Olecranon fractures represent 1% to 10% of upper-extremity fractures and typically result from direct trauma to the elbow or falling on an outstretched hand.1–3 Several different classification systems are frequently used, including AO, Mayo, and Schatzker-Schmeling.4–6 These classifications guide treatment through description of fracture morphology, displacement, and comminution; however, many other factors, including bone quality and patient age, also inform treatment.7,8 Stable fractures with less than 2 mm of articular surface step deformity and an intact extensor mechanism (ie, Mayo 1) are typically treated conservatively.9,10 When surgical management is indicated, anatomical reduction facilitates union and allows for improved range of motion.11 Most current surgical constructs can be divided into 2 broad categories, tension-band wiring (TBW) and plate and screw fixation (PF), with TBW being the most common method of fixation for simple transverse fractures.8 Many variations of TBW have been described (eg, intramedullary screw TBW, biodegradable wire TBW), but traditional Kirschner wire TBW remains the most frequently used technique.8,12–16 Alternatively, PF is often the method of choice for fractures that are oblique, comminuted, or associated with dislocation.1,5,8,9,17,18 Other methods of fixation have also been described, including figure-of-8 wiring and intramedullary nailing, but these alternatives have yet to see widespread use.8,19,20 In certain cases, such as elderly, low-demand patients with poor bone quality, fracture excision and triceps advancement may be preferable to internal fixation.9
Although both TBW and PF have been associated with good functional outcomes, TBW has been associated with shorter surgical times and lower cost.8,21,22 However, TBW has been suggested to lead to striking rates of hardware irritation, possibly as high as 80%.23–25 Accordingly, for comminuted fractures, PF is suggested over TBW owing to increased stability.8 Plate fixation may also be used regularly for noncomminuted fractures in older patients with poor bone quality.21,26 Concern arises from PF because it has been associated with longer surgical times and greater cost.21,25–28
Small samples and conflicting outcomes have prevented a clear consensus in the literature favoring TBW or PF, particularly in non-elderly adults experiencing fractures with mild or no comminution.29 In 2014, a Cochrane review reported uncertainty in treatment outcomes in TBW and PF, largely due to limited, low-quality studies.29 Since then, several higher-quality randomized controlled trials (RCTs) have been conducted comparing TBW with PF as well as other interventions for the management of olecranon fractures.16,30,31 In 1 high-quality RCT evaluating TBW vs PF, a trend toward increased complication rates in TBW was shown.31 However, few outcomes reached statistical significance, likely due to small samples in trial arms. Overall, many of these trials were underpowered to evaluate important patient functional outcomes and significant complications such as hardware removal. Therefore, the authors conducted a systematic review and meta-analysis to compare TBW with PF and to evaluate alternative surgical management strategies for patients with olecranon fractures.
Materials and Methods
The authors conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement32,33 and the Cochrane Collaboration's handbook for systematic reviews of interventions.34
The authors conducted a detailed search to identify studies examining surgical management strategies for fractures of the olecranon. Their electronic search included 5 databases: MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Library. Search strategies were developed collaboratively by all of the authors and were conducted without any restrictions on type of publication or time using key words and medical subject heading terms such as “olecranon,” “elbow fracture,” “tension-band wiring,” and “plate fixation” (Table A, available in the online version of the article). The search is current to November 20, 2018. The authors hand searched the references of included studies and reviews to identify articles not captured by electronic search criteria.
Data Extraction and Definition of Outcomes
Three of the authors (A.K., T.W., C.O.) served as reviewers and independently evaluated studies for eligibility. Articles were included if they were RCTs, prospective cohort studies, or retrospective cohort studies evaluating surgical management strategies for olecranon fractures. Disagreements were resolved through discussion and consensus among the reviewers. Case reports, case series, letters to the editor, narrative reviews, and conference abstracts were excluded. The quality of individual RCTs, prospective cohort studies, and retrospective cohort studies was evaluated using the Cochrane Collaboration's risk of bias assessment tool,34 the Newcastle-Ottawa scale,35 and the methodological index for non-randomized studies,36 respectively.
Three of the authors (A.K., T.W., S.N.) independently abstracted data from the included studies using data abstraction forms. Disagreements were resolved by consensus and, if necessary, by consultation with an additional reviewer (C.O.). Meta-analyzed outcomes included complication rate and hardware removal rate between TBW and PF. Other outcomes included Disabilities of the Arm, Shoulder and Hand score, Mayo Elbow Performance Score, elbow arc flexion, operation time, time to union, and pain. The authors defined complications as including infection, symptomatic (ie, painful) hardware, loss of reduction, or hardware migration or failure that resulted in patient complaint or nonunion.
