1
|
Woolnough T, Caines AM, Pollock JW, Papp SR. Treatment of olecranon fractures in older individuals: a cross-sectional survey of surgeon treatment preferences. JSES Int 2024; 8:227-231. [PMID: 38312299 PMCID: PMC10837697 DOI: 10.1016/j.jseint.2023.10.009] [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] [Indexed: 02/06/2024] Open
Abstract
Background With an aging population, the incidence of olecranon fractures in older patients is increasing. The standard of care has traditionally included operative management for displaced fractures. Recent literature has called this standard of care into question. Older patients may be at increased risk of operative complications and may have satisfactory functional outcomes with nonoperative management. Given recently evolving evidence, the current treatment preferences of orthopedic surgeons for older patients with displaced olecranon fractures are unknown. Methods We administered a cross-sectional survey of Canadian orthopedic surgeons via e-mail invitation and online survey form to determine treatment preferences for patients aged 65-75 and >75 years with simple displaced and comminuted displaced stable olecranon fractures. Respondents reviewed representative images and were asked to indicate their preferred treatment based on patient age. We also asked respondents to indicate their perceived importance of 11 patient factors on treatment decision-making. Results We received 200 responses (33.8% response rate). For patients aged 65-75 years with simple displaced fractures, surgeons preferred tension-band wiring (n = 110, 56%) to plating (n = 82, 42%, P = .005), while only 3% (n = 5) preferred nonoperative treatment. For patients aged >75 years with simple displaced fractures, surgeons preferred operative (n = 144, 73%) to nonoperative management (n = 51, 26%; P < .01) with either tension-band wiring (n = 77, 39%) or plating (n = 67, 34%). In these patients, early range of motion (n = 35, 18%) was preferred to immobilization (n = 16, 8%; P = .004). For comminuted fractures, plate fixation was preferred for patients aged 65-75 years (n = 189, 95%) and >75 years (n = 131, 68%). In patients aged >75 years, this was followed by early range of motion (n = 35, 18%) and immobilization (n = 24, 13%). Of the 11 factors surveyed, participation in high-intensity activities (mean rank = 9.4), independent living (mean rank = 8.8), and disrupted extensor mechanism (mean rank = 8.3) were ranked most highly for increasing likelihood of surgical treatment. Conclusion In patients aged 65 to 75 years, operative management is favored by most surgeons, with tension-band wiring preferred over plating for simple displaced fractures. In patients aged >75 years, operative management is again preferred by most respondents for simple and comminuted fractures. Despite operative preferences, there is a paucity of quality evidence to guide treatment decision-making, particularly in patients aged >75 years.
Collapse
Affiliation(s)
- Taylor Woolnough
- Division of Orthopaedic Surgery, The Ottawa Hospital – Civic Campus, Ottawa, ON, Canada
| | - Andrew M. Caines
- Division of Orthopaedic Surgery, The Ottawa Hospital – Civic Campus, Ottawa, ON, Canada
| | - JW. Pollock
- Division of Orthopaedic Surgery, The Ottawa Hospital – General Campus, Ottawa, ON, Canada
| | - Steven R. Papp
- Division of Orthopaedic Surgery, The Ottawa Hospital – Civic Campus, Ottawa, ON, Canada
| |
Collapse
|
2
|
Avisar E, Essa A, Gutman-Tirosh A, Dahan M, Assaraf E, Persitz J. Is Tension Band Wire Fixation Superior to Plate Fixation for Simple Displaced Olecranon Fractures? A Randomized Trial With Median Follow-up of 7.5 Years. Clin Orthop Relat Res 2024; 482:127-133. [PMID: 37678389 PMCID: PMC10723893 DOI: 10.1097/corr.0000000000002832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/28/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Surgeons disagree about the best surgical treatment for simple, displaced olecranon fractures. Although the tension band wiring technique and plate fixation are the most common surgical options for fixation, studies comparing both are limited. To date, there have been no randomized trials comparing patient-reported outcomes and complications at more than 5 years of follow-up. QUESTIONS/PURPOSES (1) Does tension band wiring or plate fixation result in better ROM and patient-reported outcome scores for simple displaced olecranon fractures? (2) What is the risk of complications associated with each technique? METHODS Between November 2012 and October 2017, 68 patients were treated for acute, displaced olecranon fracture in a hand and upper extremity surgery unit at a tertiary-care center. Patients 18 years or older with traumatic, nonpathologic, simple olecranon fractures who presented within 2 weeks of injury were considered potentially eligible. Based on that, 74% (50) of patients met the inclusion criteria; 16% (11) of patients declined to participate in the study, and another 10% (seven) were excluded because they did not meet the prespecified inclusion criteria. Patients were randomized on a 1:1 basis to either tension band wiring or plate fixation and were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery. At the final follow-up interval, 16% (eight) were lost to follow-up: 4% (two) in the tension band wiring group and 12% (six) in the plate fixation group. The median follow-up time was 8 years (IQR 7 to 9 years). We evaluated complications at a minimum of 6 years after surgery. The primary outcome measure was the 1-year postoperative DASH score. Additional outcome measures included the patient-reported Oxford Elbow Score, ROM, and the proportion of patients in each group who reported hardware-related symptoms and had subsequent implant removal or postoperative infection. RESULTS No differences were observed in the DASH score (tension band wiring 18 [range 3 to 65] versus plate fixation 24 [range 3 to 52], median difference -6 [95% CI -12.7 to 14.9]; p = 0.73), Oxford Elbow Score (tension band wiring 36 [range 10 to 48] versus plate fixation 39 [range 17 to 47], median difference -3; p = 0.53), or all ROM measurements (p > 0.05) between the groups at 1 year of follow-up. The odds of having surgery for symptomatic implant removal were lower for plate fixation than for tension band wiring (one of 19 versus eight of 23, OR 9.6 [95% CI 1.08 to 85.7]; p =0.02); the odds of infection, however, were higher in the plate group (three of 19 versus 0 of 23; p = 0.048). CONCLUSION No differences were observed between the two techniques in terms of ROM or patient-reported outcomes. Surgeons should consider that although the risk of implant removal is higher in tension band wiring, patients older than 85 years undergoing plate fixation for simple olecranon fractures are at a greater risk of postoperative infection. LEVEL OF EVIDENCE Level I, therapeutic study.
