Does K-wire position in tension band wiring of olecranon fractures affect its complications and removal of metal rate?

Comparative study of locking neutralization plate construct versus tension band wiring with a cannulated screw for patella fractures: experimental and finite element analysis

Transverse patella fractures, accounting for approximately 1% of Orthopedic injuries, pose intricate challenges due to their vital role in knee mechanics. This study aimed to compare the biomechanical performance of a construct, integrating cannulated screws and an anterior locking neutralization plate, with the conventional tension band wiring technique for treating these fractures. Experimental testing and Finite Element Analysis were employed to evaluate the constructs and gain profound insights into their mechanical behavior. Sixteen cadaveric knees were prepared, and transverse patella fractures were induced at the midpoints using a saw. The plate construct and tension band wire fixation were randomly assigned to the specimens. A cyclic test evaluated the implants' durability and stability, simulating knee movement during extension and flexion. Tensile testing assessed the implants' maximum failure force after cyclic testing, while Finite Element Analysis provided detailed insights into stress distribution and deformation patterns. Statistical analysis was exclusively performed for the experimental data. Results showed the plate enhanced stability with significantly lower deformation (0.09 ± 0.12 mm) compared to wire fixation (0.77 ± 0.54 mm) after 500 cycles (p = 0.004). In tensile testing, the construct also demonstrated higher failure resistance (1359 ± 21.53 N) than wire fixation (780.1 ± 22.62N) (p = 0.007). Finite Element Analysis highlighted distinct stress patterns, validating the construct's superiority. This research presents a promising treatment approach for transverse patella fractures with potential clinical impact and future research prospects. This study presents a promising advancement in addressing the intricate challenges of transverse patella fractures, with implications for refining clinical practice. The construct's improved stability and resistance to failure offer potential benefits in postoperative management and patient outcomes.

Olecranon fractures: A biomechanical comparison of three tension band wiring fixation methods on bone models

PURPOSE

This study aimed to compare the biomechanical pull-out strength of the three different tension band wiring (TBW) methods employed to fix transverse olecranon fractures on bone models.

METHODS

Three different fixation models were created in groups of seven synthetic olecranon fractured bone models. The first technique was fixed the olecranon with the traditional TBW method. The second technique was fixed the olecranon with a large intramedullary screw TBW method. The third technique was fixed the olecranon with the double-screw TBW method. The pull-out force needed for the failure of each specimen under the tensile test device was evaluated, and the results were recorded.

RESULTS

We found that the lowest average pull out strength was 55.10 N (range: 35.87-65.85 ± 10.17) in the traditional TBW method, the highest pull out strength was 84.28 N (range: 63.67-117 ± 18.87) in the double-screw TBW method. The pull out strength was 70.80 N (range: 52.60-80.95 ± 10.18) in the intramedullary screw TBW method. In terms of ultimate failure loads, there was no significant difference between the intramedullary screw TBW and the double-screw TBW (p > .05) while there was a significant difference between the traditional TBW and the other two methods (p < .05).

CONCLUSION

The use of screw(s) shows higher biomechanical stability than K-wires in the TBW method. Double-screws fixation gives similar results in terms of the biomechanical load to failure compared to a large intramedullary screw fixation. Both screw methods can be used as stable constructs in clinical practice.

LEVEL OF EVIDENCE

III, biomechanical trial.

Novel suture/suture-anchor fixation versus tension band wiring for olecranon fractures: A systematic review

Introduction

Tension Band Wiring (TBW) has traditionally been the cornerstone of operative management for simple displaced olecranon fractures but its success is limited by high complication rates, mainly related to metalwork irritation and fixation failure. Over the last twelve years, a number of novel fixation methods not involving metalwork have been described in case series (suture fixation, SF and suture-anchor fixation, SAF) with promising early results. In this systematic review, the outcomes of SF and SAF techniques are presented alongside those for TBW for the treatment of closed olecranon fractures without elbow instability.

Materials and methods

Five databases (Medline, Scholar, Scopus, Prospero and Cochrane) were searched for clinical studies involving TBW/SF/SAF for closed Mayo 1A/1B/2A/2B olecranon fractures from January 2010 onwards. Primary outcomes included overall complication and reoperation rates, as well as the rate of each specific complication. Elbow range of movement, surgeon and patient-reported outcome measures were defined as secondary outcomes.

