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Luppi V, Regis D, Maluta T, Sandri A, Trivellato A, Mirabile A, Magnan B. Conservative versus surgical treatment for displaced olecranon fractures in the elderly: a retrospective study and a review of the literature. Musculoskelet Surg 2024:10.1007/s12306-024-00853-x. [PMID: 39085686 DOI: 10.1007/s12306-024-00853-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 07/25/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Surgery is the gold standard treatment of displaced olecranon fracture, but it presents a high rate of complications, especially in the elderly, including wound breakdown and fixation failure. Conservative treatment of these fractures has recently been proposed with good functional outcomes. The aim of this retrospective study was to compare the functional results and level of satisfaction of displaced olecranon fractures which were managed surgically or conservatively in geriatric patients. The rate of implant removal and reoperation in the surgical group were also calculated. MATERIALS AND METHODS Sixteen and eleven patients aged ≥ 75 years (mean 83 and 86.2, respectively) with isolated Mayo IIA or IIB olecranon fracture were surgically and conservatively treated, respectively. All but 1 were females. Due to coronavirus pandemic, they were contacted by phone to validated clinical scores (QuickDASH, PREE and VAS), which were used to assess the outcome. RESULTS At an average follow-up of 26.5 months in the conservative group and 53.1 in the surgical group (range 4-82), the mean Quick DASH was 11.67 and 11.2, respectively, while the mean PREE was 11.36 and 12.67, respectively. There was no significant difference in functional outcomes between the two groups, and all patients were satisfied. Seven complications occurred in the surgical cohort (33.3%), requiring reoperation in 4 cases (19%). CONCLUSIONS Displaced olecranon fractures can successfully be treated conservatively in low-demand geriatric patients with good functional results and high satisfaction rate.
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Affiliation(s)
- V Luppi
- Department of Orthopedics and Traumatology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italy.
| | - D Regis
- Department of Orthopedics and Traumatology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italy
| | - T Maluta
- Department of Orthopedics and Traumatology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italy
| | - A Sandri
- Department of Orthopedics and Traumatology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italy
| | - A Trivellato
- Department of Orthopedics and Traumatology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italy
| | - A Mirabile
- Department of Orthopedics and Traumatology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italy
| | - B Magnan
- Department of Orthopedics and Traumatology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italy
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Cornefjord G, Kostogiannis I, Rogmark C, Jerrhag D, Wenger D. The With Or Without Olecranon K-wire (WOW OK) Trial of tension band wire fixation versus cerclage fixation without K-wires in displaced stable olecranon fractures: study protocol for a randomized controlled trial. Trials 2023; 24:559. [PMID: 37641082 PMCID: PMC10464474 DOI: 10.1186/s13063-023-07566-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Displaced 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. METHODS All 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. DISCUSSION Reoperation 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 REGISTRATION ClinicalTrials.gov NCT05657899 . Registered on 16 November 2022. The trial complies with SPIRIT and CONSORT guidelines. The SPIRIT figure is found in Table 2.
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Affiliation(s)
- Gustav Cornefjord
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Lund, Sweden.
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden.
| | - Ioannis Kostogiannis
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Lund, Sweden
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden
| | - Cecilia Rogmark
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Lund, Sweden
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden
| | - Daniel Jerrhag
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Lund, Sweden
| | - Daniel Wenger
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Lund, Sweden
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden
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Duckworth AD, Carter TH, Chen MJ, Gardner MJ, Watts AC. Olecranon fractures : current treatment concepts. Bone Joint J 2023; 105-B:112-123. [PMID: 36722062 DOI: 10.1302/0301-620x.105b2.bjj-2022-0703.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Thomas H Carter
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University Medical Centre, Stanford, California, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Medical Centre, Stanford, California, USA
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, UK
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Hamoodi Z, Duckworth AD, Watts AC. Olecranon Fractures: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202301000-00009. [PMID: 36638218 DOI: 10.2106/jbjs.rvw.22.00150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
» Olecranon fractures account for 10% of all elbow fractures and are more likely to result from a low-energy injury. A displaced fracture with a stable ulnohumeral joint (Mayo type 2) is the most common type of injury. » The management of an isolated olecranon fracture is based on patient factors (age, functional demand, and if medically fit to undergo surgery) and fracture characteristics including displacement, fragmentation, and elbow stability. » Nonoperative management can be successfully used in undisplaced fractures (Mayo type 1) and in displaced fractures (Mayo type 2) in frail patients with lower functional demands. » Patients with displaced olecranon fractures with a stable ulnohumeral joint without significant articular surface fragmentation (Mayo type 2A) can be managed with tension band wiring, plate osteosynthesis (PO), intramedullary fixation, or suture repair. » PO is advocated for multifragmentary fractures and fractures that are associated with ulnohumeral instability. It is essential to consider the variable anatomy of the proximal ulna during surgery.
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Affiliation(s)
- Zaid Hamoodi
- Upper Limb Unit, Wrightington Hospital, Wigan, United Kingdom
| | - Andrew D Duckworth
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wigan, United Kingdom
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Oputa TJ, Plastow R, Kennedy J, Jain N. There is no difference in the complication or re-operation rates between tension band wiring and locking plate fixation for olecranon fractures. The findings of a multicentre study. Arch Orthop Trauma Surg 2022; 142:3341-3345. [PMID: 34581860 DOI: 10.1007/s00402-021-04159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Tension band wire (TBW) and locking plate fixation (LPF) are widely used fixation methods for displaced fractures of the olecranon. The aim of our study was to review the current operative management of olecranon fractures and compare the complication and re-operation rates for patients undergoing TBW and LPF. MATERIALS AND METHODS Retrospective data were collected for all patients who underwent acute fixation of olecranon fractures in 2016 across nine hospitals in the United Kingdom. We reviewed these cases to determine the incidence of complications and re-operations. RESULTS One hundred and forty patients were included in the study. Seventy-three (52%) had TBW, 67 (48%) had LPF. Males were more likely to have LPF (p = 0.01) as were patients with comminuted fractures (p < 0.01). The overall complication rate was 25%, including an infection rate of 3%, a prominent metalwork irritation rate of 12% and the overall re-operation rate was 17%. There was no significant difference in the complication rate (p = 0.38), infection rate (p = 0.92) or rate of prominent metalwork irritation (p = 0.10) between patients undergoing TBW and LPF. Sub group analysis of patients with comminuted fractures also demonstrated no significant difference in complication rates (p = 0.75) or re-operation rates (p = 0.26). CONCLUSION LPF has previously been advocated to be advantageous to TBW due to lower reported complication and re-operation rates despite there being no significant difference in functional outcomes. In this multicentre case series, which is the largest in the literature to date, we did not observe any significant differences in complication rates or re-operation rates between the two, even amongst comminuted fractures (which are traditionally treated with LPF), when decision making was left to surgeon preference. We, therefore, recommend that choice of fixation method should be left to individual surgeon's preference.
