Olecranon fractures treated with tension band suture fixation: Complication, reoperation rates and radiographic healing outcomes.

Olecranon fractures are relatively common injuries, accounting for approximately 10% of upper extremity fractures in adults [26]. These fractures may result from a direct blow to the proximal ulna, or indirectly, via the forceful contraction of the triceps against resistance (typically, during a fall onto an outstretched hand). Less commonly, the olecranon may fracture when the elbow is hyperextended, as the bone is impacted against the olecranon fossa of the distal humerus. For unstable injuries, operative fixation typically is required. Even after recovery, loss of ROM is not uncommon. This article provides an overview of olecranon fractures in adults; therefore, discussion of olecranon fractures in skeletally immature patients is beyond the scope of this article.

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. 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. 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). 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.

Background: A recent randomized controlled trial compared operative with nonoperative treatment of olecranon fractures in patients 75 yr and older. The study was notable for high complication rates, and operative treatment was cautioned against. The purpose of this study was to determine the complication rate among geriatric patients with an olecranon fracture treated surgically with plate fixation. Methods: The records of patients 75 yr and older treated with plate fixation for an olecranon fracture at a single level I trauma center were reviewed. Variables recorded included basic demographic data, complications, need for reoperation, and union at final follow-up. Results: Thirty-six patients met inclusion criteria, with a mean follow-up of 10 mo. Thirty-four of the 36 patients went on to union successfully prior to any subsequent surgery (94%). The overall reoperation rate was 11% (4 of 36 patients). Conclusions: The complication and reoperation rates after plate fixation of geriatric olecranon fractures were low. Loss of reduction was uncommon, and most patients went on to uneventful fracture union. These results support plate fixation of olecranon fractures in geriatric patients as a viable alternative to nonoperative management.

Tension band wiring and plate fixation are common techniques used to stabilize simple olecranon fractures and osteotomies of the olecranon. All suture fixation is an alternative technique but has not been compared previously to these traditional methods. The aim of this study was to compare the clinical and radiographic outcomes of the three techniques. One hundred and sixty-eight consecutive Mayo type 1 and 2 olecranon fractures (n = 138) and olecranon osteotomies (n = 30) with a minimum follow-up time of one year were compared. The primary outcome measure was the rate of re-operation. Secondary outcome measures were the incidence of complications, rate of radiographic union and incidence of radiographic reduction loss. Fixation was performed using tension band wiring in 89 patients, plating in 38 patients and suture fixation in 41 patients. There was no significant difference in the fracture type according to the Mayo classification between the groups. The re-operation rate was significantly higher in the tension band wiring group (36%) compared with both the plate group (11%, p = 0.03) and the suture group (2%, p = 0.002). There were two revision fixations in the tension band wiring group and one in the suture group. There was one asymptomatic non-union in the suture group. All other fractures and osteotomies achieved radiographic union. Suture fixation of simple olecranon fractures and osteotomies was reliable in providing stable union and had a significantly lower re-operation rate when compared with tension band wiring.

Background: Olecranon fractures are common injuries of the upper limb in adults. Simple displaced trasverse fractures are generally surgically treated with tension-band wiring (TBW) or plate fixation (PF). The purpose of this retrospective study is to compare the clinical-functional outcome, complications and reoperation rates between TBW and PF for Mayo IIA fractures. Methods: 72 patients treated with PF or TBW at our institution, completed our survey and clinical evaluation and their demographic and clinical data were recorded and analysed. The clinical-functional outcomes were evaluated assessing ROMs and three validated scoring systems: the Disabilities of the Arm, Shoulder, and Hand (DASH), the Mayo Elbow Performance Score (MEPS) and the Patient American Shoulder and Elbow Surgeons Standardized Elbow Assessment score (pASES-e). Results: 38 patients (53%) underwent TBW and 34 (47%) PF. The mean DASH, MEPS and pASES-e scores were respectively 14.5 ± 17.2, 80.5 ± 14.7 and 83.6 ± 12.4 in the TBW group and 21 ± 21.7, 75.6 ± 15.3 and 75.1 ± 19.2 in the PF group (p = 0.16, p = 0.17 and p = 0.03). The mean duration of surgery and hospitalisation period were longer in the PF group (p = 0.002, p = 0.37) whereas the complication and reoperation rates were higher after TBW (p = 0.15, p = 0.24). Conclusions: According to the literature, both TBW and PF resulted comparable valid surgical options for the treatment of simple isolated displaced olecranon fractures. Our results corroborate previous findings, showing good/excellent outcomes without significant differences.

