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

Double-Bending Tension Band Wire for Olecranon Fractures: A Novel Technique

Purpose

This retrospective study aimed to compare the clinical outcomes and complications of conventional tension band wire (TBW), TBW with penetrating technique, and double-bending technique.

Methods

A total of 40 patients (17 men and 23 women; mean age: 64.0 ± 19.0 years) who underwent surgery for displaced olecranon fractures between January 2018 and December 2021 were included and divided into three groups based on the surgical method used (group A, conventional TBW; group B, TBW with penetrating technique; and group C, double-bending technique). Thirteen patients were assigned to group A, 17 to group B, and 10 to group C, including 2 Mayo type IB, 30 Mayo type IIA, and 8 Mayo type IIB fractures. Postoperative outcomes (elbow extension and flexion arc) and complications, such as backing out of the Kirschner wire (K-wire), were retrospectively evaluated.

Results

No significant difference was found in the general characteristics of the patients and fracture type among the three groups. The mean elbow extension arc values were 6.2°, 10.9°, and 0° in groups A, B, and C, respectively; it was significantly better in group C than in group B (P = .001). The rates of backing out of the K-wire were 84.6% (11/13) in group A, 41.2% (7/17) in group B, and 0% (0/10) in group C; the rate was significantly lower in group C than in group A (P < .001).

Conclusions

The double-bending technique may be the best procedure for preventing the backing out of the K-wire and postoperative complications, such as range of motion restriction, for treating olecranon fractures that are treatable by TBW.

Type of study/level of evidence

Therapeutic IV.

Hybrid Tension Band Wiring for Olecranon Fractures

Tension band wiring (TBW) is a standard surgical technique for treating olecranon fractures (OFs). We devised a hybrid TBW (HTBW) combining TBW using wires with eyelets and cerclage wiring. Twenty-six patients with isolated OFs with Colton classification groups 1-2C were subjected to HTBW, and the data was compared with those treated with conventional TBW (38 patients). The mean operation time and hardware removal rate were 51 versus 67 minutes (p < 0.001) and 42% versus 74% (p < 0.012), respectively. The HTBW group had one patient (4%) with surgical wire breakage. The conventional TBW group had 14 patients (37%) with symptomatic backout of Kirschner wires, three patients (8%) with loss of reduction, two patients (5%) with surgical site infection and one patient (3%) with ulnar nerve palsy. The motion and functional score ranges of the elbow were not significantly different. Therefore, this procedure may be a feasible alternative. Level of Evidence: Level V (Therapeutic).

Locked Tension Band Wiring for Mayo IIA Olecranon Fractures: Modified Surgical Technique and Retrospective Comparative Study of Clinical Outcomes and Cost-effectiveness with Locking Plate

Background: Tension band wiring (TBW) has traditionally been used for simple olecranon fractures, but due to its many complications, locking plate (LP) is increasingly being employed. To reduce the complications, we developed a modified technique for olecranon fracture repair, locked TBW (LTBW). The study aimed to compare (1) the frequency of complications and re-operations between LP and LTBW techniques, (2) clinical outcomes and the cost efficacy. Methods: We retrospectively evaluated data of 336 patients who underwent surgical treatment for simple and displaced olecranon fractures (Mayo Type ⅡA) in the hospitals of a trauma research group. We excluded open fractures and polytrauma. We investigated complication and re-operation rates as primary outcomes. As secondary outcomes, Mayo Elbow Performance Index (MEPI) and the total cost, including surgery, outpatients and re-operation, were examined between the two groups. Results: We identified 34 patients in the LP group and 29 patients in the LTBW group. The mean follow-up period was 14.2 ± 3.9 months. The complication rate in the LTBW group was comparable to that in the LP group (10.3% vs. 17.6%; p = 0.49). Re-operation and removal rates were not significantly different between the groups (6.9% vs. 8.8%; p = 1.000 and 41.4% vs. 58.8%; p = 1.00, respectively). Mean MEPI at 3 months was significantly lower in the LTBW group (69.7 vs. 82.6; p < 0.01), but mean MEPI at 6 and 12 months were not significantly different (90.6 vs. 85.2; p = 0.06, 93.9 vs. 95.2; p = 0.51, respectively). The mean cost/patient of the total cost in the LTBW group were significantly lower than those in the LP group ($5,249 vs. $6,138; p < 0.001). Conclusions: This study showed that LTBW achieved clinical outcomes equivalent to those of LP and was significantly more cost effective than LP in the retrospective cohort. Level of Evidence: Level III (Therapeutic).

