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Symes M, Harris IA, Limbers J, Joshi M. SOFIE: Surgery for Olecranon Fractures in the Elderly: a randomised controlled trial of operative versus non-operative treatment. BMC Musculoskelet Disord 2015; 16:324. [PMID: 26507718 PMCID: PMC4624605 DOI: 10.1186/s12891-015-0789-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 10/22/2015] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Michael Symes
- Gosford Hospital, Holden St, Gosford, NSW, 2250, Australia.
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, and South Western Sydney Clinical School, UNSW Australia, 1 Campbell St, Liverpool, NSW, 2170, Australia.
| | - John Limbers
- Gosford Hospital, Holden St, Gosford, NSW, 2250, Australia.
| | - Mithun Joshi
- Gosford Hospital, Holden St, Gosford, NSW, 2250, Australia.
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Niglis L, Bonnomet F, Schenck B, Brinkert D, Di Marco A, Adam P, Ehlinger M. Critical analysis of olecranon fracture management by pre-contoured locking plates. Orthop Traumatol Surg Res 2015; 101:201-7. [PMID: 25736196 DOI: 10.1016/j.otsr.2014.09.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 08/19/2014] [Accepted: 09/29/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fractures of the proximal ulna are rare and usually managed surgically. Strong fixation of the harware is essential to obtain good outcomes. We report our experience with pre-contoured locking plate fixation of complex olecranon fractures and present a critical appraisal of the outcomes. HYPOTHESIS Pre-contoured locking plates provide good outcomes, but their clinical tolerance may be limited in some instances. MATERIALS AND METHODS From September 2009 to December 2011, 28 patients were managed using a pre-contoured locking compression plate (LCP(®)). Among them, 6 were excluded because of missing data, which left 22 patients (11 males and 11 females) with a mean age of 55.7 years, including 12 who were employed. The fracture was on the dominant side in 11 patients. According to the Mayo Clinic classification, 15 fractures were type II and 7 type III. In addition to the ulnar fracture, a radial head fracture was present in 9 patients and a coronoid process fracture in 5 patients. Functional recovery was assessed using the Broberg-Morrey score and Mayo Elbow Performance Score (MEPS). Radiographs were obtained to evaluate the quality of fracture reduction and fracture healing, as well as to look for ossifications and osteoarthritis. RESULTS Mean follow-up was 20 months. Flexion was 131°, extension loss was 9.5°, pronation was 79°, and supination was 80.5°. The mean Broberg-Morrey score was 96.7 and the mean MEPS score 96.6. Fracture healing occurred in all patients, within a mean of 10.6 weeks. Evidence of early osteoarthritis was found in 6 patients, ossifications in 3 patients, and synostosis in 1 patient. An infection was successfully treated with lavage and antibiotic therapy in 1 patient. The fixation hardware was removed in 6 patients. No prognostic factors were identified. DISCUSSION-CONCLUSION Our hypothesis was confirmed. The outcomes are encouraging and comparable to those reported in the literature. The critical issue is the limited clinical tolerance of the plate with a high rate of posterior impingement requiring plate removal (27%). Rigorous technique is essential during plate implantation. LEVEL OF EVIDENCE Level IV, retrospective study.
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Affiliation(s)
- L Niglis
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - F Bonnomet
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - B Schenck
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - D Brinkert
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - A Di Marco
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - P Adam
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - M Ehlinger
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
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Gruszka D, Arand C, Nowak T, Dietz SO, Wagner D, Rommens P. Olecranon tension plating or olecranon tension band wiring? A comparative biomechanical study. INTERNATIONAL ORTHOPAEDICS 2015; 39:955-60. [PMID: 25711396 DOI: 10.1007/s00264-015-2703-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 02/02/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The complication rate of a tension band wiring (TBW) used for the internal fixation of olecranon fractures remains high. The aim of this study was to compare the stability of a novel olecranon tension plate (OTP) with TBW in a simulated fracture model. METHODS We tested 12 fresh frozen-pairs of cadaver proximal ulnae treated with OTP and TBW under cyclic loading. The elbow motion ranged from full extension to 90° of flexion, and the pulling force of the triceps tendon ranged from 50 to 350 N. The displacement of the fracture fragments was measured continuously. Data were assessed statistically using the Wilcoxon test with significance level of p < 0.05. RESULTS The cyclic loading tests showed median displacements of the fracture fragments of 0.25 mm using OTP and 1.12 mm for TBW. Statistical analysis showed the difference to be substantial (p = 0.086) but not statistically significant. No plate breakage or screw loosening occurred. CONCLUSIONS The concept of replacing prominent K-wires at the proximal end of the ulna using an low-profile plate with classical lag and multidirectional angle-stable screws demonstrated biomechanical advantages over TBW.