Collapse
Affiliation(s)
- Erez Avisar
- Department of Orthopaedic Surgery, Hand and Upper Extremity Surgery Unit, Yitzhak Shamir Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Ahmad Essa
- Department of Orthopaedic Surgery, Hand and Upper Extremity Surgery Unit, Yitzhak Shamir Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Adva Gutman-Tirosh
- Department of Orthopaedic Surgery, Hand and Upper Extremity Surgery Unit, Yitzhak Shamir Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Moshe Dahan
- Department of Orthopaedic Surgery, Hand and Upper Extremity Surgery Unit, Yitzhak Shamir Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Eran Assaraf
- Department of Orthopaedic Surgery, Hand and Upper Extremity Surgery Unit, Yitzhak Shamir Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Jonathan Persitz
- Department of Orthopaedic Surgery, Hand and Upper Extremity Surgery Unit, Yitzhak Shamir Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| |
Collapse
|
3
|
Schwartz JM, Taleghani ER, Yildirim B, Novicoff W, Freilich AM. Timing of Olecranon Fracture Fixation Does Not Affect Early Complication or Reoperation Rates. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:53-57. [PMID: 38313620 PMCID: PMC10837298 DOI: 10.1016/j.jhsg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose Surgical fixation of olecranon fractures can lead to soft-tissue complications and return to the operating room for hardware removal. While some risk factors of complications after olecranon fracture fixation have been described, the effects of fixation timing on complications and reoperation have not been evaluated. The purpose of the present study was to assess whether the timing of olecranon fracture fixation affects complication and reoperation rates. Methods All patients who underwent olecranon fracture open reduction and internal fixation at a single level 1 trauma center from January 2012 to February 2022 were included in the study. A retrospective review was performed to evaluate patients for inclusion and to identify patient demographic factors, medical comorbidities, concomitant injuries, mechanism of injury, and time to fixation. Operative and clinical notes were evaluated to identify fixation type and outcomes of interest. Patients were stratified into early, standard, and delayed fixation groups (0-3 days, 4-14 days, and >14 days, respectively) for independent analyses, and Fisher's exact test was used to identify differences in complications and reoperations between groups. Multivariate analysis was used to assess associations between patient demographic factors, complication rates, and time to surgery. Results A total of 97 patients met inclusion criteria of having an olecranon open reduction and internal fixation and had a minimum follow-up of at least 10 weeks, with an average follow-up of 7.1 months. The average time to surgery in the overall cohort was 9.3 days. There were no differences in the number of total complications and rate of reoperation among the three cohorts. Smoking was found to be significantly associated with total complications, while open fracture was significantly associated with reoperation. Polytrauma and open fracture were significantly associated with earlier operation, while smoking was significantly associated with delayed fixation. Conclusions The timing of fixation of displaced olecranon fractures does not significantly increase the rate of early complications or reoperation. Type of study/level of evidence Symptom Prevalence Study III.
Collapse
Affiliation(s)
| | - Eric R. Taleghani
- University of Virginia Department of Orthopaedics, Charlottesville, VA
| | - Baris Yildirim
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH
| | - Wendy Novicoff
- University of Virginia Department of Orthopaedics, Charlottesville, VA
| | - Aaron M. Freilich
- University of Virginia Department of Orthopaedics, Charlottesville, VA
| |
Collapse
|
4
|
Dogramatzis K, Kitridis D, Bekoulis T, Craig R. Novel suture/suture-anchor fixation versus tension band wiring for olecranon fractures: A systematic review. Shoulder Elbow 2023; 15:424-435. [PMID: 37538526 PMCID: PMC10395410 DOI: 10.1177/17585732221094828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 08/05/2023]
Abstract
Introduction Tension Band Wiring (TBW) has traditionally been the cornerstone of operative management for simple displaced olecranon fractures but its success is limited by high complication rates, mainly related to metalwork irritation and fixation failure. Over the last twelve years, a number of novel fixation methods not involving metalwork have been described in case series (suture fixation, SF and suture-anchor fixation, SAF) with promising early results. In this systematic review, the outcomes of SF and SAF techniques are presented alongside those for TBW for the treatment of closed olecranon fractures without elbow instability. Materials and methods Five databases (Medline, Scholar, Scopus, Prospero and Cochrane) were searched for clinical studies involving TBW/SF/SAF for closed Mayo 1A/1B/2A/2B olecranon fractures from January 2010 onwards. Primary outcomes included overall complication and reoperation rates, as well as the rate of each specific complication. Elbow range of movement, surgeon and patient-reported outcome measures were defined as secondary outcomes. Results Eighteen studies were included, nine of which involved SF/SAF (99 patients) and nine TBW (382 patients). SF/SAF techniques were associated with lower rates of fracture/implant displacement (2% versus 9.7%, p = 0.01), implant irritation (1% versus 30.1%, p < 0.001) and overall complications (8% versus 46.1%, p < 0.001) when compared to TBW. Reoperation rates were lower for SF/SAF (3% versus 37.2%, p < 0.001). Total flexion/extension arc achieved was similar (130.16 ± 2.11 versus 129.45 ± 0.93 degrees). On average, patients regained a functional arc of flexion (135.21 ± 4.81 TBW versus 131.32 ± 12.99 SF/SAF) and extension (1.16 ± 7.54 SF/SAF versus 5.76 ± 7.98 TBW). Conclusion Current evidence suggests that SF/SAF of simple olecranon fractures is a safe and effective alternative to the current gold standard TBW fixation, with preliminary evidence suggestive of lower complication and reoperation rates. Firm conclusions of equivalence or superiority are not possible based on the current poor quality of literature available. Until the outcomes of high-quality prospective studies are available, patients should be carefully counselled that suture methods remain novel and outcomes should be regularly audited.
