The patella forms a pivotal component of the knee’s extensor mechanism. Its sesamoid position within the quadriceps tendon increases the moment arm of the muscle group and improves the efficiency of knee extension. Because it lies directly beneath the skin and transmits forces generated by both trauma and muscular contraction, the patella is particularly vulnerable to injury. Closed patellar fractures account for roughly one percent of all skeletal injuries worldwide, although the exact proportion varies between epidemiological series.[1,2] These fractures typically arise from direct blows, most often during falls, or from indirect tensile forces encountered during road traffic collisions. Either mechanism may disturb patellofemoral congruence and compromise the extensor mechanism, particularly when displacement or articular incongruity exceeds generally accepted operative thresholds.[3,4] Over recent decades, management philosophies have shifted considerably. Earlier tendencies to perform partial or total patellectomy have been superseded by techniques that emphasise preservation of bony architecture. Modified tension-band constructs, cerclage wiring systems, and selective partial patellectomy now dominate contemporary practice because they aim to restore the articular surface and re-establish extensor continuity while permitting early rehabilitation.[5,6] Although these operative options are well documented, detailed analyses of functional outcomes following surgical treatment of closed fractures remain relatively limited, particularly in resource-constrained settings where injury patterns frequently relate to motor-vehicle trauma.[1,3] Given the functional importance of the extensor mechanism and the potential long-term impact of malreduction, evaluating postoperative recovery is essential. The present study, therefore, assessed functional outcomes after operative management of closed patellar fractures in adults, using the Modified Böstman score as a structured evaluation tool.[7]

Study Design and Setting A prospective observational study was conducted among adults presenting with closed patellar fractures at Vijayangar institute of Medical Sciences, Bellary, Karnataka, in the Year between - 2017 and 2020. Data collection and follow-up were carried out over a defined study period, and all participants were observed until six months after surgery. Participants Fifty skeletally mature individuals with radiologically confirmed closed fractures of the patella were enrolled. Eligible fracture patterns included transverse, comminuted, and polar variants. Open fractures and injuries associated with distal femoral or proximal tibial fractures were excluded to maintain sample uniformity. All patients provided informed consent before participation. Surgical Procedures The choice of operative technique was tailored to the radiographic configuration of each fracture. Tension-band wiring was used for most transverse fractures, whereas cerclage wiring was preferred for comminuted patterns with adequate bone stock. When the inferior pole was severely fragmented and unsuitable for fixation, a partial patellectomy was performed while preserving the functional articular portion. All operations were carried out under antibiotic prophylaxis. A midline incision was used to expose the patella, and the extensor retinaculum was inspected and repaired whenever torn. Stability of fixation was routinely checked through controlled knee flexion before wound closure. Drains were placed where required, and layered closure was completed with sterile dressings. Postoperative Rehabilitation A posterior cylinder splint was applied immediately after surgery with the knee in extension. Quadriceps-setting exercises, ankle pumps, and straight-leg raises with support were started on the second postoperative day. Individuals who had undergone tension-band fixation progressed to both static and dynamic quadriceps strengthening early, whereas those treated with cerclage wiring or partial patellectomy were initially restricted to static exercises. Radiographic evaluation at six weeks guided the transition to more advanced mobilisation. A long knee immobiliser replaced the slab after suture removal at two weeks. Assisted ambulation with crutches was advised until active leg control improved. Controlled flexion exercises were initiated around the third postoperative week, and gradual resistance training was commenced once union was evident. Follow-up and Outcome Assessment Participants were reviewed at two-week intervals during the first month and subsequently every four weeks. Each visit involved a structured assessment of knee function, including range of motion, extensor lag, quadriceps strength, thigh circumference, pain levels, knee effusion, stability during ambulation, and ability to squat or climb stairs. Functional status at six months was quantified using the modified Böstman scoring system, which incorporates both objective measurements and patient-reported outcomes. Scores were categorised as excellent, good, or fair/unsatisfactory based on established thresholds.

