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
Literature Review
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.
Statistical Analysis
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).
Results
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).
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).
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.
Discussion
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 precontoured 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 reoperations 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.
Conclusion
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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Functional Outcomes
Study, Year | No. of Patients | DASH Score, Mean (SD) | MEPS, Mean (SD) | Elbow Arc Flexion, Mean (Range or SD) |
---|
|
|
|
|
---|
TBW | PF | TBW | PF | TBW | PF | TBW | PF |
---|
Observational | | | | | | | | |
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 | | | | |
Randomized | | | | | | | | |
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 | Total | No. (%) |
---|
|
---|
Complication | Hardware Removal | Symptomatic Hardware | Infection | Nonunion | Hardware Migration or Failure | Other Complications |
---|
|
|
|
|
|
|
|
|
---|
TBW | PF | TBW | PF | TBW | PF | TBW | PF | TBW | PF | TBW | PF | TBW | PF | TBW | PF |
---|
Observational | | | | | | | | | | | | | | | | |
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 |
Subtotal | 206 | 300 | 90 | 65 | 64 | 34 | 53 | 26 | 9 | 9 | 5 | 7 | 15 | 2 | 13 | 22 |
Randomized | | | | | | | | | | | | | | | | |
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 |
Subtotal | 64 | 69 | 38 | 16 | 15 | 7 | 13 | 2 | 5 | 5 | 2 | 1 | 10 | 4 | 1 | 3 |
Total | 270 | 369 | 128 | 81 | 79 | 41 | 66 | 28 | 14 | 14 | 7 | 8 | 25 | 6 | 14 | 25 |
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
9 good
1 fair
0 poor | 1 (3) | 0 (0) |
Standard TBW | 32 | 80.78±11.99 | 12 excellent
12 good
5 fair
3 poor | 7 (22) | 5 (16) |
Chen et al,30 2013 | RCT | Memory connector fixation | 20 | 86.7±12.5 | 10 excellent
7 good
3 fair
0 poor | 0 (0) | NR |
Locking plate | 20 | 79.8±12.3 | 5 excellent
10 good
4 fair
1 poor | 1 (5) | NR |
Lu et al,16 2015 | RCT | Double screw TBW | 42 | 87.9±6.0 | 29 excellent
12 good
1 fair
0 poor | 0 (0) | 0 (0) |
Standard TBW | 46 | 83.67±6.6 | 16 excellent
26 good
4 fair
0 poor | 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) |
Search strategy for the Medline database
Database | Search Terms |
---|
MEDLINE 1946 - present | 1. olecranon process/ or olecranon/ or olecranon.mp. |
2. elbow*.mp. |
3. proximal ulna.mp. |
4. (tension-band wiring or tension band wiring).mp. |
5. (plate fixation or plating).mp. |
6. locking compression plate*.mp. |
7. cancellous screw*.mp. |
8. (figure-of-eight or figure of eight or figure-of-8 or figure of 8).mp. |
9. hook plate*.mp. |
10. 1 or 2 or 3 |
11. 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 |
12. 10 and 11 |
Characteristics of included studies
Randomized controlled trials |
---|
Study author, year | Baseline characteristics | Outcomes |
---|
Larsen, 1987 | Study design: quasi-randomized controlled trial Country of patient recruitment: Denmark Multi-centre: no Study interventions: modified TBW with non-sliding Netz pins, standard TBW Fracture type:
Modified TBW: 14 transverse, 3 oblique, 4 comminuted Standard TBW: 12 transverse, 2 oblique, 11 comminuted
Sample size: modified TBW: 21, standard TBW: 25 Female: 32/46 Mean age: 64.87 years Follow-up:
13 (range: 4–30 weeks) 13 (range: 4–54 weeks)
| Complications:
Modified TBW: 11 Standard TBW: 6
Implant removal:
Modified TBW: 17 Standard TBW: 11
Time to union:
Modified TBW: 6 (range: 4–12) weeks Standard TBW: 7 (range: 4–12) weeks
