Cyclic loading of olecranon fracture fixation constructs

BACKGROUND: Despite the good results that are usually reported after fixation at the sites of olecranon fractures and osteotomies, problems such as loss of fixation, nonunion, and the need for revision surgery are still encountered. Various types of fixation have been recommended, but few have been evaluated with use of clinically relevant cyclic load testing at appropriate levels of stress. The purpose of the present study was to test multiple olecranon fixation techniques under physiologic cyclic loads. METHODS: We studied ten cadaveric elbows with use of cyclic loading that simulated (1) active range of motion and (2) pushing up from a chair. Each specimen underwent fixation of a simulated 50% transverse olecranon fracture with use of intramedullary and cortically fixed tension band constructs (in randomized order) followed by fixation with a 7.3-mm-diameter cancellous screw with and without a tension band. Displacement transducers were placed posteriorly on the tension side and anteriorly near the articular surface. RESULTS: Both configurations involving the 7.3-mm-diameter cancellous screw provided the most stable fixation-nearly five times better than that provided by the Kirschner-wire techniques. Use of the tension band in conjunction with the intramedullary screw improved the stability of fixation. In none of the constructs did the AO tension band result in compression across the osteotomy gap. CONCLUSIONS AND CLINICAL RELEVANCE: The use of a 7.3-mm screw in conjunction with a tension band provided better fixation of simulated displaced transverse fractures than did the use of Kirschner wires in conjunction with a tension band or the use of a screw only. The AO principle of converting posterior tensile forces to articular compressive forces was not demonstrated in this study. We therefore question the validity of the tension band concept in olecranon fracture fixation and recommend passive rather than active range of motion in the immediate postoperative period to limit fracture distraction.     

Pediatric olecranon fractures: open reduction and internal fixation with removable Kirschner wires and absorbable sutures

The authors present an original fixation technique for pediatric olecranon fractures that avoids reoperation to remove hardware as compared with the standard fixation technique with Kirschner wires and tension band wiring as advocated by the AO technique. The authors' technique uses two percutaneously placed Kirschner wires to fixate displaced transverse and oblique olecranon fractures. Prior to the insertion of the wires, the fracture is reduced through a standard open approach. Augmentation of the pin fixation is achieved with absorbable sutures. Six patients have been treated with this technique, with a mean follow-up of 13 months. No immediate complications have been noted; one patient has a loss of extension of 10 degrees at the elbow. Radiographic results are good, with no loss of reduction. This technique avoids the need for reoperation for hardware removal without compromising the quality of reduction.     

A survey of current practices and preferences for internal fixation of displaced olecranon fractures

Background

Olecranon fractures represent 10% of upper extremity fractures. There is a growing body of literature to support the use of plate fixation for displaced olecranon fractures. The purpose of this survey was to gauge Canadian surgeons’ practices and preferences for internal fixation methods for displaced olecranon fractures.

Methods

Using an online survey tool, we administered a cross-sectional survey to examine current practice for fixation of displaced olecranon fractures.

Results

We received 256 completed surveys for a response rate of 31% (95% confidence interval [CI] 30.5–37.5%). The preferred treatment was tension band wiring (78.5%, 95% CI 73–83%) for simple displaced olecranon fractures (Mayo IIA) and plating (81%, 95% CI 75.5–85%) for displaced comminuted olecranon fractures (Mayo IIB). Fracture morphology with a mean impact of 3.31 (95% CI 3.17–3.45) and comminution with a mean impact of 3.34 (95% CI 3.21–3.46) were the 2 factors influencing surgeons’ choice of fixation method the most. The major deterrent to using tension band wiring for displaced comminuted fractures (Mayo IIB) was increased stability obtained with other methods described by 75% (95% CI 69–80%) of respondents. The major deterrent for using plating constructs for simple displaced fractures (Mayo IIA) was better outcomes with other methods. Hardware prominence was the most commonly perceived complication using either method of fixation: 77% (95% CI 71.4–81.7%) and 76.2% (95% CI 70.6–81.0%) for tension band wiring and plating, respectively.

Conclusion

Divergence exists with current literature and surgeon preference for fixation of displaced olecranon fractures.     

