The complications of surgical treatment of displaced fractures of the olecranon

The effect of Ding's screws and tension band wiring for treatment of olecranon fractures: a biomechanical study

Although tension band wiring (TBW) is popular and recommended by the AO group, the high rate of complications such as skin irritation and migration of the K-wires cannot be ignored. Ding's screw tension band wiring (DSTBW) is a new TBW technique that has shown positive results in the treatment of other fracture types. The objective of this study was to evaluate the stability of DSTBW in the treatment of olecranon fractures by biomechanical testing. We conducted a Synbone biomechanical model by using three fixation methods: DSTBW, intramedullary screw and tension band wiring (IM-TBW), and K-wire TBW, were simulated to fix the olecranon fractures. We compared the mechanical stability of DSTBW, IM-TBW, and TBW in the Mayo Type IIA olecranon fracture Synbone model using a single cycle loading to failure protocol or pullout force. During biomechanical testing, the average fracture gap measurements were recorded at varying flexion angles in three different groups: TBW, IM-TBW, and DSTBW. The TBW group exhibited measurements of 0.982 mm, 0.380 mm, 0.613 mm, and 1.285 mm at flexion angles of 0°, 30°, 60°, and 90° respectively. The IM-TBW group displayed average fracture gap measurements of 0.953 mm, 0.366 mm, 0.588 mm, and 1.240 mm at each of the corresponding flexion angles. The DSTBW group showed average fracture gap measurements of 0.933 mm, 0.358 mm, 0.543 mm, and 1.106 mm at the same flexion angles. No specimen failed in each group during the cyclic loading phase. Compared with the IM-TBW and TBW groups, the DSTBW group showed significant differences in 60° and 90° flexion angles. The mean maximum failure load was 1229.1 ± 110.0 N in the DSTBW group, 990.3 ± 40.7 N in the IM-TBW group, and 833.1 ± 68.7 N in the TBW group. There was significant difference between each groups (p < 0.001).The average maximum pullout strength for TBW was measured at 57.6 ± 5.1 N, 480.3 ± 39.5 N for IM-TBW, and 1324.0 ± 43.8 N for DSTBW. The difference between maximum pullout strength of both methods was significant to p < 0.0001. DSTBW fixation provides more stability than IM-TBW and TBW fixation models for olecranon fractures.

Elbow stiffness: Arthritis and heterotopic ossification

In elbow stiffness, pre-operative assessments should identify the articular and peri-articular tissues involved and, more specifically, they should determine how preserved the articular surfaces and osteo-articular congruity are. We will focus on the most important conditions and tissue reactions after trauma in order to understand the causes of joint stiffness. A logical surgical planning is based upon a deep knowledge of the anatomical obstacles and of the associated lesions that the trauma provoked with. The peri-articular soft tissue contractures. The osteo-articular incongruity.

The effect of ding's screw and tension band wiring for treatment of olecranon fractures: a finite element study

BACKGROUND

Tension band wiring (TBW) is a common surgical intervention for olecranon fractures. However, high rate of complications such as loss of reduction, skin irritation, and migration of the K-wires were reported up to 80%. Ding's screw tension band wiring (DSTBW) is a new TBW technique that has shown positive results in the treatment of other fracture types. The objective of this study was to evaluate the stability of DSTBW in the treatment of olecranon fractures by finite element analysis.

METHOD

We used Ding's screw tension band fixation (DSTBW) and K-wire tension band fixation (TBW) to establish a finite element model to simulate and fix olecranon fractures. The stress distribution, opening angle, twisting angle, and pullout strength of K-wires or screws were analyzed and compared.

RESULTS

The maximum von Mises stress was observed on the internal fixation for 90° elbow motion in both groups. The von Mises value of the screw in DSTBW was 241.2 MPa, and the von Mises value of k-wire in TBW was 405.0 MPa. Opening angle: TBW was 0.730° and DSTBW was 0.741° at 45° flexion; TBW was 0.679° and DSTBW was 0.693° at 90° flexion. Twisting angle: TBW was 0.146° and DSTBW was 0.180° at 45° flexion; TBW was 0.111° and DSTBW was 0.134° at 90° flexion. The pullout strength of DSTBW was significantly higher than that of TBW. Maximum pullout strength of Ding's screw was 2179.1 N, maximum pullout strength of K-wire was 263.6 N.

CONCLUSION

DSTBW technology provides stable fixation for olecranon fractures, reducing the risk of internal fixation migration and failure.

Compression Screw Fixation for Pediatric Olecranon Fractures

BACKGROUND

Pediatric olecranon fractures can be treated with several methods of fixation. Though postoperative outcomes of various fixation techniques, including cannulated intramedullary screws, have been described in adults, functional and radiographic outcomes of screw fixation in pediatric patients are unclear. In this study, we assessed clinical, radiographic, functional, and patient-reported outcomes of pediatric olecranon fractures treated with compression screw fixation.

METHODS

We retrospectively identified 37 patients aged 16 years or younger with a total of 40 olecranon fractures treated with screw fixation at our level-1 trauma center between April 2005 and April 2022. From medical records, we extracted data on demographic characteristics, time to radiographic union, range of elbow motion at final follow-up, and complications during the follow-up period. Patient-reported outcomes were evaluated using the Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Reported Outcomes Measurement Information System Pediatric Upper Extremity Short Form 8a measures.

RESULTS

There were no malunions or nonunions at the final mean follow-up of 140 days (range, 26 to 614 d). Four patients had implant failure (11%), of whom 3 experienced fracture union with no loss of fixation or need for revision surgery. One patient underwent a revision for fracture malreduction. Screw prominence was documented in 1 patient. Instrumentation was removed at our institution for 33 of 40 fractures. Mean time to radiographic union was 53 days (range, 20 to 168 d). Postoperative range of motion at the most recent follow-up visit showed a mean extension deficit of 6 degrees (range, 0-30 degrees) and mean flexion of 134 degrees (range, 60-150 degrees). At the final follow-up, the mean (±SD) Quick Disabilities of the Arm, Shoulder, and Hand score was 4.2±8.0, and the mean Patient-Reported Outcomes Measurement Information System score was 37±1.5, indicating good function and patient satisfaction.

CONCLUSIONS

All 37 patients in our series had excellent radiographic, functional, and patient-reported outcomes after screw fixation. We observed no cases of nonunion or malunion, growth disturbance, or refracture. These results suggest that screw fixation is a safe and effective option for pediatric olecranon fractures.

LEVEL OF EVIDENCE

Level IV, case series.

Olecranon fractures : current treatment concepts

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.Cite this article: Bone Joint J 2023;105-B(2):112-123.

Olecranon Fractures: A Critical Analysis Review

»

Olecranon fractures account for 10% of all elbow fractures and are more likely to result from a low-energy injury. A displaced fracture with a stable ulnohumeral joint (Mayo type 2) is the most common type of injury.

»

The management of an isolated olecranon fracture is based on patient factors (age, functional demand, and if medically fit to undergo surgery) and fracture characteristics including displacement, fragmentation, and elbow stability.

»

Nonoperative management can be successfully used in undisplaced fractures (Mayo type 1) and in displaced fractures (Mayo type 2) in frail patients with lower functional demands.

»

Patients with displaced olecranon fractures with a stable ulnohumeral joint without significant articular surface fragmentation (Mayo type 2A) can be managed with tension band wiring, plate osteosynthesis (PO), intramedullary fixation, or suture repair.

»

PO is advocated for multifragmentary fractures and fractures that are associated with ulnohumeral instability. It is essential to consider the variable anatomy of the proximal ulna during surgery.

FUNCTIONAL OUTCOME OF TREATMENT OF DEVIATED OLECRANON FRACTURE (MAYO 2A) BY AN INTRAMEDULLARY SCREW WITH TENSION BAND COMPARED TO CLASSIC TENSION BAND - A PROSPECTIVE RANDOMIZED STUDY

Objective

evaluate the functional treatment outcome of deviated transverse olecranon fractures (Mayo 2A) after treatment with tension-banded intramedullary screw (PIBT) compared to classical tension band (BTC).

Methods

Prospectively collect all deviated transverse olecranon fractures from 2012 to 2016 and randomize them into PIBT and BTC groups. Range of motion (ROM) was measured after 2 and 5 weeks, 3 and 6 months, and 1 and 2 years. Functional assessments (DASH, Oxford Elbow Score, and Mayo Elbow Performance Index) were performed after 3 and 6 months and 1 and 2 years. Complications were collected up to 2 years of follow-up.