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Affiliation(s)
- Tobenna J Oputa
- Trauma and Orthopaedics, Health Education North West, Manchester, M1 3BN, UK.
| | - Ricci Plastow
- Trauma and Orthopaedics, Health Education North West, Manchester, M1 3BN, UK
| | - James Kennedy
- Trauma and Orthopaedics, Health Education North West, Manchester, M1 3BN, UK
| | - Neil Jain
- Department of Trauma and Orthopaedics, Pennine Acute Hospitals, North Manchester General Hospital, Delaunay's Road, Manchester, M8 5RB, UK
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Long-term results of olecranon fractures treated using the XS nail® system. Chin J Traumatol 2022; 25:336-344. [PMID: 35337713 PMCID: PMC9751580 DOI: 10.1016/j.cjtee.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 12/23/2021] [Accepted: 02/10/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Olecranon fractures are particularly vulnerable to distraction and subsequent fracture dislocation due to the high tensile forces. Surgical treatment aims at reducing the fracture and restoring the anatomical joint surface condition, as well as neutralizing the strain inhibiting fracture healing. The XS nail® (Intercus GmbH, Bad Blankenberg, Germany), an intramedullary implant exerting compression across the entire fracture surface, unlike plates, leaves a minimal extra-cortical profile, and can be secured with threaded locking wires, thereby retaining the anatomical reduction without displacement or steps within the articular surface, which was often found in tension band wiring. After encouraging initial results, the long-term outcome was assessed. METHODS This retrospective study evaluated the long-term outcome of patients surgically treated at our trauma center between January 2002 and December 2005 using the XS nail®. Patients over the age of 18 years eligible for the study must have undergone surgery for isolated, recent (less than 14 days) traumatic olecranon fractures, without concomitant injuries to the ipsilateral elbow and forearm. Further exclusion criteria were pseudarthrosis, re-fractures and osteotomy for distal humerus surgery, as well as polytraumatized patients unable to aid in their own recovery. Data were retrospectively gathered by standardised questionnaire and patient records, as well as surgery and anesthesiology reports. Data analysis was performed using Microsoft Office Excel® 2016. RESULTS There were 32 patients, 13 males (mean age 49.0 years) and 19 females (mean age 68.9 years) with 11 Schatzkers type D, 7 each type A and C, 5 type B and 2 type E at an average of 55.2 months, all showing complete consolidation. Of them, 6 patients had a loss of range of motion with more than 10° in the sagittal plane, and only 1 patient exceeded 10° reduction of supination. Twenty-five patients reported being pain-free under all circumstances, and all but 2 patients (93.75%) had returned to their previous activity level. The average disabilities of the arm, shoulder and hand score was 21.15 (range 0-88.3), and the overall Mayo elbow performance index was 91.87, without complications, such as wound infection, neurovascular impairment or premature hardware removal. CONCLUSION Using the XS nail® system, all fracture types can be successfully treated and the rate of complications was lower than that treated by standard methods published in current literature. An excellent functional outcome, high range of motion as well as good retention of reduction without soft tissue irritation makes this a very suitable implant for fractures subject to tension.
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Welch JM, Zhuang T, Shapiro LM, Gardner MJ, Xiao M, Kamal RN. Cost minimization analysis of the treatment of olecranon fracture in elderly patients: a retrospective analysis. CURRENT ORTHOPAEDIC PRACTICE 2022; 33:559-564. [PMID: 36873608 PMCID: PMC9977169 DOI: 10.1097/bco.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Operative treatment of olecranon fractures in the elderly can lead to greater complications with similar outcomes to nonoperative treatment. The purpose of this study was to analyze cost differences between operative and nonoperative management of isolated closed olecranon fractures in elderly patients. Methods Using a United States Medicare claims database, the authors identified 570 operative and 1,863 nonoperative olecranon fractures between 2005 and 2014. The authors retrospectively determined cost of treatment from the payer perspective for a 1-year period after initial injury, including any surgical procedure, emergency room care, follow-up care, physical therapy, and management of complications. Results One year after diagnosis, mean costs per patient were higher for operative treatment (United States dollars [US$]10,694 vs US$2,544). 31.05% of operative cases were associated with a significant complication compared with 4.35% of nonoperative cases. When excluding complications, mean costs per patient were still higher for operative treatment ($7,068 vs $2,320). Conclusions These findings show that nonoperative management for olecranon fractures in the elderly population leads to fewer complications and is less costly. Nonoperative management may be a higher-value management option for this patient population. These results will help inform management of olecranon fractures as payers shift toward value-based reimbursement models in which quality of care and cost influence surgical decision making. Level of Evidence Level IV.
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Affiliation(s)
- Jessica M. Welch
- VOICES Health Policy Research Center, Stanford University, Department of Orthopaedic Surgery, Redwood City, CA
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Stanford University, Department of Orthopaedic Surgery, Redwood City, CA
| | - Lauren M. Shapiro
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA
| | - Michael J Gardner
- VOICES Health Policy Research Center, Stanford University, Department of Orthopaedic Surgery, Redwood City, CA
| | - Michelle Xiao
- VOICES Health Policy Research Center, Stanford University, Department of Orthopaedic Surgery, Redwood City, CA
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Stanford University, Department of Orthopaedic Surgery, Redwood City, CA
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Alvara CA, Biedron G, Dunn JC. Nonoperative Management of Olecranon Fractures in Elderly Patients: A Systematic Review. Hand (N Y) 2022; 17:734-739. [PMID: 35815367 PMCID: PMC9274873 DOI: 10.1177/1558944720944261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Despite increased utilization of conservative measures for displaced olecranon fractures in elderly patients, in whom operative fixation may be complicated by coexisting comorbidities and declining bone quality, the noninferiority of nonoperative management has yet to be proven. The purpose of this study was to review nonoperative management of displaced olecranon fractures in the elderly patient population. METHODS A literature search of the PubMed database was performed using the term olecranon fracture. Papers included those with results for patients aged 65 years and older published between 1990 and 2018 in the English language. Data were pooled to analyze outcomes and complications of nonoperative management of olecranon fractures in the elderly patient population. RESULTS Four eligible studies combined for a total of 69 patients with 70 fractures with an average age of 83.8 years (71-95 years), female predominance of 88%, and a mean follow-up of 12.4 months who underwent nonoperative management of displaced olecranon fractures. While only 25% of fractures went on to radiographic union, the mean Disabilities of the Arm, Shoulder, and Hand score was 16.9 (0-59.6), the mean arc of motion was 138°, and 92% of patients achieved excellent results. One-quarter (26%) of the patients experienced complications: radial head subluxation (1), skin sore (1), degenerative arthropathy (1), pain on movement (2), click in movement of the elbow (5), and local pain (8). CONCLUSION Displaced olecranon fractures in patients aged older than 70 years may be effectively managed with nonoperative measures to produce high satisfaction and functional range of motion.