The olecranon sled—a new device for fixation of fractures of the olecranon: A mechanical comparison of two fixation methods in cadaver elbows

Background?Tension band wiring is the most common surgical procedure for fixation of fractures of the olecranon, but symptomatic hardware prominence and migration of K-wires can cause a high re-operation rate. The olecranon sled has been designed to minimize some of these problems.

Material and methods?Simulated olecranon fractures were created in 6 matched pairs of cadaver arms. Each pair was fixed with tension band wiring used on the one arm and the olecranon sled being used on the other. Mechanical testing was done with the humerus rigidly fixed in a vertical position while the forearm was held at 1 of 3 angles of elbow fixation, 45°, 90° and 135°, respectively. For each angle, the triceps and the brachialis muscles were sequentially loaded with 5?kg (50?N) for 20 cycles and the amount of fracture displacement measured.

Results?Loading of the brachialis muscle produced no increase in the fracture gap for either of the two fixation techniques. However, an increase in the fracture gap of up to 0.23?mm was found after cyclic loading of the triceps muscle for both techniques. The amount of increase was not significantly different between the two techniques.

Interpretation?The olecranon sled appears to provide as stable fixation as tension band wiring for olecranon fractures.     

The olecranon sled--a new device for fixation of fractures of the olecranon: a mechanical comparison of two fixation methods in cadaver elbows

Background Tension band wiring is the most common surgical procedure for fixation of fractures of the olecranon, but symptomatic hardware prominence and migration of K-wires can cause a high re-operation rate. The olecranon sled has been designed to minimize some of these problems.

Material and methods Simulated olecranon fractures were created in 6 matched pairs of cadaver arms. Each pair was fixed with tension band wiring used on the one arm and the olecranon sled being used on the other. Mechanical testing was done with the humerus rigidly fixed in a vertical position while the forearm was held at 1 of 3 angles of elbow fixation, 45°, 90° and 135°, respectively. For each angle, the triceps and the brachialis muscles were sequentially loaded with 5 kg (50 N) for 20 cycles and the amount of fracture displacement measured.

Results Loading of the brachialis muscle produced no increase in the fracture gap for either of the two fixation techniques. However, an increase in the fracture gap of up to 0.23 mm was found after cyclic loading of the triceps muscle for both techniques. The amount of increase was not significantly different between the two techniques.

Interpretation The olecranon sled appears to provide as stable fixation as tension band wiring for olecranon fractures.     

Olecranon fractures: factors influencing re-operation

Purpose

We evaluated factors influencing re-operation in tension band and plating of isolated olecranon fractures.

Methods

Four hundred eighty-nine patients with isolated olecranon fractures who underwent tension band (TB) or open reduction internal fixation (ORIF) from 2003 to 2013 were identified at an urban level 1 trauma centre. Medical records were reviewed for patient information and complications, including infection, nonunion, malunion, loss of function or hardware complication requiring an unplanned surgical intervention. Electronic radiographs of these patients were reviewed to identify Orthopaedic Trauma Association (OTA) fracture classification and patients who underwent TB or ORIF.

Results

One hundred seventy-seven patients met inclusion criteria of isolated olecranon fractures. TB was used for fixation in 43 patients and ORIF in 134. No statistical significance was found when comparing complication rates in open versus closed olecranon fractures. In a multivariate analysis, the key factor in outcome was method of fixation. Overall, there were higher rates of infection and hardware removal in the TB compared with the ORIF group.

Conclusions

Our results demonstrate that the dominant factor driving re-operation in isolated olecranon fractures is type of fixation. When controlling for all variables, there is an increased chance of re-operation in patients with TB fixation.     

Olecranon fractures: different surgical techniques

Numerous systems of osteosynthesis of olecranon fractures are avaible. The numero-ulnar articulation badly bears the smallest incongruence and easily faces rigidity. Therefore the aim of therapy is the anatomical and permanent reconstruction of the articular surface of the olecranon, in order to mobilize the elbow as soon as possible. We analyzed 85 olecranon fractures, classified according to Merle d'Aubignè and treated with two different surgical techniques (intramedullart screw and AO tension band wiring technique). The results were compared at an average follow-up of 88 months. Excellent clinical results were obtained in 74,12%, good in 29.00%, sufficient 3,53%, insufficient in 2,35% of patients, with a mean of recovery in 2 months and only 2 cases of pseudoarthrosis (with dynamic procedure). Objective results were similar for two techniques adopted, whereas the subjective results in patients with screw. The screw is more suitable in medio-olecranic and basis-olecranic fractures, while the dynamic procedure gives better results in fractures of the apex of olecranon and comminute fracture. Tolerance of the intramedullary screw has generally proved to be better (65% of cases), while the dynamic assembling has been removed in most cases after fracture consolidation. Periarticular calcifications correlated with the type of fracture (e. g. comminuted, associated) rather than with the means of synthesis employed. Received: 8 February 2001/Accepted: 4 September 2001     