Results

Eighteen studies were included, nine of which involved SF/SAF (99 patients) and nine TBW (382 patients). SF/SAF techniques were associated with lower rates of fracture/implant displacement (2% versus 9.7%, p = 0.01), implant irritation (1% versus 30.1%, p < 0.001) and overall complications (8% versus 46.1%, p < 0.001) when compared to TBW. Reoperation rates were lower for SF/SAF (3% versus 37.2%, p < 0.001). Total flexion/extension arc achieved was similar (130.16 ± 2.11 versus 129.45 ± 0.93 degrees). On average, patients regained a functional arc of flexion (135.21 ± 4.81 TBW versus 131.32 ± 12.99 SF/SAF) and extension (1.16 ± 7.54 SF/SAF versus 5.76 ± 7.98 TBW).

Conclusion

Current evidence suggests that SF/SAF of simple olecranon fractures is a safe and effective alternative to the current gold standard TBW fixation, with preliminary evidence suggestive of lower complication and reoperation rates. Firm conclusions of equivalence or superiority are not possible based on the current poor quality of literature available. Until the outcomes of high-quality prospective studies are available, patients should be carefully counselled that suture methods remain novel and outcomes should be regularly audited.

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.

The effect of grip location on Kirschner wire bend characteristics: An in vitro study

OBJECTIVE

To determine the effect of Kirschner wire (K-wire) grip location on bend angle, bend radius, and torque when performing a Z-bend technique.

STUDY DESIGN

Experimental study.

SAMPLE POPULATION

Ten samples at each of five grip locations for each of three K-wire diameters.

METHODS

K-wires of three diameters (0.9, 1.1, 1.6 mm) were drilled into PVC pipe, and a Jacob's chuck was used to bend the wires at five periodic grip locations (distance from the bone model). Torque, bend angle, and bend radius were determined for each sample. Outcome variables were statistically analyzed by grip location to determine significant relationships.

RESULTS

A grip location of 2.0 cm in the 0.9 mm K-wire group minimized bend angle (mean ± SD: 75.92° ± 0.81) and bend radius (2.89 mm ± 0.08). A grip location of 3.0 cm in the 1.1 mm K-wire group minimized bend angle (72.88° ± 0.98) and bend radius (2.47 mm ± 0.20). A grip location of 3.0 cm minimized bend angle (74.38° ± 1.93) and bend radius (2.71 mm ± 0.27) in the 1.6 mm K-wire group. Torque at these grip locations for the 0.9, 1.1, and 1.6 mm K-wires was 6.50 N-m ± 0.0, 11.00 N-m ± 0.0, and 19.05 N-m ± 0.16, respectively.

CONCLUSION

Bend angle and bend radius can be minimized by bending K-wires at specific grip locations, though torque is not minimized at these locations. Clinical significance These findings provide an evidence-based recommendation of where surgeons should grip K-wires when bending them.

Comparison of two surgical techniques for the treatment of transverse olecranon fractures: A finite element study

BACKGROUND

In this study, we aimed to compare the stability of traditional tension band wiring (TBW) and screw combined TBW (SC-TBW) fixation methods performed for a transverse olecranon osteotomy-fracture during different degrees of elbow movement by using finite element analysis.

METHODS

Three-dimensional solid modeling of the olecranon was obtained by computed tomography images. Transverse olecranon fracture was created and fixed by TBW and SC-TBW with respect to triceps muscle force. Opening angle, twisting angle and interplanar translation occurring on the fracture line were evaluated at 45° and 90° elbow flexion.

RESULTS

Opening angle: 0.71°, 0.87° at 45° and 0.64°, 0.67° at 90° elbow flexion for TBW and SC-TBW, respectively. Twisting angle: -0.01°, -0.19° at 45° flexion and 0.19°, 0.30° at 90° flexion for TBW and SC-TBW, respectively. Interplanar translation: 1.93 mm, 4.65 mm at 45° flexion and 1.78 mm, 3.95 mm at 90° flexion for TBW and SC-TBW, respectively.

CONCLUSION

TBW fixation provides more stability than SC-TBW fixation model.

Augmented intramedullary screw tension band construct for olecranon fracture reduction and fixation: a review of literature and surgical technique

Olecranon fractures, which make up 10% of upper extremity fractures in adults, often require anatomic reduction and stable internal fixation. Successful olecranon fracture osteosynthesis has classically been achieved via tension band wiring or plate fixation. This article reviews the indications, outcomes, and a surgical technique as an alternative construct for tension band wiring of olecranon fractures. The technique involves placement of an ulnar intramedullary partially threaded screw that is used as a proximal point of attachment for tension band wiring of the olecranon. Although infrequently used by orthopedic surgeons, this construct has been shown to be biomechanically and clinically superior to classic Kirschner wire tension banding techniques. This review is intended to familiarize surgeons with a surgical technique that can be applied to a variety of proximal ulna fractures.

