Tension band wiring in olecranon fractures: the myth of technical simplicity and osteosynthetical perfection

Abstract

Purpose: The tension band wiring (TBW) technique is a common treatment for the fixation of olecranon fractures with up to three fragments. The literature and surgeons describe TBW as an uncomplicated, always available and convenient operation producing excellent results. The purpose of this study was to determine whether TBW is more ambitious than believed or the procedure provides an increased level of tolerance concerning the surgical technique.

Methods: This study reviewed 239 TBW cases in patients with olecranon fractures or osteotomies. We reviewed a total of 2,252 X-rays for ten operative imperfections: (1) nonparallel K-wires, (2) long K-wires, (3) K-wires extending radially outwards, (4) insufficient fixation of the proximal ends of the K-wires, (5) intramedullary K-wires, (6) perforation of the joint surface, (7) single wire knot, (8) jutting wire knot(s), (9) loose figure-of-eight configuration, and (10) incorrect repositioning.

Results: On average, there were 4.24 imperfections per intervention in the cases reviewed. A total of 1,014 of 2,390 possible imperfections were detected. The most frequent imperfections were insufficient fixation of the proximal ends of the K-wires (91% of all cases), the use of a single wire knot (78%) and nonparallel K-wires (72%). Mayo IIa (n = 188) was the most common fracture type.

Conclusions: Our results and the number of complications described by the literature together support the conclusion that TBW is not as easy as surgeons and the literature suggest. Although bone healing and the functional results of TBW are excellent in most cases, the challenges associated with this operation are underestimated.

Level of evidence: IV, treatment study.

Fig. 1

Intraoperative radiographs of the elbow joint in anteroposterior and lateral projection (example for adequate, but not ‘perfect’, tension band wiring after olecranon fracture because of the use of a single wire knot, an insufficient fixation of one K-wire end and a loose figure-of-eight configuration)

Fig. 2

Possible imperfections of tension band wiring (modified from [21])

Fig. 3

Frequency scale of surgeries with (x) imperfections

Fig. 4

Frequency distribution of detected imperfections in 239 cases

Fig. 5

Overview of the number of cases classified by Mayo Clinic classification

Fig. 6

These radiographs show non-parallel K-wires, K-wires surmounting the contralateral cortex by far, a jutting wire knot and the use of a third K-wire

Fig. 7

In this case the surgeon used two figure-of-eight configurations with one of the drilling channels being close to the cortex (risk of avulsion). In addition, the proximal ends of the K-wires are not sufficiently anchored into the bone and a fracture gap imposes postoperatively

Fig. 8

An insufficient fixation of proximal ends of the K-wires and the use of one wire knot are visible. Even more striking are the perforation of the joint surface and the fact that one K-wire surmounts the far cortex too far

Fig. 9

In this tension band wiring one K-wire extends radially outwards and erodes the neck of the proximal radius. Additionally, an insufficient fixation of proximal ends of the K-wires, a jutting wire knot and a tear of the figure-of-eight configuration are noticed

Fig. 10

For this case tension band wiring (TBW) might not have been the best option since the osteosynthesis shows imperfections like an insufficient fixation of proximal ends of the K-wires, a perforation of the joint surface, two figure-of-eight configurations and the use of an additional screw