Fifty patients who met the inclusion criteria completed the six-month follow-up assessment. Men formed the larger subset, constituting nearly two-thirds of the cohort, while women accounted for the remainder. The majority of patients fell between 20 and 60 years of age. Left-sided fractures were more common than right-sided injuries. A representative intraoperative appearance of a displaced transverse patella fracture with associated extensor retinacular disruption is shown in Figure 1. Road-traffic collisions accounted for slightly more than half of the injuries, with the rest resulting from direct falls onto the anterior knee. Transverse fractures remained the most frequent configuration, followed by polar and comminuted patterns. The principal fracture morphologies and their corresponding operative techniques are summarised schematically in Figure 3A–D. Forty of the fifty patients underwent osteosynthesis, either modified tension-band wiring or cerclage wiring, while the remaining ten required partial patellectomy due to irreparable inferior pole fragmentation. A typical postoperative appearance following tension-band wiring and retinacular repair is illustrated in Figure 2. Radiological union was documented by the fourth week in a small subset, by the eighth week in the majority, and by the twelfth week in the remaining patients. The average time to union was approximately eight weeks. Pain was common during the early postoperative period but declined steadily over subsequent reviews. By twelve weeks, only a few patients reported discomfort during routine activities. Quadriceps strength improved progressively; most patients achieved near-normal power by six months. Terminal restriction of flexion (approximately twenty degrees) occurred in a few individuals, and mild extensor lag was observed occasionally. Superficial infections resolved with local care, and no deep infections, hardware breakage, or K-wire migration was recorded. Functional outcome was assessed using the Modified Böstman Score, reproduced in Table 1. Based on this scoring system, 35 patients (70%) achieved an excellent outcome, 10 patients (20%) achieved a good outcome, and 5 patients (10%) were categorised as fair. Patients who underwent modified tension-band wiring tended to achieve excellent scores more consistently, whereas fair results were more commonly observed among those who had undergone partial patellectomy. Table 1. Modified Böstman Score Used for Functional Assessment Variable Points Pain None or pain only with strenuous activity 6 Pain with moderate exertion 3 Pain during daily activities 0 Range of Motion Full extension with flexion >120° or <10° loss compared to normal side 6 Full extension with flexion between 90° and 120° 3 Quadriceps Atrophy (difference 10 cm above the patella) <12 mm 4 12–25 mm 2 >25 mm 0 Walking Aids None 4 Occasional use 2 Constant use 0 Work Capacity Original job 4 Modified job 2 Unable to work 0 Giving-way / Instability None 2 Occasional 1 Frequent 0 Climbing Stairs Normal 2 Disturbing 1 Disabling 0 Knee Effusion None 2 Reported but minimal 1 Present 0 Outcome interpretation: Excellent: 30–28  Good: 27–20  Fair/Unsatisfactory: <20 Table 2. Postoperative Complications Among the Fifty Patients Complication Number of Patients Remarks Terminal flexion restriction (~20°) 5 Improved with physiotherapy; two remained symptomatic at six months Extensor lag (~10°) 3 Observed after both osteosynthesis and partial patellectomy Superficial infection 3 Resolved with antibiotics and dressing Hardware prominence 2 Required implant removal due to irritation Hardware breakage 0 , K-wire migration 0 , Tendon ossification 0 , Osteoporosis 0 , Figure 1. Transverse patella fracture with extensor retinaculum tear Intraoperative view of a closed transverse patella fracture showing disruption of the extensor retinaculum. Figure 2. Modified tension-band wiring with extensor retinaculum repair Postoperative appearance following modified tension-band wiring with repair of the extensor retinaculum. Figure 3A–D. Composite schematic of fracture types and fixation techniques A: transverse patella fracture; B: fixation using modified tension-band wiring; C: cerclage wiring for comminuted fracture patterns; D: partial patellectomy preserving the articular surface.

Closed fractures of the patella continue to present a particular challenge because of their direct influence on the extensor apparatus and their potential to impair knee function if alignment is not restored. The overall age distribution in the present cohort closely parallels earlier work, in which the majority of patients fell within the fourth or fifth decade of life. Böstman and colleagues reported a similar clustering of ages in their operative series [7], and Levack et al. described a comparable pattern among surgically treated patients.[8] Men formed the majority of our sample, which is consistent with the male predominance documented in previous reports from India and other regions.[2,9,10] This trend is usually attributed to occupational exposure and the higher likelihood of male involvement in high-velocity trauma. The predominance of left-sided injuries in the present series corresponds with observations from Indian studies, where higher involvement of the non-dominant limb has been noted.[9] Mechanism of injury also mirrored previous literature, with road traffic collisions forming the principal aetiology.[1,3,11] Standard reviews of patellar fractures emphasise that such high-energy mechanisms often involve a combination of direct impact and indirect tensile forces transmitted through the quadriceps, predisposing to displacement and disruption of the extensor mechanism.[3,11] Transverse fractures remained the most frequent pattern in our cohort, which is in keeping with the biomechanical nature of the injury, often involving a combination of direct trauma and sudden quadriceps contraction. Similar distributions have been documented in earlier operative series, including those by Marya et al. and Böstman et al.[7,12] The operative techniques selected in the present study, tension-band wiring for transverse fractures, cerclage wiring for comminuted patterns, and partial patellectomy for irreparable inferior pole fragments, are congruent with standard orthopaedic practice.[5,6] The tension-band construct remains widely favoured because it converts anterior tensile forces into compressive forces at the articular surface during knee flexion, thereby promoting stable union and facilitating early motion.[4,5] Union rates observed in this study were comparable with earlier literature, with most patients achieving radiological consolidation by eight weeks. Böstman et al. reported similar timelines with stable fixation techniques [7], and long-term follow-up data from Edwards et al. also underscore the importance of restoring articular congruity and extensor continuity to achieve durable results.[13] Importantly, we did not encounter hardware breakage or wire migration, complications that have been reported in some series of tension-band fixation.[6,10] This may reflect meticulous surgical technique and a supervised rehabilitation protocol that avoided excessive early loading. Quadriceps strength recovered satisfactorily in most patients, echoing previous long-term studies that have highlighted the functional benefits of preserving patellar integrity and maintaining the extensor lever arm.[14] Minor terminal restriction of flexion and occasional extensor lag were observed in our cohort; similar issues have been described in earlier reports and are often attributed to fracture comminution, soft-tissue scarring, or prolonged early immobilisation.[10,15] Contemporary reviews of patellar fracture management emphasise that, despite satisfactory union rates, a subset of patients may continue to experience residual stiffness or anterior knee discomfort, underlining the need for carefully timed mobilisation and adherence to physiotherapy.[3,10,11] The distribution of functional outcomes in the present series, predominantly excellent or good results on the Modified Böstman score, with a smaller proportion graded as fair, accords with outcomes reported in prior clinical studies. Marya et al. found excellent or good recovery in the majority of their operatively managed patients [12], and other series evaluating surgically treated patellar fractures have likewise documented high rates of functional independence, even in older age groups.[15] The slightly lower proportion of excellent scores in our cohort compared with some reports may be related to the inclusion of partial patellectomy cases, where the extensor lever arm is inevitably altered.[7,12,14] Taken together, these findings reinforce the view that anatomical reconstruction of the patella, whenever feasible, yields reliable functional restoration with relatively low complication rates.[3,7,10–12] Early recognition of fracture configuration, appropriate selection of fixation strategy, and structured postoperative rehabilitation remain key determinants of outcome. Larger, multicentric series with longer follow-up could help refine prognostic factors and clarify the long-term influence of different fixation constructs on patellofemoral joint health.

