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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 163-167

Nonabsorbable transosseous sutures for lower pole patella fractures: An effective surgical technique to prevent implant complications

Department of Orthopedics, Dr. Panjabrao Deshmukh Memorial Medical College and Hospital, Amravati, Maharashtra, India

Date of Submission10-Oct-2022
Date of Acceptance05-Dec-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Sagar Kharat
Dr. Panjabrao Deshmukh Memorial Medical College and Hospital, Amravati, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_96_22

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Background: Treatment alternatives for patella fractures with the inferior pole are still being deliberated. In addition to tension-band wiring, metal implant-related complications are also not uncommon to occur in patellar fracture treatment. It is common to encounter implant-related complications such as implants failing, palpable hardware which require supplementary techniques to resolve. We evaluated participants with inferior poles of patella fracture treated with transosseous nonabsorbable sutures on functional outcomes. Methodology: This study encompasses observation of patients having transosseous suture fixation by no. 5 Ethibond for fixation of distal pole patella fractures. This was a longitudinal study piloted at a tertiary care center between January 2020 and June 2022. Patients' functional outcomes were assessed using the Bostman score. Results: The Bostman scoring system was used to evaluate the outcome at the final follow-up. In 19 patients, 7 (36.84%) patients showed outstanding and 11 (57.89%) patients showed good outcomes at the termination of 9 months follow-up. Only one patient established an unsatisfactory result. Conclusion: Distal pole patella fractures can be effectively fixed via transosseous suturing with unabsorbable sutures. Fast recovery and minimal implant-related complications are possible with this procedure. The resurgery rate is also significantly reduced.

Keywords: Arbeitsgemeinschaft fur osteosynthesefragen classification, distal pole patella fractures, transosseous sutures

How to cite this article:
Jaiswal S, Wankhade U, Kharat S, Gudhe M, Tarekar S, Bhakare A. Nonabsorbable transosseous sutures for lower pole patella fractures: An effective surgical technique to prevent implant complications. J Orthop Traumatol Rehabil 2022;14:163-7

How to cite this URL:
Jaiswal S, Wankhade U, Kharat S, Gudhe M, Tarekar S, Bhakare A. Nonabsorbable transosseous sutures for lower pole patella fractures: An effective surgical technique to prevent implant complications. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2023 Apr 1];14:163-7. Available from: https://www.jotr.in/text.asp?2022/14/2/163/365832

  Introduction Top

Patella increases knee's lever arm, making it a crucial part of the extensor mechanism.[1] About 1% of all fractures in adults occur in this sesamoid bone, which is the largest sesamoid bone in the body.[2],[3]

Extraarticular patella inferior pole fractures consist of 9%–22% of all patellar fractures and they are frequently linked to total extensor mechanism disruption.[4],[5] In adults, patella fractures occur for about 1% of all fractures.[6],[2] The patellar tendon is usually avulsed in approximately 9.3%–22% of fractures requiring surgical fixation.[7]

Fixation is the only way to restore the knee's extensor mechanism, failing which complications such as loss of knee mobility and stiffness would result. The transosseous suture repair technique is one of several options for fixing inferior pole fractures, which are classified as extra-articular fractures under the Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification.[8],[9]

A tension-band wiring method modified by the AO is the most common operation to fix a patellar fracture.[10],[11],[s12] Whereas approximately 32.8% to 47% of implants result in complications.[13],[14] Some modified tension-band-wiring procedures have been stated to lessen difficulties linked to metal implants.[15],[16]

This type of fixation has typically been accomplished with metal implants such screws, K-wires, and stainless steel wires. However, there are a lot of issues that might arise with the use of metal implants, such as postoperative discomfort, K-wire migration, and other issues.[17],[18],[19],[20]

Nonabsorbable sutures have a similar percentage of union but a lower rate of complications and implant removal than traditional fixing methods.[21] Through longitudinal drill holes, a metal wire is dragged and wrapped around the patella's anterior surface in their method. It provides an anterior tension band, permits exceptional inter-fragmentary compression, and inhibits a backward patellar step-off.[21]

Tension-band fixation retaining two parallel Kirschner's wires and a braided polyester nonabsorbable suture, by the improved Wagoner's Hitch, displayed a smaller amount of fracture gap than other recognized tension-band suture and wire procedures in an in vitro biomechanical test.[19]

Even though clinical results have been mostly positive, all metallic wire procedures can consequence in symptomatic hardware, which is the most common consequence, with stated rates ranging from 0% to 60%.[22],[23] Implants can actually irritate and cause pain in surrounding soft tissue, necessitating a second procedure to remove the implant. Furthermore, there has been a high rate of infection.[24] As a result, while using various procedures, some writers have urged the use of nonabsorbable sutures, such as braided polyester.[25]

Suture fixation has several advantages over a wire fixation, including reduced revision surgeries, more patient compliance, and better patient tolerance to the alloplastic material with reduced irritation to tissues. Apart from this, it also has superiority in terms of operation procedure, time, and tourniquet application.[26],[27]

The objective of the present study was to share our experience of cases with distal pole patella fractures treated with nonabsorbable sutures via transosseous suture fixation to evaluate if the procedure improves knee function without implant-related problems.

