Does surgery with metallic implants achieve better outcomes than non-operative treatment or more novel techniques following patella fracture in the frail host?–A systematic review

Patella fractures are uncommon injuries but in frail patients they may confer significant morbidity. Tension band metallic wiring (TBW) is frequently employed to manage these injuries yet complication rates are high. Up to one-third of patients require reoperation. In the frail host especially, patella fractures can result in significant functional impairment impacting on independence. Using the PRISMA guidelines, this systematic review interrogates the literature on patella fractures in the frail host. The evidence was found to be minimal and of low quality, comprising only eight cohort studies or case series. Sample sizes were small; in half of the included studies, 16 participants or less were included. 2493 patients were included from all extracted studies. The average age of patients was 71 years old with 60.5 % being female. AO/OTA 34-C2/3 fractures were the most common fracture patterns, comprising 41 % of patients. Current literature suggests that computed tomography (CT) scanning pre-operatively is appropriate. Marked heterogeneity was found in operative strategy; both metallic and non-metallic implants were investigated but metallic TBW and cerclage were the most prevalent techniques. Only one study investigated non-operative treatment. More than one in four patients (26.59 %) required reoperation and over one in five patients (22.53 %) suffered hardware complications. Average range of movement achieved was 121.28° +/- 13° but the investigation of other outcome measures was inconsistent. Further investigation into both patella fractures and, more specifically patella fractures in the poor host, is warranted. Nevertheless, due to its limited incidence, a multicentre approach is required and should be considered a priority for the orthopaedic community.