Collapse
Affiliation(s)
| | - Dimitrios Kitridis
- 1st Orthopaedic Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Richard Craig
- University Hospitals Coventry and Warwickshire, Coventry, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Bouchard C, Bornes TD, Silveira A, Hemstock R, Beaupre L, Chan R. Hardware complications and reoperations following precontoured plate fixation of the olecranon: a population-based study. J Shoulder Elbow Surg 2022; 31:e418-e425. [PMID: 35568260 DOI: 10.1016/j.jse.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/06/2022] [Accepted: 04/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several fixation techniques have been described to treat acute olecranon fractures. Plate fixation is often used because of its superior mechanical properties. The reported rates of reoperation after olecranon plate fixation have been quite heterogeneous. The purpose of this study was to establish an updated reoperation rate based on modern precontoured plate constructs. METHODS This retrospective cohort study used population-level administrative data to identify all surgically treated adult patients with olecranon fractures at 4 hospitals in Edmonton, AB, Canada, between 2010 and 2015. Radiographic review was conducted to identify patients who underwent precontoured olecranon plate fixation. Fracture characteristics including Mayo fracture classification and other concomitant upper-extremity injuries were identified. Chart reviews were performed to determine patient characteristics and patients who required reoperation. The primary reason for and type of reoperation were determined. RESULTS Six hundred patients were surgically treated for olecranon fractures. Precontoured plate fixation was used in 321 patients. The average age of included patients was 56 years (standard deviation [SD], 19.4 years), and there were 173 female patients (53.9%). Reoperation was required in 90 patients (28%). For 50 patients, implant-related irritation was the primary reason for reoperation, representing 55.6% of the patients who underwent reoperation (50 of 90) and 15.6% of the total cohort (50 of 321). Other reasons for reoperation included hardware failure in 17 patients (5.3%), infection in 9 (2.8%), and contracture in 9 (2.8%). Patients who required reoperation were significantly younger (52.9 years [SD, 18.1 years] vs. 57.7 years [SD, 19.4 years]; P = .048) and had significantly higher rates of type III olecranon fractures (17.8% [16 of 90] vs. 8.2% [19 of 231]; P = .04) and Monteggia fractures (13.3% [12 of 90] vs. 4.8% [11 of 231]; P = .008). A multivariate logistic regression model also demonstrated increased odds ratios (ORs) for overall reoperation in patients with Monteggia fractures (OR, 2.99 [95% confidence interval, 1.25-7.17]; P = .014) and for reoperation due to implant-related irritation in younger patients (OR, 0.98 [95% confidence interval, 0.96-0.996]; P = .018). No discerning factors were identified for the 50 patients who underwent hardware removal for implant-related irritation compared with the whole reoperation group (n = 90). CONCLUSION This study found that patients with olecranon fractures treated with precontoured plates experienced a hardware removal rate of 15.6% for implant-related irritation. Patients who sustained more complex fractures, such as Monteggia injuries, demonstrated higher rates of reoperation. Increasing age may be associated with lower rates of reoperation. In patients who required reoperation, there were no identifiable radiographic or clinical characteristics that were associated with implant-related irritation as their primary reason for reoperation.
Collapse
Affiliation(s)
- Charles Bouchard
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Troy D Bornes
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Anelise Silveira
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; Western Upper Limb Facility, Sturgeon Hospital, St. Albert, AB, Canada; Collaborative Orthopaedic Research, University of Alberta, Edmonton, AB, Canada
| | - Riley Hemstock
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Lauren Beaupre
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; Collaborative Orthopaedic Research, University of Alberta, Edmonton, AB, Canada; Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Robert Chan
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; Western Upper Limb Facility, Sturgeon Hospital, St. Albert, AB, Canada.
| |
Collapse
|
8
|
Jia Y, Liu A, Guo T, Chen J, Yu W, Zhai J. Efficacy and safety of tension band wire versus plate for Mayo II olecranon fractures: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:373. [PMID: 35922818 PMCID: PMC9351198 DOI: 10.1186/s13018-022-03262-7] [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: 05/29/2022] [Accepted: 07/24/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose For olecranon fractures, the choice of tension band wire (TBW) or plate fixation has long been controversial. Therefore, this study aimed to evaluate the efficacy and safety of TBW and plate in the treatment of patients with Mayo II olecranon fractures by Meta-analysis.
Methods PubMed, Embase, Cochrane, the Web of Science, China National Knowledge Infrastructure, Wanfang, and China Biomedical Database were searched for randomized controlled trials (RCTs) and cohort studies (CSs) where TBW was compared with plate for Mayo II olecranon fractures (OF). Subsequently, the data were extracted by two reviewers independently and were analysed via RevMan5.4.1. Besides, mean difference (MD), risk ratio (RR), and 95% confidence intervals (CIs) were calculated. Furthermore, Cochrane Risk of Bias Tool 2.0 and Newcastle–Ottawa Scale were adopted for assessing the risk of bias. Results A total of 1RCT and 10 CSs were included, when 449 cases were treated with TBW and 378 with plate. The plate has favourable postoperative long-term (≥ 1 year) functional score in MEPS (MD: − 3.06; 95% CI − 5.50 to 0.62; P = 0.01; I2 = 41%) and Dash score (MD: 2.32; 95% CI 1.91, 2.73; P < 0.00001; I2 = 0%), also carrying fewer complications (RR: 2.13; 95% CI 1.48, 3.08; P < 0.0001; I2 = 58%). Besides, there exists no significant difference in postoperative long-term (≥ 1 year) elbow flexion (MD: − 1.82°; 95% CI − 8.54, 4.90; P = 0.60; I2 = 71%) and extension deficits (MD: 1.52°; 95% CI − 0.38, 3.42; P = 0.12; I2 = 92%). Moreover, TBW is featured with a shorter operation time (MD = − 5.87 min; 95% CI − 7.93, − 3.82; P < 0.00001; I2 = 0) and less intraoperative bleeding (MD: − 5.33 ml; 95% CI − 8.15, − 2.52; P = 0.0002; I2 = 0). In terms of fracture healing time, it is still controversial. Furthermore, the subgroup analysis has revealed that for Mayo IIA OF, the plate has a better outcome in the long-term (≥ 1 year) postoperative MEPS, the Dash score, and the incidence of postoperative complications than TBW, while there is no significant difference in the long-term (≥ 1 year) postoperative elbow motion between two groups. Conclusions Plate has better efficacy and safety for Mayo II OF. Considering that few studies are included in the meta-analysis, more high-quality RCTs are still required to confirm these findings. PROSPERO registration number: CRD42022313855. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03262-7.