The authors analyzed dichotomous outcomes by calculating the relative risks and corresponding 95% confidence intervals. They considered P<.05 statistically significant. The authors used the DerSimonian and Laird model with random effects to conduct their meta-analysis.37 Heterogeneity was evaluated by Cochran's Q test and quantified using the I2 statistic.38 Meta-analysis was conducted using R version 3.5.1 software (R Foundation for Statistical Computing, Vienna, Austria).
The initial literature search yielded 3760 articles. After de-duplication and title and abstract screening, 100 articles remained. After full-text screening, 24 articles were included in the systematic review12–17,19–22,30,31,39–50 and 10 were included in the meta-analysis21,31,39,42,43,45–47,49,50 (Figure 1; Table B, available in the online version of the article). Cochrane risk of bias for RCTs indicated that studies were of relatively low to moderate quality, with recent RCTs15,16,30,31 having moderate quality (Tables C–E, available in the online version of the article). All studies showed high risk of bias for patient blinding.
A systematic review of PF vs TBW, involving 639 patients across 7 observational studies42,43,45–47,49,50 and 3 RCTs,21,31,39 showed some clinical heterogeneity regarding reporting of outcomes. Patients had a mean age of 40.7 years at presentation and 32.6% were female. Functional outcomes were reported in 6 observational studies and 1 RCT (Table 1). Average functional outcome after both TBW and PF was either good or excellent in all studies according to Mayo Elbow Performance Scores, with all but 1 study reporting a mean elbow flexion arc greater than 130°.42 One cohort study (n=48) found significantly less terminal extension (−8.6º±7º vs −3.5º±9.3º) after hook-plate fixation49; no other studies reported functional differences between TBW and PF.
Complication rate was reported in 7 cohort studies and 3 RCTs. There were 155 of 270 (57%) patients with complications who underwent TBW and 81 of 369 (22%) patients with complications who underwent PF (Table 2). The meta-analysis revealed significantly lower complication rates with PF compared with TBW (relative risk, 0.48; 95% confidence interval, 0.36–0.64; P<.01; I2=16%; Figure 2). These results were robust to subgroup analysis for complication rate comparing RCTs with observational studies (P=.45).
List of Complications
Forest plot of tension-band wiring vs plate fixation for outcome of complications. Abbreviations: CI, confidence interval; MH, Mantel–Haenszel.
Hardware removal was reported in 7 cohort studies and 1 RCT. There were 41 of 332 (12%) patients with hardware removal who underwent PF and 79 of 236 (33%) patients with hardware removal who underwent TBW (Table 2). The meta-analysis revealed lower hardware removal with PF compared with TBW (relative risk, 0.36; 95% confidence interval, 0.25–0.50; P<.01; I2=0%; Figure 3). In addition, these results were robust to subgroup analysis for complication rate comparing RCTs with observational studies (P=.54).
Forest plot of tension-band wiring vs plate fixation for outcome of hardware removal. Abbreviations: CI, confidence interval; MH, Mantel–Haenszel.
Three RCTs and 1 quasi-RCT reported outcomes following other methods of fixation (Table 3).14–16,30 An RCT by Liu et al15 compared a modified cable pin system tension band (n=30) with standard TBW (n=32) and found that the modified cable pin system tension band was associated with significantly shorter fracture healing time (9.73±2.02 vs 11.13±2.21 weeks), significantly fewer complications (1 vs 7), and significantly greater Mayo Elbow Performance Score (88.67±6.42 vs 80.78±11.99). Lu et al16 published an RCT comparing TBW through 2 cannulated screws (n=42) with standard TBW (n=46). They reported that cannulated screw use was associated with significantly shorter fracture healing time (11.4±1.2 vs 12.6±1.8 weeks), significantly less hardware removal (0 of 42 vs 10 of 46), and significantly greater Mayo Elbow Performance Score (87.9±6.0 vs 83.67±6.6).16 An RCT by Chen et al30 comparing novel olecranon memory connector fixation (n=20) with locking PF (n=20) reported that olecranon memory connector fixation was associated with greater Mayo Elbow Performance Score (86.7±12.5 vs 79.8±12.3) and no difference in complication rate. Finally, the quasi-RCT by Ahmed et al14 examining cancellous screw TBW (n=15) vs standard K-wire TBW (n=15) found that screw TBW was associated with fewer re-operations for removal of prominent hardware (0 of 15 vs 8 of 15) and no functional differences.
