Techniques a) Patellar Tendon Reinsertion Using High-Strength Transosseous Sutures: The patient was placed in a supine position with the knee in full extension. A midline anterior approach was made from the inferior pole of the patella to the tibial tuberosity. Layer-by-layer dissection was performed to locate the fracture site, the retinacula, and the patellar tendon. The fracture site was carefully curetted and irrigated, preserving as much bone as possible. Once the patellar tendon was identified, it was sutured with high-strength sutures (FiberWire®, Arthrex) with a standard Krackow technique, from the medial proximal to the distal end, with five to six interlocking loops and then this was repeated from distal to proximal, retrieving the free end at the proximal central end of the patellar tendon. This left two suture free ends. The same procedure was repeated from the proximal lateral border of the patellar tendon, retrieving the last free end at the proximal central end of the patellar tendon. Four suture free ends should be ready for traction and reinsertion after this part. Kirschner wires 1.5 mm diameter were used to create three longitudinal tunnels through the patella, from the fracture site to the superior pole. The free ends of the sutures were passed through the tunnels: the most medial and lateral ends were passed through the medial and lateral tunnels respectively, and the central sutures were passed through the central tunnel. Then, the sutures were tied over the intact proximal edge of the patella with the knee in extension (Fig. 2 ). The stability of the construct was then evaluated by flexing the knee (0 to 60 degrees of flexion), looking for fracture gap distraction. If this happened, sutures were tensioned and tied again. b) Patellar Tendon Reinsertion with Vertical Cerclage Wire Loops: The procedure was performed following the technique described by Oh et al. (2015), which combines vertical wiring with augmentation using the Krackow suturing method. The patient was placed in a supine position with the knee extended. A midline longitudinal approach was made from the proximal pole of the patella to the tibial tuberosity. Dissection was performed in layers to locate the fracture site, the retinacula, and the patellar tendon. After careful curettage and cleaning of the fracture site, three vertical transosseous tunnels were created using 1.8 mm Kirschner wires from the posterior margin of the proximal fragment to its anterior vertex, taking care not to damage the articular cartilage. Then, three 1.6 mm wires were passed through these tunnels as the Kirschner wires were withdrawn. A 16-gauge spinal needle was then inserted through the patellar tendon just distal to the most distal margin of the patella. Through the opening created by the needle, a wire was passed from deep to superficial, distal to the distal fragment. This procedure was repeated for the remaining wires. After completing this step, the fracture was reduced with the help of a reduction clamp. A high-strength Krackow-type suture was then used at the patellar tendon. Two transosseous tunnels were created from distal to proximal, through which high-strength sutures were passed using a 2.4 guide wire. At the proximal pole of the patella, the vertical wire loops and high-strength sutures were tied (Fig. 3 ). The final stability of the construct was evaluated through a range of motion (ROM) from 0° to 60°. Postoperative Rehabilitation Rehabilitation began using hinged knee braces with active and passive ROM limited to 0–30° for the first two weeks. Then, a ROM of 0–60° was allowed for the first six weeks, followed by a ROM of 0–90° up to eight weeks. Finally, unrestricted ROM was permitted after eight weeks of treatment and upon confirmation of favorable healing on follow-up radiographs up to that point. Physical therapy sessions were initiated on the first postoperative day, with a minimum frequency of three sessions per week. Patient Evaluation Clinical data were collected from electronic medical records regarding demographic characteristics (age, sex, weight, height, BMI, smoking, hypertension, diabetes mellitus), fracture characteristics (side, AO/OTA classification, and open fracture), postoperative follow-up data, and complications including osteosynthesis failure, malreduction, joint stiffness, infection, or symptomatic osteosynthesis. Functional outcomes were evaluated at least 12 months postoperatively through phone calls and emails using patient-reported outcome measures (PROMs), including the Kujala, Lysholm and Bostman scores. Radiological measurements Radiological measurements were performed by two orthopedic surgeons from the team with subspecialty training in knee surgery (XX and YY), at immediate post operative radiograph and 12 months post operative follow up. Patellar height was assessed on true lateral radiographs of the knee using the Caton – Deschamps Index (CDI). Patellar length was also measured as the total length from proximal to distal pole in a true lateral radiograph. Statistical analysis Descriptive statistics were used to summarize the demographic data. Continuous variables were expressed as means ± standard deviation (SD) where appropriate, while dichotomous variables were presented as the number and percentage of patients. The Shapiro-Wilk normality test was employed to evaluate the normal distribution of the sample. To compare measurements between cohorts, the independent samples t-test was used. To compare differences within single variable means over time, the paired t-test was applied. Categorical variables were analyzed using the chi-square test. Non-parametric analysis was performed using the Mann-Whitney U test to determine differences between groups. Effect size of continuous variables was calculated with Cohen´s D. All statistical analyses were carried out using SPSS (Version 25; IBM Corp.). A statistical significance level was set with an alpha value of p < 0.05. Results Patients characteristics A total of 46 patellar distal pole fractures were included in this study, with 30 cases of trans osseous suture reinsertions and 16 vertical cerclage wire fixation cases. The overall cohort presented a mean age of 49.52 years (SD 13.93) at the time of surgery, and the average duration of follow up was 41.15 months (range 21-103), allowing for a comprehensive assessment of the outcomes. Importantly, baseline characteristics were comparable between groups. (Table 1). Table 1. Demographics Total (n = 46) Subgroups TOS (n = 30) VCW (n = 16) P value Age,mean (SD) 49.52 (13.93) 50.43 (13.53) 47.81 (14.95) 0.549 Male, n (%) 33 (71.74) 21 (70) 12 (75) 0.72 Right, n (%) 24 (52.17) 15 (50) 9 (56.25) 0.686 Medical History, n (%) 16 (34.78) 11 (36.67) 5 (31.25) 0.713 Arterial hypertensoin 14 (30.43) 9 (30) 5 (31.25) 0.93 Type 2 diabetes 5 (10.87) 3 (10) 2 (12.5) 0,795 Smoker 13 (28.26) 8 (26.67) 5 (31.25) 0.742 BMI, mean (SD) 27.62 (4.38) 26.81 (4.04) 29.1 (4.72) 0.093 Open fracture, n (%) 6 (13.04) 6 (20) 0 0.055 Follow up, mean (range) 41.15 (21-103) 40.63 (21-103) 42.12 (35-59) 0.113 TOS = Trans osseous sutures; VCW = vertical cerclage wires; SD = Standard deviation; yo = years old; BMI = Body Mass Index. Age expressed in years, Follow-up expressed in months. Bold figures indicate statistical significance (P < .05). Clinical Outcomes At one year follow-up, when analyzing maximum flexion, TOS reached an average 124.4º (SD 21.7) and VCW 130.5º (SD 10.6), showing no significant differences (p 0.729). On the other hand, mean extension for TOS reached 0.08º (SD 0.4) and VCW 0º (SD 0), with no significant differences (p 0.527). No extension lag was found in either treatment group (Table 2). Table 2. Clinical outcomes Overall Subgroups TOS VCW P value Lysholm 88.78% (8.83) 89.52% (9.29) 86.88% (7.68) 0.457 Kujala 85.09% (13.37) 86% (14.28) 82.77% (4.98) 0.355 Bostman 23.57% (4.83) 23.89% (1.14) 22.71% (4.64) 0.591 ROM Extension 0.05º 0.08º 0º 0.527 Flexion 126.1º 124.4º 130.5º 0.729 PROMs = patient reported outcomes; ROM = range of motion; TOS = trans osseous sutures; VCW = vertical cerclage wires. Radiographic outcomes Analysis of radiological measurements comparing immediate postoperative and 12 months postoperative follow up status showed that patellar height did not significantly vary in either TOS nor VCW groups. However, deeper analysis regarding patellar length variation showed that TOS had a significant difference in patellar length as well as VCW, with a mean increase in patellar length of 3.77 mm in contrast with a variation of 0.44 mm (p 0.001)(Table 3). This increase in patellar length had a Cohen´s D estimate of 1.07 (0.40-1.72 CI 95%), meaning TOS had a large difference in the increase of patellar length when compared with VCW. Table 3. Radiographic outcomes Subgroups TOS P value VCW P value Immediate Follow up Immediate Follow up Caton Deschamps, mean (SD) 1.06 (0.29) 1.14 (0.36) 0.152 0.95 (0.12) 0.99 (0.14) 0.15 Patellar length, mean (SD) 46.15 (5.34) 49.92 (5.97) <0.001 45.64 (5.63) 46.08 (5.6) 0.008 SD = Standard deviation. Patellar length expressed in milimeters. Bold figures indicate statistical significance (P < .05). Patient reported outcome measurements (PROMS) Patient-reported outcome measures (PROMs) were evaluated using the Lysholm and the Kujala scale to assess the functional impact of both techniques. We also analyzed the Bostman score for both techniques. At the reported follow-up, no statistically significant differences were found between TOS and VCW in either functional scale (Table 2). Complications, reinterventions and revision surgeries Analysis of complications revealed no significant differences between TOS and VCW groups (Table 4). A total of five nonunions were detected, all of which occurred in TOS (17.24%; p 0.088), but without compromising the extensor mechanism. Reinterventions were performed in 13 cases, nine of them in the TOS group (30%) and four in the VCW group (25%) (p 0.72). The main reintervention performed was arthroscopic lysis of adhesions in eight cases (five in the TOS group and three in the VCW group), followed by revision surgery, fixation removal (two cases exclusively in the TOS group) and deep infection (one case in