Standardized fracture creation in the distal humerus and the olecranon for surgical training and biomechanical testing

INTRODUCTION

Surgical training and biomechanical testing require models that realistically represent the in vivo injury condition. The aim of this work was to develop and test a method for the generation of distal humerus fractures and olecranon fractures in human specimens, while preserving the soft tissue envelope.

METHODS

Twenty-one cadaveric upper extremity specimens (7 female, 14 male) were used. Two different experimental setups were developed, one to generate distal humerus fractures and one to generate olecranon fractures. Specimens were placed in a material testing machine and fractured with a predefined displacement. The force required for fracturing and the corresponding displacement were recorded and the induced energy was derived of the force-displacement graphs. After fracturing, CT imaging was performed and fractures were classified according to the AO classification.

RESULTS

Eleven distal humerus fractures and 10 olecranon fractures with intact soft tissue envelope could be created. Distal humerus fractures were classified as AO type C (n = 9) and as type B (n = 2), all olecranon fractures were classified as AO type B (n = 10). Distal humerus fractures required significantly more load than olecranon fractures (6077 N ± 1583 vs 4136 N ± 2368, p = 0.038) and absorbed more energy until fracture than olecranon fractures (17.8 J ± 9.1 vs 11.7 J ± 7.6, p = 0.11), while the displacement at fracture was similar (5.8 mm ± 1.6 vs 5.9 mm ± 3.1, p = 0.89).

CONCLUSION

The experimental setups are suitable for generating olecranon fractures and distal humerus fractures with intact soft tissue mantle for surgical training and biomechanical testing.

Outcomes of embedded rafting k-wire technique for intermediate articular fragment fixation in comminuted olecranon fractures

BACKGROUND

Severely comminuted olecranon fractures are challenging injuries. Commonly used tension band wiring exerts excessive compressive forces causing olecranon shortening and joint incongruity. This study aimed to introduce the embedded rafting k-wire technique with the bridging technique for intermediate articular fragment fixation in comminuted olecranon fractures and evaluate its clinical and radiological outcomes.

MATERIALS AND METHODS

A total of 34 patients with comminuted olecranon fractures were treated with rafting k-wire fixation combined with a locking plate. Time to union, the number of rafting k-wires in the intermediate articular fragment, quality of joint reduction, and secondary reduction loss were analyzed. Elbow range of motion, Mayo Elbow Performance Score (MEPS), and complications were evaluated at the final follow-up.

RESULTS

Fracture union was obtained in all patients. The mean number of intermediate articular fragments was 2.4 ± 0.7, and the average number of rafting k-wires was 3.0 ± 1.2. There were mild and moderate degree early posttraumatic osteoarthritis in 6 cases (17.6%) at the mean 20.8 months of follow-up. At the final follow-up, the mean range of elbow motion was 4.6° of flexion contracture and 133.5° of further flexion. The average MEPS was 97.1 (range, 75-100). Two patients had heterotrophic ossification without functional impairment.

CONCLUSION

The embedded rafting k-wire technique with bridging plates in comminuted olecranon fractures exhibited satisfactory outcomes. This method might serve as an alternative when considering the ability to restore articular congruency and stability in severely comminuted olecranon fragments.

LEVEL OF EVIDENCE

Level IV, therapeutic.

Efficacy and safety of tension band wire versus plate for Mayo II olecranon fractures: a systematic review and meta-analysis

Purpose

For olecranon fractures, the choice of tension band wire (TBW) or plate fixation has long been controversial. Therefore, this study aimed to evaluate the efficacy and safety of TBW and plate in the treatment of patients with Mayo II olecranon fractures by Meta-analysis.