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Affiliation(s)
- Dominik Gruszka
- Department of Orthopaedics and Traumatology, University Medical Center, Mainz, Germany,
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Niéto H, Billaud A, Rochet S, Lavoinne N, Loubignac F, Pietu G, Baroan C, Espie A, Bonnevialle P, Fabre T. Proximal ulnar fractures in adults: a review of 163 cases. Injury 2015; 46 Suppl 1:S18-23. [PMID: 26528935 DOI: 10.1016/s0020-1383(15)70006-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The aim of this study was to report the epidemiological characteristics and the experience of 5 departments of trauma, in France, in the management of fractures of the proximal ulna. 163 patients with fractures of the proximal ulna with a mean age of 49.9 years (range 16-97) were managed. The most common mode of injury was a motor vehicle collision (48%). 18% sustained associated injuries to the ipsilateral limb. Open fractures were present in 42 patients (25%). A total of 109 patients had a fracture of the olecranon, with the Mayo 2A and B types most frequently seen (66%). 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 Broberg and Morrey score were evaluated. All patients had follow-up radiographs. The mean arc of elbow motion was 130° (70-150°). The mean MEPI was 91 (20-100) with good results in 23% and excellent results in 52% of the patients. The mean Broberg and Morrey score was 90 after isolated olecranon fracture, and decreased with the complexity of the lesion. 117 fractures (72%) healed with ulnohumeral congruity. 9 fracture non-unions occurred (6%). Although the fracture of the proximal ulna can be described in several classifications, none of them accommodate it satisfactorily, because of the complexity of the lesion. The coronoid process is the keystone for the stability of the elbow. It forms the anterior buttress with the radial head. Tension band wire fixation is by far the commonest technique of internal fixation used for the treatment of non-comminuted olecranon fractures. Dorsal plate fixation is a useful option by providing improved fixation of complex comminuted fractures and fracture-dislocations. The radiocapitellar joint has to be restored appropriately, preserving the radial head when possible and replacing it with a prosthesis otherwise. The lateral collateral ligament complex is commonly disrupted and usually can be reattached to its origin from the lateral epicondyle. In addition, a brief period of hinged external fixation should be considered.