BackgroundDisplaced olecranon fractures with a stable elbow joint are classified as Mayo type 2a or 2b and are commonly operated with tension band wiring, i.e. two K-wires and a cerclage. Retrospective studies have reported fewer reoperations and complications with cerclage fixation alone when compared to tension band wiring, though with similar long-term results. We decided to compare tension band wiring to cerclage fixation of displaced, stable olecranon fractures in adults in a randomized controlled trial.MethodsAll patients ≥ 18 years old with Mayo type 2a and 2b fractures presenting at Skåne University hospital will be eligible for study inclusion, unless exclusion criteria are met. Two hundred participants will be included and randomized 1:1 to cerclage fixation or tension band wiring.Outpatient physiotherapist follow-up appointments will be scheduled at 2 and 6 weeks and at 3, 12, and 36 months at the Dept. of Orthopaedics. A lateral view radiograph of the elbow will be analysed at 6 months. The primary outcome of our study is the rate of reoperations. Secondary outcomes are complication rates, severity of complications, and patient-reported outcome measures (QuickDASH, Short Musculoskeletal Function Assessment, pain level, and patient satisfaction). The sample size was calculated to give 80% power for detecting a statistically significant difference in reoperation rates (with alpha-value 0.05), based on a previous retrospective study.DiscussionReoperation and complication rates after tension band wiring of olecranon fractures are high. Treatment of these injuries is debated, and several ongoing trials compare tension band wiring with plate fixation, suture fixation, and non-operative treatment. As data from retrospective studies indicate that cerclage fixation may be superior to tension band wiring, we see a need for a randomized controlled trial comparing these methods. The WOW-OK Trial aims to obtain level-1 evidence that may influence treatment choice for this type of fracture.Trial registrationClinicalTrials.gov NCT05657899. Registered on 16 November 2022. The trial complies with SPIRIT and CONSORT guidelines. The SPIRIT figure is found in Table 2.

Olecranon fractures are common injuries that often require surgical fixation to maintain elbow function. Nonoperative management of these injuries may be indicated in the elderly, as a recent randomized controlled trial found that 81% (9) of 11 operatively managed olecranon fractures in the elderly had complications1. While traditional techniques such as tension-band wiring and plate fixation produced satisfactory functional outcomes, they are associated with high rates of complications2. Intramedullary screw fixation has gained popularity as an alternative technique for transverse olecranon fractures. The goal of this procedure is to reduce complication rates associated with olecranon open reduction and internal fixation while maintaining optimal functional outcomes. The patient is positioned in the lateral decubitus position with the arm placed over a padded Mayo stand. A direct posterior incision is made to the olecranon. Following irrigation and hematoma evacuation, the fracture is reduced. Pointed reduction clamps are used to reduce the fracture and hold a provisional reduction. A 2 to 2.5-cm longitudinal incision is made over the footprint of the triceps insertion. Next, a 3.5-mm drill is passed from the olecranon tip to the proximal ulnar diaphysis. The proximal ulna is then opened with a 4.5-mm drill, and a 6.5-mm calibrated tap is used to sound the ulna. Then a 6.5-mm, solid, partially threaded screw with a washer is placed across the fracture. Reduction aids are removed, and the surgical site is closed. The arm is splinted for 2 weeks to allow for soft-tissue healing, after which immediate full, active range of motion is allowed. Alternatives include nonoperative treatment such as immobilization with a posterior long-arm splint, operative treatment with tension-band wiring, and operative treatment with plate and screw fixation. Because of the high rates of stiffness, contracture, and joint involvement associated with nonoperative treatment of olecranon fractures, operative treatment of these injuries is often recommended3. The most common types of surgical fixation include tension-band wiring or a plate-and-screw construct. Both techniques successfully lead to fracture healing and satisfactory functional outcomes; however, the main drawback of these procedures is their high rate of complications2. A prior study reported complications in 19 (63%) of 30 patients with tension-band wiring and in 12 (38%) of 32 patients with plate-and-screw constructs. Symptomatic hardware, skin breakdown, and subsequent infection made up most of these complications2. In contrast, intramedullary screw fixation utilizes low-profile hardware that is seated within the osseous cortex. This reduces soft-tissue irritation in a region that contains low proportions of subcutaneous tissue. However, fixation with an intramedullary screw alone is contraindicated for comminuted fracture patterns or olecranon fractures associated with elbow instability. The presently described technique is largely indicated for simple, transverse olecranon fractures or for the repair of olecranon osteotomies. Patients who underwent intramedullary screw fixation for an olecranon fracture have had promising results. Although literature investigating the use of intramedullary screws is sparse, current reports indicate that the vast majority of patients progress to complete fracture healing with satisfactory patient outcomes. Patients largely achieve full range of motion, good functional outcomes, and low failure rates that are comparable with traditional techniques4-8. Notably, patients who undergo intramedullary screw fixation have significantly lower rates of complications, with a reoperation rate of 18% (35 of 199 patients). When controlling for confounding factors, intramedullary screw fixation reduced the odds of a secondary surgical procedure by 54%, compared with the use of a plate-and-screw construct. Overall, the reoperation rates for the different constructs were as follows: intramedullary screw fixation, 18% (35 of 199); tension band, 24% (31 of 128); and plate construct, 13% (29 of 229)9. When utilizing the posterior approach, curve the incision laterally along the elbow in order to prevent ulnar nerve injury and subsequent scar irritation when leaning on the elbow.An incorrect entry point or screw trajectory can cause premature engagement of the screw with the ulnar cortex, which can lead to fracture gapping and/or cortical perforation.Pointed reduction clamps and adjuvant fixation can be helpful to maintain fracture reduction while the intramedullary screw is passed.Appropriate postoperative care and early range of motion are key to a successful outcome. CT = computed tomography.