|
Hume, 1992 | Study design: randomized controlled trial Country of patient recruitment: USA Multi-centre: no Study interventions: plate fixation, standard TBW Fracture type: 3 simple reverse oblique, 11 simple transverse, 15 simple oblique, 12 comminuted Sample size:
Plate fixation: 22 Standard TBW: 19
Female: 11/41 Mean age: 30.9 (range: 18–67) years Follow-up: 28.5 (range: 16–86) weeks
| Operation time:
Plate fixation: 120 (range 85–150) min Standard TBW: 94.5 (range: 75–120) min
Complications:
Plate fixation: 1 patient Standard TBW: 9 patients
Implant removal: 13.02 (range: 8.68–26.04) weeks Time to union: 13.02 (range: 8.68–26.04) weeks
|
Juutilainen, 1995 | Study design: randomized controlled trial Country of patient recruitment: Finland Multi-centre: no Study interventions: biodegradable wire and screw TBW, standard TBW Fracture type: transverse, oblique (numbers not reported) Sample size:
Biodegradable wire and screw TBW: 15 Standard TBW: 10
Female:
Biodegradable wire and screw TBW: 9/15 Standard TBW: 8/10
Mean age:
Biodegradable wire and screw TBW: 47.2 (range: 22–77) Standard TBW: 53.8 (range: 17–85)
Follow-up:
Biodegradable wire and screw TBW: 93.6 (range: 25–104) Standard TBW: 72.8 (range: 25–104)
| Pain:
Biodegradable wire and screw TBW: 1/15 Standard TBW: 2/10
|
Ahmed, 2008 | Study design: quasi-randomized controlled trial Country of patient recruitment: Egypt Multi-centre: no Study interventions: intramedullary screw and TBW, standard TBW Fracture type:
Intramedullary screw and TBW: 10 transverse, 5 oblique Standard TBW: 6 transverse, 9 oblique
Sample size:
Intramedullary screw and TBW: 15 Standard TBW: 15
Female:
Intramedullary screw and TBW: 4/15 Standard TBW: 5/15
Mean age:
Intramedullary screw and TBW: 37.9 (SD: 18.5, range: 17–70) years Standard TBW: 28.8 (SD: 7.4, range: 18–42) years
Follow-up:
Intramedullary screw and TBW: 32.55 (SD: 9.1) weeks Standard TBW: 38.2 (SD: 11.7) weeks
| Complications:
Intramedullary screw and TBW: 0 Standard TBW: 9
Implant removal:
Intramedullary screw and TBW: 0 Standard TBW: 8
Time to union:
Intramedullary screw and TBW: 7.1 (SD: 1.7) weeks Standard TBW: 7 (SD: 1.6) weeks
|
Khanna, 2012 | Study design: quasi-randomized controlled trial Country of patient recruitment: India Multi-centre: no Study interventions: TBW, reconstruction plating Sample size:
TBW: 15 Reconstruction plating: 15
Female: 5/30 Mean age: 40 (range: 20–70) years
| Complications:
TBW: 10/15 Reconstruction plating: 3/15
Time to union: 14 weeks
|
Liu, 2012 | Study design: randomized controlled trial Country of patient recruitment: China Multi-centre: yes Study interventions: modified TBW with cable pin system, standard TBW Fracture type:
Modified TBW with cable pin system: 25 Mayo IIA, 5 Mayo IIIA Standard TBW: 25 Mayo IIA, 7 Mayo IIIA
Sample size:
Modified TBW with cable pin system: 30 Standard TBW: 32
Female:
Modified TBW with cable pin system: 14/30 Standard TBW: 18/32
Mean age:Modified TBW with cable pin system: 47.8 (SD: 12.83, range: 21–69) years Standard TBW: 46.4 (SD: 13.93, range: 20–70) years
Follow-up:
Modified TBW with cable pin system: 92.31 (SD: 36.4) weeks Standard TBW: 90.62 (SD: 36.3) years
| Mayo elbow performance score:
Modified TBW with cable pin system: 88.67 (SD: 6.42, range: 70–100) Standard TBW: 80.78 (SD: 11.99, range: 55–95)
Operation time:
Modified TBW with cable pin system: 34.83 (SD: 4.64) min Standard TBW: 35.56 (SD: 3.78) min
Complications:
Modified TBW with cable pin system: 1 Standard TBW: 7
Implant removal:Modified TBW with cable pin system: 0 Standard TBW: 5
Time to union:
Modified TBW with cable pin system: 9.73 (SD: 2.02, range: 8–12) Standard TBW: 11.13 (SD: 2.21, range: 8–16)
|
