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

Abstract

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.

Methods: We reviewed 62 patients (33 men and 29 women) with an average age of 48.6 years (range, 18-85 years) who underwent TBW osteosynthesis for isolated olecranon fractures. All patients were assessed both clinically with measurement of flexion-extension and pronation-supination arcs and radiologically with elbow X-Rays. Functional outcome was estimated using the Mayo Elbow Performance Score (MEPS), Visual Analogue Scale (VAS) subjective pain score and VAS patient satisfaction score. Follow up: 6-13 years (average 8.2 years).

Results: There was a higher prevalence of fractures among men until the 5th decade of life and among women in elderly (p = 0.032). Slip or simple fall onto the arm was the main mechanism of injury for 38 fractures (61.3%) while high energy trauma, such as fall from a height (> 2 m) or road accident, was reported in 24 fractures (38.7%). Hardware removal performed in 51 patients (82.3%) but 34 of them (66.6% of removals) were still complaining for mild pain during daily activities. The incidence of pin migration and loosening was not statistically decreased when penetration of the anterior ulnar cortex was accomplished (p = 0.304). Supination was more often affected than pronation (p = 0.027). According to MEPS, 53 patients (85.5%) had a good to excellent result, 6 (9.7%) fair and 3 (4.8%) poor result. The average satisfaction rating was 9.3 out of 10 (range, 6-10) with 31 patients (50%) to remain completely satisfied from the final result. Degenerative changes recorded in 30 elbows (48.4%). However, no correlation could be found between radiographic findings and MEPS (p = 0.073).

Conclusion: Tension band wiring fixation remains the "gold standard" for the treatment of displaced and minimally comminuted olecranon fractures. In long term, low levels of pain may be evident regardless of whether the metalware is removed and degenerative changes have been developed.

Figure 1

Mayo Classification for olecranon fractures. Adapted from [4].

Figure 2

Distribution of olecranon fractures according to sex and age.

Figure 3

Pin migration. Lateral radiograph of the right elbow 2 years after TBW of an isolated olecranon fracture in a 42-year-old woman. Despite fracture union, backing out of K-wires was evident. The patient was complaining for pain during elbow movements (VAS pain subjective score = 4) and skin irritation. Removal of metalwork was followed by partial resolution of symptoms as mild discomfort was reported even 8 years postopeartively (VAS pain subjective score = 2).

Figure 4

Visual Analogue Scale (VAS) subjective pain score in patients before and after hardware removal.

Figure 5

Mayo Elbow Performance score (MEPS) (a) and Visual Analogue Scale (VAS) patient satisfaction score (b).

Figure 6

Elbow degeneration and olecranon fracture. Mayo Type IIA fracture of the left olecranon after a fall in a 52-year-old woman (A). Lateral (B) and anteroposterior radiographs (C) at 7 years postoperatively showed signs of subchondral sclerosis and osteophytes formation in radioulnar and ulnohumeral joints.