Collapse
Affiliation(s)
- Yizhen Jia
- Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Aifeng Liu
- Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China. .,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Tianci Guo
- Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Jixin Chen
- Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Weijie Yu
- Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Jingbo Zhai
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| |
Collapse
|
9
|
Comparative Analysis of Clinical Effects of the Cable-Pin System and Kirschner Wire Tension Band (TBW) Internal Fixation in the Treatment of the Olecranon Fracture. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3073121. [PMID: 35800232 PMCID: PMC9197621 DOI: 10.1155/2022/3073121] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/24/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Abstract
Objective To explore the clinical effects of the cable-pin system and Kirschner wire tension band (TBW) internal fixation in the treatment of the olecranon fracture. Methods Fifty patients with an olecranon fracture were treated in our hospital from April 2018 to March 2020. Patients were randomly divided into control and study groups. The control group was fixed with TBW, and the study group was fixed with the cable-pin system. The operation, the circumference difference between the injured limb and the healthy limb, the VAS score, the excellent and good rate, the recovery of the range of motion of the joint 1 year after operation, and the incidence of postoperative adverse reactions were compared between the two groups. Results In terms of the operation of the two groups, the operation time, intraoperative blood loss, healing time, incision drainage, and hospital stay in the study group were lower than those in the control group (P < 0.05). In the comparison of the circumference difference between the injured limb and the healthy limb, there was no significant difference between the two groups before operation (P > 0.05), but the circumference difference between the injured limb and the healthy limb in the study group was lower than that in the control group at 24 hours, 72 hours, 7 days, and 30 days after operation, and the difference was statistically significant (P < 0.05). There was no significant difference in the VAS score between the two groups before operation, but 7-day VAS scores at 12 h, 24 h, and 72 h after operation in the study group were significantly lower than those in the control group (P < 0.05). The excellent and good rate in the study group was excellent in 18 cases, good in 5 cases, fair in 2 cases, excellent in 7 cases, good in 6 cases, fair in 8 cases, and poor in 4 cases in the control group, and the excellent and good rate in the study group (100.00%) was higher than that in the control group (84.00%), and the difference was statistically significant (P < 0.05). The patients in the two groups were followed-up for one year, and there were no shedding cases in the two groups. In terms of the recovery of range of motion one year after operation, the scores of elbow flexion, extension/degree, and elbow function in the study group were higher than those in the control group (P < 0.05), and the difference was statistically significant (P < 0.05). The incidence of postoperative adverse reactions in the study group (4.00%) was significantly lower than that in the control group (28.00%), and the difference was statistically significant (P < 0.05). The incidence of postoperative adverse reactions was significantly lower in the study group (4.00%) than that in the control group (28.00%), and the difference was statistically significant (P < 0.05), while only 1 patient in the study group had chronic pain, while 7 patients in the control group had incision ulcer (1 case), chronic pain (2 cases), and internal fixation loosening (4 cases). The difference was statistically significant (P < 0.05). Conclusion The cable-pin system for the treatment of an olecranon fracture has the advantages of simple operation, fast fracture healing time, and low incidence of complications, which is a kind of orthopedic internal fixation consumable material in line with biomechanical requirements of the human body.
Collapse
|
10
|
Wagner FC, Hamann A, Maier D, Ophoven C, Yilmaz T, Südkamp NP, Jaeger M, Reising K. Lag screw osteosynthesis of simple olecranon fractures: A biomechanical comparative study. Proc Inst Mech Eng H 2022; 236:841-847. [DOI: 10.1177/09544119221090341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Olecranon fractures are most frequently stabilized by tension band wiring (TBW), which unfortunately leads to relevant implant removal rates due to K-wire migration and soft tissue irritation. As lag screw osteosynthesis (LSO) might be a gentle and effective alternative in simple fracture patterns, the goal of the present study was to biomechanically compare LSO with TBW in simple olecranon fractures at a cadaver model. A simple olecranon fracture (Mayo type IIA) was created in eight pairs of human cadaver elbows, which were pairwise fixed by either TBW or two transcortical 4.0 mm lag screws. Biomechanical testing was conducted as a pulling force, applied to the triceps tendon in a 90° position. First, cyclic loading between 10 and 300 N was performed for 50,000 cycles. Afterward, maximum load was raised by 0.02 N/cycle until construct failure, what was defined as displacement >2 mm. Besides fracture displacement, failure cycle and failure load, the modes of failure were analyzed. Within the first five cycles, there was no significant difference in displacement (median TBW: 0.2 mm; LSO: 0.5 mm; p = 0.091). Both after 2000 (median TBW: 0.2 mm; LSO: 0.6 mm; p = 0.042) and after 20,000 cycles (median TBW: 0.4 mm; LSO: 0.9 mm; p = 0.027), the difference was significant. Failure cycle (median TBW: 72,639 cycles; LSO: 43,429 cycles; p = 0.017) and failure load (median TBW: 702 N; LSO: 303 N; p = 0.025) differed significantly as well. TBW mostly (6/8) failed at the lock of the cerclage wire, whereas most LSO constructs (5/8) failed as a pullout of the proximal fragment. In conclusion, to our biomechanical findings at human cadaver specimens, simple olecranon fractures treated by LSO show higher dislocation rates and lower failure loads compared to conventional TBW and mostly fail by pullout of the proximal fragment.
Collapse
Affiliation(s)
- Ferdinand C Wagner
- Department of Orthopedics and Trauma Surgery, Medical Centre, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- G.E.R.N. Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Alexander Hamann
- G.E.R.N. Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Dirk Maier
- Department of Orthopedics and Trauma Surgery, Medical Centre, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Christian Ophoven
- Department of Orthopedics and Trauma Surgery, Medical Centre, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Tayfun Yilmaz
- Department of Orthopedics and Trauma Surgery, Medical Centre, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Norbert P Südkamp
- Department of Orthopedics and Trauma Surgery, Medical Centre, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- G.E.R.N. Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Jaeger
- Department of Orthopedics and Trauma Surgery, Medical Centre, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Kilian Reising
- Department of Orthopedics and Trauma Surgery, Medical Centre, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- Department of Trauma Surgery, Asklepios Klinikum Hamburg, Hamburg, Germany
| |
Collapse
|
11
|
The Evolution of Olecranon Fractures and Its Fixation Strategies. Indian J Orthop 2022; 56:1385-1393. [PMID: 35928655 PMCID: PMC9283595 DOI: 10.1007/s43465-022-00646-z] [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: 01/12/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Olecranon fractures are a common fracture of the upper extremity. The primary aim was to investigate the evolution of olecranon fractures and fixation method over a period of 12 years. The secondary aim was to compare complication rates of Tension Band Wiring (TBW) and Plate Fixation (PF). MATERIALS AND METHODS Retrospective Study for all patients with surgically treated olecranon fractures from 1 January 2005 to 31 December 2016 from a tertiary trauma center. Records review for demographic, injury characteristics, radiographic classification and configuration, implant choices and complications. Results grouped into three 4-year intervals, analyzed comparatively to establish significant trends over 12 years. RESULTS 262 patients were identified. Demographically, increasing mean age (48.7 to 58.9 years old, p value 0.004) and higher ASA scores (7.1% ASA 3 to 21.0% ASA 3 p value 0.001). Later fractures were more oblique (fracture angle 86.1-100.0 degrees, p value 0.001) and comminuted (Schatzker D type 10.4-30.0%, p value 0.025, single fracture line 94.0-66.0%, p value 0.001). Implant choice, sharp increase in PF compared to TBW (PF 16.0% to PF 80.2%, p value 0.001). Complication-wise, TBW had higher rates of symptomatic implant, implant and bony failures and implant removal. CONCLUSION Demographic and fracture characteristic trends suggest that olecranon fractures are exhibiting fragility fracture characteristics (older age, higher ASA scores, more unstable, oblique and comminuted olecranon fractures). Having a high index of suspicion would alert surgeons to consider use of advanced imaging, utilize appropriate fixation techniques and manage the underlying osteoporosis for secondary fracture prevention. Despite this, trends suggest a potential overutilization of PF particularly for stable fracture patterns and the necessary precaution should be exercised.