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Affiliation(s)
- Christina A. Alvara
- Texas Tech University Health Sciences Center El Paso, USA,Christina A. Alvara, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX 79905, USA.
| | - Griffin Biedron
- Texas Tech University Health Sciences Center El Paso, USA,William Beaumont Army Medical Center, El Paso, TX, USA
| | - John C. Dunn
- William Beaumont Army Medical Center, El Paso, TX, USA
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Parkes J, Limb R, Quadri ST, Lamb JN, Mohrir G, Yousef A, West RM, Cowling P. Complications and mortality associated with olecranon fractures in the elderly: a retrospective cohort comparison from a large level one trauma centre. Shoulder Elbow 2022; 14:200-210. [PMID: 35265187 PMCID: PMC8899326 DOI: 10.1177/1758573221994860] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Olecranon fractures in the elderly have an increasing incidence. This retrospective study aims to identify the complications and survivorship of these patients. METHODS All patients >70 years old treated for an olecranon fracture at our institution were identified between 2007 and 2019. Loss of reduction and/or metalwork loosening was recorded. Also noted were wound healing problems, deep/superficial infections, and any subsequent treatment including return to surgery and/or removal of metalwork. RESULTS From a total of 177 cases, 28 presented with concomitant fractures (16%), half of which were hip fractures. The largest treatment group underwent tension band wiring (n = 82, 46%, mean age 80.8 yrs). Twenty-one of these suffered failure of fixation (26%), all requiring return to surgery. The second largest treatment group underwent plating (n = 50 28%, mean age 80.1 yrs). Four of these suffered failure of fixation (8%), all requiring return to surgery. Forty-four patients were treated non-operatively (25%, mean age 83.8 yrs). Two patients suffered other complications (4.5%). Overall 1 year survivorship was 0.82. DISCUSSION Olecranon fractures in the elderly have higher than expected 1 year mortality rates. Operative management results in high complication rates, often requiring return to surgery for metalwork problems. Significant consideration of treatment options is required in this cohort.
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Affiliation(s)
- J Parkes
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - R Limb
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - ST Quadri
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - JN Lamb
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK,School of Medicine, Worsley Building University of Leeds, Leeds, UK
| | - G Mohrir
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - A Yousef
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - RM West
- School of Medicine, Worsley Building University of Leeds, Leeds, UK
| | - P Cowling
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK,School of Medicine, Worsley Building University of Leeds, Leeds, UK,P Cowling, Chapel Allerton Hospital, Leeds, UK.
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Rantalaiho I, Laaksonen I, Launonen AP, Luokkala T, Flinkkilä T, Salmela M, Adolfsson L, Olsen B, Isotalo K, Ryösä A, Äärimaa V. Scandinavian Olecranon Research in the Elderly (SCORE): protocol for a non-inferiority, randomised, controlled, multicentre trial comparing operative and conservative treatment of olecranon fractures in the elderly. BMJ Open 2022; 12:e055097. [PMID: 35105643 PMCID: PMC8808415 DOI: 10.1136/bmjopen-2021-055097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The incidence of olecranon fractures is growing in the elderly population. The traditional operative approach is giving way among the elderly to conservative treatment, which seems to provide a comparable functional outcome with a lower complication burden. However, there is still a lack of reliable evidence to support this shift.The objective of this trial is to investigate whether conservative treatment of displaced olecranon fractures in patients aged 75 or older yields comparable results to those of operative treatment in terms of pain and daily function. METHODS AND ANALYSIS Scandinavian Olecranon Research in the Elderly (SCORE) is a randomised, controlled, multicentre, non-inferiority trial. Eligible patients will be randomised to either conservative or operative treatment. The sample size will be 68 patients and allocation done at a 1:1 ratio (34 patients per group). The randomisation is stratified according to the participating hospital and patient's sex. Both groups will receive the same postoperative physiotherapy and pain management. The primary outcome is Disabilities of the Arm, Shoulder and Hand at 1-year follow-up. Secondary outcomes are pain and satisfaction measured on visual analogue scales, Patient Reported Elbow Evaluation, range of motion of the elbow and extension strength of the elbow compared with the unaffected arm. Radiographs will be taken at each follow-up. Primary analysis of the results will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION The study protocol for this clinical trial has been approved by the Ethics Committee of the Hospital District of Southwest Finland and will be submitted for approval to the Regional Ethics Committees in Linköping, Sweden and Copenhagen, Denmark. Every recruiting centre will apply local research approvals. The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04401462. PROTOCOL VERSION This is the second protocol version dated on 16 April 2020.
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Affiliation(s)
- Ida Rantalaiho
- Department of Orthopedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Inari Laaksonen
- Department of Orthopedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Antti P Launonen
- Department of Orthopedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Toni Luokkala
- Department of Orthopedics and Traumatology, Central Finland Central Hospital, Jyvaskyla, Finland
| | - Tapio Flinkkilä
- Department of Orthopedics and Traumatology, Oulu University Hospital, Oulu, Finland
| | - Mikko Salmela
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - L Adolfsson
- Institution for Clinical and Experimental Medicine, Division of Orthopaedics, Linköping University, Linkoping, Sweden
| | - Bo Olsen
- Department of Orthopedic Surgery, Herlev and Gentofte Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Kari Isotalo
- Department of Orthopedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Anssi Ryösä
- Department of Orthopedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Äärimaa
- Department of Orthopedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
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Kaiser P, Stock K, Benedikt S, Kastenberger T, Schmidle G, Arora R. Retrospective comparison of conservative treatment and surgery for widely displaced olecranon fractures in low-demanding geriatric patients. Arch Orthop Trauma Surg 2022; 142:2659-2667. [PMID: 34226982 PMCID: PMC9474477 DOI: 10.1007/s00402-021-04031-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 06/23/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate the difference of the clinical outcome of elderly patients who were treated surgically or conservatively for a displaced olecranon fracture (Mayo type IIA or IIB). PATIENTS AND METHODS Patients above the age of 70 years who were treated surgically (n = 11) for a displaced Mayo type IIA and IIB olecranon fracture between July 2015 and February 2019 were retrospectively compared with patients who were treated conservatively (n = 6). The range of motion, elbow strength, grip strength, VAS, DASH, OES, MEPI and Broberg and Morrey scores were evaluated. RESULTS The conservative group showed a non-union with a persistent fracture gap of 17 mm (SD 12 mm) at the articular rim and 31 mm (15 mm) at the dorsal rim while there was no case of non-union in the surgical group. The arch of motion was 120° in the conservative group and 136° in the surgical group. There was no obvious difference in elbow extension strength in comparison to the healthy contralateral side (p = 0.20; 88% group I/87% group II). There was no difference in the OES (p = 0.30; 42 (SD 7) vs. 45 (SD 5)) and MEPI score (p = 0.46; (SD 8) vs. 96 (SD 19)). The conservative group presented a slightly worse DASH [p = 0.10; 26 (SD 25) vs 7 (SD 14)] and a significantly worse Broberg and Morrey score (p = 0.02; 84(SD 9) vs. 95 (SD 7)). The conservative group presented one complication (ulnar nerve palsy), while the surgical group presented two cases (prolonged lymphedema; blocked forearm rotation due to screw length with consecutive revision surgery). CONCLUSION Widely displaced olecranon fractures can successfully be treated conservatively in low-demanding geriatric patients with a satisfactory outcome. Patient selection is essential as patients that are more active might benefit from surgical treatment. Yet, treatment risks and benefits need to be balanced carefully in regard to the patient`s demands and requests.