Introduction:Patella fractures managed by fixation with metal implants often cause local soft tissue irritation and necessitate implant removal. An alternative is to utilize suture-based fixation methods. We have adopted suture and hybrid fixation in the routine management of patella fractures. Here, we compare the results of 3 fixation techniques.Materials and Methods:Eighty-seven eligible patients underwent patella fracture fixation over a 3-year period. As determined by fracture configuration, patients received (1) suture fixation (transosseous sutures and figure-of-eight tension banding with FiberWire), (2) hybrid fixation (transosseous FiberWire sutures and metal tension banding), or (3) metal fixation. Primary outcome measures included reoperation rate and soft tissue irritation. Secondary outcomes included surgical complications, radiological, and functional parameters.Results:Reoperation rate was highest for metal fixation (25/57, 43.9%) and lowest for suture fixation (2/13, 15.4%). Soft tissue irritation necessitating implant removal was the predominant reason for reoperation and was significantly less prevalent following suture fixation (1/13, 7.7%, P < .01). Hybrid fixation resulted in similar rates of soft tissue irritation (6/17, 35.3%) and implant removal (7/17, 41.2%) as compared to metal fixation. There was a significant increase in patella baja (13/17, 76.5%) and reduction in Insall-Salvati ratio (0.742; 95% confidence interval: 0.682-0.802) following hybrid fixation as compared to the other 2 fixation methods (P < .05).Discussion:Suture fixation results in the least amount of soft tissue irritation and lowest reoperation rate, but these advantages are negated with the addition of a metal tension band wire. Hybrid fixation also unbalances the extensor mechanism.Conclusion:Patients should be counseled as to the expected sequelae of their fixation method. Suture fixation is the favored means to fix distal pole fractures of the patella. An additional metal tension band loop may confer additional stability but should be applied with caution.

Subcutaneous Anterior Transposition Versus In Situ Decompression of the Ulnar Nerve in an Active Duty Military Population

Surgical repair of clavicle fractures is being employed more frequently, although most fractures are still treated conservatively. Both can result in nonunion. Current treatments for clavicle nonunion include open reduction with internal fixation (ORIF) plating without bone graft, ORIF plating with bone graft, and intramedullary pin fixation. We performed a systematic review and meta-analysis of studies reporting outcome, complication, and reoperation rates following surgical treatment for clavicle nonunion. Subgroup analysis was undertaken for outcome and complication rates between single plating and intramedullary pin fixation, bone graft use, and nonunion time length definition. Fifty-three studies met inclusion criteria (1,258 clavicle nonunions). Mean clinical follow-up was 2.6 years. Seventy-two percent of nonunions were of the middle third, 1% were proximal third, 12% were distal third, and 15% were not reported. Forty-eight percent of nonunions were atrophic or oligotrophic and 17% were hypertrophic (35% not reported). Mean time to union was 13.6 weeks. Ninety-five percent of patients achieved union after the primary nonunion surgery. Overall complication rate was 17%. Single-plating fixation had significantly faster union time (15.2 vs. 19.8 weeks), lower reoperation rate (23% vs. 37%), and hardware removal rate (20% vs. 34%) than intramedullary pin fixation. Bone graft had significantly lower rates of delayed union (0.6% vs. 3.6%) but higher complication (15% vs. 8%) and reoperation rates (29% vs. 14%) than the other groups. Studies that defined nonunion after 3 months had significantly faster union times than the 6-month studies (13 vs. 16 weeks). The 3-month group had a significantly lower overall complication rate (12% vs. 25%) and hardware/fixation failure rate (3% vs. 5.5%) than the 6-month group. This systematic review is the largest report of complications, reoperations, and patient outcomes of clavicle nonunions after surgical intervention in the current literature. Plating showed faster time to union and lower reoperation rates than intramedullary pin fixation. Bone graft use showed lower rates of delayed union but substantially higher rates of complications and reoperations. Reports with a definition of nonunion at 3 months showed faster union times and lower complication rates compared to reports with a definition of nonunion that was 6 months or greater. Surgery could be considered at 3 months post-injury in cases of symptomatic non-united clavicle fracture, and plating results in reliable outcomes. Adjuvant bone grafting requires further study to determine its value and risk/benefit ratio. Level IV, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.