Other Elbow Fixation Techniques
This systematic review and meta-analysis found that among patients who have olecranon fractures and are eligible for surgery, those who undergo PF show significantly fewer complications and hardware removals compared with those who undergo TBW. The current analysis focused on TBW and PF because they represent the most common methods of olecranon fixation; however, several novel treatment options appear promising. These findings were gathered from meta-analyses of approximately 600 patients combined for both outcomes and were robust to subgroup analyses comparing RCTs with observational studies.
With an extensive history and perceived ability to produce compression across fracture sites, TBW remains the most commonly used method of fixation for transverse noncomminuted olecranon fractures.8,51 However, biomechanical studies have highlighted several weaknesses in TBW, including less compression across fractures relative to precon-toured olecranon-specific plates.21,52,53 Despite biomechanical superiority, the authors found that the functional outcomes (Disabilities of the Arm, Shoulder and Hand score, Mayo Elbow Performance Score, and flexion arc) of TBW and PF are similar in most of the studies. This lack of difference may be the result of studies being underpowered to evaluate functional differences between TBW and PF. However, some authors have shown similar results between TBW and PF in comminuted fractures as well.34,45,49 Accordingly, there is a lack of consensus in the literature and clinical expert opinion.8 Tension-band wiring is favored by some for reasons related to initial implant cost and duration of surgery. One retrospective cohort study using data gathered in the United States reported that TBW was approximately 50% less costly than PF when hospital stay was not accounted for ($6598.36 vs $14,333.46).47 Other benefits of TBW may include reduced surgical time.21,47,49,50
Although the 2 methods lead to similar functional outcomes, this analysis showed that TBW is associated with significantly more complications and more frequent re-operations for hardware removal. Symptomatic (ie, painful or irritating) hardware was the most common complication of both TBW and PF. It would be imprudent to consider symptomatic hardware as trivial because it was also found to be the most common cause of hardware removal. Hardware removal, found to be significantly more likely after TBW, increases patient morbidity through exposure to a second operation and should carry considerable weight in initial implant decision.54,55 The cost of additional operating room time and hospital admissions associated with removal must also be considered.31,46 Two recent cost-analyses, 1 cohort study and 1 RCT, both from the United Kingdom, questioned the TBW cost-efficacy dogma; these analyses found that PF was less expensive than TBW ($8374 vs $7812) when all treatment- and admission-related costs were considered.31,49 However, the difference in implant cost reported between studies was substantial, suggesting cost-efficacy may largely depend on institution-specific implant pricing and protocols.
Patient age should also be taken into consideration when interpreting the current findings. Across the current literature, elderly patients are poorly represented. In the elderly or those with poor bone stock, precontoured olecranon-specific plates have an advantage of increased stability, although screw pullout may still occur.56,57 Limited soft tissue coverage may also influence application of the current findings to elderly populations. Evidence suggests that nonoperative management or fragment excision may yield equivalent or superior outcomes in elderly, low-demand populations.10
Several novel treatment methods appear to represent promising alternatives to traditional K-wire TBW, including cable pin system TBW, TBW with cannulated cancellous screws, and the olecranon memory connector. Lu et al16 suggest that the lower rate of implant removal in patients with TBW plus screw fixation is due to the additional fixation that screws provide, which reduces K-wire migration and is thus less likely to irritate skin and subcutaneous tissues. Potentially, added compression across the fracture site with olecranon screws reduces tension in the figure-of-8 fixation around the triceps tendon, reducing the rates of symptomatic tendonitis. Although all 3 novel methods supported by randomized data appear promising, they have each only been studied in 1 relatively small randomized trial to date. Further evidence comparing these novel methods with PF is required before their use can be advocated for in place of the more common fixation techniques.
This systematic review had several strengths. First, the authors conducted an in-depth literature search of 5 databases in duplicate to ensure all relevant studies were included. The quality of all studies was assessed independently and in duplicate using appropriate quality assessment scales. In addition, the authors conducted subgroup analyses comparing randomized and nonrandomized data to ensure their main outcomes were robust to potential differences in the methodological quality of included studies.
Nevertheless, this systematic review and meta-analysis had several limitations. Studies included in the meta-analysis were of low to moderate quality, with all studies having lack of patient blinding. In addition, the meta-analysis included 3 RCTs. Although the authors were able to support their conclusions with nonrandomized data via subgroup analysis, their primary analyses involved the inherent risks of bias common in observational studies.