Where should the pins be placed to decrease the failure rate after fixation of a Mayo IIA olecranon fracture? A biomechanical analysis

BACKGROUND

Clinically, treatment of Mayo IIA olecranon fractures (MIOF) using pins is associated with a high rate of failure. The purpose of our study was to compare the biomechanical stability and strength of four different fracture fixation configurations and to recommend the best method for the clinical treatment of MIOFs.

METHODS

Twenty synthetic ulnar models were created and equally divided into 4 different fracture fixation groups: a double cortical configuration using Kirschner (K) wires; a double cortical configuration using transcortical pins; an intramedullary pin system; and an intramedullary pin system with a 3-mm distance between the eyelet and the proximal end of the olecranon (loose fixation). The stiffness and strength of all specimens were tested under a loading rate of 2 mm/min. Between-group differences were evaluated using an independent t-test, with significance set at P < 0.05.

RESULTS

Stiffness and strength were significantly better for the K-wire than intramedullary group: stiffness, 63.467±14.063 N/mm and 36.243±5.625 N/mm, respectively (P=0.009); and strength, 624.293±148.728 N and 406.486±74.109 N, respectively (P=0.019). There was no difference in stiffness (P=0.370) or strength (P=0.929) between the use of transcortical pins and K-wires. Moreover, a 3-mm prominence of the pin at the olecranon did not have a negative effect on either stiffness (P=0.494) or strength (P=0.391).

CONCLUSIONS

Our biomechanical analysis indicated that using a double cortical pin configuration provided the best stability and strength and, thus, may lower the risk of fracture fixation failure. The use of either K-wires or pins in the double cortical configuration did not influence fixation stability. A loose double cortical configuration might decrease fracture stability, although there differences were not significant.

Is intramedullary screw fixation biomechanically superior to locking plate fixation and/or tension band wiring in transverse olecranon fractures? A cadaveric biomechanical comparison study

OBJECTIVES

To compare clinically important mechanical properties of three techniques used to fix transverse olecranon fractures (Arbeitsgemeinschaft fur Osteosynthesefragen and Orthopaedic Trauma Association class 2U1B1): (1) intramedullary (IM) screw, (2) locking plate, and (3) tension band wire in a realistic loading protocol using a cadaveric model.

METHODS

Fresh frozen cadaveric transverse olecranon fracture models were fixed with an IM screw (n = 6), a locking plate (n = 6), or a tension band (n = 6). Compression after fixation was recorded using a pressure sensor in the fracture before samples were loaded through the triceps tendon for 500 cycles of 0-500 N, assessing implant survival. The primary outcome measure was compression force before loading. The secondary outcome was frequency of implant failure defined as breakage of the implant itself or fracture gapping >5 mm. Binary outcomes were compared with χ², and continuous variables were compared with unadjusted analysis of variance and a multivariable regression model adjusting for age, sex, dual-energy X-ray absorptiometry T-score, and testing order.

RESULTS

No statistically significant difference was shown in fracture compression between IM screw (mean, 162 N; 95% confidence interval [CI], 27-297 N), locking plate (mean, 125 N; 95% CI, -9-260 N), and tension band (mean, 163 N; 95% CI, 29-298 N) in unadjusted (p = 0.89) and adjusted (p = 0.82) analyses. A 100% implant failure rate was observed with tension band compared with 0% implant failure with IM screw or locking plate (p < 0.01).

CONCLUSION

We found no statistically significant differences in compression across the fracture site among techniques. We did find a higher risk of implant failure with tension band compared with IM screw and locking plate during cyclic loading in cadaveric bone.

Olecranon mayo IIA fractures treated with transosseous high strength suture: A series of 29 cases

BACKGROUND

The aim of this study is to assess the causes and rates of re-operation in olecranon fractures in adults treated with transosseous suture.

METHODS

We prospectively recruited 29 patients who were treated with this technique between 2010 and 2018. The type of suture used, tourniquet time and surgical time were analyzed for each one. X-rays were taken after 2 weeks, 6 weeks and 6 months, recording complications, causes, rates of re-operation and the final clinical condition.

RESULTS

Median time for ischemia and surgery were 51 (95% CI:48;62) and 45 (95% CI:42;55) minutes respectively. The radiologic studies showed diastasis of the posterior cortex in the X-rays taken after 2 weeks and after 6 weeks in 7 (24,1%) cases. Of these cases, two (6,8%) were no longer followed-up after 6 months. There was only one case of aseptic non-union. Among these cases, two patients (6.8%) required surgical debridement due to acute soft tissue infection. No complication had any clinical impact, maintaining all patients full range of motion and no pain. Osteosynthesis removal was not necessary in any case.