Olecranon fractures. A clinical and radiographic comparison of tension band wiring and plate fixation.

Forty-one adult patients with displaced olecranon fractures were treated with open reduction internal fixation in a prospective, randomized study comparing tension band wiring (TBW) and plate fixation (PF). Plate fixation required longer operative time, but did not lead to an increased complication rate. Range of elbow motion at six months did not differ significantly between the two groups. Symptomatic metal prominence was frequently observed after TBW (42%), although true Kirschner wire (K-wire) migration was seen in only one patient. Postoperative loss of reduction, leading to a significant articular step-off or gap, was more frequent after TBW (53%) than after PF (5%). Tension band wiring resulted in 37% good clinical and 47% good roentgenographic results, as compared with PF, which resulted in 63% good clinical and 86% good roentgenographic results. Plate fixation should be carefully considered when planning open reduction and internal fixation of displaced olecranon fractures.     

Displaced olecranon fractures in adults. Clinical evaluation

Displaced fractures of the olecranon in adults were analyzed for pain, function, range of motion, and roentgenographic appearance. With one exception, the 38 transverse or oblique fractures were treated by reduction and internal fixation. Results were best in the group treated by screw plus wire in combination (average rating, 17.7 points). Other ratings averaged 17.2 for the intramedullary screw, 16.8 for figure-of-eight wire, and 16.7 for Arbeitsgemeinschaft fur osteosynthesefragen (AO) tension-band wire. Factors associated with poorer results included postoperative displacement or malreduction greater than or equal to 2 mm and articular involvement greater than or equal to 60%. Symptomatic metal prominence was particularly common after AO tension-band wiring, occurring in 80%. All seven comminuted fractures were treated by primary excision. The one comminuted fracture with greater than or equal to 60% articular involvement that was treated by excision had a poor result because of instability.     

Displaced olecranon fractures in adults. Biomechanical analysis of fixation methods

Four commonly used methods of internal fixation for displaced olecranon fractures were analyzed in a biomechanical model to determine strength of fixation. A transverse osteotomy in fresh cadaver specimens was internally fixed and was tested to failure by rapid loading. Screw plus wire in combination provided the greatest strength of fixation. Energy to failure averaged 31.0 Nm for cancellous screw, 32.0 Nm for figure-of-eight wire, 35.3 Nm for Arbeitsgemeinschaft fur Osteosynthesefragen (AO) tension band, and 39.4 Nm for screw-plus-wire combination. Comparison of screw and wire in combination to screw alone or to figure-of-eight wire demonstrated a significant difference (p less than 0.05). The difference between screw plus wire and AO tension-band fixation did not achieve statistical significance (0.2 greater than p greater than 0.1).     

Treatment of complex proximal humeral fractures with minimally invasive fixation of the humeral head combined with flexible intramedullary wire fixation – introduction of a new treatment concept

The treatment of three- or 4-part proximal humerus fractures is still a matter of scientific discussion. The following study presents the results of a combined procedure using limited invasive fixation techniques for reconstruction of the humerus head and retrograde intramedullary wiring with elastic nails for the treatment of displaced three- or 4-part fractures. A prospective study of 24 patients with 3-part and 4-part fractures was performed from September 1995 to December 1998. Combined biologic fixation for reconstruction of the humerus head, including intramedullary wiring, was utilized. Fracture reduction was performed in an open soft-tissue-preserving technique through a limited lateral approach. Fixation of the head fragments was performed using screw and/or cerclage wire fixation. The reconstructed humerus head was stabilized to the shaft with intramedullary wires, with retrograde insertion 2 cm above the olecranon fossa. Supportive fixation of the head fragments was achieved using fully threaded cancellous screws. At the 1-year postoperative follow-up, 40% of the 18 patients had excellent results using the Neer and Constant score. Forty-five percent had satisfactory and 15% unsatisfactory results. The initial results of this study reveal that a combination of limited internal fixation of the humerus head and retrograde elastic intramedullary wiring provide stable fixation with limited soft-tissue destruction. This approach has been shown to be especially useful for the combined treatment of three- or four-part fractures of the humeral head.     

