Olecranon fractures are a common injury, representing 10% of all upper extremity fractures.1 Displaced fractures require fixation to restore anatomical alignment and minimize posttraumatic arthrosis.2,3 Multiple surgical techniques have been developed to treat these fractures, with implant choice largely dictated by fracture pattern and associated injuries. Simple, noncomminuted, transverse, proximal fractures can be treated with a tension-band construct, and fractures that are comminuted, oblique, distal to the midpoint of the sigmoid notch, or associated with complex elbow injuries generally require locking-plate fixation.4,5 Although both tension bands and locking plates have been used successfully (Figures 1A, 1B), they remain some of the most frequently removed orthopedic implants, usually because of implant prominence.6
Both fixation devices have potential advantages and disadvantages. Tension-band fixation requires relatively “low-tech” instrumentation and implants and, as a result, has less cost and potentially less operative time for application. As it is smaller than a plate-and-screw construct, a tension band may be less prone to prominence, but this has not been substantiated in the literature.7-14 Implant migration has been a reported complication of tension-band fixation.7,11,13,15
Locking-plate fixation has been shown to be biomechanically stronger,16 and some reports have shown fewer repeat operations for implant prominence than with tension-band fixation.1,8,17-22 Because of more advanced product development and manufacturing, however, it comes at a higher cost. Plate fixation also requires more steps for application, which may require more operative time, and implant prominence has remained a problem, even with modern plates with lower profiles.19
Previous studies of olecranon fixation have included complex fractures and osteotomies or did not include current-generation precontoured locking plates. We found no other study that compared the outcomes, complications, and costs of tension-band and modern locking-plate fixation of isolated transverse olecranon fractures.
To determine if there are significant differences in outcomes and costs between tension-band and locking-plate fixation of transverse olecranon fractures in adults, we retrospectively compared functional outcomes, complications, and costs in 2 matched cohorts of displaced transverse olecranon fractures. We hypothesized that there would be no differences in functional outcomes, implant prominence, posttraumatic arthrosis, complications, or operative time, but that costs would be less with tension-band fixation.
Materials and Methods
After obtaining institutional review board approval, we retrospectively reviewed the medical records of patients who had undergone fixation of an isolated, transverse, noncomminuted olecranon fracture (Orthopaedic Trauma Association 21B1) at our institution between 2004 and 2011. Inclusion criteria included use of a tension-band construct or a precontoured locking plate, skeletal maturity at time of injury, and minimum 2-year follow-up. Exclusion criteria were open fractures, osteotomies, any other ipsilateral upper extremity fracture, and fractures with comminution, obliquity, or distal location.
Although, based on fracture pattern, tension-band fixation is appropriate for olecranon osteotomies used for distal humeral exposure, we did not include osteotomies because functional outcomes would likely be different from those of true olecranon fractures, in addition to the possibility that the soft-tissue injury from a distal humeral fracture and resultant exposure could result in a different level of implant prominence. To control for demographic variables, we used a cohort design in which patients were matched on age and length of follow-up.
During the study period, we treated 287 olecranon fractures. Forty-nine patients met the inclusion criteria. The study population consisted of 20 patients, 10 in each cohort matched on age and length of follow-up. There were no statistically significant differences between groups in demographic variables, including dominant arm involved and number of worker’s compensation claims (Table 1). Mechanisms of injury were similar in the groups. In the tension-band group, 9 patients fell directly onto their elbow, and 1 fell onto her outstretched hand. In the locking-plate group, 8 patients fell directly onto the elbow, 1 fell onto her outstretched hand, and 1 was injured in a motorcycle accident.
All surgeons, regardless of implant selected, used a posterior incision that curved slightly laterally about the tip of the olecranon. Surgeon preference determined which fixation construct to use. Tension-band fixation was performed using 2 bicortical Kirschner wires and a stainless-steel wire through a distal drill hole to complete the tension band. Of the 10 locking-plate constructs used, 4 were PERI-LOC olecranon locking plates (Smith & Nephew), 3 were LCP olecranon plates (Synthes), and 3 were periarticular proximal ulna locking plates (Zimmer).
All returning patients were seen by either Dr. Amini or Mr. Wilson and underwent range of motion (ROM) measurement with a goniometer; assessment for subjective and objective implant prominence (graded none, mild, moderate, or severe/already had implant removed); and functional scoring using the Mayo Elbow Performance Score (MEPS) and the Quick Disability of the Arm, Shoulder, and Hand (QDASH). Results were classified excellent (MEPS, >90), good (75-89), fair (60-74), and poor (<60).23