Results

22 patients were included, 11 in each group. The mean age was 47.9 years, and the left side was injured in 13 (59.0%) patients. All patients completed the 2-year follow-up. There was no ROM difference at any time between the two groups (p> 0.005). Flexion and extension gain was maximum at three months and remained unchanged until two years. Neither flexion nor extension returned to normal, missing around 10°. Pronation and supination returned to normal. All three functional scores showed almost complete recovery of elbow function after three months postoperatively, with no difference between the groups. No group had complications, no reoperation, and no implant removal.

Conclusion

PIBT had similar results in ROM and functional score compared to BTC. Both had low complication rates and no need for implant removal. Level of evidence I; Randomized Trial .

Arc Centre Distance Change after Treatment of Complex Transverse Olecranon Fractures with a Large Impacted Articular Fragment Treated with Tension Band Wiring and Bone Graft

Background: The treatment of complex transverse olecranon fractures (CTOFs), also known as olecranon fractures with the impacted articular fragments (IAF), was reported recently. We fix IAFs with absorbable pins supported by autologous bone graft followed by olecranon fracture fixation. We have used the arc centre distance (ACD) method to evaluate the congruency of this concentric hinge joint. The aim of this study is to present the outcomes of this fixation technique and evaluate the value of the ACD method.

Methods: We reviewed 26 cases of CTOF treated at our hospital from 2014 to 2020. The functional outcome and range of motion of the elbow joint was measured by MEPS (Mayo Elbow Performance Score). We measured the ACD of each fragment of the ulnotrochlear joint [coronoid process (CP), IAF and olecranon process (OP)] with the CT image taken at 15 months postoperatively on average.

Results: The mean arc of elbow motion was 3º to 132º. The mean MEPS at 1 year postoperatively was 94, and 25 of 26 cases (96%) achieved a good or excellent outcome. Twelve patients, who took the elbow CT at least more than 3 months post-operatively, were included for ACD measurement. The postoperative joint incongruency of each fragment was as follows, 0.39 ± 0.70, 0.40 ± 0.69 and 0.29 ± 0.72 mm (CP, IAF and OP, respectively) according to the ACD method. The ACD value for each fragment was significantly different before and after the surgery (p < 0.05).

Conclusions: Accurate reduction of IAF with absorbable pins completed by tension band wiring with autogenous bone grafting can be an effective technique for CTOF with a large IAF. The restoration of the joint improved ACD.

Level of Evidence: Level IV (Therapeutic)

Nonoperative Management of Olecranon Fractures in Elderly Patients: A Systematic Review

BACKGROUND

Despite increased utilization of conservative measures for displaced olecranon fractures in elderly patients, in whom operative fixation may be complicated by coexisting comorbidities and declining bone quality, the noninferiority of nonoperative management has yet to be proven. The purpose of this study was to review nonoperative management of displaced olecranon fractures in the elderly patient population.

METHODS

A literature search of the PubMed database was performed using the term olecranon fracture. Papers included those with results for patients aged 65 years and older published between 1990 and 2018 in the English language. Data were pooled to analyze outcomes and complications of nonoperative management of olecranon fractures in the elderly patient population.

RESULTS

Four eligible studies combined for a total of 69 patients with 70 fractures with an average age of 83.8 years (71-95 years), female predominance of 88%, and a mean follow-up of 12.4 months who underwent nonoperative management of displaced olecranon fractures. While only 25% of fractures went on to radiographic union, the mean Disabilities of the Arm, Shoulder, and Hand score was 16.9 (0-59.6), the mean arc of motion was 138°, and 92% of patients achieved excellent results. One-quarter (26%) of the patients experienced complications: radial head subluxation (1), skin sore (1), degenerative arthropathy (1), pain on movement (2), click in movement of the elbow (5), and local pain (8).

CONCLUSION

Displaced olecranon fractures in patients aged older than 70 years may be effectively managed with nonoperative measures to produce high satisfaction and functional range of motion.

Intramedullary Screw Fixation of Olecranon Fractures Reduces the Risk of Early Unplanned Reoperation: A Retrospective Review of 556 Patients

OBJECTIVES

To determine the effect of intramedullary screw-based fixation on early postoperative complications after olecranon fractures. We hypothesized that intramedullary screw-based fixation results in decreased need for reoperation compared with plate and screw-based and tension band-based fixation.

DESIGN

Retrospective cohort.

SETTING

Two academic Level-1 trauma centers.

PATIENTS/PARTICIPANTS

Five hundred fifty-six patients treated with a tension band-based, plate and screw-based, or intramedullary screw-based construct for an olecranon fracture over a 10-year period.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENT

Unplanned reoperation. Demographic, injury type and severity, supplemental fixation, and length of follow-up data were viewed as potential confounders and analyzed as such.

RESULTS

We identified 556 relevant patients. One hundred ninety-nine patients were treated with an intramedullary screw-based construct, 229 with a plate and screw-based construct, and 128 with a tension band-based construct. We observed significant differences in the age, fracture type, percentage of open fractures, use of supplemental fixation, and treating institution between the treatment groups. Ninety-five patients (17.1%) had an unplanned reoperation. When we adjusted for confounders, intramedullary screw-based fixation reduced the odds of an unplanned reoperation by 54% compared with plate and screw-based treatment. In the adjusted analysis, we did not observe a difference between plate and screw-based treatment and tension band-based fixation.

CONCLUSIONS

Intramedullary screw-based fixation of olecranon fractures results in decreased need for early reoperation compared with more common olecranon fixation strategies.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tension-band wiring of displaced stable olecranon fractures with Eyelet-pins in the elderly: A series of 17 cases

BACKGROUND

Tension-band wiring (TBW) and plate fixation are commonly used to fix displaced olecranon fractures. However, the high incidence of complications in the elderly, such as wound breakdown, infection, and loss of reduction, remain a concern for orthopaedic surgeons. Furthermore, patients frequently suffer from removal of the hardware. Even so, the operation seems to be indicated for independent elderly patients to return to their former activities of daily living.

HYPOTHESIS

TBW of displaced stable olecranon fractures with Eyelet-pins in the independent elderly reduce the incidence of complications and allow early elbow joint exercise to keep their former activities.

PATIENTS AND METHODS

We operated on the displaced stable olecranon fractures of 17 independent patients aged ≥ 70 using TBW with two Eyelet-pins. Eyelet-pins have an eyelet at the trailing end to prevent pin migration by passing a soft wire through it. The patients were reviewed clinically and radiologically at 2, 6, 12, and 24 weeks, and clinically at 1 year after the surgery.

RESULTS

All fractures were united within 12 weeks, and the anatomic reduction was maintained. Mean radiographic proximal migration of the Eyelet-pins was 0.4mm (0.1 ∼ 1.2mm). Mean active elbow flexion was 136° (115° ∼ 145°) and extension 6.2° (0° ∼ 30°). Two patients had mild local pain and pain on motion at the tip of the eyelet. No patient required removal of the hardware. Other complications, such as superficial or deep wound infections, and neurological symptoms or signs, were not seen. All patients were able to maintain their former activities of daily living.

CONCLUSION

TBW with Eyelet-pins for displaced stable olecranon fractures is useful for independent elderly patients to reduce the incidence of complications and to maintain their former activities of daily living without removal of the hardware.

LEVEL OF EVIDENCE

IV; single-centre retrospective study.

A biomechanical study comparing the mean load to failure of two different osteosynthesis techniques for step-cut olecranon osteotomy

Background

Olecranon osteotomies are frequently used to expose distal humeral intraarticular fractures. The step-cut olecranon osteotomy (SCOOT) is an augmented version of the oblique olecranon osteotomy, which has recently been evaluated biomechanically with tension band wiring (TBW) fixation. However, complications with TBW are common. In this study, we, therefore, compared the mean load to failure of TBW with compression screws for SCOOT fixation. We hypothesized a higher load to failure for the compression screw group.

Methods

We performed a SCOOT on 36 Sawbones. Eighteen were fixed with TBW, and another 18 with two compression screws. The humeroulnar joint was simulated using an established test setup, which allows the application of triceps traction force through a tendon model to the ulna, while the humeroulnar joint is in a fixed position. Eight models of each fixation group were tested at 20°, and eight at 70° of flexion by isometrical loading until failure, which was defined as either a complete fracture or gap formation of more than 2 mm at the osteotomy site.

Results

At 20° of flexion, mean load to failure was similar between the TBW group (1360 ± 238 N) and the compression screw group (1401 ± 261 N) (P = .88). Also, at 70° of flexion, the mean load to failure was similar between the TBW group (1398 ± 215 N) and the compression screw group (1614 ± 427 N) (P = .28).