Chen, 2013 | Study design: randomized controlled trial Country of patient recruitment: China Multi-centre: no Study interventions: olecranon memory connector fixation, locking plate fixation Fracture type:Olecranon memory connector fixation: 13 Mayo II, 7 Mayo III Locking plate fixation: 14 Mayo II, 6 Mayo III
Sample size:
Olecranon memory connector fixation: 20 Locking plate fixation: 20
Female:
Olecranon memory connector fixation: 8/20 Locking plate fixation: 10/20
Mean age:
Olecranon memory connector fixation: 47.85 (SD: 17.6, range: 21–77) years Locking plate fixation: 48.9 (SD: 15.5, range: 28–64) years
Follow-up:
Olecranon memory connector fixation: 158.4 (SD: 32.1) years Locking plate fixation: 158.8 (SD: 40.4) years
| Disabilities of the arm, shoulder, hand score
Olecranon memory connector fixation: 3.3 (SD: 4) Locking plate fixation: 4 (SD: 6.9)
Mayo elbow performance score:
Olecranon memory connector fixation: 86.7 (SD: 12.5) Locking plate fixation: 79.8 (SD: 12.3)
Complications:
Olecranon memory connector fixation: 0 Locking plate fixation: 1
|
Lu, 2015 | Study design: randomized controlled trial Country of patient recruitment: China Multi-centre: yes Study interventions: double screw TBW, standard TBW Fracture type:
Double screw TBW: 18 transverse, 24 oblique Standard TBW: 21 transverse, 25 oblique
Sample size:Double screw TBW: 42 Standard TBW: 46
Female:
Double screw TBW: 16/42 Standard TBW: 15/46
Mean age:
Double screw TBW: 39.81 (SD: 12.7) years Standard TBW: 43.74 (SD: 11.6) years
Follow-up: 141.92 (range: 104.2–173.6) weeks
| Mayo elbow performance score:
Double screw TBW: 87.9 Standard TBW: 83.67
Operation time:
Double screw TBW: 48.71 (SD: 10.1) min Standard TBW: 48.42 (SD: 9.7) min
Complications:
Double screw TBW: 0 Standard TBW: 21
Implant removal:
Double screw TBW: 0 Standard TBW: 10
Time to union:Double screw TBW: 11.38 (SD: 1.2) weeks Standard TBW: 12.6 (SD: 1.8) weeks
|
Duckworth, 2017 | Study design: randomized controlled trial and cost-analysis Country of patient recruitment: United Kingdom Multi-centre: no Study interventions: TBW, plate fixation Fracture type: isolated displaced Mayo type IIA Sample size:
TBW: 34 Plate fixation: 33
Female:
TBW: 13/34 Plate fixation: 16/33
Mean age:
TBW: 43 (SD: 15, range: 19–73) Plate fixation: 52 (SD: 17, range: 18–74)
Follow-up: 1-year follow-up 85%
| Disabilities of the arm, shoulder, hand score:
TBW: 12.8 (SD: 20, range: 0–79) Plate fixation: 8.5 (SD: 10, range: 0–41)
Mayo elbow performance score:
TBW: 90 (SD: 14, range: 40–100) Plate fixation: 96 (SD: 6.8, range: 85–100)
Complications:
TBW: 19/30 Plate fixation: 12/32
Implant removal:
TBW: 15/30 Plate fixation: 7/32
|
Prospective cohort study |
Study | Baseline characteristics | Outcomes |
Johnson, 1986 | Study design: prospective cohort Country of patient recruitment: USA Multi-centre: no Study interventions: AO cancellous screw alone, TBW plus AO cancellous screw Fracture type: 17 transverse, 4 oblique, 2 dislocations, 5 fractures with associated elbow injuries Sample size:
AO cancellous screw alone: 16 TBW plus AO cancellous screw: 12
Female: 12/28 Mean age: 36.4 (range: 16–78) years Follow-up: 13 weeks
| Complications: 4 total Pain:
AO cancellous screw alone: 6 TBW plus AO cancellous screw: 8
Revision: 6 total
|
Retrospective cohort studies |
Study | Baseline characteristics | Outcomes |
Gartsman, 1981 | Study design: Retrospective comparative cohort Country of patient recruitment: USA Multi-centre: no Study interventions: primary excision, open reduction and internal fixation (using various methods) Sample size:
Primary excision: 53 Open reduction and internal fixation: 54
Female: 65/107 Mean age: 57 (range: 19–92) years Follow-up: 187.2 (range: 104–780) weeks
| Complications:
