Tension band wiring fixation is associated with good functional outcome after olecranon fractures at a Togo Hospital
Anani A1, Akouété B3, Yaovi Edem J1, Ekoué D2, Atsi W1, Assang D1 Affi liation: 1-Department of Orthopaedics, Tokoin Teaching Hospital 2- Department of General Surgery, Tokoin Teaching Hospital 3- Surgical clinic of Lomé (CCL), Lomé / TOGO Correspondence: Docteur ABALO Anani, Post Code: 7 BP: 13607 Lomé / TOGO Fax : 00228 2226119 E-mail:
Background: Tension band wiring (TBW) is a widely accepted tech-nique for olecranon fractures. Various investigators have reported a significant rate of complications especially hardware prominence. The purpose of this study was to determine the clinical and radiological outcome after tension band wiring of olecranon fractures.
Methods: Sixty three patients (42 men and 21 women) were treated for fractures of the olecranon by TBW technique. Their mean age at the time of operation was 28 years (19 to 48). The mean follow-up period was 74.5 months (35 to 121). The overall outcome was evalu-ated using functional rating index described by Broberg and Morrey, the Visual Analogue Scale (VAS) subjective pain score (10 = unbear-able pain) and patient satisfaction score (10 = complete satisfaction). Results: Wound infection developed in six patients (09.5%). No non-unions, malunion or ulnar nerve palsies complicated the postopera-tive period. Hardware removal was recorded in 45 patients (71.4%) due to pin prominence, localized pain or direct complaint. Removal was not significantly affected by pin position (p = 0.201). Elbow pain persisted in 12 patients. Four patients (06.3%) had significantly reduced flexion arcs affecting the functional outcome. None of the patients had objective evidence of instability of the elbow.
The mean range of elbow flexion, pronation and supination was 135°, 70° and 79° respectively. 29 patients (46%) had an excellent functional result while four (6.4%) had poor result. The poor results were significantly associated with fracture type (p = 0.001) and the duration of immobilization (p = 0.003). The average satisfaction rat-ing was 9.1 out of 10 (range, 5–10).
Conclusion: Tension band wiring fixation for isolated olecranon fractures leads to good elbow function and minimal loss of physical capacity.
Olecranon fractures commonly occur after slips, fall-ing onto the arm or in high energy trauma (1,2). The fractures are usually isolated but associated lesions can occur in complex injuries and polytrauma cases. Due to the intra-articular extension of fractures, anatomic re-duction and early mobilization should be achieved in each case (3,4). Open reduction and internal fixation for displaced fractures allows early mobilization and re-duces postoperative elbow joint stiffness (1,5). Of the various methods of internal fixation including wires, in-tramedullary screws and screw and plate fixation (1,2,6-8), tension band wiring (TBW) is the widely accepted technique (5,7). However, while TBW has been shown to be rigid under biomechanical testing, various inves-tigators have reported significant rates of complications, most frequently hardware prominence (8,9). Helm et al reported that 82% of patients in their series needed removal of hardware following TBW.
The purpose of this study was to determine the clinical and radiological outcomes in patients treated for olecranon fractures by tension band wiring technique in our hospitals
Materials and Methods
Between 2000 and 2007, we treated 63 patients (42 men and 21 women) with fractures of the olecranon. Their mean age was 28 years (19 to 48). The mechanism of injury included motor vehicle crashes (31 patients), in-dustrial accident (13 patients), and fall (19 patients). Six of the fractures were open (type I in four patients and type II in two (11).
The fractures were classified according to the Mayo clas-sification (4) (Figure 1). There were 4 (6.4%) type IB, 29 (46%) type IIA, 7 (11.1%) type IIB, 19 (30.1%) type IIIA, and 4 (6.4%) type IIIB. There were no associated neuro-vascular injuries. The mean interval between injury and operation was 12 days (2 to 21). The six patients with open fractures were treated by débridement, primary wound closure, and delayed internal fixation. Fracture osteosynthesis was achieved with the insertion of two parallel 1.8 mm Kirschner wires from the tip of the olecranon into the shaft of the ulna. Sometimes we
used three Kirschner wires (figure 2). 0.8mm cerlage wire was passed round the K wires and tightened to cre-ate compession. Grafting with autogeneous bone was performed in seven patients.
The elbow was immobilised in a long-arm splint for a mean of 6.4 days (3 to 35) after operation, after which active exercises were started.
The mean follow-up period was 74.5 months (35 to 121). Evaluation at follow-up consisted of assessment of the stability, muscle strength, the active range of flexion and extension of the elbow, and rotation of the forearm. Anteroposterior and lateral radiographs were taken to assess bony union, articular congruity and post-traumat-ic degenerative changes. The overall outcome was evaluated using functional rating index described by Broberg and Morrey (12), the Visual Analogue Scale (VAS) sub-jective pain score (10 = unbearable pain) and VAS pa-tient satisfaction score (13) (10 = complete satisfaction). The SPSS program 8.0 (SPSS Inc, Chicago, IL, USA) was used for data management. Statistical analysis was con-ducted using Chi-square test and Student's t-test as ap-propriate. P values less than 0.05 were considered to be statistically significant.