the TOS group). Revision surgery was needed in two cases (one case per group) due to early failure of the fixation method (before eight weeks), resulting in the complete loss of the extensor mechanism function. The first case (primary VCW fixation) required patellar tendon reinsertion due to resorption of the bone fragment, using two 5.0 titanium anchors plus an anterior tibialis allograft augmentation. The second case was revised with VCW fixation. Table 4. Complications Total Subgroups TOS VCW P value Non union, n (%) 5 (11.36%) 5 (17.24%) 0 0.088 Reinterventions, n (%) 13 (28.26%) 9 (30%) 4 (25%) 0.72 Arthroscopic lysis of adhesions, n (%) 8 (17.39%) 5 (16.67%) 3 (18.75%) 0.859 Revision surgery, n (%) 2 (4.35%) 1 (3.33%) 1 (6.25%) 0.644 Fixation removal, n (%) 2 (4.35%) 2 (6.67%) 0 0.291 Infection, n (%) 1 (2.17%) 1 (3.33%) 0 0.46 TOS = Trans osseous sutures; VCW = vertical cerclage wires; SD = Standard deviation. Discussion The main results of this study show that regarding PROMs, specifically Lysholm and Kujala scales, neither technique is superior to the other. A specific outcome to note is patellar height, which showed no differences between techniques. Despite this result, TOS showed an increase in patellar length at follow up compared with VCW. Complications among both techniques are also a concern, but both are comparable with a similar rate of events. Surgical treatment with tension-band wiring with screws or the novel addition of anatomical plates has become the standard of care for transverse and comminuted patella fractures. However, treatment of inferior pole patella fractures remains a challenge for the trauma surgeon, mainly because of the presence of highly comminuted fracture patterns, absence of an intact anterior cortical and non-fixable small fragments [ 6 , 10 ]. Inferior pole patella fractures are mainly extra-articular fractures, making the objective of the surgery to recover the extensor mechanism function [ 6 , 8 – 10 ]. Different techniques have been reported throughout literature. In the authors knowledge, this is the first study comparing two of these techniques: TOS and VCW. The use of TOS is well known and was initially described in association with partial patellectomy [ 6 , 12 ]. Good clinical, radiological and functional outcomes have been reported for TOS in the literature, being not inferior compared to other surgical techniques and listing a similar complication prevalence [ 18 – 20 ]. Chang et al in their systematic review of different surgical techniques, found that TOS had similar results in terms of PROMs, range of motion and similar rate of major complications, despite no meta-analysis was performed due to lack of randomized controlled studies[ 3 ]. Egol compared TOS to tension band technique with comparable Lysholm and SF-36 scores and range of motion, but with a non significant trend to more frequent reoperations due to hardware pain or failure in the tension band group [ 20 ]. Chang et al reported similar outcomes between TOS and tension band wiring, with an important non-significant occurrence of non union in the TOS group [ 19 ]. In our series, we took particular care and did not excise comminuted fragments, and reattached them to the main fragment of proximal patella via TOS. Likewise, the use of VCW is not novel, reported initially by Yang & Byun in 2003, as a modification of Lister's original technique [ 5 ]. In their article, they compared both techniques, reporting significantly higher ultimate loads to failure and stiffness on the VCW group, and good clinical and radiological outcomes in the same group [ 5 ]. The authors highlight that regardless of the good biomechanical features and outcomes reported by their technique, sudden quadriceps contraction may cause fixation failure. In order to increase the ultimate load of failure of the construct, some authors have presented their results on modified VWC, by adding an extra perimetral circular wire frame, an inferior rim plate, high resistance braided sutures or semicircular wire frame with a superior arm passing through the bone [ 6 , 10 , 14 ]. All modified techniques were reported in order to address critical aspects of inferior pole patellar fractures, like comminution or poor bone quality in elderly patients, and excellent outcomes have been described for all the above mentioned procedures. Patient reported outcomes in patellar fractures, specifically transverse and comminuted fractures, have been explored more frequently in the recent years [ 21 ]. However, PROMs in fractures of the distal pole of the patella are rarely explored [ 18 , 19 ]. In a recent article of the Swedish Fracture Register, none of the patellar fractures had PROMs in their follow up [ 22 ]. In our study, both surgical modalities achieved high postoperative scores in the evaluated self-reported scales Lysholm and Kujala. The Lysholm scale scored an overall 88.78%, which corresponds to a good result. In the TOS group the final score was 89.52% and for the VCW group this score was 86.88%. This score is scarcely reported for patellar fractures, with results reaching up to 91% [ 23 ]. In the authors´ knowledge, no articles report Kujala scores related to distal pole fractures of the patella. Bostman score is the most reported patient reported scale in the treatment of patellar distal pole fractures. Excellent results have previously been reported for both techniques [ 3 , 6 , 10 , 24 ]. In our study we found a mean score of 23.57 points (23.89 in TOS and 22.71 in VCW; p 0.591), equivalent to good results. One explanation for this result is that the population treated in our hospital is subject to workers´ compensation insurance, thus explaining persistent discomfort for our patients. Another explanation is the higher percentage of comminuted fractures in both groups, which implies more severe trauma and, therefore, not excellent results. Range of motion (ROM) is a concern of paramount importance in patellar fractures and distal pole fractures are not an exception. A particular issue of interest with these fractures is the potential extension lag after fracture repair. The second concern is achieving full ROM. In Oh´s original article [ 6 ], all patients managed with VCW achieved this. In the study by Cho et al[ 10 ], only one out of 12 cases did not achieve full ROM with their modified plate and VCW fixation; in contrast with Song´s group, who presented their results with isolated VCW technique [ 14 ] and in their case series six out of 21 cases did not achieve full ROM. In a recent meta analysis by Kim et al, which did not include comparative studies, showed that both TOS and VCW had similar outcomes in terms of final range of motion, supporting our results [ 8 ]. We did not find cases with extension lag greater than 5º and regarding extension and flexion did not show significant differences, however a trend to greater extension and flexion was seen in the VCW group. Patellar height is a less reported outcome when observing patellar distal pole fracture treatment. In our series, we did not find a significant variation in patellar height in either treatment group. However, deeper analysis of radiologic parameters showed that TOS increased patellar length significantly by a mean 3.77 millimeters, and the same happens with VCW, with an increase in patellar length by 0.44 millimeters. This phenomenon results in a longer cephalocaudal patella, similar to Gresalmer´s Cyrano patella [ 25 ], but with a different pathogenesis: fracture related patellar elongation with or without full consolidation. In our results, both techniques developed an elongated patella, but elongation in TOS was greater than what was observed in VCW. Patellar fracture nonunion is a rare event, mainly reported in neglected fractures and in large cohorts, occurring in up to 2.4% [ 26 , 27 ]. Non union showed a trend to be more frequent in TOS with five cases (17.24%) compared with VCW(no non unions, p 0.088). This could be explained due to a greater patellar length increase in the first group. Despite these nonunion rates, no impact in extensor mechanism function was observed, thus clinical relevance of this phenomenon is unclear. Biomechanical studies show that TOS may present fracture gap displacement after cyclic loading [ 28 ], but no studies have been performed either evaluating VCW alone or comparing these with TOS. At final follow up we did not find greater reoperation rates due to nonunion. Reinterventions in patellar fractures are common, with up to 60% of secondary procedures [ 29 ]. In our study, a total of 13 cases had a secondary procedure. The main cause of reintervention was knee arthrofibrosis with eight cases, five of them in TOS and three in VCW groups, on which an arthroscopic lysis of adhesions was performed. Only two cases of fixation removal were observed, both in the TOS group. One case of deep infection was recorded in the TOS group. This study has several limitations that should be acknowledged. First, its retrospective design introduces potential selection and information bias. Second, given that this represents a specific subgroup within patellar fractures, the sample size was relatively small, which limits the statistical power to identify differences between groups, particularly regarding the reported complications. Additionally, interobserver reliability for radiological measurements was not formally quantified, which may affect reproducibility. Fourth, although the follow-up period was adequate to assess bone healing and functional recovery, it was insufficient to evaluate long-term complications such as post-traumatic osteoarthritis or late extensor mechanism dysfunction. Finally, this was a single-center study with surgeries performed by different surgeons, and all patients were managed under a workers’ compensation system, which may limit the generalizability of the results to other institutions or settings. Conclusions Both transosseous sutures and vertical cerclage wires reinsertion techniques achieve good clinical and radiographic outcomes. Nonetheless, the finding of patellar elongation warrants further investigation, ideally through biomechanical analyses, to elucidate its etiology and potential clinical relevance. Declarations Potential Conflicts of Interest and Funding Sources none Author Contribution JIL, JTM, DM, SB Wrote the main manuscriptSB prepared figure 1JIL prepared figures 2 and 3TR collected primary dataAll authors reviewed the manuscript Acknowledgement Thanks to illustrator Victoria Aguirre for figures 2 and 3 References Vesterager JD, Torngren H, Elsoe R, Larsen P. Complications following surgical treatment of patella fractures - a systematic review and proportional meta-analysis. Eur J Trauma Emerg Surg. 2024;50:1985–94. https://doi.org/10.1007/s00068-024-02592-x Sayum Filho J, Lenza M, Tamaoki MJ, Matsunaga FT, Belloti JC. Interventions for treating fractures of the patella in adults. Cochrane Database Syst Rev. 2021;2:CD009651. https://doi.org/10.1002/14651858.CD009651.pub3 Chang C-H, Shih C-A, Kuan F-C, Hong C-K, Su W-R, Hsu K-L. Surgical treatment of inferior pole fractures of the patella: a systematic review. J Exp Orthop. 