Conclusions

SCOOTs fixed with TBW and compression screws showed similar loads to failure. A SCOOT fixed with compression screws might be a valuable alternative for surgeons when treating intraarticular distal humeral fractures. However, future in vivo studies are necessary to confirm our results in a clinical setting.

Locked plating of geriatric olecranon fractures leads to low fixation failure and acceptable complication rates

Hypothesis

The purpose of this study was to report the rate of major complications in patients with geriatric olecranon fractures managed operatively with a locking plate. Secondary objectives included minor complications, as well as pain and range of motion at the final follow-up. We hypothesized that these patients have a low rate of complications as well as low pain and satisfactory elbow range of motion at the final follow-up.

Materials and Methods

A retrospective review of isolated geriatric olecranon fractures presenting from 2006 to 2019 was performed at a single level I trauma center. Inclusion criteria were ≥75 years of age, operative management with a locking plate, and clinic follow-up at least until evidence of radiographic union or a major complication. Exclusion criteria included nonoperative management, insufficient follow-up, and absence of locking plate in surgical technique. Variables examined included demographic information, Charleston comorbidity index, American Society of Anesthesiologists score, living independence, gait assistance, mechanism of injury, open vs. closed fracture, Mayo radiographic classification, Arbeitsgemeinschaft für Osteosynthesefragen classification, time to surgery, implant type, presence of triceps offloading suture, length of postoperative immobilization, date of radiographic union, range of motion at the final follow-up, pain visual analog scale score at the final follow-up, major and minor complications, and return to the operative room. A major complication was defined as a return to the operative room for deep infection or loss of fixation (displacement of fracture >5 mm). A minor complication was defined as any other complication.

Results

A total of 65 patients ≥75 years of age with olecranon fractures were identified. Of these, 36 patients met inclusion criteria with an average follow-up of 23 weeks (range 5-207). The mean length of immobilization was 13 days (range 0-29 days). Thirty-two of 36 (88.8%) patients achieved radiographic evidence of union at an average of 8.9 weeks (range 5.3-24.1 weeks). There were 4 remaining patients who underwent secondary intervention before primary union representing an 11.1% major complication rate including 2 deep infections (5.6%) and 3 failures of fixation (8.3%). There were 7 minor complications in 5 of 36 (13.9%) patients. At the final follow-up, the average visual analog scale score was 2.6 (range 0-6), the average elbow arc of motion was 120° (range 70-147°), and mean pronation/supination was 85°/84° (range 45-90°/45-90°).

Conclusion

Geriatric olecranon fractures are a challenging orthopedic problem with remaining controversy regarding ideal treatment. Despite advancement in geriatric fracture care, there is scant literature on the outcomes of locked plating technology in geriatric olecranon fractures. This study supports use of operative anatomic fixation with precontoured locked plates and early mobilization with an acceptable failure rate.

Olecranon fractures in the elderly during the COVID-19 pandemic: Is non-operative treatment reasonable? Review of the current evidence

The current COVID-19 global pandemic presents a major challenge and unprecedented pressures on health systems. The national guidelines in the UK advise non-operative treatment of fractures whenever possible to reduce the risk of surgical intervention to both patient and healthcare staff. The elderly population over 70 years are highlighted as a high-risk group in this pandemic as well as being often high risk for surgery in general due to co-morbidities. This article reviews the current literature regarding treatment of displaced olecranon fractures in the elderly. Literature search of the available databases. One randomised controlled trial has been published, comparing operative versus non-operative treatments of olecranon fractures in this age group. The study was terminated prematurely due to the high complication rate in the operative group. No difference in functional scores was recorded. Other published retrospective case series report good functional outcome scores and high satisfaction rates in the majority of patients in whom olecranon fractures were treated non-operatively. Non-operative treatment of olecranon fractures in elderly patients seems to be safe and an acceptable management option in these unprecedented times.

Low-Profile, Suture Anchor Tension Band Construct for Olecranon Fractures and Osteotomies

Olecranon fractures are common and frequently require surgical intervention when they are displaced or unstable. Treatment is largely dictated by fracture type and surgeon preference. Traditional methods of fixation, including tension band wiring and locking plate fixation, have adequate union rates; however, both techniques are associated with increased reoperation rates due to symptomatic hardware. The aim of this article is to describe a technique using a low-profile, suture anchor tension band construct for simple transverse olecranon fractures, triceps avulsions, and olecranon osteotomies. The goal of this technique is to produce stable fixation and allow early range of motion while mitigating the reoperation rate caused by symptomatic or prominent hardware with olecranon plate fixation during fracture and olecranon osteotomies.

Displaced olecranon fractures in the elderly: outcomes after non-operative treatment - a narrative review

Operative treatment with tension band wiring or plate is the gold standard of care for displaced olecranon fractures.

In elderly patients, multiple comorbidities combine with increased intraoperative risks, and postoperative complications may yield poor results.

There are small series in the literature that show promising results with non-operative treatment.

Non-operative treatment may provide reasonable function and satisfaction in the elderly population and could be considered as a treatment option in this group, especially for those with comorbidities, to avoid postoperative complications and the need for re-operation.

Cite this article: EFORT Open Rev 2020;5:391-397. DOI: 10.1302/2058-5241.5.190041

Advantages of expulsion-proof pins in the treatment of olecranon fractures with tension band wiring: Comparison with a control group

INTRODUCTION

Tension band wiring is considered the standard treatment for transverse olecranon fractures. Its main complications are pin migration and discomfort caused by the hardware. We have designed and used "expulsion-proof" pins (EPP) that are shaped to prevent migration and reduce discomfort. This study compared the complication rate between our device and Kirschner pins (controls).

HYPOTHESIS

We hypothesised that EPP would have lower migration rates and fewer complications than standard Kirschner pins.

MATERIALS AND METHODS

This retrospective, single-center, multi-operator, observational, study examined data from January 1996 to December 2014. The primary outcome was the occurrence of pin migration. Secondary outcomes were the occurrence of one or more additional complications and the hardware removal rate.

RESULTS

The study enrolled 101 patients: 53 (52.4%) with expulsion-proof pins and 48 (47.6%) controls. The mean follow-up was 240.6days in the EPP group and 268.9days in the control group. No cases of migration (0%) were found in the EPP group versus 21 (43.7%) cases in the controls (p<0.05). One or more complications occurred in 18 (33.9%) patients in the EPP group versus 46 (95.8%) controls (p<0.05). There was material discomfort in 13 (24.5%) cases and 1 (1.9%) case of secondary displacement in the EPP group, compared with 38 (79.2%) and 7 (14.6%) cases, respectively, in the controls (p<0.05). The rate of delayed consolidation was statistically identical in the two groups (p=0.103). The hardware was removed in 13 (24.5%) cases in the EPP group compared with 36 (75%) controls (p<0.05).

CONCLUSION

EPPs are useful for management of olecranon fractures treated via TBW: the pins do not migrate and can reduce complications, discomfort, secondary displacement, and the hardware removal rate.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Surgical technique in tension band wiring method for selected comminuted olecranon fractures

BACKGROUND

The use of tension band wiring (TBW) for comminuted olecranon fractures is less recommendable these days. However, some experts preferentially apply TBW to comminuted fractures resulting in favorable outcomes. We here present the surgical technique using TBW with eyelet and absorbable pins for selected comminuted olecranon fractures and review the clinical and radiographic outcomes.

METHODS

Twenty-four surgically treated patients with Colton Group 2C or 2D olecranon fractures in focus on the intermediate fragment (IMF) were enrolled. IMFs were primarily fixed with buried bioabsorbable poly-L-lactic acid pins followed by definitive fixation of the olecranon process with TBW with eyelet. The adequacy of the reconstructed notch was especially estimated by parameters on radiographs using digital imaging software.

RESULTS

The average follow-up was 30 months (10 to 86 months). All 24 fractures achieved union, and the maintenance of the articular curvature was confirmed according to statistical analysis on radiographs. The average elbow flexion was 135.1° (range 100° to 145°), and the average elbow extension was - 4.8° (range - 20° to 10°). The mean Mayo Elbow Performance score was 97.3 points (range 80 to 100 points). No cases of pin migration, infection, nerve problem, heterotrophic ossification, or secondary osteoarthritis were observed.

CONCLUSIONS

For selected comminuted olecranon fractures, TBW with the eyelet pins and biodegradable pins could yield satisfactory clinical and radiographic outcomes.