Is tension band wiring technique the "gold standard" for the treatment of olecranon fractures? A long term functional outcome study

Background  

Tension band wiring (TBW) remains the most common operative technique for the internal fixation of olecranon fractures despite the potential occurrence of subjective complaints due to subcutaneous position of the hardware. Aim of this long term retrospective study was to evaluate the elbow function and the patient-rated outcome after TBW fixation of olecranon fractures.     

Behandlung von isolierten Olekranonfrakturen

Background

Isolated fractures of the olecranon account for 7-10% of all osseous injuries in adults. These fractures are usually treated surgically by conventional tension band wiring. The percutaneous double-screw fixation is an optional treatment in patients with two fragment olecranon fractures with some postoperative advantages.

Patients and methods

A total of 13 patients with isolated fractures of the olecranon (Schatzker-Schmelling type A) treated by percutaneous double-screw fixation were included in this prospective study. The mean age of patients was 43.6 ± 11.0 years. Intraoperative and postoperative complications were recorded. Functional results were assessed after a mean follow-up of 38.2 ± 11.5 months using the Quick-DASH score. The results were compared with those obtained in the control group including 26 patients treated by conventional tension band wiring.

Results

No intraoperative complications were observed in both groups. In the group with percutaneous double-screw fixation the scar length was significantly shorter (2.4 ± 0.4 cm vs. 11.0 ± 1.8 cm, p < 0.001) and the hardware removal was substantially less frequent that in the group with conventional tension band wiring with 38.5 % and 73.1 %, respectively. At the minimum follow-up of 2 years comparable functional results were obtained in both groups (Quick-DASH score 2.3 vs. 0.0 points, respectively, p = 0.155); however, the range of elbow motionwas significantly higher in the group with percutaneous double-screw fixation (extension/flexion 145° vs. 130°, p < 0.001; pronation/supination 165° vs. 155°, p < 0.001).

Conclusions

The percutaneous double-screw fixation is a safe and viable treatment option in patients with isolated fractures of the olecranon (Schatzker-Schmelling type A). The functional results regarding DASH scores obtained using this technique were comparable with those observed in patients with conventional tension band wiring; however, range of elbow motion and cosmetic results were significantly better in the patient group with percutaneous double-screw fixation.     

Complications and re-operation rate after tension-band wiring of olecranon fractures

Tension-band wire fixation of olecranon fractures leads to a high re-operation rate because of the need to remove the metalware. This problem has commonly been thought to be related mainly to the backing-out of the Kirschner wires. A retrospective study was carried out in 55 patients with displaced olecranon fractures operated on with the tension-band wiring technique, in whom there was an overall 71.7% re-operation rate. Complications were few and minor in most patients. The main reason for the removal of the metalware was a direct complaint from the patient (in 61.3% of all removals). A literature review analyzing the causes of metalware removal is also presented. Received: May 17, 1999 / Accepted: December 13, 1999     

Open intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children

PURPOSE. To compare the outcomes of intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children aged older than 10 years. METHODS. Records of 32 children aged 10 to 15 (mean, 12) years with displaced fractures of the radius and ulna were retrospectively reviewed. 17 boys and 4 girls underwent intramedullary Kirschner wiring, whereas 10 boys and one girl underwent plating. All patients had been initially treated with closed reduction and casting. Indications for surgical intervention were fractures with angulation of >10 degrees and total displacement. Patients were followed up for a mean of 24 (range, 13-40) months. Angulation and range of movements of the elbow, wrist, and forearm, as well as clinical and cosmetic results were compared. RESULTS. Both treatments achieved excellent clinical outcomes, but intramedullary Kirschner wiring resulted in better cosmesis, shorter operating times, easier hardware removal, and lower implant costs. CONCLUSION. Intramedullary Kirschner wiring is a better option than plating for the treatment of unstable forearm fractures in older children.     