2023;10:58. https://doi.org/10.1186/s40634-023-00622-y Edoardo M, Andrea DD, Silvia C, Fabio M, Alessandro C, Adnan S, et al. Fixation of patella fractures with metallic implants is associated with a significantly higher risk of complications and re-operations than non-metallic implants: a systematic review and meta-analysis. Int Orthop. 2022;46:2927–37. https://doi.org/10.1007/s00264-022-05565-0 Yang KH, Byun YS. Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella. The Journal of Bone and Joint Surgery British volume. 2003;85-B:1155–60. https://doi.org/10.1302/0301-620X.85B8.14080 Oh H-K, Choo S-K, Kim J-W, Lee M. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury. 2015;46:2512–5. https://doi.org/10.1016/j.injury.2015.09.026 Huang W, Wu T, Wei Q, Peng L, Cheng X, Gao G. Suture repair of patellar inferior pole fracture: Transosseous tunnel suture compared with anchor suture. Exp Ther Med. 2021;22:998. https://doi.org/10.3892/etm.2021.10430 Dong Y, Huang W, Wei L, Du Y, Lin B. Comparison of the treatment of patellar inferior pole fractures with combined vertical wire and mini steel plate fixation versus independent vertical wire fixation. Knee. 2025;52:43–57. https://doi.org/10.1016/j.knee.2024.09.015 Franulic NI Piero; Laso, José Ignacio; Olivieri, Rodrigo; Gaggero, Nicolás. Manejo de fracturas conminutas del polo distal de la patela con asas verticales de alambre: Reporte de casos. Revista Chilena de Ortopedia y Traumatología. Thieme Revinter Publicações Ltda.; 2022;63:e1–8. https://doi.org/10.1055/s-0042-1744267 Cho J-W, Kim J, Cho W-T, Gujjar PH, Oh C-W, Oh J-K. Comminuted inferior pole fracture of patella can be successfully treated with rim-plate-augmented separate vertical wiring. Arch Orthop Trauma Surg. 2018;138:195–202. https://doi.org/10.1007/s00402-017-2807-7 Andrews JR, Hughston JC. Treatment of patellar fractures by partial patellectomy. South Med J. 1977;70:809–13, 817. https://doi.org/10.1097/00007611-197707000-00014 Saltzman CL, Goulet JA, McClellan RT, Schneider LA, Matthews LS. Results of treatment of displaced patellar fractures by partial patellectomy. J Bone Joint Surg Am. 1990;72:1279–85. van Raay JJ, van Loon A, Wissing JC, van der Werken C. [Partial and total patellectomy as treatment of comminuted patella fracture]. Ned Tijdschr Geneeskd. 1990;134:1308–11. Song HK, Yoo JH, Byun YS, Yang KH. Separate Vertical Wiring for the Fixation of Comminuted Fractures of the Inferior Pole of the Patella. Yonsei Med J. 2014;55:785. https://doi.org/10.3349/ymj.2014.55.3.785 Hargett DI, Sanderson BR, Little MTM. Patella Fractures: Approach to Treatment. J Am Acad Orthop Surg. 2021;29:244–53. https://doi.org/10.5435/JAAOS-D-20-00591 Posner AD, Zimmerman JP. Surgical Management of Patella Fractures: A Review. Arch Orthop. Scientific Archives; 2022;Volume 3:17–21. https://doi.org/10.33696/Orthopaedics.3.026 Kakazu R, Archdeacon MT. Surgical Management of Patellar Fractures. Orthopedic Clinics of North America. 2016;47:77–83. https://doi.org/10.1016/j.ocl.2015.08.010 Kuo L-Y, Chen C-Y, Lin K-C. Combining a transosseous cerclage wire after patellar tendon reattachment to treat patella distal pole fracture did not improve functional outcome. Sci Rep. Nature Publishing Group; 2022;12:9587. https://doi.org/10.1038/s41598-022-13641-z Chang C-H, Chuang H-C, Su W-R, Kuan F-C, Hong C-K, Hsu K-L. Fracture of the inferior pole of the patella: tension band wiring versus transosseous reattachment. J Orthop Surg Res. 2021;16:365. https://doi.org/10.1186/s13018-021-02519-x Egol K, Howard D, Monroy A, Crespo A, Tejwani N, Davidovitch R. PATELLA FRACTURE FIXATION WITH SUTURE AND WIRE: YOU REAP WHAT YOU SEW. :5. Buschbeck S, Götz K, Klug A, Barzen S, Gramlich Y, Hoffmann R. Comminuted AO-C3 fractures of the patella: good outcome using anatomically contoured locking plate fixation. International Orthopaedics (SICOT). 2022;46:1395–403. https://doi.org/10.1007/s00264-022-05374-5 Kruse M, Wolf O, Mukka S, Brüggemann A. Epidemiology, classification and treatment of patella fractures: an observational study of 3194 fractures from the Swedish Fracture Register. Eur J Trauma Emerg Surg. 2022;48:4727–34. https://doi.org/10.1007/s00068-022-01993-0 Huang S, Zou C, Kenmegne GR, Yin Y, Lin Y, Fang Y. Management of comminuted patellar fractures using suture reduction technique combined with the modified Kirschner-wire tension band. BMC Surg. 2023;23:251. https://doi.org/10.1186/s12893-023-02153-w Kim YM, Yang JY, Kim KC, Kang C, Joo YB, Lee WY, et al. Separate Vertical Wirings for the Extra-articular Fractures of the Distal Pole of the Patella. Knee Surg Relat Res. 2011;23:220–6. https://doi.org/10.5792/ksrr.2011.23.4.220 Grelsamer RP, Proctor CS, Bazos AN. Evaluation of Patellar Shape in the Sagittal Plane: A Clinical Analysis. Am J Sports Med. SAGE Publications Inc STM; 1994;22:61–6. https://doi.org/10.1177/036354659402200111 Harna B, Gupta P, Singh J, Rousa S, Gupta A. Surgical Management of Non-Union Patella Fracture: A Case Series and Review of the Literature. Arch Bone Jt Surg. 2021;9:554–8. https://doi.org/10.22038/abjs.2020.49755.2472 Kadar A, Sherman H, Drexler M, Katz E, Steinberg EL. Anchor suture fixation of distal pole fractures of patella: twenty seven cases and comparison to partial patellectomy. International Orthopaedics (SICOT). 2016;40:149–54. https://doi.org/10.1007/s00264-015-2776-9 Seggewiss J, Nicolini LF, Lichte P, Greven J, Ribeiro M, Prescher A, et al. Transosseous suture versus suture anchor fixation for inferior pole fractures of the patella in osteoporotic bone: a biomechanical study. European Journal of Medical Research. 2022;27:270. https://doi.org/10.1186/s40001-022-00903-9 Bel J-C, Lefèvre C. Reconstruction of patella fractures with the tension band technique: A review on clinical results and tips and tricks. Injury. 2024;55 Suppl 1:111401. https://doi.org/10.1016/j.injury.2024.111401 LeBrun CT, Langford JR, Sagi HC. Functional Outcomes After Operatively Treated Patella Fractures: Journal of Orthopaedic Trauma. 2012;26:422–6. https://doi.org/10.1097/BOT.0b013e318228c1a1 Greenberg A, Kadar A, Drexler M, Sharfman ZT, Chechik O, Steinberg EL, et al. Functional outcomes after removal of hardware in patellar fracture: are we helping our patients? Arch Orthop Trauma Surg. 2018;138:325–30. https://doi.org/10.1007/s00402-017-2852-2 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 23 Mar, 2026 Reviews received at journal 21 Mar, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviews received at journal 21 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers invited by journal 08 Feb, 2026 Editor assigned by journal 07 Feb, 2026 Submission checks completed at journal 31 Jan, 2026 First submitted to journal 25 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8695399","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588162921,"identity":"5390a41f-56c3-4ee8-b673-ed10958df273","order_by":0,"name":"Jose Ignacio Laso","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDCCA2DSAsqrAGJm5gZCWhiBKiRASoGcMyCakRQtB9tAQgS08B1vfv7g4x4Jefn2/qObP86rjeZvB2r5UbENpxbJM8cMG2c8kzDccOYw242D247nzjjM2MDYc+Y2Ti0GN3IYm3kOSDBukEgGaTmW2wDUwszYRliL/fwZIC1zjuXOJ1ZLYsMNkJaGmtwNhLSA/DJzxgGJZKBfzG6cOXYgdyNQy0F8fgGG2IMPHw7Y2M5vb3x2o6KmLnfe+cMHH/yowK0FHRwGkweIVg8EdaQoHgWjYBSMghECANh6Z0PeRbAMAAAAAElFTkSuQmCC","orcid":"","institution":"Andrés Bello National University","correspondingAuthor":true,"prefix":"","firstName":"Jose","middleName":"Ignacio","lastName":"Laso","suffix":""},{"id":588162922,"identity":"2bb51008-1fed-4b03-9b11-2e1cda685f6b","order_by":1,"name":"Jose Tomas Muñoz","email":"","orcid":"","institution":"Hospital del Trabajador","correspondingAuthor":false,"prefix":"","firstName":"Jose","middleName":"Tomas","lastName":"Muñoz","suffix":""},{"id":588162923,"identity":"027b9da4-1d98-4a46-ab81-a2475e40e736","order_by":2,"name":"Sebastian Bianchi","email":"","orcid":"","institution":"Hospital del Trabajador","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Bianchi","suffix":""},{"id":588162924,"identity":"feac3ed7-cbc3-4237-9114-8084814c9679","order_by":3,"name":"Diego Martínez","email":"","orcid":"","institution":"Hospital del Trabajador","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"","lastName":"Martínez","suffix":""},{"id":588162925,"identity":"d0d8c534-7cf5-42bd-b8e6-2913c695a0c8","order_by":4,"name":"Tania Rojas","email":"","orcid":"","institution":"Andrés Bello National University","correspondingAuthor":false,"prefix":"","firstName":"Tania","middleName":"","lastName":"Rojas","suffix":""},{"id":588162926,"identity":"c3b0b92b-3069-4872-a307-6f431777d7d4","order_by":5,"name":"Nicolas Franulic","email":"","orcid":"","institution":"Hospital del Trabajador","correspondingAuthor":false,"prefix":"","firstName":"Nicolas","middleName":"","lastName":"Franulic","suffix":""},{"id":588162927,"identity":"2eb5e1b5-94ea-446a-bb51-11fa39fcca28","order_by":6,"name":"Rodrigo Olivieri","email":"","orcid":"","institution":"Hospital del Trabajador","correspondingAuthor":false,"prefix":"","firstName":"Rodrigo","middleName":"","lastName":"Olivieri","suffix":""}],"badges":[],"createdAt":"2026-01-26 01:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8695399/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8695399/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102594758,"identity":"44a8e25f-a66f-4ff6-9092-817bbbe9af52","added_by":"auto","created_at":"2026-02-13 11:57:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":104792,"visible":true,"origin":"","legend":"\u003cp\u003eInclusion criteria for patients enrolled in the study. TOS = transosseous suture fixation; VCW = vertical cerclage wire fixation.