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Affiliation(s)
- H Niéto
- Department of Trauma and Orthopaedics, Niort, France
| | - A Billaud
- Department of Trauma and Orthopaedics, Pau, France
| | - S Rochet
- University Hospital of Besançon, France
| | - N Lavoinne
- Department of Trauma and Orthopaedics, Saint Jean de Luz, France
| | - F Loubignac
- Department of Trauma and Orthopaedics, Toulon, France
| | - G Pietu
- University Hospital of Nantes, France
| | - C Baroan
- Department of Trauma and Orthopaedics, Niort, France
| | - A Espie
- Department of Trauma and Orthopaedics, Albi, France
| | | | - T Fabre
- University Hospital of Bordeaux, France
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Matar HE, Ali AA, Buckley S, Garlick NI, Atkinson HD. Surgical interventions for treating fractures of the olecranon in adults. Cochrane Database Syst Rev 2014; 2014:CD010144. [PMID: PMID: 25426876 PMCID: PMC6599821 DOI: 10.1002/14651858.cd010144.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Hosam E Matar
- Trauma and OrthopaedicsSpeciality RegistrarMersey RotationLiverpoolUK
| | - Amjid A Ali
- Northern General HospitalDepartment of Trauma and OrthopaedicsHerries RoadSheffieldUKS5 7AU
| | - Simon Buckley
- Northern General HospitalDepartment of Trauma and OrthopaedicsHerries RoadSheffieldUKS5 7AU
| | - Nicholas I Garlick
- Royal Free HospitalDepartment of Trauma and OrthopaedicsPond StreetHampsteadLondonUKNW3 2QG
| | - Henry D Atkinson
- North Middlesex University HospitalDepartment of Trauma and OrthopaedicsSterling WayLondonUKN18 1QX
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Tamaoki MJS, Matsunaga FT, Silveira JD, Balbachevsky D, Matsumoto MH, Belloti JC. Reproducibility of classifications for olecranon fractures. Injury 2014; 45 Suppl 5:S18-20. [PMID: 25528618 DOI: 10.1016/s0020-1383(14)70015-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fractures of the olecranon are relatively common injuries in adults and are of great clinical importance. Classification systems have been developed as tools to assist surgeons in grouping different types of fractures, to facilitate communication and to standardise treatment, but none of the systems used today is universally accepted for olecranon fractures. METHODS Fifty-nine olecranon fractures were classified according to the Schatzker, Colton, Mayo and AO/ASIF systems by four observers with different levels of expertise. Intra- and inter-observer agreement was assessed. Each observer analysed the images at three different times; the images were randomised and presented in a different sequence at each assessment. RESULTS There was higher mean intra-observer agreement in the AO/ASIF (0.60) and Mayo (0.64) classifications compared with the Schatzker (0.49) and Colton (0.38) classifications. Inter-observer agreement was better with AO/ASIF and Mayo (0.35 and 0.32, respectively) than with Schatzker and Colton (0.29 and 0.12, respectively). CONCLUSION The results of this study indicate that the most commonly used classifications for olecranon fractures are associated with low reproducibility.
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Affiliation(s)
- Marcel Jun Sugawara Tamaoki
- Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina (Unifesp-EPM), São Paulo, Brazil
| | - Fabio Teruo Matsunaga
- Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina (Unifesp-EPM), São Paulo, Brazil.
| | - Juliana Doering Silveira
- Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina (Unifesp-EPM), São Paulo, Brazil
| | - Daniel Balbachevsky
- Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina (Unifesp-EPM), São Paulo, Brazil
| | - Marcelo Hide Matsumoto
- Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina (Unifesp-EPM), São Paulo, Brazil
| | - João Carlos Belloti
- Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina (Unifesp-EPM), São Paulo, Brazil