Primary excision: 2 Open reduction and internal fixation: 13
Implant removal:Primary excision: 0 Open reduction and internal fixation: 13
Revision:
Primary excision: 0 Open reduction and internal fixation: 13
|
Murphy, 1986 | Study design: Retrospective comparative cohort Country of patient recruitment: USA Multi-centre: no Study interventions: intramedullary screw, TBW, intramedullary screw and wire, figure-of-eight wire, Rusk rod with figure-of-eight wire Fracture type: 26 transverse, 12 oblique, 7 comminuted Sample size:
Intramedullary screw: 13 TBW: 10 Intramedullary screw and wire: 10 Figure-of-eight wire: 2 Rusk rod with figure-of-eight wire: 2
Female: 27/45 Mean age: 43.3 (range: 17–81) years total
Intramedullary screw: 56.4 years TBW: 35.4 years Intramedullary screw and wire: 46.4 years Figure-of-eight wire: not reported Rusk rod with figure-of-eight wire: not reported
Follow-up: 141.9 (range: 26–403.6) weeks
| Complications:
Intramedullary screw: 2 TBW: 10 Intramedullary screw and wire: 3 Figure-of-eight wire: not reported Rusk rod with figure-of-eight wire: not reported
|
Mullett, 2000 | Study design: Retrospective comparative cohort Country of patient recruitment: Ireland Multi-centre: no Study interventions: transcortical TBW, intramedullary TBW Fracture type: displaced closed transverse Sample size:
Transcortical TBW: 35 Intramedullary TBW: 45
Mean age:
Transcortical TBW: 58.2 years Intramedullary TBW: 54.7 years
Follow-up:
Transcortical TBW: 169.3 weeks Intramedullary TBW: 186.6 weeks
| Complications:
Transcortical TBW: 9 Intramedullary TBW: 50
Implant removal:
Transcortical TBW: 4 Intramedullary TBW: 19
|
Karlsson, 2002 | Study design: Retrospective comparative cohort Country of patient recruitment: Sweden Multi-centre: no Study interventions: TBW, figure-of-eight wiring Fracture type: 51 displaced >2mm, 16 comminuted Sample size:
TBW: 32 Figure-of-eight wiring: 35
Female: 41/67 Mean age:
TBW: 47.3 Figure-of-eight wiring: 42.1
Follow-up: 946.4 (range: 728–1300) weeks
| Complications:
TBW: 0 Figure-of-eight wiring: 1
Implant removal:
TBW: 26 Figure-of-eight wiring: 15
|
Aslam, 2003 | Study design: Retrospective comparative cohort Country of patient recruitment: United Kingdom Multi-centre: no Study interventions: AO TBW, plate fixation Sample size:
AO TBW: 25 Plate fixation: 23
Mean age:
AO TBW: 50 (range: 27–42) Plate fixation: 58 (range: 23–77)
| Complications:AO TBW: 12 Plate fixation: 5
Implant removal:AO TBW: 11 Plate fixation: 2
Revision:
AO TBW: 11 Plate fixation: 2
|
Ruden, 2011 | Study design: Retrospective comparative cohort Country of patient recruitment: Germany Multi-centre: no Study interventions: TBW figure-of-eight, posterior plating +/− intramedullary screw Fracture type: Mayo II, Mayo III Sample size:
TBW figure-of-eight: 29 Posterior plating +/− intramedullary screw: 51
Female: 36/80
| Complications:
TBW figure-of-eight: 6 Posterior plating +/− intramedullary screw: 1
Revision:
TBW figure-of-eight: 4 Posterior plating +/− intramedullary screw: 1
|
Lan, 2013 | Study design: Retrospective comparative cohort Country of patient recruitment: Taiwan Multi-centre: no Study interventions: pre-shaped non-locking plating, locking plate Fracture type: comminuted Sample size:
Pre-shaped non-locking plating: 10 Locking plate: 13
Female:
Pre-shaped non-locking plating: 6/10 Locking plate: 7/13
Mean age:
Pre-shaped non-locking plating: 36.5 years Locking plate: 43.4 years
Follow-up:
Pre-shaped non-locking plating: 160.6 weeks Locking plate: 60.8 weeks
| Mayo elbow performance score:
Pre-shaped non-locking plating: 95 Locking plate: 94
Complications:
Pre-shaped non-locking plating: 3 Locking plate: 0
Implant removal:Pre-shaped non-locking plating: 3 Locking plate: 3
Time to union:
Pre-shaped non-locking plating: 13.45 weeks Locking plate: 12.59 weeks
|
Tarallo, 2014 | Study design: Retrospective comparative cohort Country of patient recruitment: Italy Multi-centre: no Study interventions: TBW, plate fixation Fracture type:TBW: 21 Mayo IIA, 12 Mayo IIB Plate fixation: 10 Mayo IIA, 35 Mayo IIB
Sample size:TBW: 33 Plate fixation: 45
Female:
TBW: 20 Plate fixation: 28
Mean age:
TBW: 51.82 (SD: 10.05) Plate fixation: 49.38 (SD: 12.7)
Follow-up: 143.2 (range: 52.1–386.3) weeks
| Disabilities of the arm, shoulder, hand score:
TBW: 12.4 (SD: 12) Plate fixation: 10.7 (SD: 12.5)
Mayo elbow performance score:
TBW: 88.3 (SD: 10.9) Plate fixation: 9.1 (SD: 11.1)
Complications:
TBW: 14 Plate fixation: 10
Implant removal:
TBW: 4 Plate fixation: 0
Non-union:
TBW: 3 Plate fixation: 3
Revision:
TBW: 5 Plate fixation: 8
Pain:
TBW: 4 Plate fixation: 4
|
Snoddy, 2014 | Study design: Retrospective comparative cohort Country of patient recruitment: USA Multi-centre: no Study interventions: plate fixation, TBW Fracture type:
Plate fixation: 2 OTA class 21-A1, 131 OTA class 21-B1 TBW: 1 OTA class 21-A1, 41 OTA 21-B1, 1 OTA class 21-C1
Sample size:
TBW: 134 Plate fixation: 43
Female:
TBW: 70 Plate fixation: 26
Mean age:TBW: 45.8 (SD: 20.3, range: 27-61) Plate fixation: 43.27 (SD: 21.8, range: 22–54)
| Complications:
TBW: 41 Plate fixation: 23
Implant removal:
TBW: 25 Plate fixation: 10
Non-union:
TBW: 4 Plate fixation: 0
Time to union:
TBW: 25 weeks Plate fixation: 20 weeks
|
Schliemann, 2014 | Study design: Retrospective comparative cohort Country of patient recruitment: Germany Multi-centre: no Study interventions: plate fixation, TBW Fracture type: Mayo IIA Sample size:Plate fixation: 13 TBW: 13
Female:
Plate fixation: 7 TBW: 6
Mean age:
Plate fixation: 48.6 (range: 18–67) TBW: 38.1 (range: 18–67)
Follow-up:
Plate fixation: 118.92 (range: 56.4–173.6) weeks TBW: 264.31 (range 82.5–520.8) weeks
| Disabilities of the arm, shoulder, hand score
Plate fixation: 14 (SD: 13.6, range: 0–45) TBW: 12.5 (SD: 8.7, range: 0–37)
Complications:
Plate fixation: 12 TBW: 16
Implant removal:
Plate fixation: 7 TBW: 12
Pain:
Plate fixation: 2 TBW: 5
Revision:
Plate fixation: 7 TBW: 12
|
Amini, 2015 | Study design: Retrospective comparative cohort and cost analysis Country of patient recruitment: USA Multi-centre: no Study interventions: TBW, locking plate Fracture type: isolated, transverse, non-comminuted Sample size:
TBW: 10 Locking plate: 10
Mean age:
TBW: 51.7 years Locking plate: 55.2 years
Follow-up:
TBW: 265.2 weeks Locking plate: 182 weeks
| Disabilities of the arm, shoulder, hand score:TBW: 97 Locking plate: 95
Complications:TBW: 7 Locking plate: 3
Implant removal:
TBW: 4 Locking plate: 1
Non-union:
TBW: 0 Locking plate: 0
|
Chan, 2015 | Study design: Retrospective comparative cohort Country of patient recruitment: United Kingdom Multi-centre: no Study interventions: Transcortical K-wire TBW, intramedullary K-wire TBW Fracture type:
48 Mayo IIA, 15 Mayo IIB
Sample size:
Intramedullary: 47 Transcortical: 16
Female: 35/63 Mean age: 58 years (range 20–95) Follow-up: 56 (range 20-116) weeks
| Complications:
Transcortical K-wire: 4 Intramedullary K-wire: 9
Implant removal:
Transcortical K-wire: 4 Intramedullary K-wire: 9
|
DelSole, 2016 | Study design: Retrospective comparative cohort Country of patient recruitment: USA Multi-centre: no Study interventions: TBW, hook plate Fracture type:
TBW: 1 Mayo IA, 18 Mayo IIA, 3 Mayo IIB, 1 Mayo IIIB Hook plate: 0 Mayo IA, 15 Mayo IIA, 10 Mayo IIB, 0 Mayo IIIB
Sample size:TBW: 23 Hook plate: 25
Female:
TBW: 18 Hook plate: 19
Mean age:
TBW: 64.5 (SD: 20) Hook plate: 65.76 (SD: 17.2)
Follow-up:
TBW: 58.59 (SD: 42.1) Hook plate: 62.5 (SD: 50.3)
| Mayo elbow performance score:
TBW: 97 (SD: 5.8) Hook plate: 93.6 (SD: 7.1)
Complications:
TBW: 7 Hook plate: 5
Implant removal:
TBW: 2 Hook plate: 0
Non-union:
TBW: 1 Hook plate: 0
Time to union:
TBW: 12.2 (SD: 5.5) Hook plate: 19.1 (SD: 7.7)
Revision:
TBW: 2 Hook plate: 0
|
Powell, 2018 | Study design: Retrospective comparative cohort and cost analysis Country of patient recruitment: United Kingdom Multi-centre: no Study interventions: TBW, locking plate Fracture type: 64 Mayo IIA Sample size:TBW: 48 Locking plate: 16
Female:
TBW: 28 Locking plate: 12
Mean age:
TBW: 57 (range 15–93) Locking plate: 60 (range 22–80)
Follow-up:
TBW: 42 (range 28–78) months Locking plate: 32 (range 28–54) months
| QuickDASH:
TBW: 12.9 Locking plate: 15.0
Complications:
TBW: 19 Locking plate: 0
Non-union:
TBW: 1 Locking plate: 0
Implant removal:
TBW: 13 Locking plate: 0
Revision:
TBW: 2 Locking plate: 0
Cost per patient:
TBW: £480.33 Locking plate: £244.00
|
Cochrane risk of bias for randomized controlled trials
Larsen et al, 1987 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | high | “Patients were selected for the two methods according to whether they were admitted on even or odd days” |
Allocation concealment | high | Quasi-randomization suggests no allocation concealment implemented. |
Blinding of patients | high | No mention of blinding of patients. |
Blinding of outcome assessor | high | No mention of blinding of outcome assessor. |
Incomplete outcome data | low | All patients included in analysis. |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | No mention of industry sponsorship. |
Hume et al, 1991 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | unclear | “patients with displaced olecranon fractures requiring open reduction and internal fixation were randomized” |
Allocation concealment | unclear | Unclear whether allocation concealment was implemented. |
Blinding of patients | high | No mention of blinding of patients. |
Blinding of outcome assessor | high | No mention of blinding of outcome assessor. |
Incomplete outcome data | low | All patients included in analysis. |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | No mention of industry sponsorship. |
Juutilainen et al, 1995 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | unclear | “patients with closed olecranon (transverse/oblique) or patella fractures were randomized to SR-PLLA wire and SR-PGA screw or SR-PLLA plug fixation or to metallic cerclage wire and two Kirschner wires fixation” |
Allocation concealment | unclear | Unclear whether allocation concealment was implemented. |
Blinding of patients | high | No mention of blinding of patients. |
Blinding of outcome assessor | high | No mention of blinding of outcome assessor. |
Incomplete outcome data | low | Patients eligible for trial were included in analysis. |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | No mention of industry sponsorship. |
Ahmed et al, 1995 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | high | “patients were randomly divided into two groups of equal number where patients with odd numbers were treated using AO tension band wiring and those with even numbers by intramedullary screw plus tension band” |
Allocation concealment | high | Quasi-randomization suggests no allocation concealment implemented. |
Blinding of patients | high | No mention of blinding of patients. |
Blinding of outcome assessor | high | No mention of blinding of outcome assessor. |
Incomplete outcome data | low | All patients included in analysis. |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | “No funds were received in support of this study” |
Liu et al, 2012 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | low | “patients were then randomly divided into two groups for treatment with open reduction and different types of internal fixation, using an adaptive biased coin design” |