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Affiliation(s)
- Peter Kaiser
- grid.5361.10000 0000 8853 2677Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Kerstin Stock
- grid.5361.10000 0000 8853 2677Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Stefan Benedikt
- grid.5361.10000 0000 8853 2677Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Tobias Kastenberger
- grid.5361.10000 0000 8853 2677Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Gernot Schmidle
- grid.5361.10000 0000 8853 2677Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Rohit Arora
- grid.5361.10000 0000 8853 2677Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
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12
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Wenger D, Cornefjord G, Rogmark C. Cerclage fixation without K-wires is associated with fewer complications and reoperations compared with tension band wiring in stable displaced olecranon fractures in elderly patients. Arch Orthop Trauma Surg 2022; 142:2669-2676. [PMID: 34236459 PMCID: PMC9474339 DOI: 10.1007/s00402-021-04027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 06/23/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Tension band wiring of olecranon fractures has high reported rates of complications and reoperations. We aimed to compare classic tension band wiring to cerclage fixation without K-wires in the treatment of displaced olecranon fractures in elderly patients. The primary outcome was reoperation. Secondary outcomes included complications and patient reported outcomes. Outcomes following non-operative treatment were also studied. MATERIALS AND METHODS Patients aged > 69 years presenting with Mayo class 2a and 2b olecranon fractures at our institution from 2004 through 2016 (n = 239) were eligible for study. Fracture type, treatment method, complications and reoperations were assessed from radiographs and hospital files. QuickDASH surveys were collected by mail. RESULTS Patients operated with tension band wire technique had more reoperations (p value 0.03): relative risk (RR) 2.2 (CI 1.08-4.3), odds ratio (OR) 2.6 (CI 1.05-6.4), and complications (p value 0.001): RR 2.5 (CI 1.51-4.1), OR 3.7 (CI 1.67-8.2), compared with those operated with cerclage technique. Non-operative treatment yielded similar complication (p value 0.2) and reoperation rates (p value 0.06) as cerclage fixation. The answer rate was insufficient to compare QuickDASH scores between treatments methods. CONCLUSIONS In patients 70 years and older undergoing cerclage fixation for displaced stable olecranon fractures (Mayo class 2), the reoperation and complications rates were less than half of those in patients undergoing TBW fixation. Non-operative treatment yielded similar reoperation and complication rates to cerclage fixation, in selected cases. LEVEL OF EVIDENCE III-retrospective comparative cohort study.
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Affiliation(s)
- Daniel Wenger
- Department of Orthopedics, Skåne University Hospital, Inga Marie Nilssons gata 22, 205 02 Malmo, Sweden ,Lund University, Lund, Sweden
| | | | - Cecilia Rogmark
- Department of Orthopedics, Skåne University Hospital, Inga Marie Nilssons gata 22, 205 02 Malmo, Sweden ,Lund University, Lund, Sweden
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13
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Beaudouin E, Augustin B. Is surgery needed for displaced olecranon fractures in patients aged 75 years or over? Orthop Traumatol Surg Res 2021; 107:103089. [PMID: 34601162 DOI: 10.1016/j.otsr.2021.103089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/11/2021] [Accepted: 07/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND For displaced olecranon fractures, surgery is the standard of care in young adults but remains controversial in patients aged 75 years or over. The objective of this study was to assess the functional and radiological outcomes and to describe the complications of surgical treatment in this older population. HYPOTHESIS Surgery is the optimal treatment for displaced olecranon fractures in patients aged 75 years or over. MATERIALS AND METHODS We retrospectively reviewed the files of patients who were 75 years of age or older when they underwent surgery for displaced olecranon fractures at our centre between January 2013 and December 2017. Functional and radiological outcomes were assessed at radiological fracture healing or at last follow-up. RESULTS We included 29 patients with 30 fractures. Mean age was 82 years (range, 75-93 years). All 30 fractures were Mayo II or III, A or B. Tension-band wiring was used for 21 fractures, locked-plate fixation for 7 fractures, and double-plate fixation for 2 fractures. The mean Mayo Elbow Performance Score was 82.5 (range, 45-100). Complications occurred for 11 (37%) fractures, and the material was removed for 11 (37%) fractures. DISCUSSION The complications resulted from a mismatch between fracture type, bone quality, and the internal fixation material. Compared to tension-band wiring, plate fixation was associated with more complications, many of which required removal of the material. Tension-band wiring was not sufficient for proximal fractures and type III B fractures, for which lacing is an alternative. Conservative functional treatment remains a wise option for type II olecranon fractures in these elderly patients. Surgery is required, however, in patients with type III fractures (fracture-dislocations). LEVEL OF EVIDENCE IV, retrospective, single-centre, observational cohort study.
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Affiliation(s)
- Emmanuel Beaudouin
- Department of orthopaedic surgery and traumatology, Centre Hospitalier Métropole de Savoie, BP 31125, 73160 Chambéry cedex, France.
| | - Bermann Augustin
- Department of orthopaedic surgery and traumatology, Centre Hospitalier Métropole de Savoie, BP 31125, 73160 Chambéry cedex, France
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14
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Tsujino S, Tsujino A, Matsubara M. Tension-band wiring of displaced stable olecranon fractures with Eyelet-pins in the elderly: A series of 17 cases. Orthop Traumatol Surg Res 2021; 107:103076. [PMID: 34563734 DOI: 10.1016/j.otsr.2021.103076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/16/2021] [Accepted: 07/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tension-band wiring (TBW) and plate fixation are commonly used to fix displaced olecranon fractures. However, the high incidence of complications in the elderly, such as wound breakdown, infection, and loss of reduction, remain a concern for orthopaedic surgeons. Furthermore, patients frequently suffer from removal of the hardware. Even so, the operation seems to be indicated for independent elderly patients to return to their former activities of daily living. HYPOTHESIS TBW of displaced stable olecranon fractures with Eyelet-pins in the independent elderly reduce the incidence of complications and allow early elbow joint exercise to keep their former activities. PATIENTS AND METHODS We operated on the displaced stable olecranon fractures of 17 independent patients aged ≥ 70 using TBW with two Eyelet-pins. Eyelet-pins have an eyelet at the trailing end to prevent pin migration by passing a soft wire through it. The patients were reviewed clinically and radiologically at 2, 6, 12, and 24 weeks, and clinically at 1 year after the surgery. RESULTS All fractures were united within 12 weeks, and the anatomic reduction was maintained. Mean radiographic proximal migration of the Eyelet-pins was 0.4mm (0.1 ∼ 1.2mm). Mean active elbow flexion was 136° (115° ∼ 145°) and extension 6.2° (0° ∼ 30°). Two patients had mild local pain and pain on motion at the tip of the eyelet. No patient required removal of the hardware. Other complications, such as superficial or deep wound infections, and neurological symptoms or signs, were not seen. All patients were able to maintain their former activities of daily living. CONCLUSION TBW with Eyelet-pins for displaced stable olecranon fractures is useful for independent elderly patients to reduce the incidence of complications and to maintain their former activities of daily living without removal of the hardware. LEVEL OF EVIDENCE IV; single-centre retrospective study.
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Affiliation(s)
- Shohei Tsujino
- Department of Orthopaedic Surgery, Tamagawa Hospital, Setagaya, Tokyo, Japan; Miraidaira Orthopaedic Clinic, Tsukubamirai, Japan.
| | | | - Masaaki Matsubara
- Department of Orthopaedic Surgery, Tamagawa Hospital, Setagaya, Tokyo, Japan
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15
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Metikala S, Poulos NG, Hasan K, Vallem MMR. Olecranon Fracture in an Older Adult Treated With Locking Plate Osteosynthesis. Cureus 2021; 13:e18836. [PMID: 34804691 PMCID: PMC8592798 DOI: 10.7759/cureus.18836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/12/2022] Open
Abstract
Although olecranon fractures are not uncommon in the geriatric population, there has been a considerable difference of opinion between surgical and nonsurgical treatments. Surgical treatment is usually deferred in the elderly, even for displaced olecranon fractures, because of inherent risks associated with poor bone quality and soft tissues, which often necessitate further surgeries. However, nonoperative treatment frequently results in an inability to regain full extension strength of the elbow, which can be disabling in select older adults with higher functional demands. We present an active older adult with a displaced olecranon fracture, who achieved a satisfactory result after open reduction and internal fixation (ORIF) using a low-profile locking plate.