Wound infection developed in six patients (09.5%). They resolved after intravenous antibiotics and surgical débridement. No nonunions, malunion or ulnar nerve
palsies complicated the postoperative period (figure 3). The anterior ulnar cortex was perforated by both Kirsch-ner wires in 19 fractures (30.2%), by one in 13 fractures (20.6%). They were placed intramedullary in 31 frac-tures (49.2%).
Hardware removal was recorded in 45 patients (71.4%) due to pin prominence, localized pain or direct com-plaint (figure 4). The above event was not affected by pin position (p = 0.201). Pain persisted in 12 patients (19%) after metal work removal (VAS 1–2).
The mean range of flexion was 135° (95 to 145). The mean pronation was 70° (60 to 80), and the mean su-pination was 79° (70 to 90). Four patients (06.3%) had significantly reduced flexion arcs affecting the functional outcome. The rest of cases had some degrees of flexion or extension deficit without being functionally disabled. There was mild loss of the strength of flexion and exten-sion in seven patients. The strength of pronation and su-pination was almost normal in all patients. No patients had objective evidence of instability of the elbow.
According to the functional index of Broberg and Mor-rey, 29 patients (46%) had an excellent result, 22 pa-tients (34.9%) good result, eight patients (12.7%) fair result, and four patients (6.4%) poor result. The poor results were significantly associated with fracture type III (p = 0.001) and the immobilization period up to one week (p = 0.003). The average satisfaction rating was 9.1 out of 10 (range, 5–10) with 56 patients (73%) stating complete satisfaction of the final result. Degenerative changes were found in 20 elbows (31.7%) but no corre-lation with the final outcome was identified (p = 0.026).
Open reduction and rigid internal fixation has become the accepted method of treatment for displaced fractures of the olecranon in order to allow early mobilisation, and the prevention of contracture of the elbow (1,2). The goals of fixation are realignment of the longitudinal axis of the olecranon, the provision of sufficient stability for mobilisation, preservation of the coronoid process, and anatomical restoration of the articular surface of the trochlear notch (13). At present, tension band wiring is the widely accepted technique (5,7). A tension band converts the tensile forces at the fracture site created as a result of muscle action into compressive forces (14-16). In 1963, Weber and Vasey (17) introduced the concept of combining the tension band with Kirschner wires to increase the stability of the fixation. This technique was further modified by the AO group by placing the Kirschner wires obliquely to engage the anterior cortex of the ulna in order to increase the stability of the frac-ture fixation and to prevent the wires from backing out. A biomechanical analysis of this technique showed a sig-nificant increase in fracture stability when compared to the original Weber-Vasey technique (18). Other authors had suggested various modifications in order to improve the biomechanical properties of the technique (19,20). While tension band wiring has been shown to be rigid under biomechanical testing, there are have reports of significant rates of complications, most frequently hard-ware prominence (5,8,9,21). Helm et al (10) reported that 82% of patients in their series needed removal of hardware following tension band wiring.
In the randomized study by Hume and Wiss (8), eight patients (42%) in the tension band group had symp-tomatic hardware compared to one in the plate fixation group. Rommens et al (21) stated that suboptimal pins place-ment (Kirschner wires which are not inserted parallel or do not transverse the opposite cortex of the proximal ulna) was not correlated with increased rate of implant loosening or secondary procedures. The above finding was also evident in our study. We have reported a rate of 71.4% of pins prominence. To avoid hardware prob-lems with TBW technique, some authors have recom-mended plating osteosynthesis for fracture stabilization (2,8,13). Bailey et al (13) reported high patient satisfac-tion (9.7/10) with a low pain rating (1/10) after plate fixation in Mayo types II and III fractures.
Since this study, the policy in our department is to use one-third tubular plate fixation when fracture comminu-tion (Types IIB and IIIB) couldn't support compression with the TBW technique. Various degrees of postoperative elbow stiffness and def-icit of range of motion have been reported in literature after surgical treatment of olecranon fractures (21,22). Degenerative changes are not uncommon after olecra-non fractures and they have been related to the length of follow up (23). Karlsson et al (24) found that with a mean of 19 years after isolated olecranon fractures 50% of the patients developed degenerative changes. However, these patients did not report any substantial symptoms and no correlation could be found between radiographic findings and patient subjective outcome. In 31.7% of our patients, degenerative changes were identi-fied after an average of 6.2 years postoperatively. Non-union, ulnar nerve palsy and wound infections have been described in approximately 2–10% of olecranon fractures (4,10). Even though the subcutaneous position of the Kirschner wires and their subsequent migration may be responsible for secondary displacement and wound healing problems, careful operative technique and appropriate soft tissue management are of greatest importance in order to minimize these complications.
Tension band wiring fixation for isolated olecranon frac-tures leads to good elbow function and minimal loss of physical capacity.
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