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8695399/v1/d517baac51f4dbf35e5168b9.png"},{"id":102594760,"identity":"aba25141-eb96-4b8f-a2ff-9f32916adaf2","added_by":"auto","created_at":"2026-02-13 11:57:47","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65805,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the transosseous suture reinsertion technique, anteroposterior and lateral radiographs.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8695399/v1/989c7b5c1159d5585df31d87.jpeg"},{"id":102594759,"identity":"6c0e00f7-9c94-4de9-94f6-2a0aeb5461b8","added_by":"auto","created_at":"2026-02-13 11:57:47","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":65845,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the vertical cerclage wire loops technique, anteroposterior and lateral radiographs.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8695399/v1/cfbddf1294c858de982ae970.jpeg"},{"id":102747870,"identity":"99698ef7-c2d7-4905-9d49-a886675bf5bf","added_by":"auto","created_at":"2026-02-16 09:05:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":965174,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8695399/v1/410e10b3-1e3b-4076-b994-29eefeb21150.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patellar distal pole fracture treatment with transosseous sutures vs vertical cerclage wire techniques: a comparative retrospective cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePatellar fractures constitute approximately 0.5% to 2% of all fracture cases, with an estimated incidence of 13.1 per 100,000 individuals annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These fractures exhibit a characteristic bimodal distribution, affecting younger individuals typically involved in high-energy incidents or sports activities, and older adults\u0026mdash;predominantly women\u0026mdash;who sustain low-energy injuries, such as ground level falls resulting in direct impact to the knee[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Effective management of these fractures demands the restoration of the articular anatomy, and recovery of the knee's extensor mechanism, promoting early mobilization [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFractures of the inferior pole of the patella are relatively uncommon, accounting for approximately 5% to 22.4% of all patellar fractures [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These fractures are often complex, characterized by significant comminution and displacement, which complicates their reduction and fixation. Additionally, the distal fragments tend to be small, and the cancellous bone is typically weak, posing a challenge for stabilization using conventional techniques [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Since most of these injuries are extraarticular, the main goal of surgical treatment is to restore the knee's extensor mechanism rather than to precisely align the articular surface [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Moreover, these fractures are susceptible to complications, particularly implant-related issues such as fixation failure and symptomatic osteosynthesis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVarious surgical techniques have been proposed, yet there is no current consensus on which one is the best [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The traditional approach involves performing a distal partial patellectomy combined with patellar tendon reinsertion using sutures and transosseous tunnels [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Alternatively, in order to preserve bone tissue, distal pole fixation with vertical cerclage wire loops has been proposed [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Over time, several modifications of this technique have been introduced, contributing to its widespread adoption [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. To date, however, no comparative studies between these two techniques have been published.\u003c/p\u003e \u003cp\u003eThis study aims to compare two surgical techniques for treating distal pole patellar fractures and evaluate their equivalence in terms of patient reported outcome measures (PROM), radiographic outcomes and complications.\u003c/p\u003e"},{"header":"Materials \u0026 methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthics Committee Approval\u003c/h2\u003e \u003cp\u003e The study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki and Resolution 008430 of 1993. It was approved by the Institutional Ethics Committee, and informed consent was obtained from all patients participating in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eA retrospective cohort study was conducted by analyzing records of patients with Arbeitsgemeinschaft f\u0026uuml;r Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 34 A1b fracture type surgically managed with transosseous suture fixation (TOS) or vertical cerclage wire fixation (VCW) at a single trauma center that primarily treats conditions secondary to occupational accidents. Surgical indications for fracture fixation were based on previously described by Harget et al [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], Posner et al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and Kakazu et al [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and included: 1) fractures that affects de extensor mechanism; 2)\u0026thinsp;\u0026gt;\u0026thinsp;3 mm of fracture displacement; 3) open fractures. The choice of surgical technique was determined according to each patient's surgeon's criteria. The aforementioned trauma center treats patients under an occupational insurance that covers all aspects of the injury, including but not limited to: primary consult at the emergency department; all imaging studies including preoperative and postoperative follow ups; surgical treatment; postoperative rehabilitation; surgical and non surgical complications and their diagnosis and treatment; injury and complication related sick days; diagnosis and treatment of sequelae.\u003c/p\u003e \u003cp\u003eThe institutional electronic medical record database was retrospectively reviewed for patients who underwent TOS or VCW between January 2015 and June 2023, w-ith a minimum follow-up of 12months.\u003c/p\u003e \u003cp\u003e Exclusion criteria included: 1) prior fractures in the currently fractured patella; 2) bilateral patellar fractures; 3) concurrent lower limb injuries; 4) neurological injuries preventing early mobilization; and 5) insufficient follow-up.\u003c/p\u003e \u003cp\u003eInfection was prevented according to the institutional protocol. After surgery for closed fractures, patients received intravenous cefazolin 2 g as a single dose (not weight-adjusted) or vancomycin for patients allergic to beta-lactams, which was adjusted by weight (1 g for less than 70 kg, 1.5 g for 70\u0026ndash;100 kg, and 2 g for \u0026gt;\u0026thinsp;100 kg). In the case of open fractures, Gustilo \u0026amp; Anderson I-II, the same antibiotics are used but administered for 24 h after surgical debridement (one dose every 8 h for cefazolin and one dose every 12 hours for vancomycin). In the case of open fractures, Gustilo \u0026amp; Anderson III added gentamicin, adjusted by weight (4 mg/kg/day, with a maximum daily dose of 560 mg), and the treatment regimen was maintained for 72 hours after cleaning if there was bone coverage. In cases of wounds exposed to fresh or saltwater, ciprofloxacin 400 mg/day intravenously every 12 h was added to the usual regimen. If contamination with anaerobic microorganisms is suspected, metronidazole (500 mg intravenously every 8 hours) is added to the usual regime.\u003c/p\u003e \u003cp\u003eThe characteristics of the patients included in the study are summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSurgical Techniques\u003c/b\u003e \u003c/p\u003e\n\u003ch3\u003ea) Patellar Tendon Reinsertion Using High-Strength Transosseous Sutures:\u003c/h3\u003e\n\u003cp\u003eThe patient was placed in a supine position with the knee in full extension. A midline anterior approach was made from the inferior pole of the patella to the tibial tuberosity. Layer-by-layer dissection was performed to locate the fracture site, the retinacula, and the patellar tendon. The fracture site was carefully curetted and irrigated, preserving as much bone as possible. Once the patellar tendon was identified, it was sutured with high-strength sutures (FiberWire\u0026reg;, Arthrex) with a standard Krackow technique, from the medial proximal to the distal end, with five to six interlocking loops and then this was repeated from distal to proximal, retrieving the free end at the proximal central end of the patellar tendon. This left two suture free ends. The same procedure was repeated from the proximal lateral border of the patellar tendon, retrieving the last free end at the proximal central end of the patellar tendon. Four suture free ends should be ready for traction and reinsertion after this part.\u003c/p\u003e \u003cp\u003eKirschner wires 1.5 mm diameter were used to create three longitudinal tunnels through the patella, from the fracture site to the superior pole. The free ends of the sutures were passed through the tunnels: the most medial and lateral ends were passed through the medial and lateral tunnels respectively, and the central sutures were passed through the central tunnel. Then, the sutures were tied over the intact proximal edge of the patella with the knee in extension (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The stability of the construct was then evaluated by flexing the knee (0 to 60 degrees of flexion), looking for fracture gap distraction. If this happened, sutures were tensioned and tied again.