Surgical reconstruction of closed patella fractures produced consistently favourable functional outcomes in this study, with most patients achieving excellent or good recovery by six months. Stable fixation, preservation of the extensor mechanism, and early supervised rehabilitation contributed to reliable union and low complication rates. When fracture patterns are appropriately matched to the operative technique, restoration of knee function can be achieved in the majority of patients with minimal long-term disability.

1. Melvin JS, Mehta S. Patellar fractures in adults. J Am Acad Orthop Surg. 2011;19(4):198–207. 2. Boström Å. Fracture of the patella. A clinical study of 422 patellar fractures. Acta Orthop Scand Suppl. 1972;143:1–80. 3. Gwinner C, Märdian S, Schwabe P, Schaser KD, Krapohl BD, Jung TM. Current concepts review: fractures of the patella. GMS Interdiscip Plast Reconstr Surg DGPW. 2016;5:Doc01. 4. Mehdi Nasab SA, Sarrafan N, Tabatabaei S. Comparison of displaced patellar fracture treatment by two methods: cerclage circumferential wiring versus tension band wiring. Pak J Med Sci. 2012;28(5):787–790. 5. Bedi A, Karunakar MA. Patellar fractures and extensor mechanism injuries. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P, eds. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 1756–1767. 6. Veselko M, Kastelec M. Inferior patellar pole avulsion fractures: osteosynthesis compared with pole resection. J Bone Joint Surg Am. 2004;86(4):696–701. 7. Böstman O, Kiviluoto O, Santavirta S, Nirhamo J, Wilppula E. Fractures of the patella treated by operation. Arch Orthop Trauma Surg. 1983;102(2):78–81. 8. Levack B, Flannagan JP, Hobbs S. Results of surgical treatment of patellar fractures. J Bone Joint Surg Br. 1985;67(3):416–419. 9. Maini PS, Sangwan SS, Sharma JC, Chawla PN, Kochar A. Rigid fixation of various fractures by tension-band wiring. Indian J Orthop. 1986;20:162–167. 10. Della Rocca GJ. Displaced patella fractures. J Knee Surg. 2013;26(5):293–299. 11. Wild M, Windolf J, Flohé S. Fractures of the patella. Zentralbl Chir. 2010;135(5):447–456. 12. Marya SKS, Bhan S, Dave PK. Comparative study of knee function after patellectomy and osteosynthesis with tension band wire following patellar fractures. Int Surg. 1987;72(4):211–213. 13. Edwards B, Johnell O, Redlund-Johnell I. Patellar fractures: a 30-year follow-up. Acta Orthop Scand. 1989;60(6):712–714. 14. Jakobsen J, Christensen KS, Rasmussen OS. Patellectomy: a 20-year follow-up. Acta Orthop Scand. 1985;56(5):430–432. 15. Shabat S, Mann G, Kish B, Stern A, Sagiv P, Nyska M. Functional results after patellar fractures in elderly patients. Arch Gerontol Geriatr. 2003;37(1):93–98.