  Methodology Top

The present study was a longitudinal study. In this study, a total of 19 patients were included, among them, 9 were females and 10 were male. The same team of orthopedic surgeons performed all surgeries between January 2012 and January 2022.

Inclusion criteria

  1. Patients who are skeletally mature and over 18 years of age
  2. Posttraumatically, the lower pole of the patella was fractured; such patients are involved
  3. Closed lower pole patella fractures
  4. Fresh fractures (<1 week old) were included.

Exclusion criteria

  1. Open wound
  2. Any other bone fractured of the ipsilateral lower limb
  3. Patients with active infections were not included
  4. The patients with previous ipsilateral knee surgery
  5. Patients with polytrauma or head injuries that definitely influence rehabilitation was removed in our study.

Preoperative standard laboratory tests, a full history review, a physical examination, and radiographs of the anteroposterior and lateral views of the knee joint were all performed on the patients. Altogether the patients were given spinal anesthesia during the procedure. Patients were told to lie flat on a radiolucent surgery table and a pneumatic tourniquet was used for the procedure word [Figure 1].
Figure 1: Preoperative X-ray lower pole patella fracture

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A typical midline longitudinal skin incision was made, running from the tibial tuberosity to the superior pole of the patella. Fractures, retinal tears, and patellar tears arise after raising flaps, and the tendon was visible. Clots and hematomas were cleared by performing saline irrigation at the operative field. Free, denuded skeletal fragments were eliminated, but the majority of the bone material was retained. Placing the knee in flexion, two vertical holes were drilled through the articular margin of the proximal fragment and the superior border of the patella. One the path was created, fixation was achieved by the use of four-stranded transosseous suturing using a beath pin (two on either side). For the purpose of suturing the patellar tendon, sutures were held at the superior pole of the patella and before securing the knot, knee flexion was assessed up to 90° The material and the procedure used for this purpose was no. 5 Ethibond via Krackow technique through the medial and lateral half of the patellar tendon. Sutures were put on the superior pole patella while the knee was held extended. The patellar tendon was gently everted and positioned so that it would rest against the patellar remnants' untreated, fragmented surface close to the articular surface. Utilizing absorbable sutures, the torn retinaculum was fixed. On the table, the knee's flexion was examined, as well as the repair of any gaps. The surgical incision was stitched up in layers. The surgical incisions were covered with sterile bandages, and a lengthy knee brace was put on.

Postoperatively, the patient was advised to start doing ankle pumps and isometric quadriceps workouts the day after surgery. After that, for the first 4 weeks, no knee motion was permitted with the help of bilateral axillary crutches on a knee immobilizer, and patients were permitted to bear weight as tolerated. Four weeks after surgery, activities to increase the range of motion and strengthen the quadriceps and hamstrings were begun, and the use of crutches was gradually reduced. After 6 weeks, the immobilizer was stopped being used. A physiotherapist oversaw all of the rehabilitation work directly [Figure 2].
Figure 2: Postoperative X-ray lower pole of patella fracture

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The patients were evaluated clinically and radiologically on a regular basis for the 9 months (2 weeks, 6 weeks, 12 weeks, 6 months, as well as 9 months).

Statistical analysis

Microsoft Excel 2016 (Windows 10) was used to collect the data, and SPSS version 20 (Statistical Package for Social Science, version 20, I.B.M., and Armony, New York) was utiliszd to conduct the analysis. Transcribing, checking the raw data, analyzing the content, and interpreting the results were the steps in the data analysis process. Age, sex, side, and manner of injury were categorical factors that were expressed as a percentage of patients.

  Results Top

In the present study, the average age was 50.15 ± 7.92. The 19 patients who went into the surgery during the study period ranged in age from 38 to 64 years. 10 out of 19 patients were male and 9 were female. From [Table 1], we see that right knee involvement in this study was 10 (52.63%), which was higher than left knee involvement, i.e., 9 (43.37%). More damage was caused to the right patella than the left.
Table 1: Distribution of sex and side of injury

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From [Table 2], we see that 14 (73.68%) patients were in the age group of 36–55 years. It might be because people in this age group are more active and participate in outdoor activities as compared to elderly patients, which was 5 (26.32%) in the study.
Table 2: Age group (years) distribution

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In the present study, 3 (15.79%) patients were involved in a road traffic accident, among 7 (36.84%) patients, mode of injury was fall and 9 (47.37%) patients were found physically injured [Table 3].
Table 3: Distribution of mode of injury

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[Table 4] shows that five patients (26.32%) had diabetes mellitus, four patients (21.05%) had hypertension, and 10 patients (52.63%) had no other comorbidities.
Table 4: Distribution of types of comorbidities

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Bostman score outcome

Out of 19 patients, 7 (36.84%) patients showed outstanding results and 11 (57.89%) patients had superior outcomes at the end of 9 months feedback. Only one patient demonstrated an unsatisfactory result [Graph 1].