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eb) Patellar Tendon Reinsertion with Vertical Cerclage Wire Loops:\u003c/h3\u003e\n\u003cp\u003eThe procedure was performed following the technique described by Oh et al. (2015), which combines vertical wiring with augmentation using the Krackow suturing method. The patient was placed in a supine position with the knee extended. A midline longitudinal approach was made from the proximal pole of the patella to the tibial tuberosity. Dissection was performed in layers to locate the fracture site, the retinacula, and the patellar tendon. After careful curettage and cleaning of the fracture site, three vertical transosseous tunnels were created using 1.8 mm Kirschner wires from the posterior margin of the proximal fragment to its anterior vertex, taking care not to damage the articular cartilage.\u003c/p\u003e \u003cp\u003eThen, three 1.6 mm wires were passed through these tunnels as the Kirschner wires were withdrawn. A 16-gauge spinal needle was then inserted through the patellar tendon just distal to the most distal margin of the patella. Through the opening created by the needle, a wire was passed from deep to superficial, distal to the distal fragment. This procedure was repeated for the remaining wires.\u003c/p\u003e \u003cp\u003eAfter completing this step, the fracture was reduced with the help of a reduction clamp. A high-strength Krackow-type suture was then used at the patellar tendon. Two transosseous tunnels were created from distal to proximal, through which high-strength sutures were passed using a 2.4 guide wire. At the proximal pole of the patella, the vertical wire loops and high-strength sutures were tied (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The final stability of the construct was evaluated through a range of motion (ROM) from 0\u0026deg; to 60\u0026deg;.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003ePostoperative Rehabilitation\u003c/h3\u003e\n\u003cp\u003eRehabilitation began using hinged knee braces with active and passive ROM limited to 0\u0026ndash;30\u0026deg; for the first two weeks. Then, a ROM of 0\u0026ndash;60\u0026deg; was allowed for the first six weeks, followed by a ROM of 0\u0026ndash;90\u0026deg; up to eight weeks. Finally, unrestricted ROM was permitted after eight weeks of treatment and upon confirmation of favorable healing on follow-up radiographs up to that point. Physical therapy sessions were initiated on the first postoperative day, with a minimum frequency of three sessions per week.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient Evaluation\u003c/h2\u003e \u003cp\u003eClinical data were collected from electronic medical records regarding demographic characteristics (age, sex, weight, height, BMI, smoking, hypertension, diabetes mellitus), fracture characteristics (side, AO/OTA classification, and open fracture), postoperative follow-up data, and complications including osteosynthesis failure, malreduction, joint stiffness, infection, or symptomatic osteosynthesis.\u003c/p\u003e \u003cp\u003eFunctional outcomes were evaluated at least 12 months postoperatively through phone calls and emails using patient-reported outcome measures (PROMs), including the Kujala, Lysholm and Bostman scores.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRadiological measurements\u003c/h3\u003e\n\u003cp\u003eRadiological measurements were performed by two orthopedic surgeons from the team with subspecialty training in knee surgery (XX and YY), at immediate post operative radiograph and 12 months post operative follow up. Patellar height was assessed on true lateral radiographs of the knee using the Caton \u0026ndash; Deschamps Index (CDI). Patellar length was also measured as the total length from proximal to distal pole in a true lateral radiograph.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize the demographic data. Continuous variables were expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) where appropriate, while dichotomous variables were presented as the number and percentage of patients.\u003c/p\u003e \u003cp\u003eThe Shapiro-Wilk normality test was employed to evaluate the normal distribution of the sample. To compare measurements between cohorts, the independent samples t-test was used. To compare differences within single variable means over time, the paired t-test was applied. Categorical variables were analyzed using the chi-square test.\u003c/p\u003e \u003cp\u003eNon-parametric analysis was performed using the Mann-Whitney U test to determine differences between groups. Effect size of continuous variables was calculated with Cohen\u0026acute;s D. All statistical analyses were carried out using SPSS (Version 25; IBM Corp.). A statistical significance level was set with an alpha value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatients characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 46 patellar distal pole fractures were included in this study, with 30 cases of trans osseous suture reinsertions and 16 vertical cerclage wire fixation cases. The overall cohort presented a mean age of 49.52 years (SD 13.93) at the time of surgery, and the average duration of follow up was 41.15 months (range 21-103), allowing for a comprehensive assessment of the outcomes. Importantly, baseline characteristics were comparable between groups. (Table 1).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"660\" style=\"margin-right: calc(5%); width: 95%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"bottom\" style=\"width: 36.7335%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Demographics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.9084%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 5.3936%;\"\u003e\n \u003cp\u003eTotal\u003cbr\u003e\u0026nbsp;(n = 46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 15.897%;\"\u003e\n \u003cp\u003eSubgroups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0.9084%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003eTOS\u003cbr\u003e\u0026nbsp;(n = 30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003eVCW\u003cbr\u003e\u0026nbsp; (n = 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eAge,mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.9084%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e49.52 (13.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e50.43 (13.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e47.81 (14.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.549\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.9084%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e33 (71.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e21 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e12 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eRight, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.9084%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e24 (52.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e15 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e9 (56.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.686\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eMedical History, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 0.9084%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e16 (34.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e11 (36.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e5 (31.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.713\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eArterial hypertensoin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e14 (30.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e9 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e5 (31.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eType 2 diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e5 (10.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e3 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0,795\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e13 (28.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e8 (26.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e5 (31.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.742\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eBMI, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e27.62 (4.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e26.81 (4.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e29.1 (4.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eOpen fracture, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.9084%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e6 (13.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e6 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.7396%;\"\u003e\n \u003cp\u003eFollow up, mean (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.9084%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.3936%;\"\u003e\n \u003cp\u003e41.15 (21-103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.564%;\"\u003e\n \u003cp\u003e40.63 (21-103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.7381%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.5072%;\"\u003e\n \u003cp\u003e42.12 (35-59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.8516%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.1794%;\"\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" rowspan=\"2\" valign=\"top\" style=\"width: 36.7335%;\"\u003e\n \u003cp\u003eTOS = Trans osseous sutures; VCW = vertical cerclage wires; SD = Standard deviation; \u0026nbsp;yo = years old; BMI = Body Mass Index. Age expressed in years, Follow-up expressed in months. \u0026nbsp;Bold figures indicate statistical significance (P \u0026lt; .05).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.3407%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 0.3407%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt one year follow-up, when analyzing maximum flexion, TOS reached an average 124.4\u0026ordm; (SD 21.7) and VCW 130.5\u0026ordm; (SD 10.6), showing no significant differences (p 0.729). On the other hand, mean extension for TOS reached 0.08\u0026ordm; (SD 0.4) and VCW 0\u0026ordm; (SD 0), with no significant differences (p 0.527). No extension lag was found in either treatment group (Table 2).