Collapse
|
12
|
Steadman JN, Stephens AR, Zhang C, Presson AP, Kazmers NH. Cost Assessment of Plating Versus Tension Band Wiring Constructs for Treating Mayo Type 2A Olecranon Fractures. J Hand Surg Am 2022; 47:311-319. [PMID: 35131112 PMCID: PMC8995360 DOI: 10.1016/j.jhsa.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/30/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Tension band wiring (TBW) or plating may be used for fixation with similar clinical outcomes for adults with displaced Mayo 2A olecranon fractures. The primary hypothesis is that total direct costs (TDCs) for surgery are lower for TBW than plating. Our secondary hypothesis is that combined surgical TDCs are lower for TBW even with a 100% rate of subsequent tension band hardware removal and a 0% rate of plate removal. METHODS Patients who underwent TBW or plating of an isolated unilateral Mayo 2A olecranon fracture between July 2011 and January 2020 at a single academic medical center were identified. Then, TDC for each surgery on plate fixation, TBW, and hardware removal was obtained and converted to 2020 US dollars using information technology cost tools provided by our institution. Finally, relative TDCs were compared between plate fixation and TBW groups using univariate and multivariable generalized estimating equations with log-link. RESULTS Of the 97 included patients, the mean age was 50 ± 21 years, and 48% were female. Tension band wiring and plate fixation were performed on 18% (17/97) and 82% (80/97) of male and female patients, respectively. Demographics were similar between groups, although the finding that plate fixation cost 2.6 times that of TBW within the index surgery was significant in the multivariable model, independent of potential confounders (coefficient 2.55, 95% confidence interval: 2.09-3.10). Additionally, mean TDC remained significantly greater for plate fixation even under the hypothetical situation where 100% TBW were removed, and the plate removal rate was 0% (cost difference 181%). CONCLUSIONS Using TBW relative to plate fixation may improve the cost of care for operative Mayo 2A olecranon fractures. Furthermore, this finding was robust to the rate of hardware removal. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and Decision Analyses III.
Collapse
Affiliation(s)
- Jesse N. Steadman
- University of Utah, School of Medicine, 30N 1900E, Salt Lake City, UT, USA 84132
| | - Andrew R. Stephens
- University of Utah, School of Medicine, 30N 1900E, Salt Lake City, UT, USA 84132
| | - Chong Zhang
- University of Utah, Division of Public Health, 375 Chipeta Way, Salt Lake City, UT, USA 84108
| | - Angela P. Presson
- University of Utah, Division of Public Health, 375 Chipeta Way, Salt Lake City, UT, USA 84108
| | - Nikolas H. Kazmers
- University of Utah, Department of Orthopaedics, 590 Wakara Way, Salt Lake City, UT, USA 84108,Corresponding Author: Nikolas H. Kazmers, MD MSE, 590 Wakara Way, Salt Lake City, UT, USA 84108, , Phone: 248-895-0568
| |
Collapse
|
13
|
Wegmann S, Rausch V, Hackl M, Leschinger T, Scaal M, Müller LP, Wegmann K. Anatomic evaluation of the triceps tendon insertion at the proximal olecranon regarding placement of fracture fixation devices. Surg Radiol Anat 2022; 44:627-634. [PMID: 35301578 PMCID: PMC8960582 DOI: 10.1007/s00276-022-02921-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Olecranon fractures, especially with a small proximal fragment, remain a surgical challenge. Soft tissue irritation and affection of the triceps muscle bear a risk of complications. In order to find an area for a soft-tissue sparing placement of implants in the treatment of olecranon fractures, we aimed to define and measure the segments of the proximal olecranon and evaluate them regarding possible plate placement. METHODS We investigated 82 elbow joints. Ethical approval was obtained from the local ethics committee, After positioning in an arm holder and a posterior approach we described the morphology of the triceps footprint, evaluated and measured the surface area of the triceps and posterior capsule and correlated the results to easily measurable anatomical landmarks. RESULTS We found a bipartite insertional footprint with a superficial tendinous triceps insertion of 218.2 mm2 (± 41.2, range 124.7-343.2), a capsular insertion of 159.3 mm2 (± 30.2, range 99.0-232.1) and a deep, muscular triceps insertion area of 138.1 mm2 (± 30.2, range 79.9-227.5). Olecranon height was 26.7 mm (± 2.3, range 20.5-32.2), and olecranon width was 25.3 mm (± 2.4, range 20.9-30.4). Average correlation between the size of the deep insertion and ulnar (r = 0.314) and radial length (r = 0.298) was obtained. CONCLUSIONS We demonstrated the bipartite morphology of the distal triceps footprint and that the deep muscular triceps insertion area by its measured size could be a possible site for the placement of fracture fixations devices. The size correlates with ulnar and radial length.
Collapse
Affiliation(s)
- Sebastian Wegmann
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany.
- Department for Orthopedic and Trauma Surgery, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Köln, Germany.
| | - V Rausch
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - M Hackl
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - T Leschinger
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - M Scaal
- Faculty of Medicine, Department of Anatomy II, University of Cologne, Cologne, Germany
| | - L P Müller
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - K Wegmann
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| |
Collapse
|
14
|
Wadhwa H, Oquendo YA, Goodnough LH, DeBaun MR, Bishop JA, Gardner MJ. Mini-fragment plating of olecranon fractures is comparable to precontoured small-fragment plating. J Orthop 2022; 30:41-45. [PMID: 35241886 PMCID: PMC8857267 DOI: 10.1016/j.jor.2022.02.009] [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: 12/09/2021] [Revised: 02/06/2022] [Accepted: 02/09/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Though long-term functional outcomes of olecranon fracture plate fixation are favorable, postoperative implant irritation commonly leads to elective removal. We hypothesized that mini-fragment plates will decrease implant removal compared to precontoured plates. METHODS Patients with isolated olecranon fracture (AO/OTA 2U1-B1) treated with plate fixation were retrospectively reviewed. Patients were stratified into groups based on whether they underwent open reduction and internal fixation with a (1) surgeon contoured mini-fragment or (2) precontoured olecranon-specific plate. Rates of symptomatic implants and implant removal were compared. RESULTS 98 and 32 patients were treated with precontoured and mini-fragment plates, respectively. Baseline demographics and comorbidities were similar. Mean follow-up was 20.6 months. There were no differences in rates of postoperative complication (22/98, 22.4% vs. 5/32, 15.6%; p = 0.41) or reoperation (37/98, 37.8% vs. 8/32, 25%; p = 0.19). Symptomatic implants were common in the precontoured cohort (44/98, 44.9% vs. 7/32, 21.9%; p < 0.05). Implant removal rates were 36.7% and 18.8%, respectively (p = 0.06). DISCUSSION/CONCLUSION Olecranon fracture stabilization with mini-fragment plate is associated with lower rates of symptomatic implants, with no difference in postoperative complications or reoperations. Mini-fragment plating is a safe and promising alternative to precontoured plating.