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Affiliation(s)
| | - Nicholas G Poulos
- Orthopaedics, Virginia Commonwealth University School of Medicine, Richmond, USA
| | - Khalid Hasan
- Orthopaedics, Virginia Commonwealth University School of Medicine, Richmond, USA
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16
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Abstract
Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.
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Affiliation(s)
- Naoko Onizuka
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Julie Switzer
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Chad Myeroff
- TRIA Orthopedic Center, 155 Radio Drive, Woodbury, MN 55125, USA.
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17
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Baertl S, Alt V, Rupp M. Surgical enhancement of fracture healing - operative vs. nonoperative treatment. Injury 2021; 52 Suppl 2:S12-S17. [PMID: 33234264 DOI: 10.1016/j.injury.2020.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/02/2023]
Abstract
Although the success story of surgical fracture treatment led to a tremendous improvement of treatment outcome for certain fractures such as femur or tibia shaft fractures, the overall benefit of surgical versus conservative treatment remains controversial for several types of fractures. For this sake, we carried out a narrative review of high-level of evidence studies comparing treatment outcomes in fractures with controversial debates on the value of surgical therapy in clavicle, proximal humerus, olecranon, ankle, calcaneus and Jones fractures. We identified eight studies (Level-I and -2) with functional and quality of life outcomes in these fractures. Only in Jones fractures of the fifth metatarsal bone, bone healing and functional outcomes were significantly better after surgical compared to conservative treatment. In terms of patient-related quality of life, surgical treatment was not found to be superior compared to conservative treatment in all the above-mentioned fractures. In many trials, lower nonunion rates after surgical treatment were offset by complications due to the surgical procedure. Nonunion after conservative treatment often seemed to have only limited impact on functional results. However, the comparability of studies was limited due to age-differences between patients. Therefore, we emphasize the need for further investigations to determine which patient-related factors favor a conservative treatment approach and for whom surgery is the best option.
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Affiliation(s)
- Susanne Baertl
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany.
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18
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Wise KL, Peck S, Smith L, Myeroff C. Locked plating of geriatric olecranon fractures leads to low fixation failure and acceptable complication rates. JSES Int 2021; 5:809-815. [PMID: 34223435 PMCID: PMC8245976 DOI: 10.1016/j.jseint.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hypothesis The purpose of this study was to report the rate of major complications in patients with geriatric olecranon fractures managed operatively with a locking plate. Secondary objectives included minor complications, as well as pain and range of motion at the final follow-up. We hypothesized that these patients have a low rate of complications as well as low pain and satisfactory elbow range of motion at the final follow-up. Materials and Methods A retrospective review of isolated geriatric olecranon fractures presenting from 2006 to 2019 was performed at a single level I trauma center. Inclusion criteria were ≥75 years of age, operative management with a locking plate, and clinic follow-up at least until evidence of radiographic union or a major complication. Exclusion criteria included nonoperative management, insufficient follow-up, and absence of locking plate in surgical technique. Variables examined included demographic information, Charleston comorbidity index, American Society of Anesthesiologists score, living independence, gait assistance, mechanism of injury, open vs. closed fracture, Mayo radiographic classification, Arbeitsgemeinschaft für Osteosynthesefragen classification, time to surgery, implant type, presence of triceps offloading suture, length of postoperative immobilization, date of radiographic union, range of motion at the final follow-up, pain visual analog scale score at the final follow-up, major and minor complications, and return to the operative room. A major complication was defined as a return to the operative room for deep infection or loss of fixation (displacement of fracture >5 mm). A minor complication was defined as any other complication. Results A total of 65 patients ≥75 years of age with olecranon fractures were identified. Of these, 36 patients met inclusion criteria with an average follow-up of 23 weeks (range 5-207). The mean length of immobilization was 13 days (range 0-29 days). Thirty-two of 36 (88.8%) patients achieved radiographic evidence of union at an average of 8.9 weeks (range 5.3-24.1 weeks). There were 4 remaining patients who underwent secondary intervention before primary union representing an 11.1% major complication rate including 2 deep infections (5.6%) and 3 failures of fixation (8.3%). There were 7 minor complications in 5 of 36 (13.9%) patients. At the final follow-up, the average visual analog scale score was 2.6 (range 0-6), the average elbow arc of motion was 120° (range 70-147°), and mean pronation/supination was 85°/84° (range 45-90°/45-90°). Conclusion Geriatric olecranon fractures are a challenging orthopedic problem with remaining controversy regarding ideal treatment. Despite advancement in geriatric fracture care, there is scant literature on the outcomes of locked plating technology in geriatric olecranon fractures. This study supports use of operative anatomic fixation with precontoured locked plates and early mobilization with an acceptable failure rate.
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Affiliation(s)
- Kelsey L. Wise
- University of Minnesota Department of Orthopaedic Surgery, Minneapolis, MN, USA
| | - Sarah Peck
- Regions Hospital Department of Orthopedic Surgery, Saint Paul, MN, USA
| | - Lauren Smith
- University of Minnesota Department of Orthopaedic Surgery, Minneapolis, MN, USA
| | - Chad Myeroff
- University of Minnesota Department of Orthopaedic Surgery, Minneapolis, MN, USA
- Regions Hospital Department of Orthopedic Surgery, Saint Paul, MN, USA
- TRIA Orthopedic Center, Woodbury, MN, USA
- Corresponding author: Chad Myeroff, MD, Mail Stop 11503L, 640 Jackson Street, St Paul, MN, 55101-2595, USA.
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19
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Abdelmalek A, Crowther M. Olecranon fractures in the elderly during the COVID-19 pandemic: Is non-operative treatment reasonable? Review of the current evidence. Musculoskelet Surg 2021; 105:125-130. [PMID: 33511549 PMCID: PMC7843878 DOI: 10.1007/s12306-021-00699-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/07/2021] [Indexed: 11/24/2022]
Abstract
The current COVID-19 global pandemic presents a major challenge and unprecedented pressures on health systems. The national guidelines in the UK advise non-operative treatment of fractures whenever possible to reduce the risk of surgical intervention to both patient and healthcare staff. The elderly population over 70 years are highlighted as a high-risk group in this pandemic as well as being often high risk for surgery in general due to co-morbidities. This article reviews the current literature regarding treatment of displaced olecranon fractures in the elderly. Literature search of the available databases. One randomised controlled trial has been published, comparing operative versus non-operative treatments of olecranon fractures in this age group. The study was terminated prematurely due to the high complication rate in the operative group. No difference in functional scores was recorded. Other published retrospective case series report good functional outcome scores and high satisfaction rates in the majority of patients in whom olecranon fractures were treated non-operatively. Non-operative treatment of olecranon fractures in elderly patients seems to be safe and an acceptable management option in these unprecedented times.