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"536\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"bottom\" style=\"width: 536px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Clinical outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 104px;\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 301px;\"\u003e\n \u003cp\u003eSubgroups\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 12px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003eTOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eVCW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eLysholm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e88.78% (8.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e89.52% (9.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e86.88% (7.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.457\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eKujala\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e85.09% (13.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e86% (14.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e82.77% (4.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eBostman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e23.57% (4.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e23.89% (1.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e22.71% (4.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.591\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eROM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eExtension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.05\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.08\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.527\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eFlexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e126.1\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e124.4\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e130.5\u0026ordm;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.729\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 536px;\"\u003e\n \u003cp\u003ePROMs = patient reported outcomes; ROM = range of motion; TOS = trans osseous sutures; VCW = vertical cerclage wires.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eRadiographic outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of radiological measurements comparing immediate postoperative and 12 months postoperative follow up status showed that patellar height did not significantly vary in either TOS nor VCW groups. However, deeper analysis regarding patellar length variation showed that TOS had a significant difference in patellar length as well as VCW, with a mean increase in patellar length of 3.77 mm in contrast with a variation of 0.44 mm (p 0.001)(Table 3). This increase in patellar length had a Cohen\u0026acute;s D estimate of 1.07 (0.40-1.72 CI 95%), meaning TOS had a large difference in the increase of patellar length when compared with VCW.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"657\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"13\" valign=\"bottom\" style=\"width: 657px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Radiographic outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"11\" style=\"width: 458px;\"\u003e\n \u003cp\u003eSubgroups\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003eTOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eVCW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eFollow up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eFollow up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 200px;\"\u003e\n \u003cp\u003eCaton Deschamps, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e1.06 (0.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1.14 (0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.95 (0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.99 (0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003ePatellar length, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e46.15 (5.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e49.92 (5.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e45.64 (5.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e46.08 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"13\" valign=\"top\" style=\"width: 657px;\"\u003e\n \u003cp\u003eSD = Standard deviation. Patellar length expressed in milimeters. Bold figures indicate statistical significance (P \u0026lt; .05).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePatient reported outcome measurements (PROMS)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient-reported outcome measures (PROMs) were evaluated using the Lysholm and the Kujala scale to assess the functional impact of both techniques. We also analyzed the Bostman score for both techniques. At the reported follow-up, no statistically significant differences were found between TOS and VCW in either functional scale (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications, reinterventions and revision surgeries\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of complications revealed no significant differences between TOS and VCW groups (Table 4). A total of five nonunions were detected, all of which occurred in TOS (17.24%; p 0.088), but without compromising the extensor mechanism. Reinterventions were performed in 13 cases, nine of them in the TOS group (30%) and four in the VCW group (25%) (p 0.72). The main reintervention performed was arthroscopic lysis of adhesions in eight cases (five in the TOS group and three in the VCW group), followed by revision surgery, fixation removal (two cases exclusively in the TOS group) and deep infection (one case in the TOS group).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRevision surgery was needed in two cases (one case per group) due to early failure of the fixation method (before eight weeks), resulting in the complete loss of the extensor mechanism function. The first case (primary VCW fixation) required patellar tendon reinsertion due to resorption of the bone fragment, using two 5.0 titanium anchors plus an anterior tibialis allograft augmentation. The second case was revised with VCW fixation.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Complications\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 229px;\"\u003e\n \u003cp\u003eSubgroups\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eTOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eVCW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eNon union, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5 (11.36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e5 (17.24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eReinterventions, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e13 (28.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e9 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e4 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eArthroscopic lysis of adhesions, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e8 (17.39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e5 (16.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e3 (18.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eRevision surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (4.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e1 (3.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e1 (6.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.644\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eFixation removal, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (4.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e2 (6.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.291\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eInfection, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (2.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e1 (3.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eTOS = Trans osseous sutures; VCW = vertical cerclage wires; SD = Standard deviation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main results of this study show that regarding PROMs, specifically Lysholm and Kujala scales, neither technique is superior to the other. A specific outcome to note is patellar height, which showed no differences between techniques. Despite this result, TOS showed an increase in patellar length at follow up compared with VCW. Complications among both techniques are also a concern, but both are comparable with a similar rate of events.\u003c/p\u003e \u003cp\u003eSurgical treatment with tension-band wiring with screws or the novel addition of anatomical plates has become the standard of care for transverse and comminuted patella fractures. However, treatment of inferior pole patella fractures remains a challenge for the trauma surgeon, mainly because of the presence of highly comminuted fracture patterns, absence of an intact anterior cortical and non-fixable small fragments [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Inferior pole patella fractures are mainly extra-articular fractures, making the objective of the surgery to recover the extensor mechanism function [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Different techniques have been reported throughout literature. In the authors knowledge, this is the first study comparing two of these techniques: TOS and VCW.