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Yi PH, Weening AA, Shin SR, Hussein KI, Tornetta P, Jawa A. Injury patterns and outcomes of open fractures of the proximal ulna do not differ from closed fractures. Clin Orthop Relat Res 2014; 472:2100-4. [PMID: 24504649 PMCID: PMC4048433 DOI: 10.1007/s11999-014-3489-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence and injury patterns of open fractures of the proximal ulna are poorly elucidated and little evidence exists to guide management. QUESTIONS/PURPOSES The purpose of this study was to compare the (1) bony injury patterns; (2) range of motion (ROM) and frequency of union; and (3) postoperative complications between open and closed fractures of the proximal ulna. METHODS Seventy-nine consecutive open fractures of the proximal ulna were identified. After excluding fracture-dislocations, penetrating injuries, and pediatric injuries, 60 were compared in a retrospective case-control study with an age- and sex-matched group of 91 closed fractures to compare the bony injury patterns based on radiographic review. In a subset of 39 open and 39 closed fractures with sufficient followup, chart and radiographic review was performed by someone other than the operating surgeon to compare differences in final ROM, union, and postoperative complication rates at a minimum followup of 3 months (mean, 22 and 15 months; range, 3-86 months and 3-51 months for open and closed fractures, respectively). A total of 12% of the fractures were open (79 of 671) at the three study centers, and the majority of fractures were intraarticular (45 of 60 [75%]) with Gustilo-Anderson Type I and II wounds (54 of 60 [90%]). RESULTS Overall, open fractures of the proximal ulna overall did not have more complex bony injury patterns, but there were more anterior olecranon fracture-dislocations among the open fracture group (nine of 60 [15%] versus two of 91 [2%]; p = 0.004) and more posterior olecranon fracture-dislocations in the closed fracture group (31 of 91 [34%] versus seven of 60 [12%]; p = 0.002). Final ROM was not different in both groups and all fractures healed. There was no difference in wound infection rate but a higher secondary procedure rate among open fractures of the proximal ulna (39% versus 23%, p = 0.014). CONCLUSIONS In contrast to open fractures of the distal humerus, open fractures of the proximal ulna present with mild soft tissue injuries and do not have more complex bony injury patterns than closed fractures. Our findings suggest that open fractures of the proximal ulna are the result of tension failure of the skin secondary to the limited soft tissue envelope around the proximal ulna. Open fractures of the proximal ulna should be regarded as relatively mild injuries that are not different in severity and prognosis compared with closed fractures. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Paul H. Yi
- />Boston University Medical Center, Boston, MA USA , />23 Wigglesworth Street, Boston, MA 02120 USA
| | | | | | | | | | - Andrew Jawa
- />Boston University Medical Center, Boston, MA USA
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Snoddy MC, Lang MF, An TJ, Mitchell PM, Grantham WJ, Hooe BS, Kay HF, Bhatia R, Thakore RV, Evans JM, Obremskey WT, Sethi MK. Olecranon fractures: factors influencing re-operation. INTERNATIONAL ORTHOPAEDICS 2014; 38:1711-6. [PMID: 24893946 DOI: 10.1007/s00264-014-2378-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 05/06/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE We evaluated factors influencing re-operation in tension band and plating of isolated olecranon fractures. METHODS Four hundred eighty-nine patients with isolated olecranon fractures who underwent tension band (TB) or open reduction internal fixation (ORIF) from 2003 to 2013 were identified at an urban level 1 trauma centre. Medical records were reviewed for patient information and complications, including infection, nonunion, malunion, loss of function or hardware complication requiring an unplanned surgical intervention. Electronic radiographs of these patients were reviewed to identify Orthopaedic Trauma Association (OTA) fracture classification and patients who underwent TB or ORIF. RESULTS One hundred seventy-seven patients met inclusion criteria of isolated olecranon fractures. TB was used for fixation in 43 patients and ORIF in 134. No statistical significance was found when comparing complication rates in open versus closed olecranon fractures. In a multivariate analysis, the key factor in outcome was method of fixation. Overall, there were higher rates of infection and hardware removal in the TB compared with the ORIF group. CONCLUSIONS Our results demonstrate that the dominant factor driving re-operation in isolated olecranon fractures is type of fixation. When controlling for all variables, there is an increased chance of re-operation in patients with TB fixation.