Intramedullary screw fixation for simple displaced olecranon fractures

Purpose

Olecranon fractures are common and typically require surgical fixation due to displacement generated by the pull of the triceps muscle. The most common techniques for repairing olecranon fractures are tension-band wiring or plate fixation, but these methods are associated with high rates of implant-related soft-tissue irritation. Another treatment option is fixation with an intramedullary screw, but less is known about surgical results using this strategy. Thus, the purpose of this study was to report the clinical and functional outcomes of olecranon fractures treated with an intramedullary cannulated screw.

Methods

We identified 15 patients (average age at index procedure 44 years, range 16–83) with a Mayo type I or IIA olecranon fracture who were treated with an intramedullary cannulated screw at a single level 2 trauma center between 2012 and 2017. The medical record was reviewed to assess radiographic union, postoperative range of motion and complications (including hardware removal). Patient-reported outcome was evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) score. Average follow-up was 22 months (range 8–36 months).

Results

By the 6th month post-operative visit, 14 patients had complete union of their fracture and 1 patient had an asymptomatic non-union that did not require further intervention. Average flexion was 145° (range 135–160) and the average extension lag was 11° (range 0–30). Implants were removed in 5 patients due to soft-tissue irritation. Average DASH score (± standard deviation) by final follow-up was 16 ± 10.

Conclusions

Fixation of simple olecranon fractures with an intramedullary screw is a safe and easy fixation method in young patients, leading to good functional and radiological results. Compared to available data, less hardware removal is necessary than with tension-band wiring or plate fixation.

Use of an Additional Nonlocking Screw in Olecranon Fracture Osteosynthesis Changes Failure Mechanism

Hardware-related complications can occur when plate fixation is used to stabilize osteoporotic fractures involving the olecranon. The use of an additional nonlocking screw, placed retrograde into the proximal fracture segment, may improve stability under load. The purpose of this study was to conduct a biomechanical comparison of olecranon repair constructs with and without this additional retrograde screw. Nine matched pairs of elderly fresh-frozen cadaveric upper extremities were used. Two-part olecranon fractures were modeled, and fracture stabilization was performed. Olecranon plates were implanted either with the standard surgical technique (CTRL) or with an additional retrograde screw (EXPT). Dynamic extensions of increasingly loaded forearms were performed, and comparisons of sustained cycles, maximum load, and total work were made. Relative motion of bone segments was tracked, and modes of failure were assessed. Seventy-eight percent of specimens from the CTRL group failed due to relative fragment displacement exceeding 3 mm, while 78% of EXPT specimens failed due to instantaneous catastrophic failure. There were no significant differences in terms of number of survived cycles, maximum load, or work performed between the groups. The addition of a retrograde screw in this plating technique changes the failure mode from fracture displacement to catastrophic failure. The use of a 3.5-mm retrograde screw in the relatively small proximal ulnar fragment should be avoided, but screws with a smaller diameter may still have potential to improve fixation. Further biomechanical and clinical research is necessary to improve strategies for plate fixation of olecranon fractures in the elderly population. [Orthopedics. 2019; 42(1):e74-e80.].

Excellent results and low complication rate for anatomic polyaxial locking plates in comminuted proximal ulna fractures

BACKGROUND

Comminuted fractures of the proximal ulna remain a great challenge in orthopedic surgery. The purpose of this study was to report the outcomes of comminuted proximal ulna fractures treated with a new construct type-anatomically preformed polyaxial locking compression plates.

METHODS

Between 2013 and 2016, 46 patients with isolated comminuted fractures were treated with a 2.7-/3.5-mm VA-LCP Olecranon Plate (Synthes, Umkirch, Germany). Of these, 44 were available for an assessment after a mean follow-up period of 2.5 years (range, 12-50 months). We evaluated range of motion, time to recovery, revision rate, and indications, as well as functional scores. Radiographs were analyzed.

RESULTS

The study included 8 Mayo IB, 29 Mayo IIB, and 7 Mayo IIIB fractures. All fractures showed bony union, and only 2 revision surgical procedures were performed because of a new trauma. No other complications occurred. Mean range of motion was 139° (range, 105°-150°), and the mean pain level was less than 1 on a visual analog scale. Regarding elbow function, we found a mean Mayo Elbow Performance Score of 98; a mean Oxford Elbow Score of 44; and a mean Disabilities of the Arm, Shoulder and Hand score of 6. Of the plates, 41% were removed after an average time of 16 months, whereby a significant improvement in extension deficit was detected (P < .01). Ninety-five percent of all patients returned to their pretrauma sports level.

CONCLUSION

The 2.7-/3.5-mm VA-LCP Olecranon Plate represents an effective option with excellent fracture reduction, sufficient stability for early postoperative functional rehabilitation, and a minimum of complications.

Outcomes of displaced olecranon fractures treated with the Olecranon Sled

BACKGROUND

Tension-band wiring is largely considered the gold standard for fixation of displaced olecranon fractures despite high rates of hardware complications. The purpose of this study was to report the outcomes of displaced olecranon fractures treated with the Olecranon Sled.

METHODS

We retrospectively reviewed all displaced olecranon fractures from 2011-2015 treated with the Olecranon Sled. Inclusion was limited to functionally independent patients with Mayo type II fractures and minimum 12-month follow-up. We assessed clinical outcomes including range of motion; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score.

RESULTS

Twenty-two patients with a mean follow-up period of 31.8 months (range, 12-71 months) were included in the study. All patients indicated satisfactory outcomes. The mean Mayo Elbow Performance Score was 95.5 (range, 70-100), and the mean Disabilities of the Arm, Shoulder and Hand score was 3.1 (range, 0-18.3). The mean total arc of elbow flexion was 145° (range, 134°-158°), and the mean total arc of forearm rotation was 175° (range, 160°-180°). There were no hardware-related complications. The overall complication rate was 4.5% (1 of 22) as significant heterotopic ossification developed in 1 patient, requiring contracture release.

CONCLUSION

The Olecranon Sled is a reliable and well-tolerated implant for the treatment of olecranon fractures. This device results in excellent functional outcomes and may obviate hardware removal.

Prospective randomised trial of non-operative versus operative management of olecranon fractures in the elderly

AIMS

The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years.

PATIENTS AND METHODS

Patients were randomised to either non-operative management or operative management with either tension-band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year.

RESULTS

A total of 19 patients were randomised to non-operative (n = 8) or operative (n = 11; tension-band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non-operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05).

CONCLUSION

These data further support the role of primary non-operative management of isolated displaced fractures of the olecranon in the elderly. However, the non-inferiority of non-operative management cannot be proved as the trial was stopped prematurely. Cite this article: Bone Joint J 2017;99-B:964-72.

Type II olecranon fractures in patients over 65. Tension band or pre-formed plate? Analysis and results

OBJECTIVE

The objective of this study was to compare the clinical outcomes of surgical treatment using tension band with needles and preformed plates in type ii olecranon fractures according to the Mayo classification in patients older than 65 years.

MATERIAL AND METHOD

A descriptive, retrospective study of 49 patients with a mean age of 75.1 years who underwent surgery olecranon fracture using 2 different fixing systems. The Mayo classification was used to define them, excluding type i and iii, and the VAS to assess postoperative pain. Patients were assessed functionally by the questionnaire Quick DASH. All measurement was performed with goniometer and joint balance serial radiographs at one month, 3, 6 and 12 months. Minimum follow-up was one year.

RESULTS

In 26 patients the tension band was used and the preformed plates in 23. There were no statistically significant differences in functional outcomes, joint balance or postoperative VAS between the 2 groups. There were a greater proportion of patients who had to be operated because of problems related to osteosynthesis material in those in which preformed plates were used.

CONCLUSIONS

Treatment of olecranon fractures with tension band with needles and cerclage remains the surgery of choice in patients older than 65 years.

Reconstruction of Monteggia-like proximal ulna fractures using different fixation devices: A biomechanical study

BACKGROUND

Comminuted proximal ulna fractures are rare and reconstruction of these fractures is discussed controversially. The aim of this study was to test three currently available plate devices in a standardized comminuted four-part fracture model created in proximal ulna sawbones.

MATERIAL AND METHODS

A standardized four-part fracture of the proximal ulna was created in 80 sawbones. Reconstruction was performed by five experienced test surgeons according to a standardized reconstruction protocol. Each surgeon reconstructed 4 fractures with a 3.5mm eight-hole reconstruction plate, 4 fractures with seven-hole third-tubular double plates and 4 fractures with a 3.5mm anatomical seven-hole locked angle proximal ulna plate. 4 more fractures were reconstructed with simple K-wires as a reference construct for further experiments. Outcome measurements were time for reconstruction, quality of reconstruction and stability of the reconstruction. Stability testing was done in 90° and 30° flexion of the elbow. Testing in 30° flexion was done to test the anteroposterior stability regarding the fixed coronoid process.

