Where should Kirschner wires be placed when fixing patella fracture with modified tension-band wiring? A finite element analysis

Background: The position of Kirschner wires (K-wires) has an influence on the outcome of modified tension-band wiring (MTBW) in fixing patella fractures. However, the instruction for K-wires positioning is not clear enough. This study tried to clarify the effect of K-wires positioning and provide evidence for a more definite instruction.

Methods: The sagittal position (SP) suitable for placing K-wires was evenly divided into SP 1-5 from anterior to posterior, and the finite element models of midpatella transverse fractures fixed by the figure-of-eight or figure-of-zero MTBW were built up at each SP. Separating displacement of the fracture, stress of the fracture, and stress of the internal fixations were measured at 45° knee flexion by using finite element analysis.

Results: The separating displacement of the fracture was smaller at SP 3-5 (23% smaller than SP 1-2). From SP 1 to 5, the compression of the fracture surfaces increased (R = 0.99, P = 0.001); the improper stress area of the fracture surfaces decreased (R = - 0.96, P = 0.01), and so was the stress of K-wires (R = - 0.93, P = 0.02). However, the stress of stainless steel wires showed a stable trend.

Conclusions: The SP of K-wires plays a role in the function of MTBW in the surgical management of transverse patella fracture. At 45° knee flexion, posteriorly placed (close to the articular surface) K-wires enable optimal stability and stress for the fracture, which provides basis for the positioning of K-wires in clinical practice.