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Affiliation(s)
- Mark Christopher Snoddy
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200 Medical Center East, South Tower, Nashville, TN, 37232, USA
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109
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Flinterman HJA, Doornberg JN, Guitton TG, Ring D, Goslings JC, Kloen P. Long-term outcome of displaced, transverse, noncomminuted olecranon fractures. Clin Orthop Relat Res 2014; 472:1955-61. [PMID: 24522384 PMCID: PMC4016441 DOI: 10.1007/s11999-014-3481-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 01/23/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Operative treatment of a displaced, transverse, noncomminuted fracture of the olecranon is associated with good to excellent elbow function in retrospective short-term followup studies. However, to our knowledge, no studies have evaluated objective and subjective outcomes using standardized outcome instruments (ie, DASH and Mayo Elbow Performance Index [MEPI]) to quantify long-term outcome of these specific fractures. QUESTIONS/PURPOSES We evaluated (1) factors associated with disability, as measured with the DASH questionnaire; (2) factors associated with ulnohumeral motion; (3) factors associated with pain intensity; and (4) general descriptive findings for posttraumatic arthrosis, MEPI, ulnar neuropathy symptoms, and return to work between 10 and 32 years after open reduction and internal fixation (ORIF) of a transverse, noncomminuted fracture of the olecranon. METHODS Between 1977 and 1997, we performed ORIFs of transverse, noncomminuted olecranon fractures in 109 patients, of whom 35 had died, 14 had incomplete data in our registry, and 19 were lost to followup or declined participation, leaving 41 patients available for followup at a minimum of 10 years after surgery. During that time, our general indication for performing ORIF was greater than 2 mm displacement. The average age of these patients at the time of injury was 35 years (range, 18-73 years). Patient-reported outcome was quantified using the DASH questionnaire, and physician-based outcome was evaluated using the MEPI. To identify factors associated with disability (DASH), impairment (MEPI), ulnohumeral motion, and pain, we examined demographic and clinical data in bivariate analyses, and subsequently significant factors in multivariate analysis to identify independent predictors of outcome. RESULTS The sole factor associated with higher DASH scores in multivariable analysis was age at surgery, explaining 20% of the variability, with younger patients performing better. The mean arc of elbow flexion was 142° (range, 110°-160°), and the variation was associated with arthrosis alone (ie, a greater arc of motion was associated with a lesser grade of arthrosis according to the system of Broberg and Morrey). Pain was uncommon and generally was correlated with adverse events. CONCLUSIONS The good results of operative fixation (tension-band wiring) of a transverse, displaced olecranon fracture are durable with time. Patient-reported outcomes are excellent in the majority of patients. Residual patient-rated disability does not correlate with arthrosis or loss of extension. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Job N. Doornberg
- Orthotrauma Research Center Amsterdam, Amsterdam, The Netherlands ,University of Amsterdam Orthopaedic Residency Program, Amsterdam, The Netherlands ,Department of Orthopaedic Surgery, Academic Medical Center Amsterdam, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands
| | - Thierry G. Guitton
- University of Amsterdam Orthopaedic Residency Program, Amsterdam, The Netherlands
| | - David Ring
- Department of Orthopaedic Surgery, Harvard Medical School, Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA USA
| | - J. Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Peter Kloen
- Orthopaedic Trauma, Department of Orthopaedic Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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Gallucci GL, Piuzzi NS, Slullitel PAI, Boretto JG, Alfie VA, Donndorff A, De Carli P. Non-surgical functional treatment for displaced olecranon fractures in the elderly. Bone Joint J 2014; 96-B:530-4. [DOI: 10.1302/0301-620x.96b4.33339] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We retrospectively evaluated the clinical and radiological outcomes of a consecutive cohort of patients aged > 70 years with a displaced fracture of the olecranon, which was treated non-operatively with early mobilisation. We identified 28 such patients (27 women) with a mean age of 82 years (71 to 91). The elbow was initially immobilised in an above elbow cast in 90° of flexion of the elbow for a mean of five days. The cast was then replaced by a sling. Active mobilisation was encouraged as tolerated. No formal rehabilitation was undertaken. At a mean follow-up of 16 months (12 to 26), the mean ranges of flexion and extension were 140° and 15° respectively. On a visual analogue scale of 1 (no pain) to 10, the mean pain score was 1 (0 to 8). Of the original 28 patients 22 developed nonunion, but no patients required surgical treatment. We conclude that non-operative functional treatment of displaced olecranon fractures in the elderly gives good results and a high rate of satisfaction. Cite this article: Bone Joint J 2014;96-B:530–4.