Collapse
Affiliation(s)
| | | | | | | | | | - Michael J. Gardner
- Corresponding author. Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway St., Pavilion C, 4th Floor Redwood City, CA, 94063, USA
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Qiu L, Li Y, Wu H, Chen R, Zhang Z, Wang X, Huang Y. More metalwork removals in patients with olecranon fracture treated by tension band wiring than plate fixation-a propensity score matching analysis. BMC Musculoskelet Disord 2021; 22:692. [PMID: 34389015 PMCID: PMC8364058 DOI: 10.1186/s12891-021-04559-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 07/12/2021] [Indexed: 12/03/2022] Open
Abstract
Background Traditional tension band wiring and plate fixation represent the commonest methods for treating olecranon fractures. However, there is no agreement on which method provides the best outcome. The aim of this retrospective study is to compare the outcomes of tension band wiring (TBW) and plate fixation (PF) for treating displaced olecranon fractures. This is the first study to use propensity score matching analysis to compare treatment methods for olecranon fracture. Method A total of 107 patients aged between 18 and 85 had acute isolated and displaced olecranon fractures. The patients were divided into either TBW (n = 49) or PF (n = 58) groups. To conduct propensity score matching for the treatment method (TBW versus PF), 58 patients were analyzed by logistic regression (29 patients in each group). Various demographic and treatment-related variables were examined and analyzed to determine their correlation. Results Functional effects between two groups are similar (in terms of Mayo Elbow Performance Score (MEPS), the patients’ range of elbow motion (ROM) and forearm rotation (RFR), the time return to work (RTW)). The total adverse events rate and metalwork removal events rate are higher in TBW than that in PF. After propensity score matching analysis, similar primary treatment efficacy (indicated by MEPS> 90) in 2 groups and more primary adverse events (indicated by metalwork removal) were perceived in TBW than that in PF. Logistic regression analysis revealed that fracture type was an independent factor that affected the efficacy of a treatment (regression coefficient = − 1.24 < 0, P = 0.03), indicating that fracture severity was inversely proportional to the efficacy of a treatment for olecranon fracture. Furthermore, logistic regression analysis demonstrated that the treatment method was an independent factor that affected metalwork removal of olecranon fracture (regression coefficient 2.38 > 0, OR = 10.77, P < 0.01), indicating that the risk of metalwork removal in the TBW Group was 10.77 times that in the PF Group. Conclusion When initially discussing the surgical approach with patients, physicians should fully weigh the possibility that TBW may lead to a second surgery due to the higher risk of internal fixation removal and that TBW won’t yield better functional outcomes than PF .
Collapse
Affiliation(s)
- Longhai Qiu
- Department of Traumatology and Orthopaedic Surgery, Institute of Orthopaedics, Huizhou Municipal Central Hospital, Huizhou, Guangdong, 516001, People's Republic of China
| | - Yi Li
- Department of Traumatology and Orthopaedic Surgery, Institute of Orthopaedics, Huizhou Municipal Central Hospital, Huizhou, Guangdong, 516001, People's Republic of China
| | - Hongbo Wu
- Department of Traumatology and Orthopaedic Surgery, Institute of Orthopaedics, Huizhou Municipal Central Hospital, Huizhou, Guangdong, 516001, People's Republic of China
| | - Ruixiong Chen
- Department of Traumatology and Orthopaedic Surgery, Institute of Orthopaedics, Huizhou Municipal Central Hospital, Huizhou, Guangdong, 516001, People's Republic of China
| | - Zhiwen Zhang
- Department of Traumatology and Orthopaedic Surgery, Institute of Orthopaedics, Huizhou Municipal Central Hospital, Huizhou, Guangdong, 516001, People's Republic of China
| | - Xiaofeng Wang
- Department of Traumatology and Orthopaedic Surgery, Institute of Orthopaedics, Huizhou Municipal Central Hospital, Huizhou, Guangdong, 516001, People's Republic of China
| | - Yuliang Huang
- Department of Traumatology and Orthopaedic Surgery, Institute of Orthopaedics, Huizhou Municipal Central Hospital, Huizhou, Guangdong, 516001, People's Republic of China.
| |
Collapse
|
17
|
Masood QM, Qulaghassi M, Grewal U, Bawale R, Kammela M, Singh B. Proximal ulna fractures in adults: A review of diagnosis and management. J Clin Orthop Trauma 2021; 20:101481. [PMID: 34211834 PMCID: PMC8240031 DOI: 10.1016/j.jcot.2021.101481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/13/2021] [Accepted: 06/17/2021] [Indexed: 11/19/2022] Open
Abstract
Proximal ulna fractures are relatively common upper limb injuries, which may represent fragility fractures or result from high-energy trauma. These include fractures of the olecranon, coronoid and associated radial head dislocations. A wide variety of treatment options are available for the management of these injuries that makes the selection of most appropriate treatment difficult. We aim to provide a brief overview of the treatment options for such injuries.
Collapse
Affiliation(s)
| | - Mahdi Qulaghassi
- Medway NHS Foundation Trust, Windmill Road, Gillingham, ME7 5, NY, UK
| | - Urpinder Grewal
- Frimley Park Hospital NHS Foundation Trust, Portsmouth Rd, Frimley, GU16 7UJ, UK
| | - Rajesh Bawale
- Medway NHS Foundation Trust, Windmill Road, Gillingham, ME7 5, NY, UK
| | - Madhavi Kammela
- Medway NHS Foundation Trust, Windmill Road, Gillingham, ME7 5, NY, UK
| | - Bijayendra Singh
- Medway NHS Foundation Trust, Windmill Road, Gillingham, ME7 5, NY, UK
- Corresponding author.
| |
Collapse
|
18
|
Marder RS, Koehler SM, Aibinder WR. The top 50 most cited articles on olecranon fractures: a bibliometric analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:99-106. [PMID: 33740128 DOI: 10.1007/s00590-021-02928-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/06/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Citation analysis has been used to determine the impact of an article in a medical specialty. The purpose of this study was to identify the 50 most cited articles on olecranon fracture outcomes, indications, techniques, procedural descriptions, and complications and analyse their characteristics. METHODS The Web of Science database was used to search for publications related to olecranon fractures. The top 50 most cited articles that met the inclusion criteria were recorded and reviewed in terms of journal and year of publication, country of origin, type of study, and level of evidence. RESULTS The top 50 articles were cited a total of 2165 times and the year of publication ranged from 1957 to 2014. Of the 50 articles identified, 43 were case series correlating with a Level IV evidence designation. The top 50 articles were published in 20 different medical journals and originated from 18 different countries. CONCLUSION The majority of the articles analysed were uncontrolled case series that reported outcomes and complications surrounding the operative treatment of olecranon fractures. The top 50 most influential articles pertaining to olecranon fractures provides physicians and residency programs with a high-yield list of publications to reference on the topic.