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Affiliation(s)
| | - Mark Crowther
- Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
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20
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Aibinder WR, Sims LA, Athwal GS, King GJW, Faber KJ. Outcomes of nonoperative management of displaced olecranon fractures in medically unwell patients. JSES Int 2021; 5:291-295. [PMID: 33681852 PMCID: PMC7910720 DOI: 10.1016/j.jseint.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Surgical treatment of displaced olecranon fractures in the elderly has a high rate of complications, including wound breakdown and fixation failure. The purpose of this study was to assess the clinical, radiographic, and functional outcomes of nonsurgical management of displaced olecranon fractures in low-demand elderly and medically unwell patients. Methods A retrospective review of 28 patients with displaced closed olecranon fractures was performed with an average follow-up of 11 months. The mean age at the time of injury was 79 ± 10 years. The average Charlson Comorbidity Index was 6.4 ± 2.6. Treatment modalities were at the discretion of the treating surgeon. A sling alone was used in 3 cases, an extension circumferential cast in 9, or a plaster or thermoplastic splint in 16. The mean period of immobilization was 5 ± 1 weeks. Outcomes included range of motion, ability to perform active overhead extension, as well as radiographic and functional outcomes. Results At final follow-up, the mean elbow range of motion for the cohort was from 28° ± 21° extension to 127° ± 15° flexion. Active overhead elbow extension against gravity was noted or documented in 24 (86%) patients. Two patients (7%) were unable to perform active extension. No pain was noted in 18 elbows, severe pain was present in 1 elbow, and the remainder reported mild occasional pain. All olecranon fractures in this cohort were displaced on the initial lateral radiograph. The mean displacement was 11 ± 7 mm. Nonunion at final radiographic outcome was observed in 23 (82%) elbows. Two (7%) patients developed skin complications related to posteriorly placed splints; one of which was severe. Discussion This study adds to the growing literature that supports nonoperative management of displaced olecranon fractures in elderly and medically unwell patients with low upper extremity demand. Patients can be counseled that they have a good chance of obtaining overhead extension, with minimal pain. Posteriorly based splints should not be used to minimize skin complications.
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Affiliation(s)
- William R Aibinder
- Department of Orthopaedic Surgery & Rehabilitation Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Laura A Sims
- Department of Orthopedics, University of Saskatchewan, Saskatoon, SK, Canada
| | - George S Athwal
- Roth McFarlane Hand and Upper Limb Center, University of Western Ontario, London, ON, Canada
| | - Graham J W King
- Roth McFarlane Hand and Upper Limb Center, University of Western Ontario, London, ON, Canada
| | - Kenneth J Faber
- Roth McFarlane Hand and Upper Limb Center, University of Western Ontario, London, ON, Canada
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21
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Surgical and Nonoperative Management of Olecranon Fractures in the Elderly: A Systematic Review and Meta-Analysis. J Orthop Trauma 2021; 35:10-16. [PMID: 32569071 DOI: 10.1097/bot.0000000000001865] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of this comparative effectiveness study was to perform a meta-analysis of adverse events and outcomes in closed geriatric olecranon fractures, without elbow instability, after treatment with surgical or nonoperative management. DATA SOURCES PubMed, Web of Science, and Embase databases. STUDY SELECTION Articles were included if they contained clinical data evaluating outcomes in patients ≥65 years of age with closed olecranon fractures, without elbow instability, treated surgically, or with nonoperative management. DATA EXTRACTION Data regarding patient age, olecranon fracture type, fracture union, adverse events, reoperation, elbow range of motion, and surgeon and patient reported outcome measures were recorded according to intervention. The interventions included for analysis were tension band wire fixation, plate fixation, or nonoperative management. DATA SYNTHESIS Separate random effects meta-analyses were conducted for each outcome according to intervention. Prevalence and 95% confidence intervals were calculated for dichotomous variables, whereas weighted means and confidence intervals were calculated for continuous variables. CONCLUSIONS Comparable outcomes were achieved with surgical or nonoperative management of olecranon fractures in geriatric patients. Surgical intervention carried a high risk of reoperation regardless of whether plate or tension band wire fixation was used. Functional nonunion can be anticipated if nonoperative treatment is elected in low-demand elderly patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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22
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Emara AK, Klika AK, Piuzzi NS. Evidence-Based Orthopedic Surgery—From Synthesis to Practice. JAMA Surg 2020; 155:1009-1010. [DOI: 10.1001/jamasurg.2020.1521] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ahmed K. Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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23
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Savvidou OD, Koutsouradis P, Kaspiris A, Naar L, Chloros GD, Papagelopoulos PJ. Displaced olecranon fractures in the elderly: outcomes after non-operative treatment - a narrative review. EFORT Open Rev 2020; 5:391-397. [PMID: 32818066 PMCID: PMC7407865 DOI: 10.1302/2058-5241.5.190041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Operative treatment with tension band wiring or plate is the gold standard of care for displaced olecranon fractures. In elderly patients, multiple comorbidities combine with increased intraoperative risks, and postoperative complications may yield poor results. There are small series in the literature that show promising results with non-operative treatment. Non-operative treatment may provide reasonable function and satisfaction in the elderly population and could be considered as a treatment option in this group, especially for those with comorbidities, to avoid postoperative complications and the need for re-operation.
Cite this article: EFORT Open Rev 2020;5:391-397. DOI: 10.1302/2058-5241.5.190041
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Affiliation(s)
- Olga D Savvidou
- First Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, School of Medicine, 'ATTIKON' University General Hospital, Athens, Hellenic Republic, Greece
| | | | - Angelos Kaspiris
- Laboratory of Molecular Pharmacology/ Sector for Bone Research, School of Health Sciences, University of Patras, Patras 26504, Greece
| | - Leon Naar
- First Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, School of Medicine, 'ATTIKON' University General Hospital, Athens, Hellenic Republic, Greece
| | - George D Chloros
- First Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, School of Medicine, 'ATTIKON' University General Hospital, Athens, Hellenic Republic, Greece
| | - Panayiotis J Papagelopoulos
- First Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, School of Medicine, 'ATTIKON' University General Hospital, Athens, Hellenic Republic, Greece
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Bugarinovic G, McFarlane KH, Benavent KA, Janssen SJ, Blazar PE, Earp BE. Risk Factors for Hardware-Related Complications After Olecranon Fracture Fixation. Orthopedics 2020; 43:141-146. [PMID: 32191948 DOI: 10.3928/01477447-20200314-03] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/17/2019] [Indexed: 02/03/2023]
Abstract
The aim of this study was to evaluate risk factors for symptomatic hardware and removal of hardware (ROH) after olecranon open reduction and internal fixation (ORIF) and to assess differences between olecranon locking plate and screws (P&S) or tension band (TB) wire cohorts. The medical records of 331 patients with olecranon fractures treated at two academic level I trauma centers with ORIF from 2012 to 2016 were reviewed. A total of 189 patients were included in the study. Complications, ROH, and subsequent surgery were assessed and compared between cohorts. There were 124 cases in the P&S cohort and 65 in the TB cohort. The overall reoperation rate was 31.2% (59 of 189). The overall incidence of ROH for all cases was 29.1% (55 of 189). Patients who required ROH or developed symptomatic hardware were significantly younger than those who did not (P&S, P<.003; TB, P<.004). Age and body mass index (BMI) were associated with ROH plus symptomatic hardware after P&S. Age (but not BMI) was associated with ROH/symptomatic hardware after TB. Measured hardware prominence was not associated with ROH or ROH plus symptomatic hardware for either the P&S or the TB cohort. Risk factors including patient age and BMI were found to be significantly associated with hardware-related complications. [Orthopedics. 2020;43(3):141-146.].