CONCLUSION

Transosseous suture with high strength thread is a valid alternative for treating Mayo IIA olecranon fractures in adult patients, decreasing re-operation rates for implant removal. There may be, in a moderate percentage of cases, radiologic diastasis of the posterior cortex at the fracture site, without causing pain nor limiting mobility LEVEL OF EVIDENCE: III.

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 Management for Olecranon Fractures in Adults: A Systematic Review and Meta-analysis

Olecranon fractures are common upper-extremity fractures amenable to various surgical techniques. The authors conducted a systematic review and meta-analysis to evaluate surgical management strategies for olecranon fractures in adult patients. Two investigators independently screened articles from records obtained from MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Library databases. The authors compared tension-band wiring (TBW) with plate fixation (PF) for the outcomes of complications and hardware removal. Subgroup analyses were conducted comparing randomized controlled trials with observational studies for each outcome. In addition, the authors evaluated novel fixation techniques other than TBW and PF. Twenty-four studies were included in the systematic review and 10 studies were included in the meta-analysis of TBW vs PF. Compared with TBW (n=270), patients who underwent PF (n=369) had a significantly lower complication rate (relative risk, 0.48; 95% confidence interval, 0.36-0.64; P<.01; I²=16%). Plate fixation (41 of 332) also had less hardware removal compared with TBW (79 of 236; relative risk, 0.36; 95% confidence interval, 0.25-0.50; P<.01; I²=0%). Subgroup analyses showed no difference when comparing randomized controlled trials with observational studies for the outcomes of complication rate (P=.45) and hardware removal (P=.54). Qualitative analysis revealed novel methods of olecranon fixation: a modified cable pin system, tension banding through 2 cannulated screws, olecranon memory connector fixation, and cancellous screw TBW. This meta-analysis revealed significantly lower complication and hardware removal rates for PF compared with TBW. Several novel methods of olecranon fixation may represent viable alternatives. [Orthopedics. 2019; 42(2):75-82.].

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.

Management of type IIB and IIIB olecranon fractures. Case series

•

Management of type IIB and IIIB olecranon fractures.

•

Report and evaluate the functional outcome of plate fixation.

•

Oxford elbow score.

•

Rotational range of movement and flexion arc.

Objectives

to report and evaluate the functional outcome of plate fixation in comminuted olecranon fractures (Mayo types IIB and IIIB).

Method

23 consecutive patients with comminuted fractures of the olecranon presenting to our unit Between Feb 2011 and Jan 2015, at a mean follow-up of thirty-six months. Main outcome measurements include radiographic healing, post-operative range of motion, complications, outcome score and patient satisfaction.

Results

Our study included thirteen females and ten males with a mean age of 55(18–97). Fourteen were Mayo type IIB and nine were Mayo type IIIB. Eighteen patients had no complications post-operatively with good outcome with mean oxford score of 45, full rotational ROM and mean flexion arc of 20–130 °. Five patients had range of motion between 40–90 ° with full rotational ROM and mean oxford score of 24. Two patients out of five required metal work removal. No non-unions were noted in our series.

Conclusion

Plate fixation of complex olecranon fracture is an effective, reliable method of treatment with low risk of non-union. Restoration of a functional flexion arc of movement can be expected with application of correct technique.

Societal costs in displaced transverse olecranon fractures: using decision analysis tools to find the most cost-effective strategy between tension band wiring and locked plating

BACKGROUND

Tension band wiring (TBW) and locked plating are common treatment options for Mayo IIA olecranon fractures. Clinical trials have shown excellent functional outcomes with both techniques. Although TBW implants are significantly less expensive than a locked olecranon plate, TBW often requires an additional operation for implant removal. To choose the most cost-effective treatment strategy, surgeons must understand how implant costs and return to the operating room influence the most cost-effective strategy. This cost-effective analysis study explored the optimal treatment strategies by using decision analysis tools.

METHODS

An expected-value decision tree was constructed to estimate costs based on the 2 implant choices. Values for critical variables, such as implant removal rate, were obtained from the literature. A Monte Carlo simulation consisting of 100,000 trials was used to incorporate variability in medical costs and implant removal rates. Sensitivity analysis and strategy tables were used to show how different variables influence the most cost-effective strategy.

RESULTS

TBW was the most cost-effective strategy, with a cost savings of approximately $1300. TBW was also the dominant strategy by being the most cost-effective solution in 63% of the Monte Carlo trials. Sensitivity analysis identified implant costs for plate fixation and surgical costs for implant removal as the most sensitive parameters influencing the cost-effective strategy. Strategy tables showed the most cost-effective solution as 2 parameters vary simultaneously.

CONCLUSION

TBW is the most cost-effective strategy in treating Mayo IIA olecranon fractures despite a higher rate of return to the operating room.