RESULTS

Time for reconstruction was significantly less for K-wire fixation than for the plate devices. Time for reconstruction plating and locked angle plating was significantly lower than for double plating (p<0.005). Quality of reduction did not differ between the three plate systems (p<0.05). K-wire fixation showed the best quality of reduction (p<0.005). In 90° of elbow flexion the anatomic locked angle olecranon plate showed a significantly higher stability compared to the other devices. Furthermore the tubular double plating was significantly more stable than reconstruction plating or K-wire fixation (p<0.05). In anteroposterior loading at 30°, the stability did not differ between the 4 different fixation techniques (p>0.05). For all devices the testing in 30° flexion showed a significantly higher rigidity compared to 90° flexion.

CONCLUSION

The locked angle plate system showed the highest stability in 90° of elbow flexion. Each implant was more stable in 30° flexion than in 90° flexion. Testing of the anterior stability of the elbow did not show any differences between the different implants. Because of the superior stability of this device, we conclude that locked angle plating should be preferred for reconstruction of monteggia like complex proximal ulna fractures.

Outcome after olecranon fracture repair: Does construct type matter?

PURPOSE

This study compares clinical and functional outcomes of patients with displaced olecranon fractures treated with either tension band wiring (TBW) or a hook plate construct.

METHODS

We performed a retrospective review of olecranon fractures operatively treated with either TBW or plate fixation (PF) using a hook plate over a 7-year period. Patient demographics, injury information, and surgical management were recorded. Fractures were classified according to the Mayo system. Measured outcomes included range of elbow motion, time to union, and development of postoperative complications. Mayo Elbow Performance Index (MEPI) scores were obtained for all patients. All patients were followed for a minimum of 6 months.

RESULTS

A total of 48 patients were included in this study, 23 treated with TBW and 25 treated with hook PF. Groups did not differ with respect to patient demographics, Mayo fracture type, or duration of follow-up. Patients undergoing PF had less terminal extension than TBW patients (-8.6° ± 7° vs. -3.5° ± 9.3°, p = 0.036) and a longer time to radiographic union (19 ± 8 vs. 12 ± 6 weeks, p = 0.001). There were no differences in rates of symptomatic hardware, MEPI scores, or other clinical outcomes. Two patients in each group required a second surgery.

CONCLUSIONS

TBW and PF of olecranon fractures had similarly excellent functional outcomes in this study. Patients undergoing PF had a longer time to union and slightly worse extension at final follow-up. TBW remains an effective treatment for appropriately selected olecranon fractures and in this cohort outperformed plate osteosynthesis.

Malpositioned olecranon fracture tension-band wiring results in proximal radioulnar synostosis

Background

Tension-band wiring (TBW) is a well-established fixation technique for two-part, transverse fracture types of the olecranon. However, complication rates up to 80 % are reported. By reporting on the enormous impact on the patient if failed the aim of the present report was to emphasize the importance of correct K wire positioning in TBW.

Case presentation

We present the case of a 49-year-old woman who suffered from a radioulnar synostosis of the forearm due to malpositioned K wires after TBW treatment. The patient was treated by heterotopic bone resection supported by ossification prophylaxis (radiotherapy and Indomethacin). At follow-up of 12 months after revision surgery, elbow motion was unrestricted with a strength grade 5/5. The patient was free of pain and reported no restrictions in daily as well as sporting activities. Radiologic assessment showed no recurrence of heterotopic bone tissue.

Conclusion

Intraoperative radiographic and clinical examination of the elbow is highly recommended to identify incorrect hardware positioning and, therefore, to avoid serious postoperative complications in TBW.

SOFIE: Surgery for Olecranon Fractures in the Elderly: a randomised controlled trial of operative versus non-operative treatment

Background

Displaced olecranon fractures after a simple fall are common in elderly patients. This patient group often has multiple medical co-morbidities and low functional demands. Standard treatment for these fractures has been operative fixation, using either wires or a plate. Recent case series suggest that such injuries can be managed without surgery with good functional outcomes. There has been no published trial comparing operative to non-operative treatment for displaced olecranon fractures.

This project aims to test for superiority of operative treatment versus non-operative treatment for displaced olecranon fractures in the elderly, by comparing pain and function in the affected limb up to one year after the injury.

Methods/Design

SOFIE is an international study with a multicentre pragmatic randomised controlled trial design. The primary objective of the study is to compare a patient related outcome, the Disability of the Arm Shoulder and Hand (DASH) Score, between patients treated operatively and non-operatively at twelve months.

Patients will be considered for the study if they are 75 years of age or older, medically fit for surgery, have an isolated displaced olecranon fracture, and present within 14 days of injury. Eligible patients willing to participate will be randomised either to operative fixation, with surgery using the preferred technique of the treating orthopaedic surgeon (tension band wiring or plate fixation), or to non-operative treatment involving early range of motion as tolerated.

Secondary outcome measures will include pain, active range of motion, elbow extension strength, and any adverse events (infection, secondary interventions) at 3 and 12 months.

Discussion

The study will answer an important clinical question about the effectiveness of a commonly performed orthopaedic procedure, and will guide future treatment for displaced olecranon fractures in the elderly.

Trial registration number

World Health Organisation Universal Trial Number (WHO UTN) - U111111574090.

Australian and New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12614000588695.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0789-6) contains supplementary material, which is available to authorized users.

Presentation of the vascular supply of the proximal ulna using a sequential plastination technique

PURPOSE

The purpose of this study was to demonstrate the peri- and intraosseous vascular supply of the proximal ulna.

METHODS

Eleven fresh human cadaveric elbows were sequentially plastinated beginning with arterial injection, followed by block and secondary slice plastination of the whole elbow. With this technique, we obtained completely transparent cadaveric slices in which the peri- and intraosseous vascular architecture could be studied.

RESULTS

Proximal ulna vascularization is due to an arterial network: a superior and inferior collateral ulnar artery and the profunda brachial artery climbing to the olecranon from proximal. An anterior artery and a posterior recurrent artery climb up distally to the medial parts of the ulna and an interosseous recurrent artery is responsible for the lateral and posterolateral proximal part of the ulna. The intraosseous vascularization is due to directly penetrating branches out of the posterior recurrent ulnar artery and a vascular plexus at the olecranon tip. In addition, we saw a major distal bone penetration branch coming from the recurrent posterior artery, climbing intraosseously without junction to the proximal penetrating branches.

CONCLUSION

The peri- and intraosseous vascularization of the proximal ulna was shown. A transitional zone of the intraosseous vascularization of the proximal ulna was detected.

Biomechanical testing of an innovative fixation procedure to stabilize olecranon osteotomy

For the treatment of distal humerus an approach involving olecranon osteotomy is frequently preferred as it offers a clearer view, especially in cases of complex intraarticular fractures. It is however associated with the high risk of osteotomy-related complications such as nonunion, delayed healing, implant failure and migration of wires. The aim of the present study was to evaluate the stability of different new procedures that stabilize olecranon osteotomy compared with conventional tension band wiring. We hypothesize that the new implants provide equivalent stability as the conventional tension band wiring. To test the hypothesis 27 biomechanically evaluated synthetic ulnae were osteotomized and stabilized with either the application of tension band wiring, the Olecranon Hook LCP (Synthes, Switzerland), or the Olecranon Osteotomy nail (Synthes, Switzerland). Loading was performed providing a tensile load to simulate the tensile force applied by the triceps muscle. Cyclic force-controlled loading was performed at 300 alternating forces between 10N and 500N at a speed of 200N/sec. An ultrasound-based system measured displacement to an accuracy of 0.1 mm. Statistical analysis showed significantly less displacement in the Olecranon Hook LCP and Olecranon Osteotomy nail groups compared with tension banding. Comparison of plate and nail yielded no differences in stability. Biomechanical testing did however show significantly higher stability for newer fixation methods for olecranon osteotomies compared with the frequently applied technique of tension band wiring. Whether the use of these implants will also lower complication rates remains to be evaluated in future clinical studies.

Level of evidence: Basic Science Study, Biomechanical Study.

Surgical interventions for treating fractures of the olecranon in adults

BACKGROUND

Fractures of the olecranon (the bony tip of the elbow) account for approximately 1% of all upper extremity fractures. Surgical intervention is often required to restore elbow function. Two key methods of surgery are tension band wire fixation and plate fixation.