Posterior olecranon plating: biomechanical and clinical evaluation of a new operative technique

The purpose of this investigation was to compare the biomechanical analysis of a new plating technique for olecranon fractures to tension band wiring, and review early clinical results. Six matched pairs of cadaveric ulnae were used for the biomechanical analysis. A transverse osteotomy of the mid part of the olecranon was made. One ulna of each pair was stabilized using a tension band and the other with a posterior hook plate. The ulnae were mounted and loaded, and displacement at the osteotomy site recorded. Twenty patients treated with this new technique (14 fractures and 6 osteotomies) were reviewed at one year (range: 8 to 18 months) for infection, union rate, hardware related complaints. and removal. Statistical analysis showed significantly less displacement occurred at the osteotomy site in the plating group. Clinically, all patients had fracture union, and there were no hardware related problems. Posterior plating with this technique achieves greater stability compared to tension band wiring. Early clinical results indicate a low level of hardware related complications.     

国产可吸收螺钉在尺骨鹰嘴骨折中的临床应用

目的 探讨国产聚-DL-乳酸可吸收螺钉治疗尺骨鹰嘴骨折的效果. 方法 1999年12月至2006年12月,对54例尺骨鹰嘴骨折分别采用国产聚-DL-乳酸可吸收螺钉(22例)和张力带钢丝(32例)同定,对两组的疗效进行对比.结果 所有患者均一期愈合,随访7～49个月(平均24.8个月).按照Weseley标准评定肘关节功能:螺钉组优良率为90.9%(20/22).无肘后疼痛及局部隆起,螺钉致上尺桡关节固定1例,术后5个月时旋转功能完全恢复.1例伴尺桡骨中段骨折者于术后2周复查X线片时发现鹰嘴骨折部内固定失效,骨折块分离移位,改行张力带钢丝固定,术后12个月复查,肘关节功能为良.张力带组优良率为93.8%(30/32),无内固定失效,肘后隆起伴活动时刺痛9例(28.1%),X线片显示克氏针退针3例(9.4%).所有患者均在手术后8～15个月内行第二次手术,取出内固定物.经非参数检验(Wilcoxon检验),两组优良率差异无统计学意义(W=845.0,P=0.485). 结论 国产聚-DL-乳酸可吸收螺钉完全能用于治疗尺骨鹰嘴横形、斜形及骨块较大且相对完整的粉碎性骨折,且效果满意.由于可吸收螺钉能完全降解,避免二次手术,在减少患者治疗时间和费用、更快恢复原有工作方面具有明显的优势.     

Functional Outcomes Following Plating or Tension Band Wiring of Olecranon Fractures

Purpose:   

To evaluate the outcome following internal fixation of olecranon fractures using the techniques of tension band wiring and plating. Design: retrospective evaluation. Setting: regional trauma center.     

Transverse fractures of the olecranon: a biomechanical comparison of three fixation techniques

Introduction  

The gold standard for treating transverse olecranon fractures is tension band fixation. A problem with this technique is migration of the K-wires leading to premature hardware removal. The aim of this study is to compare stability provided by two new techniques designed to eliminate the problem with backing out of K-wires, with that of the recommended tension band technique, performed with a biomechanical in vitro investigation. Our hypothesis was that the two new techniques would provide at least equal stability as the traditional tension band fixation.     

Surgical treatment of displaced olecranon fractures by tension band wiring technique

Forty-five displaced olecranon fractures including 14 accompanying dislocated radial heads and seven radial head fractures were treated over a 13-year period by the tension band wiring technique. The use of supplemental internal fixation when necessary allows excellent results with the use of this technique, even in the presence of severe comminution or radial head dislocation. Primary silicone radial head implants fractured in all three patients in which they were used, necessitating repeat surgery in two patients to date. While loss of motion in terminal extension was a common aftermath of displaced olecranon fracture (59%), it was usually minor and functionally insignificant. True Kirschner-wire migration was not a common problem and can probably be eliminated by proper technique. The presence of gaps in the intraarticular surface of the semilunar notch of the ulna produced no ill effects and was compatible with excellent results. If only those cases with isolated olecranon fractures in this series are considered, there were good and excellent results in 29 of 30 cases (97%). Excision of the olecranon fragment(s) should be reserved for those cases when anatomic restoration cannot be achieved with internal fixation.