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Rantalaiho IK, Miikkulainen AE, Laaksonen IE, Äärimaa VO, Laimi KA. Treatment of Displaced Olecranon Fractures: A Systematic Review. Scand J Surg 2019; 110:13-21. [PMID: 31822216 DOI: 10.1177/1457496919893599] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS The incidence of olecranon fractures is rising. Displaced fractures are usually operated either by tension band wiring or plate fixation. The aim of this review is to evaluate the best current evidence on the management of displaced olecranon fractures. MATERIALS AND METHODS Randomized controlled trials were systematically gathered in May 2018 from CENTRAL, MEDLINE, Embase, CINAHL, Scopus, and PEDro databases. The methodological quality of articles was assessed according to the Cochrane Collaboration's domain-based framework. Prospero database registration number: CRD42018096650. RESULTS Of 1518 identified records, finally, 5 were relevant. Four trials were found on tension band wiring: two compared tension band wiring with plate fixation (n = 108), one compared plate fixation with an olecranon memory connector (n = 40), and one trial compared tension band wiring with a modified tension band wiring called Cable Pin System (n = 62). In addition, one trial compared operative and conservative treatment in elderly (n = 19). The risk of bias was considered low in two and high in three of the trials. The follow-up time was 5-36 months, and outcome measures varied from patient-rated and physician-rated measures to radiological outcomes. In the analysis, there was no difference between tension band wiring and plate fixation. The data were insufficient for further quantitative analysis. CONCLUSION No differences were found in clinical or patient-rated outcome measures between the two most frequent fixation methods (tension band wiring and plate fixation) of displaced olecranon fractures. Current data are not sufficient to evaluate other treatment methods; however, conservative treatment might serve as an option for selected patients in the elderly population.
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Affiliation(s)
- I K Rantalaiho
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - A E Miikkulainen
- Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - I E Laaksonen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - V O Äärimaa
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - K A Laimi
- Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland
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Di Francia R, Letissier H, Le Nen D, Lefèvre C, Dubrana F, Stindel É. Advantages of expulsion-proof pins in the treatment of olecranon fractures with tension band wiring: Comparison with a control group. Orthop Traumatol Surg Res 2019; 105:1593-1599. [PMID: 31767442 DOI: 10.1016/j.otsr.2019.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/18/2019] [Accepted: 08/22/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Rémi Di Francia
- Centre Hospitalier Régional Universitaire de Brest, Service de Chirurgie Orthopédique et Traumatologique, 29200 Brest, France.
| | - Hoel Letissier
- Centre Hospitalier Régional Universitaire de Brest, Service de Chirurgie Orthopédique et Traumatologique, 29200 Brest, France
| | - Dominique Le Nen
- Centre Hospitalier Régional Universitaire de Brest, Service de Chirurgie Orthopédique et Traumatologique, 29200 Brest, France
| | - Christian Lefèvre
- Centre Hospitalier Régional Universitaire de Brest, Service de Chirurgie Orthopédique et Traumatologique, 29200 Brest, France
| | - Frédéric Dubrana
- Centre Hospitalier Régional Universitaire de Brest, Service de Chirurgie Orthopédique et Traumatologique, 29200 Brest, France
| | - Éric Stindel
- Centre Hospitalier Régional Universitaire de Brest, Service de Chirurgie Orthopédique et Traumatologique, 29200 Brest, France
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Marot V, Bayle-Iniguez X, Cavaignac E, Bonnevialle N, Mansat P, Murgier J. Results of non-operative treatment of olecranon fracture in over 75-year-olds. Orthop Traumatol Surg Res 2018; 104:79-82. [PMID: 29258962 DOI: 10.1016/j.otsr.2017.10.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/07/2017] [Accepted: 10/14/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgery is the gold-standard treatment of displaced olecranon fracture, but is associated with numerous complications, especially in the elderly. Functional results of non-operative treatment in this population have never been analyzed in a prospective study. STUDY HYPOTHESIS Non-operative treatment of isolated olecranon fracture with stable elbow-joint in over 75-year-olds gives functional results comparable to those of surgery as reported in the literature, with fewer complications. MATERIAL AND METHODS A prospective study analyzed functional results of non-operative treatment of isolated closed Mayo I and II olecranon fracture with stable elbow, in patients aged ≥75 years. The principal assessment criterion was functional recovery on the Mayo Elbow Performance Score (MEPS) and QuickDASH at 6 months. RESULTS Twenty-two fractures in 21 patients were included. Mean MEPS was 95.26/100 (range, 85-100), and mean QuickDASH 4.3 (range, 0-29.55). Eighteen fractures showed osteoarthritis of the olecranon. There were no cases of elbow instability. There were no complications. DISCUSSION Non-operative treatment of olecranon fracture in patients aged ≥75 years provided excellent functional results at 6 months, without associated complications. TYPE OF STUDY Single-center prospective observation cohort study. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- V Marot
- Département de chirurgie orthopédique et traumatologique, hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Docteur-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - X Bayle-Iniguez
- Département de chirurgie orthopédique et traumatologique, hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Docteur-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - E Cavaignac
- Département de chirurgie orthopédique et traumatologique, hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Docteur-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - N Bonnevialle
- Département de chirurgie orthopédique et traumatologique, hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Docteur-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - P Mansat
- Département de chirurgie orthopédique et traumatologique, hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Docteur-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - J Murgier
- Département de chirurgie orthopédique et traumatologique, hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Docteur-Baylac, TSA 40031, 31059 Toulouse cedex 9, France.
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Putnam MD, Christophersen CM, Adams JE. Pilot report: non-operative treatment of Mayo Type II olecranon fractures in any-age adult patient. Shoulder Elbow 2017; 9:285-291. [PMID: 28932286 PMCID: PMC5598825 DOI: 10.1177/1758573217711889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/21/2017] [Accepted: 04/29/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND We report on the non-operative treatment of Mayo Type II olecranon fractures. METHODS Fourteen isolated Mayo Type II olecranon fractures were treated non-operatively, followed to discharge, and retrospectively reviewed. Treatment was splinting in extension followed by protected active motion beginning 3 weeks to 4 weeks post-injury. Mayo Elbow Performance Index (MEPI) and Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were available in 86% and 64% of cases, respectively. Follow-up radiographs were obtained. RESULTS At discharge, the mean (SD) MEPI score was 95 (5). The mean (SD) elbow motion arc was 121° (21°). One patient re-fractured his elbow after discharge by falling on the ice. He recovered after open reduction and internal fixation. One patient (documented Marfan syndrome) developed an asymptomatic non-union. Excepting the patient who fell, no patient received additional care. CONCLUSIONS In this pilot report, Mayo Type II olecranon fractures were treated non-operatively to discharge. Good to excellent results were obtained in all patients according to the MEPI. Supportive care of these fractures should be comparatively studied. A downside risk to providing supportive care for these fractures was not identified.