OBJECTIVES

To assess the effects (benefits and harms) of different surgical interventions in the treatment of olecranon fractures in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (22 September 2014), the Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 8), MEDLINE (1946 to September week 2 2014), EMBASE (1980 to 19 September 2014), trial registers, conference proceedings and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCT) and quasi-RCTs that compared different surgical interventions for the treatment of olecranon fractures in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction. The primary outcomes of this review were function, pain and adverse events.

MAIN RESULTS

We included six small trials involving 244 adults with olecranon fractures. Of these, four were RCTs and two were quasi-RCTs; both of were at high risk of selection bias. All six trials were at high risk of performance bias, reflecting lack of blinding, and four trials were at high risk of detection bias. The quality of the evidence for most outcomes was generally very low because of limitations in study design and implementation, and either imprecision of the results or inadequate outcome measures. Thus, we are very uncertain about the estimates of effect.One trial (41 participants) comparing plate fixation with standard tension band wiring provided very low quality evidence at 16 to 86 weeks' follow-up of a better clinical outcome after plate fixation (good outcome (little pain or loss of elbow motion): 19/22 versus 9/19, risk ratio (RR) 1.82 favouring plate fixation, 95% confidence interval (CI) 1.10 to 3.01). There was very low quality evidence of less symptomatic prominent metalwork after plate fixation (1/22 versus 8/19; RR 0.11, 95% CI 0.01 to 0.79). The results for other adverse effects (infection and delayed or non-union) were inconclusive. Evidence is pending from a newly (September 2014) completed trial (67 participants) making the same comparison.Four trials compared four different modified techniques of tension band wiring (i.e. additional intramedullary screw fixation, biodegradable pins, Netz pins and cable pin system) versus standard tension band wiring. There was very low quality evidence of little difference at six to 14 months in function assessed by a non-validated scoring tool from the addition of an intramedullary screw. However, there were fewer cases of metalwork prominence in the intramedullary screw group (1/15 versus 8/15; RR 2.00, 95% CI 1.15 to 3.49; one trial; 30 participants). There was very low quality evidence from one trial (25 participants) of little difference in subjectively or objectively assessed good outcome at a mean of 20 months between tension band wiring with biodegradable implants versus metal implants. There were no adverse events, either non-union or sinus or fluid accumulation, reported. All 10 participants in the metalwork group had an extra operation to remove their metalwork at one year. One trial, which did not report on function or pain, provided very low quality evidence of lower rates of metalwork for any reason or for symptoms after Netz pin tension band wiring compared with standard tension band wiring (11/21 with Netz pin versus 17/25 with standard tension band wiring; RR 0.77, 95% CI 0.47 to 1.26; 46 participants); this evidence also supports the possibility of higher rates of metalwork removal for Netz pins. Two intra-operative complications occurred in the Netz pin group. The fourth trial, which compared the cable pin system with standard procedure, found low quality evidence that cable pin improved functional outcome at a mean of 21 months (Mayo Elbow Performance Score (MEPS), range 0 to 100: best outcome: mean difference (MD) 7.89 favouring cable pin, 95% CI 3.14 to 12.64; one trial; 62 participants). It also found low quality evidence of fewer postoperative complications in the cable pin group (1/30 with cable pin system versus 7/32 standard tension band wiring; RR 0.15, 95% CI 0.02 to 1.17), although the evidence did not rule out the converse.One trial provided very low quality evidence of similar patient-reported function using the Disabilities of the Arm, Shoulder and Hand questionnaire (0 to 100: worst function) at two or more years after fixation using a novel olecranon memory connector (OMC) compared with locking plate fixation (MD -0.70 favouring OMC, 95% CI -4.20 to 2.80; 40 participants). The only adverse event was a superficial infection in the locking plate group.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw robust conclusions on the relative effects of the surgical interventions evaluated by the included trials. Further evidence, including patient-reported data, on the relative effects of plate versus tension band wiring is already pending from one recently completed RCT. Further RCTs, using good quality methods and reporting validated patient-reported measures of function, pain and activities of daily living at set follow-ups, are needed, including checking positive findings such as those relating to the use of an intramedullary screw and the cable pin system. Such trials should also include the systematic assessment of complications, further treatment including routine removal of metalwork and use of resources.

Simple and comminuted displaced olecranon fractures: a clinical comparison between tension band wiring and plate fixation techniques

INTRODUCTION

The purpose of this retrospective study is to compare the clinical, functional outcome and complications occurrence between tension band wiring (TBW) and plate fixation both for simple and comminuted displaced olecranon fractures.

MATERIALS AND METHODS

Between January 2005 and June 2012 (minimum 1-year follow-up), 78 consecutive patients with Mayo type IIA and IIB fractures were treated with the following methods: tension band wire or plate and screws fixation. The primary outcome of this study was the functional outcome, assessed by the following self-administered evaluation scales: the disabilities of the arm, shoulder and hand, and the Mayo Elbow Performance Score. Secondary outcome measures included the assessment of pain level, analysis of passive range of motion, and the occurrence of any early or late complications.

RESULTS

Comparing the clinical results between the two groups, at mean 33 months follow-up, no significant differences in the functional and clinical outcome were observed. Complications were reported in 48 and 17 % of cases, following TBW and plate fixation in patients treated for type IIA fractures, and similarly in 40 and 23 % of cases in type IIB fractures, respectively. Hardware removal was more frequently performed in TBW group: 38 versus 17 % for type IIA fractures and 20 versus 6 % for type IIB fractures.

CONCLUSIONS

The findings of this study indicate that both with the use of TBW and plate fixation excellent/good clinical outcomes with minimal loss of physical capacity, little pain and disability can be obtained in the majority of patients with simple and comminuted displaced olecranon fractures. Hardware removal was most frequently observed after TBW.

Tension band wiring in olecranon fractures: the myth of technical simplicity and osteosynthetical perfection

PURPOSE

The tension band wiring (TBW) technique is a common treatment for the fixation of olecranon fractures with up to three fragments. The literature and surgeons describe TBW as an uncomplicated, always available and convenient operation producing excellent results. The purpose of this study was to determine whether TBW is more ambitious than believed or the procedure provides an increased level of tolerance concerning the surgical technique.

METHODS

This study reviewed 239 TBW cases in patients with olecranon fractures or osteotomies. We reviewed a total of 2,252 X-rays for ten operative imperfections: (1) nonparallel K-wires, (2) long K-wires, (3) K-wires extending radially outwards, (4) insufficient fixation of the proximal ends of the K-wires, (5) intramedullary K-wires, (6) perforation of the joint surface, (7) single wire knot, (8) jutting wire knot(s), (9) loose figure-of-eight configuration, and (10) incorrect repositioning.

RESULTS

On average, there were 4.24 imperfections per intervention in the cases reviewed. A total of 1,014 of 2,390 possible imperfections were detected. The most frequent imperfections were insufficient fixation of the proximal ends of the K-wires (91% of all cases), the use of a single wire knot (78%) and nonparallel K-wires (72%). Mayo IIa (n = 188) was the most common fracture type.

CONCLUSIONS

Our results and the number of complications described by the literature together support the conclusion that TBW is not as easy as surgeons and the literature suggest. Although bone healing and the functional results of TBW are excellent in most cases, the challenges associated with this operation are underestimated.

LEVEL OF EVIDENCE

IV, treatment study.

Nonoperative management of displaced olecranon fractures in low-demand elderly patients

BACKGROUND

The aim of this study was to document both the short and the long-term outcomes following primary nonoperative management of isolated displaced fractures of the olecranon.

METHODS

We identified, from our prospective trauma database, all patients who had been managed nonoperatively for a displaced olecranon fracture over a thirteen-year period. Inclusion criteria included all isolated fractures of the olecranon with >2-mm displacement of the articular surface. The primary short-term outcome measure was the Broberg and Morrey Elbow Score. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

There were forty-three patients with a mean age of seventy-six years (range, forty to ninety-eight years) in the study cohort. A low-energy fall from a standing height accounted for 84% of all injuries, and one or more comorbidities were documented in thirty-eight patients (88%). At a mean of four months (range, 1.5 to ten months) following injury, the mean Broberg and Morrey score was 83 points (range, 48 to 100 points), with 72% of the patients having an excellent or good short-term outcome. No patient underwent surgery for a symptomatic nonunion. At a mean of six years (range, two to fifteen years) postinjury, the mean DASH score was 2.9 points (range, 0 to 33.9 points) and the mean Oxford Elbow Score was 47 points (range, 42 to 48 points); 91% (twenty-one) of twenty-three patients available for follow-up expressed satisfaction with the result of the procedure.