Only one patient out of 19 showed loss of reduction and 13 patients (68.42%) had no further complications during the trial. Whereas five patients experienced stiffness during the study [Table 5].
Table 5: Complications of patients

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  Discussion Top

The recommended treatment for displaced inferior pole patella fractures is surgical fixation. The Patients were found who permit the inferior pole patella fractures have some limited options for fracture fixation and suture repair was clinically satisfactory and biomechanically confirmed.[19],[28] Numerous treatments have been discussed for the prognosis of these fractures, but none of them have been deemed appropriate yet. When inferior pole fractures are treated using K-wires, the reoperation rate ranges from 20% to 50%.[29] The objective of the present study was to determine the functional outcomes in patients who underwent transosseous nonabsorbable suture treatment for an inferior pole patella fracture. According to the present study, out of 19 patients, 7 (36.84%) patients indicated outstanding and 11 (57.89%) patients had good outcomes at the end of 9 months follow-up. Only one patient demonstrated with unsatisfactory results. These discoveries were in concordance with the study done by Mondal et al. evaluated last follow-up by using the Bostman grading method. During the final follow-up, 8 (72.8%) out of 11 patients displayed excellent results and 3 (27.2%) of the patients exhibited good results. No patient displayed an unfavorable outcome. They came to the conclusion that nonabsorbable transosseous suturing is a secure fixation method for treating distal pole patella fractures. It enables quick recovery with few implant-related issues. In addition, it greatly lowers the rates of reoperation.[30]

Similarly, Srikant et al. showed a prospective study on a total of 12 patients. In the treatment of articular inferior pole patella fractures, it was discovered that fractional patellectomy and patellar tendon reconstruction with transosseous sutures were a very efficient approaches. Twenty-seven patients after 6 months had positive results and were back to their preinjury activity levels. There was no case that required reoperation.[31]

Recently, Hoshino et al. accomplished a retrospective study of surgically treated patellar fractures. They stated that elective implant removal was performed in 37% and 23% of patients treated, respectively, using K-wires and cannulated screws.[32]

The no. 5 Ethibond suture material, which was nonabsorbable and had a high molecular weight, was used in the current investigation. Long-chain linear polyester and a distinctive braid structure are also present. High knot-breaking strength and exceptional strength are also features of No. 5 Ethibond suture material. Similarly, Gosal et al. used this material in their study and determined that nonmetallic implants were used for patella fractures because the metallic group had infection, resurgery, and morbidity charges that were six times higher than those of the nonabsorbable polyester group.[ 18]

According to Huang et al., anterior inferior pole fixation with K-wires results in 20% to 50% more reoperations and further decreases the range of motion in the knee joint. Ordinary wires or screws are ineffective in fixing bone fragments because of their inherent weakness and size.[33]

The current study shows that only one patient out of 19 showed loss of reduction and 13 patients (68.42%) had no further complications during the trial. Whereas five patients experienced stiffness during the study. Our findings were related to the work of Egol et al., who conducted a retrospective cohort study. In this study, a total of 49 patients were included who were with patella fractures. Egol et al. stated that fracture fixation options were limited for patients suffering from inferior pole patella fractures. The result of suture repair was comparable to that of metal implants for patella fractures. There are fewer hardware-related postoperative complications among patients undergoing suture repair than those undergoing wire fixation for mid-pole fractures.[34]

The present study demonstrates a safe and reliable fixation method for treating distal pole patella fractures was transosseous suturing using nonabsorbable sutures. It enables quick recovery with few implant-related issues. It decreases the rates of re-surgery significantly in the current study. Our findings were consistent with those of Buezo et al., who demonstrated a recent surgical technique by treating 8 patients in the hospital. Open reductions are carried out with internal fixation by completing three longitudinal tunnels and crossing double high-resistance sutures within each longitudinal tunnel.[35] Out of 19 patients, only one patient showed unsatisfactory results, at the end of 9 months as well as all participants showed fruitful outcomes and reverted to their preinjury activity level.

  Conclusion Top

The result of the study concludes that the distal pole patella fractures can be effectively fixed via transosseous suturing with nonabsorbable sutures. Fast recovery and minimal implant-related complications are possible with this procedure. The resurgery rate is also significantly reduced.


We gratefully acknowledge Neuron Institute of Applied Research for their generous help in editing and technical help.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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