\u003c/p\u003e \u003cp\u003eThe use of TOS is well known and was initially described in association with partial patellectomy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Good clinical, radiological and functional outcomes have been reported for TOS in the literature, being not inferior compared to other surgical techniques and listing a similar complication prevalence [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Chang et al in their systematic review of different surgical techniques, found that TOS had similar results in terms of PROMs, range of motion and similar rate of major complications, despite no meta-analysis was performed due to lack of randomized controlled studies[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Egol compared TOS to tension band technique with comparable Lysholm and SF-36 scores and range of motion, but with a non significant trend to more frequent reoperations due to hardware pain or failure in the tension band group [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Chang et al reported similar outcomes between TOS and tension band wiring, with an important non-significant occurrence of non union in the TOS group [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our series, we took particular care and did not excise comminuted fragments, and reattached them to the main fragment of proximal patella via TOS. Likewise, the use of VCW is not novel, reported initially by Yang \u0026amp; Byun in 2003, as a modification of Lister's original technique [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In their article, they compared both techniques, reporting significantly higher ultimate loads to failure and stiffness on the VCW group, and good clinical and radiological outcomes in the same group [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The authors highlight that regardless of the good biomechanical features and outcomes reported by their technique, sudden quadriceps contraction may cause fixation failure.\u003c/p\u003e \u003cp\u003eIn order to increase the ultimate load of failure of the construct, some authors have presented their results on modified VWC, by adding an extra perimetral circular wire frame, an inferior rim plate, high resistance braided sutures or semicircular wire frame with a superior arm passing through the bone [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. All modified techniques were reported in order to address critical aspects of inferior pole patellar fractures, like comminution or poor bone quality in elderly patients, and excellent outcomes have been described for all the above mentioned procedures.\u003c/p\u003e \u003cp\u003ePatient reported outcomes in patellar fractures, specifically transverse and comminuted fractures, have been explored more frequently in the recent years [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, PROMs in fractures of the distal pole of the patella are rarely explored [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In a recent article of the Swedish Fracture Register, none of the patellar fractures had PROMs in their follow up [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study, both surgical modalities achieved high postoperative scores in the evaluated self-reported scales Lysholm and Kujala. The Lysholm scale scored an overall 88.78%, which corresponds to a good result. In the TOS group the final score was 89.52% and for the VCW group this score was 86.88%. This score is scarcely reported for patellar fractures, with results reaching up to 91% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In the authors\u0026acute; knowledge, no articles report Kujala scores related to distal pole fractures of the patella. Bostman score is the most reported patient reported scale in the treatment of patellar distal pole fractures. Excellent results have previously been reported for both techniques [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In our study we found a mean score of 23.57 points (23.89 in TOS and 22.71 in VCW; p 0.591), equivalent to good results. One explanation for this result is that the population treated in our hospital is subject to workers\u0026acute; compensation insurance, thus explaining persistent discomfort for our patients. Another explanation is the higher percentage of comminuted fractures in both groups, which implies more severe trauma and, therefore, not excellent results.\u003c/p\u003e \u003cp\u003eRange of motion (ROM) is a concern of paramount importance in patellar fractures and distal pole fractures are not an exception. A particular issue of interest with these fractures is the potential extension lag after fracture repair. The second concern is achieving full ROM. In Oh\u0026acute;s original article [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], all patients managed with VCW achieved this. In the study by Cho et al[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], only one out of 12 cases did not achieve full ROM with their modified plate and VCW fixation; in contrast with Song\u0026acute;s group, who presented their results with isolated VCW technique [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and in their case series six out of 21 cases did not achieve full ROM. In a recent meta analysis by Kim et al, which did not include comparative studies, showed that both TOS and VCW had similar outcomes in terms of final range of motion, supporting our results [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. We did not find cases with extension lag greater than 5\u0026ordm; and regarding extension and flexion did not show significant differences, however a trend to greater extension and flexion was seen in the VCW group.\u003c/p\u003e \u003cp\u003ePatellar height is a less reported outcome when observing patellar distal pole fracture treatment. In our series, we did not find a significant variation in patellar height in either treatment group. However, deeper analysis of radiologic parameters showed that TOS increased patellar length significantly by a mean 3.77 millimeters, and the same happens with VCW, with an increase in patellar length by 0.44 millimeters. This phenomenon results in a longer cephalocaudal patella, similar to Gresalmer\u0026acute;s Cyrano patella [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], but with a different pathogenesis: fracture related patellar elongation with or without full consolidation. In our results, both techniques developed an elongated patella, but elongation in TOS was greater than what was observed in VCW.\u003c/p\u003e \u003cp\u003ePatellar fracture nonunion is a rare event, mainly reported in neglected fractures and in large cohorts, occurring in up to 2.4% [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Non union showed a trend to be more frequent in TOS with five cases (17.24%) compared with VCW(no non unions, p 0.088). This could be explained due to a greater patellar length increase in the first group. Despite these nonunion rates, no impact in extensor mechanism function was observed, thus clinical relevance of this phenomenon is unclear. Biomechanical studies show that TOS may present fracture gap displacement after cyclic loading [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], but no studies have been performed either evaluating VCW alone or comparing these with TOS. At final follow up we did not find greater reoperation rates due to nonunion.\u003c/p\u003e \u003cp\u003eReinterventions in patellar fractures are common, with up to 60% of secondary procedures [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In our study, a total of 13 cases had a secondary procedure. The main cause of reintervention was knee arthrofibrosis with eight cases, five of them in TOS and three in VCW groups, on which an arthroscopic lysis of adhesions was performed. Only two cases of fixation removal were observed, both in the TOS group. One case of deep infection was recorded in the TOS group.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be acknowledged. First, its retrospective design introduces potential selection and information bias. Second, given that this represents a specific subgroup within patellar fractures, the sample size was relatively small, which limits the statistical power to identify differences between groups, particularly regarding the reported complications. Additionally, interobserver reliability for radiological measurements was not formally quantified, which may affect reproducibility. Fourth, although the follow-up period was adequate to assess bone healing and functional recovery, it was insufficient to evaluate long-term complications such as post-traumatic osteoarthritis or late extensor mechanism dysfunction. Finally, this was a single-center study with surgeries performed by different surgeons, and all patients were managed under a workers\u0026rsquo; compensation system, which may limit the generalizability of the results to other institutions or settings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eBoth transosseous sutures and vertical cerclage wires reinsertion techniques achieve good clinical and radiographic outcomes. Nonetheless, the finding of patellar elongation warrants further investigation, ideally through biomechanical analyses, to elucidate its etiology and potential clinical relevance.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003ePotential Conflicts of Interest and Funding Sources\u003c/h2\u003e \u003cp\u003enone\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJIL, JTM, DM, SB Wrote the main manuscriptSB prepared figure 1JIL prepared figures 2 and 3TR collected primary dataAll authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThanks to illustrator Victoria Aguirre for figures 2 and 3\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVesterager JD, Torngren H, Elsoe R, Larsen P. Complications following surgical treatment of patella fractures - a systematic review and proportional meta-analysis. Eur J Trauma Emerg Surg. 2024;50:1985\u0026ndash;94. https://doi.org/10.1007/s00068-024-02592-x \u003c/li\u003e\n\u003cli\u003eSayum Filho J, Lenza M, Tamaoki MJ, Matsunaga FT, Belloti JC. Interventions for treating fractures of the patella in adults. Cochrane Database Syst Rev. 2021;2:CD009651. https://doi.org/10.1002/14651858.CD009651.pub3 \u003c/li\u003e\n\u003cli\u003eChang C-H, Shih C-A, Kuan F-C, Hong C-K, Su W-R, Hsu K-L. Surgical treatment of inferior pole fractures of the patella: a systematic review. J Exp Orthop. 2023;10:58. https://doi.org/10.1186/s40634-023-00622-y \u003c/li\u003e\n\u003cli\u003eEdoardo M, Andrea DD, Silvia C, Fabio M, Alessandro C, Adnan S, et al. Fixation of patella fractures with metallic implants is associated with a significantly higher risk of complications and re-operations than non-metallic implants: a systematic review and meta-analysis. Int Orthop. 2022;46:2927\u0026ndash;37. https://doi.org/10.1007/s00264-022-05565-0 \u003c/li\u003e\n\u003cli\u003eYang KH, Byun YS. Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella. The Journal of Bone and Joint Surgery British volume. 