CONCLUSIONS

We found satisfactory short-term and long-term outcomes following the nonoperative management of isolated displaced olecranon fractures in older, lower-demand patients.

Use of Kirschner wires with eyelets for tension band wiring of olecranon fractures

PURPOSE

To evaluate the clinical and radiographic outcomes of tension band wiring of displaced olecranon fractures treated using Kirschner wires with eyelets to assess their clinical performance with respect to complications such as backing out of the K-wires, restriction of forearm rotation, and neurovascular injury.

METHODS

The authors retrospectively reviewed 44 patients treated for an isolated, displaced olecranon fracture and checked range of motion, postoperative pain, complications, and incidence of hardware removal. The mean follow-up period was 41 months (range, 26-73 mo).

RESULTS

All fractures united, and anatomical reduction was achieved in all cases at final follow-up. Mean elbow flexion was 135° (range, 115° to 140°), and mean elbow extension was 4° (range, 0° to 15°). No pin migration, restriction of forearm rotation, or neurovascular injury occurred. Hardware removal was performed in 8 cases (18%). Compared to previous results with conventional Kirschner wires, no meaningful improvement in postoperative pain level or in the rate of hardware removal was observed.

CONCLUSIONS

Tension band wiring using the pin studied produced excellent clinical and radiologic outcomes for the treatment of isolated, displaced Mayo type IIA and some type IIB olecranon fractures. The pin was effective in preventing the backing out of Kirschner wires and avoiding the complications associated with anterior cortical engagement of Kirschner wires, such as neurovascular injury or restriction of forearm rotation.

Potential dangers of tension band wiring of olecranon fractures: an anatomic study

PURPOSE

Displaced olecranon fractures are often amenable to treatment with open reduction and tension-band wiring. The purpose of this study is to examine the relationships of the tips of K-wires used in a tension-band construct to volar neurovascular structures in the proximal forearm and the proximal radioulnar joint.

METHODS

We performed simulated percutaneous pinnings of the proximal ulna under fluoroscopic guidance on 15 cadavers with intact proximal ulnas. The K-wires were drilled obliquely through the tip of the olecranon process and directed to engage the anterior ulnar cortex, distal to the coronoid. Using calipers, we measured the distance from the tip of each pin to the anterior interosseous nerve (AIN), ulnar artery, proximal radioulnar joint (PRUJ), and volar cortex of the ulna, as well as the distance from the volar cortex of the ulna to the AIN and ulnar artery. The angle created by the K-wires and the longitudinal axis of the ulna was measured on both anteroposterior and lateral radiographs.

RESULTS

The distance from pin tip to the AIN and ulnar artery measured a mean of 16 mm with a standard deviation of 6 mm and 14 mm with a standard deviation of 5 mm, respectively, with 1 pin abutting the artery. The shortest distance from both the AIN (11 ± 5 mm) and the ulnar artery (8 ± 6 mm) was measured with the shallowest angle of insertion, ranging from 10° to 14.9° on lateral radiographs. The mean distance between the pin tip and the PRUJ measured 7 mm with a standard deviation of 4 mm, with 3 pins penetrating the PRUJ.

CONCLUSIONS

The impaction of K-wires under the triceps is often approximately 1 cm, which is similar to the distance of the K-wire tips to the AIN and ulnar artery. Our findings suggest that larger insertion angles might help avoid neurovascular injury when the insertion point of the K-wires is at or just proximal to the tip of the olecranon. In this study, the safe zone for pin insertion on the anteroposterior view is 0° to 10°, and on the lateral view it is 20° to 30°.

CLINICAL RELEVANCE

This anatomic study was done to diminish the chance of complications resulting from K-wire placement during tension-band wiring for olecranon fractures.

BIOMECHANICAL ASSESSMENT OF TENSION-BAND WIRING FOR OLECRANON FRACTURES

Tension-band wiring is the preferred method of treatment for olecranon fractures and is widely used throughout the world. This technique simply and effectively transforms the forces produced by the pulling of the triceps into forces causing compression of the fracture. Although the procedure is associated with a high union rate, the incidence of skin complications is also high. The most frequent complication is symptomatic prominence of the Kirschner wires (K-wires). The purpose of this retrospective study was to identify the optimal fixation of tension-band wiring in the treatment of olecranon fractures using biomechanical techniques. Sixty-two patients were divided into two groups: a bicortical Kirschner wire group and an intramedullary K-wire group. The migration rate of the K-wires and the union rate of fractured bone were measured in both groups. Achievement of radiographic union was similar in the two groups. However, the K-wire migration rate was higher in the intramedullary K-wire group than in the bicortical K-wire group. With appropriate surgical technique, the use of bicortical K-wires is biomechanically superior to the use of intramedullary K-wires in the treatment of olecranon fractures.

Comminuted fractures of the proximal ulna--Preliminary results with an anatomically preshaped locking compression plate (LCP) system

INTRODUCTION

The purpose of this investigation was to review the preliminary results and patients outcome following treatment with an anatomically preshaped LCP in patients with comminuted fractures of the proximal ulna. We hypothesized that this fixation system provides equal or superior results in fracture care when compared with other available plating devices, but results in better patient's comfort due to its low-profile design.

PATIENTS AND METHODS

Between 2007 and 2009, 15 patients with comminuted fractures of the proximal ulna including three posterior Monteggia fractures were managed with the preshaped LCP olecranon plate. The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the shortened Disability of the Arm, Shoulder and Hand (Quick-DASH) score, postoperative range of motion, objective muscle-strengths testing and patient's satisfaction were evaluated. All patients had follow-up radiographs.

RESULTS

Fourteen patients were available for evaluation. The mean arc of elbow motion was 129°. The mean MEPI was 97 with good results in two patients and excellent results in 12 patients. The mean Quick-DASH was 13. Thirteen of fourteen patients documented satisfaction with their elbow outcome. There was one patient with symptomatic hardware and one patient complained about deficit of motion. In four patients the hardware was removed including two patients with elective removal. Fourteen fractures healed with ulnohumeral congruity after a mean time to union of 11 weeks. One fracture non-union occurred without mechanical failure or loss of reduction.

CONCLUSION

Anatomically preshaped LCP olecranon plating is an effective fixation method for comminuted fractures of the proximal ulna allowing reliable stability for early elbow motion. The functional results are comparable with formerly described plating systems. A low rate of symptomatic hardware removal suggests better patient's compatibility.

Repair of olecranon fractures using fiberWire without metallic implants: report of two cases

Olecranon fractures are a common injury in fractures. The tension band technique for olecranon fractures yields good clinical outcomes; however, it is associated with significant complications. In many patients, implants irritate overlying soft tissues and cause pain. This is mostly due to protrusion of the proximal ends of the K-wires or by the twisted knots of the metal wire tension band. Below we described 2 cases of olecranon fractures treated with a unique technique using FiberWire without any metallic implants. Technically, the fragment was reduced, and two K-wires were inserted from the dorsal cortex of the distal segment to the tip of the olecranon. K-wire was exchanged for a suture retriever, and 2 strands of FiberWire were retrieved twice. Each of the two FiberWires was manually tensioned and knotted on the posterior surface of the olecranon. Bony unions could be achieved, and patients had no complaint of pain and skin irritation. There was only a small loss of flexion and extension in comparison with that of the contralateral side, and the patient did not feel inconvenienced in his daily life. Using the method described, difficulty due to K-wire or other metallic implants was avoided.

Plate osteosynthesis for severe olecranon fractures

PURPOSE

To review outcomes of 10 patients who underwent plate osteosynthesis for severe olecranon fractures.

METHODS

Records of 7 men and 3 women aged 33 to 73 years who underwent plate osteosynthesis for severe olecranon fractures were reviewed. All had some degree of soft-tissue injury; 6 presented with associated fractures. Seven patients were treated with a limited contact dynamic compression plate, and the remaining 3 received a locking compression plate. Patients were followed up for fracture healing, range of motion, nerve damage, heterotopic ossification, infection, hardware complaints, and the need of a secondary surgical procedure. The Mayo Elbow Performance Score (MEPS) was determined at the final follow-up. The patient-answered questionnaire (PAQ) portion of the Liverpool Elbow Score (LES) was evaluated 2 to 37 months later by telephone.

