European Journal of Trauma and Emergency Surgery

, Volume 44, Issue 5, pp 697–706 | Cite as

Functional outcome and economic burden of operative management of patellar fractures: the pivotal role of onerous implants

  • M. Reul
  • M. Verschaeve
  • T. Mennes
  • S. Nijs
  • H. HoekstraEmail author
Original Article



The complication rate following operative treatment of patellar fractures remains high and is associated with a poor functional outcome. The primary goal of this study was to evaluate our functional outcome of patellar fracture osteosynthesis and define strategies to improve the outcome. The healthcare costs and utilization were calculated.


All demographic, clinical, radiographic variables and hospital-related costs of 111 patients with 113 surgically treated patellar fractures between January 2005 and December 2014 were analyzed. Fractures were grouped as either simple or complex. Functional outcome was assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS).


There were 67 simple fractures (59.3%) and 46 complex fractures (40.7%). The overall complication rate was 48.7%, including 19.5% implant-related complications. In 69 patients (61.1%), implants were removed. The outcome was rather poor, with considerable impairment in all KOOS subscales with the knee-related quality of life rated worst (median 62.5, IQR 37.5–81.25). Poor outcome correlated significantly with complex patellar fractures and extensive tension-band constructs.


The operative treatment of patellar fractures was associated with a high complication rate, functional impairment and reduced quality of life. Complex patellar fractures and extensive tension-band constructs were identified as the main determinants of poor outcome and increased economic burden due to higher reinterventions rates. Strategies to reduce complications and improve outcome should focus on less onerous implants.


Patellar fractures KOOS Functional outcome Economics 


Compliance with ethical standards

Conflict of interest

Maike Reul, Marie Verschaeve, Tillo Mennes, Stefaan Nijs and Harm Hoekstra have no conflicts of interest.