Collapse
Affiliation(s)
- Ryan S Marder
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, State University of New York (SUNY), 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, State University of New York (SUNY), 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | - William R Aibinder
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, State University of New York (SUNY), 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA.
| |
Collapse
|
19
|
Çağlar C, Akçaalan S, Özaslan Hİ, Yağar H, Uğurlu M. Comparison of tension band wiring and plate fixation in Mayo type 2A olecranon fractures. Jt Dis Relat Surg 2021; 32:85-92. [PMID: 33463422 PMCID: PMC8073451 DOI: 10.5606/ehc.2021.75812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES This study aims to compare clinically and functionally patients who had previously undergone tension band wiring (TBW) or plate fixation (PF) procedure due to the diagnosis of Mayo type 2A olecranon fracture in our clinic. PATIENTS AND METHODS Data of 92 patients (51 males, 41 females; mean age 42.3±12.6 years; range, 16 to 75 years) operated on for olecranon fractures between January 2014 and December 2018 were recorded retrospectively. Forty-four patients received TBW and 48 patients received PF treatment. Their Disabilities of the Arm, Shoulder, and Hand (DASH) and Mayo scores and elbow range of motion (ROM) measurements were used for clinical and functional evaluations. Data including the time to return to work, revision rate, and follow-up time were also recorded. RESULTS The mean follow-up time was 38.2±17.2 months. Patients returned to work in 9.2±4.1 weeks in the TBW group and 7.8±3.6 weeks in the PF group (p=0.279). The revision rate was 14% in the TBW group and 2% in the PF group (p=0.335). The mean DASH score was 10.0±1.8 in the TBW group and 7.7±1.2 in the PF group (p=0.001). The mean Mayo score was 84.0±9.3 in the TBW group and 88.3±9.1 in the PF group (p=0.049). For elbow flexion-extension ROM, 4° of difference was measured in favor of the PF group (p=0.043). Mean Mayo score, mean DASH score, and mean flexion-extension ROM values were statistically significantly different between the two groups. CONCLUSION Both surgical techniques are suitable and reliable in the treatment of olecranon fractures. Although TBW treatment is low-cost and simple to apply, its biggest disadvantage is a high rate of secondary surgery for implant removal due to irritation of the skin.
Collapse
Affiliation(s)
- Ceyhun Çağlar
- Ankara Şehir Hastanesi Ortopedi ve Travmatoloji Kliniği, 06800 Çankaya, Ankara, Türkiye.
| | | | | | | | | |
Collapse
|
20
|
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.
Collapse
|
21
|
Long-term outcomes after different types of Horne and Tanzer olecranon fractures. Arch Orthop Trauma Surg 2021; 141:709-716. [PMID: 32328720 PMCID: PMC8049928 DOI: 10.1007/s00402-020-03453-z] [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: 10/08/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND It is unclear whether the outcomes differ after different Horne and Tanzer types of olecranon fractures. MATERIALS AND METHODS We evaluated 40 men and 55 women with isolated olecranon fractures, journals and radiographs from fracture event. The fractures were classified according to Horne and Tanzer. After a mean 19 years after the fracture events, we evaluated subjective, clinical and radiographic outcomes, using the uninjured arms as controls. RESULTS 95% of patients with type I fractures reported, at follow-up, no differences between the elbows, 80% with type II fractures and 95% with type III fractures (p = 0.43). The three types of fractures had no differences in elbow range of motion or hand grip strength (when comparing injured and uninjured arms) and the proportions of individuals with radiographic elbow degenerative changes or joint space reduction were no different (all p > 0.05). Individuals with elbow degenerative changes had no inferior subjective elbow function compared to individuals with normal radiographs (p = 0.66), in contrast to those with joint space reduction compared to individuals with normal radiographs (p < 0.001). INTERPRETATION All types of Horne and Tanzer olecranon fractures have favourable long-term outcome. Elbow joint space reduction is associated with inferior subjective elbow function while degenerative changes are not.
Collapse
|
22
|
Crozier-Shaw G, Mahon J, Bayer TC. The use of bioabsorbable compression screws & polyethylene tension band for fixation of displaced olecranon fractures. J Orthop 2020; 22:525-529. [PMID: 33132626 PMCID: PMC7588653 DOI: 10.1016/j.jor.2020.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/03/2020] [Accepted: 08/26/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Transverse fractures of the olecranon are commonly fixed using tension-band wiring techniques. However the superficial nature of this area leads to high complication rates requiring removal of metalwork. The purpose of this retrospective study is to report and evaluate functional outcomes of polyethylene tension-band and bioabsorbable Magnesium alloy screw fixation of olecranon fractures. METHODS A retrospective case-control study was undertaken. Demographics, injury type and post-operative details were collected. All patients were treated in the same institution by a single surgeon. Primary outcomes included radiographic healing and post-operative range of motion. Secondary outcome was post-operative complications. RESULTS A total of five cases were identified. Mean age was 52.4. The control group was made up of six patients treated with a traditional tension band wire fixation. One patient in study group was lost to follow up. 80% of fractures in study group demonstrated anatomic post-operative radiographic union, compared with 83% of control group. All patients had range of motion above 100°, with full protonation and supination. One patient did have an extension lag of 15°. CONCLUSION Surgical repair of olecranon fractures is often complicated by the need for re-operation. This method provides both intramedullary fixation and conversion of distraction forces to compression forces with bioabsorbable materials, and aims to reduce the high re-operation rates commonly seen by avoiding the use of permanent indwelling metal hardware.