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Affiliation(s)
- Matthew D. Putnam
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA,Matthew D. Putnam, Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN 55454, USA.
| | | | - Julie E. Adams
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Duckworth AD, Clement ND, McEachan JE, White TO, Court-Brown CM, McQueen MM. Prospective randomised trial of non-operative versus operative management of olecranon fractures in the elderly. Bone Joint J 2017; 99-B:964-972. [PMID: 28663405 DOI: 10.1302/0301-620x.99b7.bjj-2016-1112.r2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/01/2017] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years. PATIENTS AND METHODS Patients were randomised to either non-operative management or operative management with either tension-band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year. RESULTS A total of 19 patients were randomised to non-operative (n = 8) or operative (n = 11; tension-band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non-operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05). CONCLUSION These data further support the role of primary non-operative management of isolated displaced fractures of the olecranon in the elderly. However, the non-inferiority of non-operative management cannot be proved as the trial was stopped prematurely. Cite this article: Bone Joint J 2017;99-B:964-72.
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Affiliation(s)
- A D Duckworth
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - N D Clement
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - J E McEachan
- Queen Margaret Hospital, Dunfermline KY12 0SU, UK
| | - T O White
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - C M Court-Brown
- University of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - M M McQueen
- University of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
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Duckworth AD, Clement ND, White TO, Court-Brown CM, McQueen MM. Plate Versus Tension-Band Wire Fixation for Olecranon Fractures: A Prospective Randomized Trial. J Bone Joint Surg Am 2017; 99:1261-1273. [PMID: 28763412 DOI: 10.2106/jbjs.16.00773] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [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 single-center, single-blinded, prospective randomized trial was to compare the outcomes of tension-band wire (TBW) and plate fixation for simple isolated, displaced fractures of the olecranon. METHODS We performed a prospective randomized trial involving 67 patients who were ≥16 to <75 years of age and had an acute isolated, displaced fracture of the olecranon. Patients were randomized to either TBW (n = 34) or plate fixation (n = 33) and were evaluated at 6 weeks, 3 months, 6 months, and 1 year following surgery. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year. RESULTS The baseline demographic and fracture characteristics of the 2 groups were comparable, except for age, which was lower in the TBW group. The 1-year follow-up rate was 85% (n = 57), with 84% (n = 56) completing the DASH. There was a significant improvement in the DASH score over the 1-year period following surgery (p < 0.001). At 1 year, the DASH score for the TBW group (12.8) did not differ significantly from that of the plate group (8.5) (p = 0.315). The groups also did not differ significantly in terms of range of motion, the Broberg and Morrey score, the Mayo Elbow Score, or the DASH at all assessment points over the 1 year (all p ≥ 0.05). Complication rates were significantly higher in the TBW group (63% compared with 38%; p = 0.042), predominantly because of a significantly higher rate of metalwork removal in symptomatic patients (50.0% compared with 22%; p = 0.021). Four infections occurred, all in the plate group (0% versus 13%; p = 0.114), as did 3 revision surgeries (0% versus 9.4%; p = 0.238). CONCLUSIONS Among active patients with a simple isolated, displaced fracture of the olecranon, no difference was found between TBW and plate fixation in the patient-reported outcome at 1 year following surgery. The complication rate was higher following TBW fixation and was due to a higher rate of implant removal in symptomatic patients. However, the more serious complications of infection and the need for revision surgery occurred exclusively following plate fixation in this trial. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew D Duckworth
- 1Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Motisi M, Kurowicki J, Berglund DD, Triplet JJ, Disla S, Niedzielak T, Levy JC. Trends in Management of Radial Head and Olecranon Fractures. Open Orthop J 2017; 11:239-247. [PMID: 28567151 PMCID: PMC5420188 DOI: 10.2174/1874325001711010239] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/23/2017] [Accepted: 02/28/2017] [Indexed: 11/28/2022] Open
Abstract
Background: Advancement in surgical techniques and implants has improved the ability to manage radial head and olecranon fractures. However, trends in management of these fractures are largely unstudied. Objective: This purpose of this study is to evaluate management trends for these common fractures. Methods: A retrospective review of a comprehensive Humana database was performed using Pearl Diver supercomputer (Warsaw, IN, USA) for radial head and neck (RHNF) and olecranon fractures (OF) between 2007 and 2014. Treatment methods including open reduction internal fixation (ORIF), radial head arthroplasty (RHA), and non-operative treatment were reviewed. Total reported incidence of office visits and utilization of each treatment modality were investigated. Sub-analysis with stratification by age 15-74 and greater than 75-years was performed for OF. Results: A total of 10,609 OF and 20,400 RHNF were identified between 2007 and 2014. A significant trend increase in the annual incidence of RHNF (266 cases/year, p<0.001) and OF (133.9 cases/year, p=0.001) was observed. A significant trend increase in annual percent utilization of RHA (0.22% per year, p=0.011) and a significant trend decrease in the annual percent utilization of ORIF (-1.0% per year, p=0.004) and non-operative management (-0.53% per year, p=0.046) was observed for RHNF. A significant trend increase was observed in percent utilization (0.40% per year, p=0.022) for OF non-operative management, especially in patients over 75 years (66% per year, p=0.034). Conclusion: The percentage of patients being treated with RHA is increasing. Non-operative management of OF has increased, specifically in the patients who are over 75 years.
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Affiliation(s)
- Matthew Motisi
- Broward Health Medical Center, 1800 NW 49th Street Fort Lauderdale, FL 33309, USA
| | - Jennifer Kurowicki
- Holy Cross Orthopedic Institute, 5597 N. Dixie Highway Fort Lauderdale, FL 33334, USA
| | - Derek D Berglund
- Holy Cross Orthopedic Institute, 5597 N. Dixie Highway Fort Lauderdale, FL 33334, USA
| | - Jacob J Triplet
- Doctors Hospital- Ohio Health, 5100 West Broad Street, Columbus, OH 43228, USA
| | - Shanell Disla
- Holy Cross Orthopedic Institute, 5597 N. Dixie Highway Fort Lauderdale, FL 33334, USA
| | - Timothy Niedzielak
- Nova Southeastern University, College of Osteopathic Medicine, 3301 College Avenue Fort Lauderdale, FL 33314, USA
| | - Jonathan C Levy
- Holy Cross Orthopedic Institute, 5597 N. Dixie Highway Fort Lauderdale, FL 33334, USA
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Nieto H, Baroan C. Limits of internal fixation in long-bone fracture. Orthop Traumatol Surg Res 2017; 103:S61-S66. [PMID: 28082050 DOI: 10.1016/j.otsr.2016.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 11/09/2016] [Accepted: 11/09/2016] [Indexed: 02/02/2023]
Abstract
Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary according to technique. The present study examines these limitations, based on comparative or large-scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open fracture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equivalent when treated by intramedullary nailing or external fixation, if wound care and debridement are effective, antibiotherapy is initiated rapidly and skin cover is restored within 7days. Conversion from primary external fixation to intramedullary nailing is possible if the external fixator was fitted less than 28days previously and skin cover was restored within 7days. The pulmonary and systemic impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in multiple trauma calls for caution and what is known as "damage-control orthopedics" (DCO), a term covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary nailing is thus contraindicated in case of hemorrhagic shock (blood pressure<90mmHg), hypothermia (<33°C), coagulation disorder (platelet count<90,000) or peripheral lesions such as multiple long-bone fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde nailing with a small-diameter nail and without reaming are preferable.
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Affiliation(s)
- H Nieto
- Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France.
| | - C Baroan
- Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France
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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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