  1. 1.
    Melvin JS, Metha S. Patellar fractures in adults. J Am Acad Orthop Surg. 2011;19(4):198–207.CrossRefGoogle Scholar
  2. 2.
    Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691–7.CrossRefGoogle Scholar
  3. 3.
    Perry J, Antonelli D, Ford W. Analysis of knee-joint forces during flexed-knee stance. J B Jt Surg Am. 1975;57(7):961–7.CrossRefGoogle Scholar
  4. 4.
    Kaufer H. Mechanical function of the patella. J B Jt Surg. 1971;53(8):1551–60.CrossRefGoogle Scholar
  5. 5.
    Cramer K, Moed B. Patellar fractures. contemporary approach to treatment. J Am Acad Orthop Surg. 1997;5(6):323–31.CrossRefGoogle Scholar
  6. 6.
    Berg EE. Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring through parallel cannulated compression screws. J Orthop Trauma. 1997;11(8):573–6.CrossRefGoogle Scholar
  7. 7.
    Galla M, Lobenhoffer P. Patella. fractures. Der Chirurg Zeitschrift Fur Alle Gebiete Der Operativen Medizen. 2005;76(10):987–97. (quiz 998–999).CrossRefGoogle Scholar
  8. 8.
    Müller ME, Allgöwer M, Schneider R, et al. Manual of internal fixation: techniques recommended by the AO group. Berlin: Springer; 1979.CrossRefGoogle Scholar
  9. 9.
    Lin T, Liu J, Xiao B, et al. Comparison of the outcomes of cannulated screws vs. modified tension band wiring fixation techniques in the management of mildly displaced patellar fractures. BMC Musculoskelet Disord. 2015;16(1):282.CrossRefGoogle Scholar
  10. 10.
    Carpenter JE, Kasman RA, Patel N, et al. Biomechanical evaluation of current patella fracture fixation techniques. J Orthop Trauma. 1997;11(5):351–6.CrossRefGoogle Scholar
  11. 11.
    Sayum FJ, Lenza M, Teixeira de Carvalho R, et al. Interventions for treating fractures of the patella in adults. Cochrane Database Syst Rev. 2015;2:CD009651.Google Scholar
  12. 12.
    Lazaro LE, Wellman DS, Sauro G, et al. Outcomes after operative fixation of complete articular patellar fractures: assessment of functional impairment. J B Jt Surg Am. 2013;95(14):e96. (1–8).CrossRefGoogle Scholar
  13. 13.
    Gosal HS, Singh P, Field RE. Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester—a study of 37 cases. Injury. 2001;32(2):129–35.CrossRefGoogle Scholar
  14. 14.
    Smith ST, Cramer KE, Karges DE, et al. Early complications in the operative treatment of patella fractures. J Orthop Trauma. 1997;11(3):183–7.CrossRefGoogle Scholar
  15. 15.
    Wild M, Khayal T, Miersch D, et al. Dynamic cerclage wiring of patellar fractures. Complications and midterm functional results. Unfallchirurg. 2008;111(11):892–7.CrossRefGoogle Scholar
  16. 16.
    Traa WA, Oomen PJ, a, Den Hamer, A, et al. Biomechanical studies on transverse olecranon and patellar fractures: a systematic review with the development of a new scoring method. Br Med Bull. 2013;108(1):131–57.CrossRefGoogle Scholar
  17. 17.
    Kumar G, Mereddy PK, Hakkalamani S, et al. Implant removal following surgical stabilization of patella fracture. Orthopedics. 2010;33(5):301.Google Scholar
  18. 18.
    Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: orthopaedic trauma association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–133.CrossRefGoogle Scholar
  19. 19.
    Brinker MR. Nonunions. Evalution and treatment. In: Browner BD, Levine AM, Jupiter JB, Trafton PG, editors. Skeletal trauma: basic science, management and reconstruction. 3rd ed. Philadelphia: W.B. Saunders; 2003. pp. 507–604.Google Scholar
  20. 20.
    Smeets B, Nijs S, Nderlita M, Vandoren C, Hoekstra H. Health care usage and related costs in fibular plating for AO type 44-B ankle fractures in a Belgian University Hospital: an exploratory analysis. J Foot Ankle Surg. 2016. doi: 10.1053/j.jfas.2016.02.004.CrossRefPubMedGoogle Scholar
  21. 21.
  22. 22.
    Roos EM, Roos HP, Lohmander LS, et al. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sport Phys Ther. 1998;28(2):88–96.CrossRefGoogle Scholar
  23. 23.
    de Groot IB, Favejee MM, Reijman M, et al. The Dutch version of the Knee Injury and Osteoarthritis Outcome Score: a validation study. Health Qual Life Outcomes. 2008;6:16.CrossRefGoogle Scholar
  24. 24.
    Roos EM, Roos HP, Ekdahl C, et al. Knee injury and Osteoarthritis Outcome Score (KOOS)—validation of a Swedish version. Scand J Med Sci Sport. 1998;8(6):439–48.CrossRefGoogle Scholar
  25. 25.
    Roos E, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score(KOOS)—validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes. 2003;I:17.CrossRefGoogle Scholar
  26. 26.
    LeBrun CT, Langford JR, Sagi HC. Functional outcomes after operatively treated patella fractures. J Orthop Trauma. 2012;26(7):422–6.CrossRefGoogle Scholar
  27. 27.
    Paradowski PT, Bergman S, Sundén-Lundius A, et al. Knee complaints vary with age and gender in the adult population. Population-based reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS). BMC Musculoskelet Disord. 2006;7:38.CrossRefGoogle Scholar
  28. 28.
    Cameron KL, Thompson BS, Peck KY, et al. Normative values for the KOOS and WOMAC in a young athletic population: history of knee ligament injury is associated with lower scores. Am J Sports Med. 2013;41(3):582–9.CrossRefGoogle Scholar
  29. 29.
    Williamson T, Sikka R, Tompkins M, Nelson BJ. Use of the Knee Injury and Osteoarthritis Outcome Score in a healthy United States population. Am J Sport Med. 2016;44(2):440–6. doi: 10.1177/0363546515616812.CrossRefGoogle Scholar
  30. 30.
    Roos EM, Lohmander LS. The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes. 2003;1:64.CrossRefGoogle Scholar
  31. 31.
    Knee Injury and Osteoarthritis Outcome Score. A user’s guide to Knee Injury and Osteoarthritis Outocme Score (KOOS). Accessed October 2015.
  32. 32.
    Levack B, Flannagan JP, Hobbs S. Results of surgical treatment of patellar fractures. J B Jt Surg Br. 1985;67(3):416–9.CrossRefGoogle Scholar
  33. 33.
    Böstman O, Kiviluoto O, Nirhamo J. Comminuted displaced fractures of the patella. Injury. 1981;13(3):196–202.CrossRefGoogle Scholar
  34. 34.
    Böstman O, Kiviluoto O, Santavirta S, et al. Fractures of the patella treated by operation. Arch Orthop Trauma Surg. 1983;102(2):78–81.CrossRefGoogle Scholar
  35. 35.
    Hung LK, Chan KM, Chow YN, et al. Fractured patella: operative treatment using the tension band principle. Injury. 1985;16(5):343–7.CrossRefGoogle Scholar
  36. 36.
    Anand S, Hahnel J. C. R., Giannoudis PV. Open patellar fractures: high energy injuries with a poor outcome? Injury. 2008;39(4):480–4.CrossRefGoogle Scholar
  37. 37.
    Scott JC. Fractures of the patella. J B Jt Surg Am. 1949;31:76–81.CrossRefGoogle Scholar
  38. 38.
    Wilkinson J. Fracture of the patella treated by total excision. A long-term follow up. J B Jt Surg Br. 1977;59:352–4.CrossRefGoogle Scholar
  39. 39.
    Thelen S, Betsch M, Schneppendahl J, et al. Fixation of multifragmentary patella fractures using a bilateral fixed-angle plate. Orthopedics. 2013;36(11):e1437–e43.CrossRefGoogle Scholar
  40. 40.
    Thelen S, Schneppendahl J, Baumgärtner R, et al. Cyclic long-term loading of a bilateral fixed-angle plate in comparison with tension band wiring with K-wires or cannulated screws in transverse patella fractures. Knee Surg Sport Traumatol Arthrosc. 2013;21(2):311–7.CrossRefGoogle Scholar
  41. 41.
    Thelen S, Schneppendahl J, Jopen E, et al. Biomechanical cadaver testing of a fixed-angle plate in comparison to tension wiring and screw fixation in transverse patella fractures. Injury. 2012;43(8):1290–5.CrossRefGoogle Scholar
  42. 42.
    Wild M, Thelen S, Jungbluth P, et al. Fixed-angle plates in patella fractures— a pilot cadaver study. Eur J Med Res. 2011;16(1):41–6.CrossRefGoogle Scholar
  43. 43.
    Benjamin J, Bried J, Dohm M, et al. Biomechanical evaluation of various forms of fixation of transverse patellar fractures. J Orthop Trauma. 1987;1(3):219–22.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • M. Reul
    • 1
  • M. Verschaeve
    • 2
  • T. Mennes
    • 2
  • S. Nijs
    • 1
    • 2
    • 3
  • H. Hoekstra
    • 1
    • 2
    • 3
    Email author
  1. 1.Department of Trauma SurgeryUniversity Hospitals LeuvenLeuvenBelgium
  2. 2.Faculty of MedicineKU Leuven-University of LeuvenLeuvenBelgium
  3. 3.Department of Development and RegenerationKU Leuven-University of LeuvenLeuvenBelgium

Personalised recommendations