Tension band wiring and plate fixation for Olecranon fractures: a systematic review and meta-analysis

Treatment of olecranon fractures using an intramedullary cancellous screw and suture tension band: minimum 2-year follow-up

BackgroundTraditional tension band wiring and plate fixation represent the commonest methods for treating olecranon fractures. However, there is no agreement on which method provides the best outcome. The aim of this retrospective study is to compare the outcomes of tension band wiring (TBW) and plate fixation (PF) for treating displaced olecranon fractures. This is the first study to use propensity score matching analysis to compare treatment methods for olecranon fracture.MethodA total of 107 patients aged between 18 and 85 had acute isolated and displaced olecranon fractures. The patients were divided into either TBW (n = 49) or PF (n = 58) groups. To conduct propensity score matching for the treatment method (TBW versus PF), 58 patients were analyzed by logistic regression (29 patients in each group). Various demographic and treatment-related variables were examined and analyzed to determine their correlation.ResultsFunctional effects between two groups are similar (in terms of Mayo Elbow Performance Score (MEPS), the patients’ range of elbow motion (ROM) and forearm rotation (RFR), the time return to work (RTW)). The total adverse events rate and metalwork removal events rate are higher in TBW than that in PF. After propensity score matching analysis, similar primary treatment efficacy (indicated by MEPS> 90) in 2 groups and more primary adverse events (indicated by metalwork removal) were perceived in TBW than that in PF. Logistic regression analysis revealed that fracture type was an independent factor that affected the efficacy of a treatment (regression coefficient = − 1.24 < 0, P = 0.03), indicating that fracture severity was inversely proportional to the efficacy of a treatment for olecranon fracture. Furthermore, logistic regression analysis demonstrated that the treatment method was an independent factor that affected metalwork removal of olecranon fracture (regression coefficient 2.38 > 0, OR = 10.77, P < 0.01), indicating that the risk of metalwork removal in the TBW Group was 10.77 times that in the PF Group.ConclusionWhen initially discussing the surgical approach with patients, physicians should fully weigh the possibility that TBW may lead to a second surgery due to the higher risk of internal fixation removal and that TBW won’t yield better functional outcomes than PF .

To compare outcomes between open reduction internal fixation (ORIF), total elbow replacement (TER) and distal humerus hemiarthroplasty (DHH) for AO type-C (AOC) fractures of the distal humerus in patients aged 50 years or older. A retrospective analysis of acute AOC distal humerus fractures in patients aged 50 years or older between 2016 and 2022. Outcomes measured: Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), complication rate, re-operation rate and range of movement (ROM). Sixty-five patients met the inclusion criteria (20 males, 45 females). Mean age was 64.4, 77.1 and 61.3 years old for ORIF, TER and DHH respectively. Logistic model analysis revealed a statistically significant increased complication rate in the ORIF group compared to the TER and DHH groups (ORIF vs TER p = 0.01; ORIF vs DHH p = 0.048). There was a higher re-operation rate in the ORIF group compared to the DHH group (p = 0.03). There were no differences in OES, MEPS or ROM between groups. This supports the use of TER in elderly patients with AOC distal humerus fractures. In the younger patient, DHH may have lower rates of complications and re-operations compared to ORIF, but function remains similar. We propose a prospective randomised control trial.

Hardware complications and reoperations following precontoured plate fixation of the olecranon: a population-based study.