RESULTS

All patients had bone union. None had nerve damage or heterotopic ossification. Patients 4, 6, and 8 with type-IIIB fractures developed deep infections and severe soft-tissue swelling; all had been treated with the limited contact dynamic compression plate. Four patients underwent plate removal owing to hardware complaints. One patient underwent a secondary procedure to restore complete range of elbow motion. The mean MEPS score was 84 (range, 35-100); 5 patients attained excellent scores, one good, 2 satisfactory, and 2 unsatisfactory. The mean PAQ portion of the LES score was 31 (range, 23-36).

CONCLUSION

Plate osteosynthesis achieves satisfactory results for severe olecranon fractures. The deep infection rate is higher in patients with severe soft-tissue injury.

The use of three types of suture and stainless steel wire tension banding for the fixation of simulated olecranon fractures

Using an osteotomy of the olecranon as a model of a transverse fracture in 22 cadaver elbows we determined the ability of three different types of suture and stainless steel wire to maintain reduction when using a tension-band technique to stabilise the bone. Physiological cyclical loading simulating passive elbow movement (15 N) and using the arms to push up from a chair (450 N) were applied using an Instron materials testing machine whilst monitoring the osteotomy site with a video extensometer. Each osteotomy was repaired by one of four materials, namely, Stainless Steel Wire (7), No 2 Ethibond (3), No 5 Ethibond (5), or No 2 FiberWire (7).

There were no failures (movement of > 2 mm) with stainless steel wire or FiberWire and no significant difference in the movements measured across the site of the osteotomy (p = 0.99). The No. 2 Ethibond failed at 450 N and two of the five of No. 5 Ethibond sutures had a separation of > 2 mm at 450 N.

FiberWire as the tension band in this model held the reduction as effectively as stainless steel wire and may reduce the incidence of discomfort from the hardware. On the basis of our findings we suggest that a clinical trial should be undertaken

Olecranon fracture fixation with a new implant: biomechanical and clinical considerations

This study aims to describe the first clinical results in the treatment of dislocated olecranon fractures with 2.2-mm, fine-threaded wires with a washer. Furthermore, in the second part of the article, the stability of these new implants has been compared to standard tension band wiring in a sawbone model.

PATIENTS

The radiological and clinical outcomes in 24 patients (mean age: 53.6 years) with 24 isolated Mayo type I and II fractures of the olecranon were evaluated in a prospective study after open reduction and internal fixation (ORIF) with a new fixation device (FFS; Orthofix). The quality of reduction with the implementation of 24 FFS constructions was compared with 24 tension band-wiring procedures performed by six different surgeons in a standard sawbone Mayo type IIa fracture model. Stability was tested in all constructs using a single cycle load to failure protocol (group I), cyclic loading for 300 cycles between 10 and 500 N (group II) and incremental sinusoidal loading from 10 to 200 N with an incremental increase of 10 N per cycle (group III) in a laboratory study.

RESULTS

The Morrey elbow score was excellent in 23 patients and good in one patient, with mean DASH score of 1.6. No implant migration, secondary dislocation or nonunion was observed. In the sawbone model, the quality of reduction was the same with the FFS implants compared to the tension band wiring in the sawbone model. Here, bending moments in all three groups showed no significant difference, whereas displacement at failure was significantly greater in the tension band-wiring group at a single cycle load (p=0.017).

CONCLUSION

Clinical results were comparable to tension band wiring and stability of the implants in the sawbone model was the same; thus, we conclude that the FFS technique can serve as an alternative treatment option for isolated olecranon fractures.

Olecranon fractures

Several options exist for the management olecranon fractures. These include tension band, plate and intramedullary fixation techniques as well as fragment excision with triceps advancement and non-operative management. No one technique is suitable for the management of all olecranon fractures. In deciding how to treat this common trauma presentation, the surgeon needs a good understanding of the anatomy, different fracture morphologies, surgical options and potential complications. With appropriate management and early mobilisation good functional results can be expected in the majority of patients.

Safe zone for anterior cortical perforation of the ulna during tension-band wire fixation: a magnetic resonance imaging analysis

Placing K-wires obliquely through the anterior ulnar cortex is a common modification of traditional olecranon tension-band wiring. Wire tip protrusion, however, risks injury to adjacent neurovascular structures and may impede forearm rotation. This study examines the proximity of neurovascular structures to the anterior proximal ulnar cortex. The anatomy of 47 adult elbows was examined through magnetic resonance imaging. A radiologist measured the spatial relationship of 6 neurovascular structures to a mid-sagittal reference point 1.5 cm distal to the coronoid on the anterior surface of the ulna. Distance and angular measurements were made in the transverse plane of the reference point. Within a reasonable arc of K-wire placement, the ulnar artery and median nerve were at greatest risk yet were still beyond 10 mm from the anterior ulnar cortex. To avoid iatrogenic neurovascular injury during tension-band wiring of the olecranon, protrusion of wire tips beyond the anterior ulnar cortex should be no more than 1 cm at a distance of 1.5 cm distal to the coronoid.

Congruent elbow plate fixation of olecranon fractures

OBJECTIVES

We hypothesize that clinical results and patient outcomes following treatment of olecranon fractures with a congruent elbow plating system will be comparable to other available plating systems. Our results will be compared to previously published reports.

DESIGN

Retrospective study.

SETTING

Level 1 academic referral center.

PATIENTS/PARTICIPANTS

The trauma registry was reviewed to identify all olecranon fractures treated with open reduction and internal fixation between January 2001 and December 2004 using the Mayo Congruent Elbow Plate system. Thirty-two patients were identified. Postoperative range of motion was initiated within 2 weeks postoperatively. Mean time to follow-up was 2.2 years (0.7-5.1). All patients had follow-up radiographs. Outcome scores were available on 24 of the 32 patients.

INTERVENTION

Medical records and radiographs of all patients were reviewed.

MAIN OUTCOME MEASUREMENTS

Objective measures included radiographic healing, postoperative range of motion, and complications. Subjective functional results included Mayo Elbow Performance (MEP) score; Disability of the Arm, Shoulder, and Hand (DASH) score; and patient satisfaction.

RESULTS

Of the 32 fractures, 30 went on to union. Three patients had symptomatic hardware that was removed. There was 1 infection and 1 failure of fixation also requiring hardware removal. Average arc of motion was 120 degrees. Subjective follow-up was available in 75% of patients. Mean DASH was 32. Mean MEPS was 89, with 92% good or excellent results.

CONCLUSIONS

Congruent anatomic plating is a safe, effective option for the treatment of olecranon fractures with a low rate of hardware removal and stability with early motion.

The olecranon sled--a new device for fixation of fractures of the olecranon: a mechanical comparison of two fixation methods in cadaver elbows

BACKGROUND

Tension band wiring is the most common surgical procedure for fixation of fractures of the olecranon, but symptomatic hardware prominence and migration of K-wires can cause a high re-operation rate. The olecranon sled has been designed to minimize some of these problems.

MATERIAL AND METHODS

Simulated olecranon fractures were created in 6 matched pairs of cadaver arms. Each pair was fixed with tension band wiring used on the one arm and the olecranon sled being used on the other. Mechanical testing was done with the humerus rigidly fixed in a vertical position while the forearm was held at 1 of 3 angles of elbow fixation, 45 degrees , 90 degrees and 135 degrees , respectively. For each angle, the triceps and the brachialis muscles were sequentially loaded with 5 kg (50 N) for 20 cycles and the amount of fracture displacement measured.

RESULTS

Loading of the brachialis muscle produced no increase in the fracture gap for either of the two fixation techniques. However, an increase in the fracture gap of up to 0.23 mm was found after cyclic loading of the triceps muscle for both techniques. The amount of increase was not significantly different between the two techniques.

INTERPRETATION

The olecranon sled appears to provide as stable fixation as tension band wiring for olecranon fractures.

New tension band material for fixation of transverse olecranon fractures: a biomechanical study

This study tested the use of braided polyethylene cable as an option for repairing transverse olecranon fractures. Six cadaveric elbows underwent a transverse olecranon osteotomy followed by fixation with tension band constructs using 18-gauge wire and Secure-Strand (U.S. Surgical, North Haven, Conn). Distraction forces up to 450 N were applied to the triceps tendon while measuring fracture displacement with an extensometer. The average maximal fracture gap with the standard AO tension band technique using stainless steel wire was 0.66 +/- 0.43 mm, as opposed to 0.68 +/- 0.45 mm with braided polyethylene cable. A paired t test indicated no significant difference between the two materials. These results support the feasibility of braided polyethylene cable as an alternative to the standard steel-wire tension band.