Collapse
Affiliation(s)
- Geoff Crozier-Shaw
- Department of Trauma and Orthopaedic Surgery, Midland Regional Hospital Tullamore, Co Offaly, Ireland
| | - John Mahon
- Department of Trauma and Orthopaedic Surgery, Midland Regional Hospital Tullamore, Co Offaly, Ireland
| | - Thomas C. Bayer
- Department of Trauma and Orthopaedic Surgery, Midland Regional Hospital Tullamore, Co Offaly, Ireland
| |
Collapse
|
23
|
Ellwein A, Lill H, Warnhoff M, Hackl M, Wegmann K, Müller LP, Gramlich Y, Hoffmann R, Klug A. Can low-profile double-plate osteosynthesis for olecranon fractures reduce implant removal? A retrospective multicenter study. J Shoulder Elbow Surg 2020; 29:1275-1281. [PMID: 32284307 DOI: 10.1016/j.jse.2020.01.091] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Because of poor soft-tissue coverage at the proximal ulna and prominent posteriorly positioned implants, hardware removal remains the most common reason for revision surgery of olecranon fractures that were operatively treated using plate osteosynthesis. We hypothesized that low-profile double-plate osteosynthesis would reduce the number of soft tissue-related hardware removals compared with single posterior plating whereas the functional results would be comparable. METHODS This study retrospectively included patients who were treated with low-profile double-plate osteosynthesis or a posterior 2.7-/3.5-mm locking compression plate (LCP) for isolated olecranon fractures from 3 study centers. In addition to the implant removal rate, functional outcome measures (range of motion; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score) were statistically compared. RESULTS The study included 79 patients, with a mean follow-up period of 36 months (range, 24-77 months). Of these patients, 37 were treated with low-profile double-plate osteosynthesis and 42, with a 2.7-/3.5-mm LCP. The mean age was 57 years (range, 18-93 years). Range of motion after treatment with low-profile double-plate osteosynthesis and a 2.7-/3.5-mm LCP measured 129° (range, 80°-155°) and 139° (range, 100°-155°), respectively. The Mayo Elbow Performance Scores were 95 (range, 65-100) and 99 (range, 85-100), respectively (P = .028), and the Disabilities of the Arm, Shoulder and Hand scores were 5.0 (range, 0-49) and 4.6 (range, 0-28), respectively (P = .673). Hardware was removed in 32% and 50% of patients after treatment with double-plate osteosynthesis and a 2.7-/3.5-mm LCP, respectively (P = .11). Hardware removal owing to soft-tissue irritation was noted in 27% of patients after double-plate osteosynthesis and 38% after LCP treatment (P = .30). DISCUSSION Low-profile double-plate osteosynthesis for treating olecranon fractures resulted in good clinical outcomes. However, the rate of hardware removal was not significantly reduced, and the functional results were comparable to those of common single-posterior plate osteosynthesis.
Collapse
Affiliation(s)
- Alexander Ellwein
- Department for Orthopaedic Surgery, Medical School Hannover, Diakovere Annastift, Hannover, Germany; Department for Orthopaedic Surgery and Traumatology, Diakovere Friederikenstift, Hannover, Germany.
| | - Helmut Lill
- Department for Orthopaedic Surgery and Traumatology, Diakovere Friederikenstift, Hannover, Germany
| | - Mara Warnhoff
- Department for Orthopaedic Surgery and Traumatology, Diakovere Friederikenstift, Hannover, Germany
| | - Michael Hackl
- Department for Orthopaedic and Trauma Surgery, University Medical Center of Cologne, Cologne, Germany
| | - Kilian Wegmann
- Department for Orthopaedic and Trauma Surgery, University Medical Center of Cologne, Cologne, Germany
| | - Lars-Peter Müller
- Department for Orthopaedic and Trauma Surgery, University Medical Center of Cologne, Cologne, Germany
| | - Yves Gramlich
- Department for Traumatology and Orthopaedic Surgery, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department for Traumatology and Orthopaedic Surgery, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Alexander Klug
- Department for Traumatology and Orthopaedic Surgery, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| |
Collapse
|
24
|
Sinha S, Maharjan R, Khanal GP, Pokharel B, Drolia N, Gupta S, Kanojia RK, Chaudhary P. Comparison of Functional and Radiological Outcomes of Olecranon Fractures Treated with Tension Band Wiring with Kirschner Wires to Transcortical Screw Fixation-A Randomised Controlled Study. Strategies Trauma Limb Reconstr 2020; 15:131-137. [PMID: 34025792 PMCID: PMC8121108 DOI: 10.5005/jp-journals-10080-1510] [Citation(s) in RCA: 2] [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] [Indexed: 11/23/2022] Open
Abstract
Aim To compare the clinical and radiological outcomes of fixation of olecranon fractures by a transcortical screw with conventional tension band wiring (TBW) using a Kirschner wire (K-wire). Materials and methods This is a non-blinded randomised controlled trial comprising two groups (n = 30 each) with Mayo type A olecranon fractures fixed with either TBW or transcortical cancellous screws (CCS). Outcomes included the Mayo elbow performance index (MEPI), time to union, range of motion (ROM), and rates of complication among these two groups. Results Most of the patients showed excellent scoring as per MEPI in both the groups at 6 weeks (90% in TBW group and 76.7% in CCS group) and were not significant (p = 0.719). Signs of the radiological union were noted in 80% of the cases at 6 weeks and complete at 6 months. Hardware-related complications (8.3% symptomatic hardware and 6.7% implant back-out), infection, and mean ROM were similar between the two groups (elbow flexion was 142.33 ± 24.67° in TBW group and 143.1 ± 10.19° in transcortical screw group, p = 0.246) at the end of the study. Conclusion There were no statistically significant differences in the clinical–radiological outcomes and complications fixing the non-comminuted olecranon fractures with either transcortical screw or TBW. Clinical significance Transcortical screw fixation is an acceptable alternative to TBW for non-comminuted olecranon fractures in terms of union and functional outcome. How to cite this article Sinha S, Maharjan R, Khanal GP, et al. Comparison of Functional and Radiological Outcomes of Olecranon Fractures Treated with Tension Band Wiring with Kirschner Wires to Transcortical Screw Fixation—A Randomised Controlled Study. Strategies Trauma Limb Reconstr 2020;15(3):131–137.
Collapse
Affiliation(s)
- Siddhartha Sinha
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Rajiv Maharjan
- Department of Orthopaedics, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Guru P Khanal
- Department of Orthopaedics, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Bishnu Pokharel
- Department of Orthopaedics, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Nikhil Drolia
- Patliputra Multispeciality Hospital, Dhanbad, Jharkhand, India
| | - Sumit Gupta
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Rajesh K Kanojia
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Pashupati Chaudhary
- Department of Orthopaedics, B P Koirala Institute of Health Sciences, Dharan, Nepal
| |
Collapse
|