Methods

PubMed, Embase, Cochrane, the Web of Science, China National Knowledge Infrastructure, Wanfang, and China Biomedical Database were searched for randomized controlled trials (RCTs) and cohort studies (CSs) where TBW was compared with plate for Mayo II olecranon fractures (OF). Subsequently, the data were extracted by two reviewers independently and were analysed via RevMan5.4.1. Besides, mean difference (MD), risk ratio (RR), and 95% confidence intervals (CIs) were calculated. Furthermore, Cochrane Risk of Bias Tool 2.0 and Newcastle–Ottawa Scale were adopted for assessing the risk of bias.

Results

A total of 1RCT and 10 CSs were included, when 449 cases were treated with TBW and 378 with plate. The plate has favourable postoperative long-term (≥ 1 year) functional score in MEPS (MD: − 3.06; 95% CI − 5.50 to 0.62; P = 0.01; I² = 41%) and Dash score (MD: 2.32; 95% CI 1.91, 2.73; P < 0.00001; I² = 0%), also carrying fewer complications (RR: 2.13; 95% CI 1.48, 3.08; P < 0.0001; I² = 58%). Besides, there exists no significant difference in postoperative long-term (≥ 1 year) elbow flexion (MD: − 1.82°; 95% CI − 8.54, 4.90; P = 0.60; I² = 71%) and extension deficits (MD: 1.52°; 95% CI − 0.38, 3.42; P = 0.12; I² = 92%). Moreover, TBW is featured with a shorter operation time (MD = − 5.87 min; 95% CI − 7.93, − 3.82; P < 0.00001; I² = 0) and less intraoperative bleeding (MD: − 5.33 ml; 95% CI − 8.15, − 2.52; P = 0.0002; I² = 0). In terms of fracture healing time, it is still controversial. Furthermore, the subgroup analysis has revealed that for Mayo IIA OF, the plate has a better outcome in the long-term (≥ 1 year) postoperative MEPS, the Dash score, and the incidence of postoperative complications than TBW, while there is no significant difference in the long-term (≥ 1 year) postoperative elbow motion between two groups.

Conclusions

Plate has better efficacy and safety for Mayo II OF. Considering that few studies are included in the meta-analysis, more high-quality RCTs are still required to confirm these findings.

PROSPERO registration number: CRD42022313855.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03262-7.

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

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

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

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

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

Level of Evidence: Level IV (Therapeutic)

Comparison of the efficacy of the tension band wiring with eyelet wire versus anatomical locking plate fixation for the treatment of displaced olecranon fractures

BACKGROUND

This retrospective study was conducted to assess the clinical outcome and complications between tension band wiring (TBW) with eyelet wire and locking plate fixation used for the treatment of displaced olecranon fractures.

METHODS

A total of 58 patients (36 males and 22 females; mean age: 63 years) were reviewed between April 2014 and September 2020. TBW with Ring Pin (RP group) was applied in 24 patients, including 15 Mayo type ⅡA and 9 Mayo type ⅡB patients. Anatomical locking plate (ALP group) was used in 34 patients, including 22 Mayo type ⅡA and 12 Mayo type ⅡB patients. Clinical outcome was evaluated using the Mayo Elbow Performance Score (MEPS), and active range of motion of the elbow and forearm and postoperative complications were reviewed.

RESULTS

General characteristic of the patients and the fracture type were similar in the two groups. The mean MEPS values were 96.5 ± 7.3 in the RP group and 94.9 ± 9.4 in the ALP group. The mean elbow flexion arc was 127°±11 in the RP group. The mean elbow flexion arc was 122°±18 in the ALP group. No significant differences in clinical outcomes were observed between the two groups. Complication rates were significantly higher in the ALP group (19/34: 56%) than in the RP group (6/24: 25%).

CONCLUSION

Although there were no statistically significant differences in clinical outcomes between the two groups, the ALP group had a higher proportion of any complication than the RP group.