2003;85-B:1155\u0026ndash;60. https://doi.org/10.1302/0301-620X.85B8.14080 \u003c/li\u003e\n\u003cli\u003eOh H-K, Choo S-K, Kim J-W, Lee M. Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing. Injury. 2015;46:2512\u0026ndash;5. https://doi.org/10.1016/j.injury.2015.09.026 \u003c/li\u003e\n\u003cli\u003eHuang W, Wu T, Wei Q, Peng L, Cheng X, Gao G. Suture repair of patellar inferior pole fracture: Transosseous tunnel suture compared with anchor suture. Exp Ther Med. 2021;22:998. https://doi.org/10.3892/etm.2021.10430 \u003c/li\u003e\n\u003cli\u003eDong Y, Huang W, Wei L, Du Y, Lin B. Comparison of the treatment of patellar inferior pole fractures with combined vertical wire and mini steel plate fixation versus independent vertical wire fixation. Knee. 2025;52:43\u0026ndash;57. https://doi.org/10.1016/j.knee.2024.09.015 \u003c/li\u003e\n\u003cli\u003eFranulic NI Piero; Laso, Jos\u0026eacute; Ignacio; Olivieri, Rodrigo; Gaggero, Nicol\u0026aacute;s. Manejo de fracturas conminutas del polo distal de la patela con asas verticales de alambre: Reporte de casos. Revista Chilena de Ortopedia y Traumatolog\u0026iacute;a. Thieme Revinter Publica\u0026ccedil;\u0026otilde;es Ltda.; 2022;63:e1\u0026ndash;8. https://doi.org/10.1055/s-0042-1744267 \u003c/li\u003e\n\u003cli\u003eCho J-W, Kim J, Cho W-T, Gujjar PH, Oh C-W, Oh J-K. Comminuted inferior pole fracture of patella can be successfully treated with rim-plate-augmented separate vertical wiring. Arch Orthop Trauma Surg. 2018;138:195\u0026ndash;202. https://doi.org/10.1007/s00402-017-2807-7 \u003c/li\u003e\n\u003cli\u003eAndrews JR, Hughston JC. Treatment of patellar fractures by partial patellectomy. South Med J. 1977;70:809\u0026ndash;13, 817. https://doi.org/10.1097/00007611-197707000-00014 \u003c/li\u003e\n\u003cli\u003eSaltzman CL, Goulet JA, McClellan RT, Schneider LA, Matthews LS. Results of treatment of displaced patellar fractures by partial patellectomy. J Bone Joint Surg Am. 1990;72:1279\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003evan Raay JJ, van Loon A, Wissing JC, van der Werken C. [Partial and total patellectomy as treatment of comminuted patella fracture]. Ned Tijdschr Geneeskd. 1990;134:1308\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eSong HK, Yoo JH, Byun YS, Yang KH. Separate Vertical Wiring for the Fixation of Comminuted Fractures of the Inferior Pole of the Patella. Yonsei Med J. 2014;55:785. https://doi.org/10.3349/ymj.2014.55.3.785 \u003c/li\u003e\n\u003cli\u003eHargett DI, Sanderson BR, Little MTM. Patella Fractures: Approach to Treatment. J Am Acad Orthop Surg. 2021;29:244\u0026ndash;53. https://doi.org/10.5435/JAAOS-D-20-00591 \u003c/li\u003e\n\u003cli\u003ePosner AD, Zimmerman JP. Surgical Management of Patella Fractures: A Review. Arch Orthop. Scientific Archives; 2022;Volume 3:17\u0026ndash;21. https://doi.org/10.33696/Orthopaedics.3.026 \u003c/li\u003e\n\u003cli\u003eKakazu R, Archdeacon MT. Surgical Management of Patellar Fractures. Orthopedic Clinics of North America. 2016;47:77\u0026ndash;83. https://doi.org/10.1016/j.ocl.2015.08.010 \u003c/li\u003e\n\u003cli\u003eKuo L-Y, Chen C-Y, Lin K-C. Combining a transosseous cerclage wire after patellar tendon reattachment to treat patella distal pole fracture did not improve functional outcome. Sci Rep. Nature Publishing Group; 2022;12:9587. https://doi.org/10.1038/s41598-022-13641-z \u003c/li\u003e\n\u003cli\u003eChang C-H, Chuang H-C, Su W-R, Kuan F-C, Hong C-K, Hsu K-L. Fracture of the inferior pole of the patella: tension band wiring versus transosseous reattachment. J Orthop Surg Res. 2021;16:365. https://doi.org/10.1186/s13018-021-02519-x \u003c/li\u003e\n\u003cli\u003eEgol K, Howard D, Monroy A, Crespo A, Tejwani N, Davidovitch R. PATELLA FRACTURE FIXATION WITH SUTURE AND WIRE: YOU REAP WHAT YOU SEW. :5. \u003c/li\u003e\n\u003cli\u003eBuschbeck S, G\u0026ouml;tz K, Klug A, Barzen S, Gramlich Y, Hoffmann R. Comminuted AO-C3 fractures of the patella: good outcome using anatomically contoured locking plate fixation. International Orthopaedics (SICOT). 2022;46:1395\u0026ndash;403. https://doi.org/10.1007/s00264-022-05374-5 \u003c/li\u003e\n\u003cli\u003eKruse M, Wolf O, Mukka S, Br\u0026uuml;ggemann A. Epidemiology, classification and treatment of patella fractures: an observational study of 3194 fractures from the Swedish Fracture Register. Eur J Trauma Emerg Surg. 2022;48:4727\u0026ndash;34. https://doi.org/10.1007/s00068-022-01993-0 \u003c/li\u003e\n\u003cli\u003eHuang S, Zou C, Kenmegne GR, Yin Y, Lin Y, Fang Y. Management of comminuted patellar fractures using suture reduction technique combined with the modified Kirschner-wire tension band. BMC Surg. 2023;23:251. https://doi.org/10.1186/s12893-023-02153-w \u003c/li\u003e\n\u003cli\u003eKim YM, Yang JY, Kim KC, Kang C, Joo YB, Lee WY, et al. Separate Vertical Wirings for the Extra-articular Fractures of the Distal Pole of the Patella. Knee Surg Relat Res. 2011;23:220\u0026ndash;6. https://doi.org/10.5792/ksrr.2011.23.4.220 \u003c/li\u003e\n\u003cli\u003eGrelsamer RP, Proctor CS, Bazos AN. Evaluation of Patellar Shape in the Sagittal Plane: A Clinical Analysis. Am J Sports Med. SAGE Publications Inc STM; 1994;22:61\u0026ndash;6. https://doi.org/10.1177/036354659402200111 \u003c/li\u003e\n\u003cli\u003eHarna B, Gupta P, Singh J, Rousa S, Gupta A. Surgical Management of Non-Union Patella Fracture: A Case Series and Review of the Literature. Arch Bone Jt Surg. 2021;9:554\u0026ndash;8. https://doi.org/10.22038/abjs.2020.49755.2472 \u003c/li\u003e\n\u003cli\u003eKadar A, Sherman H, Drexler M, Katz E, Steinberg EL. Anchor suture fixation of distal pole fractures of patella: twenty seven cases and comparison to partial patellectomy. International Orthopaedics (SICOT). 2016;40:149\u0026ndash;54. https://doi.org/10.1007/s00264-015-2776-9 \u003c/li\u003e\n\u003cli\u003eSeggewiss J, Nicolini LF, Lichte P, Greven J, Ribeiro M, Prescher A, et al. Transosseous suture versus suture anchor fixation for inferior pole fractures of the patella in osteoporotic bone: a biomechanical study. European Journal of Medical Research. 2022;27:270. https://doi.org/10.1186/s40001-022-00903-9 \u003c/li\u003e\n\u003cli\u003eBel J-C, Lef\u0026egrave;vre C. Reconstruction of patella fractures with the tension band technique: A review on clinical results and tips and tricks. Injury. 2024;55 Suppl 1:111401. https://doi.org/10.1016/j.injury.2024.111401 \u003c/li\u003e\n\u003cli\u003eLeBrun CT, Langford JR, Sagi HC. Functional Outcomes After Operatively Treated Patella Fractures: Journal of Orthopaedic Trauma. 2012;26:422\u0026ndash;6. https://doi.org/10.1097/BOT.0b013e318228c1a1 \u003c/li\u003e\n\u003cli\u003eGreenberg A, Kadar A, Drexler M, Sharfman ZT, Chechik O, Steinberg EL, et al. Functional outcomes after removal of hardware in patellar fracture: are we helping our patients? Arch Orthop Trauma Surg. 2018;138:325\u0026ndash;30. https://doi.org/10.1007/s00402-017-2852-2 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Patellar fractures, Distal Pole, Inferior Pole, Extensor mechanism injury, Patellar trauma","lastPublishedDoi":"10.21203/rs.3.rs-8695399/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8695399/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo compare transosseous sutures (TOS) and vertical wire cerclage (VCW) for treating distal pole patellar fractures and evaluate their equivalence in terms of clinical outcomes, patient reported outcome measures (PROMs), radiographic outcomes and complications.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e We conducted a non-concurrent cohort study retrospectively reviewing all patients surgically treated for patellar distal pole fractures (AO/OTA 34A1b) with either TOS or VCW between 2015 and 2023. Patient characteristics, surgical technique and postoperative follow-up data, patellar height and complications were recorded. Functional outcomes were evaluated at least 12 months postoperatively using PROMs (Kujala, Lysholm and Bostman scores). Internal approval of the Institutional Ethics Committee was gained, and informed consent was obtained from all patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 46 patellar distal pole fractures were included; 30 TOS and 16 VCW. Baseline characteristics were comparable between groups. No significant differences were found between groups regarding clinical nor functional outcomes or complications. No significant differences were found respecting patellar height. However, significant length variation was found in the TOS group, with a mean elongation of 3.77 mm (p 0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBoth Transosseous sutures and vertical cerclage wires reinsertion techniques achieve good clinical and radiographic outcomes. Nonetheless, the finding of patellar elongation warrants further investigation to elucidate its etiology and potential clinical relevance.\u003c/p\u003e","manuscriptTitle":"Patellar distal pole fracture treatment with transosseous sutures vs vertical cerclage wire techniques: a comparative retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 11:57:36","doi":"10.21203/rs.3.rs-8695399/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T07:46:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-21T06:29:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170963308821255052810062292499982884427","date":"2026-03-19T12:21:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-21T22:16:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5262956129254725994393104542837350631","date":"2026-02-09T10:04:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-08T10:05:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-07T07:14:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-31T10:12:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2026-01-26T00:57:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e7ddbe84-03a5-43f7-b463-0f8e7104254e","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T06:55:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 11:57:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8695399","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8695399","identity":"rs-8695399","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}