Plate fixation yields significantly lower rates of complication as well as hardware removal compared with TBW. This article highlights the need to consider the increased complications associated with TBW before deciding on a method of fixation in adults with olecranon fractures.
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|Study, Year||No. of Patients||DASH Score, Mean (SD)||MEPS, Mean (SD)||Elbow Arc Flexion, Mean (Range or SD)|
| Aslam et al,42 2003||20||19||130° (100°–140°)||119° (60°–150°)|
| Tarallo et al,45 2014||33||45||12.4 (12)||10.7 (12.5)||88.3 (10.9)||9.1 (11.1)|
| Schliemann et al,22 2014||13||13||12.5 (8.7)||14 (13.6)||141° (5.6°)||144° (6.7°)|
| Amini et al,47 2015||10||10||10||10.5||97||95||132°||132°|
| DelSole et al,49 2016||23||25||97 (5.8)||93.6 (7.1)||135.4° (6.7°)||134° (11.2°)|
| Powell et al,50 2018||48||16||12.9||15|
| Hume et al,21 1992||19||22||12.8 (20)||8.5 (10)||90 (14)||96 (6.8)||137° (15°)||131° (15°)|
List of Complications
|Study, Year||No. (%)|
|Total||Complication||Hardware Removal||Symptomatic Hardware||Infection||Nonunion||Hardware Migration or Failure||Other Complications|
| Aslam et al,42 2003||20||19||12 (60)||5 (26)||11 (55)||2 (11)||7 (35)||NR||1 (5)||1 (5)||NR||NR||4 (20)||2 (11)||NR||NR|
| von Rüden et al,43 2011||29||51||6 (21)||1 (2)||4 (14)||1 (2)||NR||NR||2 (7)||NR||NR||NR||3 (10)||NR||1 (3)||NR|
| Tarallo et al,45 2014||33||45||14 (42)||10 (22)||10 (30)||4 (9)||2 (6)||1 (2)||NR||NR||3 (9)||3 (7)||4 (12)||NR||4 (12)||6 (13)|
| Snoddy et al,46 2014||43||134||23 (53)||41 (31)||20 (47)||25 (19)||15 (35)||17 (13)||6 (14)||8 (6)||NR||4 (3)||1 (2)||NR||2 (5)||14 (10)|
| Amini et al,47 2015||10||10||9 (90)||3 (30)||4 (40)||1 (10)||7 (70)||3 (30)||NR||NR||NR||NR||1 (10)||NR||1 (10)||NR|
| DelSole et al,49 2016||23||25||7 (30)||5 (20)||2 (9)||1 (4)||7 (30)||5 (20)||NR||NR||1 (4)||NR||NR||NR||5 (22)||2 (8)|
| Powell et al,50 2018||48||16||19 (40)||0 (0)||13 (27)||0 (0)||15 (31)||NR||NR||NR||1 (2)||NR||2 (4)||NR||NR||NR|
| Hume et al,21 1992||19||22||9 (47)||1 (5)||NR||NR||8 (42)||1 (5)||2 (11)||NR||2 (11)||NR||NR||NR||1 (5)||NR|
| Duckworth et al,10 2017||30||32||19 (63)||12 (38)||15 (50)||7 (22)||NR||NR||NR||4 (13)||NR||NR||8 (27)||4 (13)||NR||3 (9)|
| Khanna et al,39 2012||15||15||10 (67)||3 (20)||NR||NR||5 (33)||1 (7)||3 (20)||1 (7)||NR||1 (7)||2 (13)||NR||NR||NR|
Other Elbow Fixation Techniques
|Study, Year||Type of Study||Intervention||No. of Patients||MEPS, Mean±SD||Elbow Function (MEPS), No.||Complications, No. (%)||Hardware Removal, No. (%)|
|Liu et al,15 2012||RCT||Cable pin system TBW||30||88.67±6.42||20 excellent||1 (3)||0 (0)|
|Standard TBW||32||80.78±11.99||12 excellent||7 (22)||5 (16)|
|Chen et al,30 2013||RCT||Memory connector fixation||20||86.7±12.5||10 excellent||0 (0)||NR|
|Locking plate||20||79.8±12.3||5 excellent||1 (5)||NR|
|Lu et al,16 2015||RCT||Double screw TBW||42||87.9±6.0||29 excellent||0 (0)||0 (0)|
|Standard TBW||46||83.67±6.6||16 excellent||21 (46)||10 (22)|
|Ahmed et al,14 2008||Quasi-RCT||Intramedullary screw + TBW||15||0 (0)||0 (0)|
|TBW||15||9 (60)||8 (53)|