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Affiliation(s)
- G. L. Gallucci
- Hospital Italiano Buenos Aires, Dr
Carlos E. Ottolenghi Orthopaedic Service, Buenos Aires, Argentina
| | - N. S. Piuzzi
- Hospital Italiano Buenos Aires, Dr
Carlos E. Ottolenghi Orthopaedic Service, Buenos Aires, Argentina
| | - P. A. I. Slullitel
- Hospital Italiano Buenos Aires, Dr
Carlos E. Ottolenghi Orthopaedic Service, Buenos Aires, Argentina
| | - J. G. Boretto
- Hospital Italiano Buenos Aires, Dr
Carlos E. Ottolenghi Orthopaedic Service, Buenos Aires, Argentina
| | - V. A. Alfie
- Hospital Italiano Buenos Aires, Dr
Carlos E. Ottolenghi Orthopaedic Service, Buenos Aires, Argentina
| | - A. Donndorff
- Hospital Italiano Buenos Aires, Dr
Carlos E. Ottolenghi Orthopaedic Service, Buenos Aires, Argentina
| | - P. De Carli
- Hospital Italiano Buenos Aires, Dr
Carlos E. Ottolenghi Orthopaedic Service, Buenos Aires, Argentina
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111
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Transcortical screw fixation of the olecranon shows equivalent strength and improved stability compared with tension band fixation. J Orthop Trauma 2014; 28:137-42. [PMID: 23681413 DOI: 10.1097/bot.0b013e31829a25d2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Currently, the standard for 21-B3.1 olecranon fracture fixation is the tension band wire construct described by the AO foundation. Although this technique effectively repairs displaced olecranon fractures and osteotomies, it is associated with a high rate of secondary surgery for implant removal due to hardware "back out," prominence, and discomfort. The senior author of this study has used transcortical screw fixation for olecranon fractures and osteotomies to avoid hardware discomfort but has been unable to find literature documenting the strength of this method. Accordingly, we compared the strength and stability of transcortical screw fixation with tension band fixation of simple transverse olecranon fractures under cyclical loading. METHODS Eighteen fourth-generation synthetic biomechanical testing ulnas underwent a transverse olecranon osteotomy and were repaired by tension banding or screw fixation. Two 4.0 mm partially threaded screws inserted across the fracture gap into the anterior cortex of the ulna achieved screw fixation. Ulnas were tested in 2 ways as follows: (1) cyclic loading that simulated pushing up from a chair; and (2) single cycle loading to failure. Fracture displacement was recorded using a transducer that was placed on the posterior surface of the ulna. RESULTS Differences between screw fixation and tension banding in the peak displacement during cyclic loading and single cycle load to failure were not significant. Screw fixation did show significantly less "trough" displacement (resting position between cycles) during cyclic loading indicating less plastic deformation. CONCLUSIONS In a synthetic bone model of simple transverse olecranon fractures, screw fixation provided equivalent strength and less plastic deformation as compared with tension banding.
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112
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Duckworth AD, Bugler KE, Clement ND, Court-Brown CM, McQueen MM. Nonoperative management of displaced olecranon fractures in low-demand elderly patients. J Bone Joint Surg Am 2014; 96:67-72. [PMID: 24382727 DOI: 10.2106/jbjs.l.01137] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Andrew D Duckworth
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, Scotland. E-mail address for A.D. Duckworth:
| | - Kate E Bugler
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, Scotland. E-mail address for A.D. Duckworth:
| | - Nicholas D Clement
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, Scotland. E-mail address for A.D. Duckworth:
| | - Charles M Court-Brown
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, Scotland. E-mail address for A.D. Duckworth:
| | - Margaret M McQueen
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, Scotland. E-mail address for A.D. Duckworth:
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Duckworth AD, McQueen MM. Letter regarding "olecranon fractures". J Hand Surg Am 2013; 38:1263. [PMID: 23707027 DOI: 10.1016/j.jhsa.2013.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 04/04/2013] [Indexed: 02/02/2023]
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Abstract
Olecranon fractures are common injuries of the upper extremity; majority are treated surgically. A variety of fixation techniques are available to surgeons in modern practice, but there is little comparative clinical research to guide one's decision. Nonetheless, good results over all are to be expected after surgical management. This article presents a review of the current understanding and available evidence in the treatment of olecranon fractures, their relevant anatomy, fracture patterns, fixation options, and outcomes.
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Affiliation(s)
- Nicolai Baecher
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC 20007, USA
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Matar HE, Ali AA, Buckley S, Garlick NI, Atkinson HD. Surgical interventions for treating fractures of the olecranon in adults. Cochrane Database Syst Rev 2012. [DOI: 10.1002/14651858.cd010144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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