Allocation concealment | low | “randomization was carried out by a research assistant whenever an eligible patient was admitted and the grouping result was placed in a sealed envelope” |
Blinding of patients | high | Patients were unblinded after allocated to treatment group. |
Blinding of outcome assessor | low | “an independent group of physicians (not involved in the initial fracture treatment and blinded to the fixation method) evaluated the clinical outcomes of all patients” |
Incomplete outcome data | low | All patients included in analysis. |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | “authors had no conflicts of interest to declare in relation to this article” |
Chen et al, 2013 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | unclear | Randomization conducted but random sequence generation unclear. |
Allocation concealment | low | “all reviewers were blinded to evaluate the postoperative function by means of a randomised block design” |
Blinding of patients | high | No mention of blinding of patients. |
Blinding of outcome assessor | low | “all reviewers were blinded to evaluate the postoperative function by means of a randomised block design” |
Incomplete outcome data | low | “no loss to follow-up” |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | “authors declare no conflict of interest” |
Lu et al, 2015 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | unclear | Randomization conducted but random sequence generation unclear. |
Allocation concealment | unclear | Unclear whether allocation concealment was implemented. |
Blinding of patients | high | No mention of blinding of patients. |
Blinding of outcome assessor | low | “all digital radiographics were assessed by an independent senior radiologist” |
Incomplete outcome data | low | All patients included in analysis. |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | “no conflicts declared” |
Duckworth et al, 2017 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | unclear | Randomization conducted but random sequence generation unclear. |
Allocation concealment | low | “performed by block randomization using sequential closed opaque envelopes” |
Blinding of patients | high | No mention of blinding of patients. |
Blinding of outcome assessor | low | “a full clinical outcome assessment was completed by a blinded research physiotherapist or research fellow not involved in the patient's management” |
Incomplete outcome data | low | “1-year follow-up rate was 85%”; loss to follow-up <20% |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | Sponsorship was not industry-related. |
Khanna et al, 2012 |
Risk of bias domain | Author's judgment | Evidence or support for judgment |
Random sequence generation | high | “patients with closed olecranon fractures were taken who were distributed alternatively to two groups” |
Allocation concealment | high | Quasi-randomization suggests no allocation concealment implemented. |
Blinding of patients | high | No mention of blinding of patients. |
Blinding of outcome assessor | high | No mention of blinding of outcome assessor. |
Incomplete outcome data | low | “every patient of each group then is graded during his follow-up for clinical and radiological results” |
Selective reporting | low | Outcomes specified in methods were reported in results. |
Other bias (industry sponsorship) | low | No mention of industry sponsorship. |
Newcastle-Ottawa for prospective cohort studies
Study | Selection | Comparability | Outcome |
---|
1 | 2 | 3 | 4 | 1 | 1 | 2 | 3 |
---|
Johnson et al, 1986 | * | * | - | * | - | - | * | * |
MINORS for retrospective cohort studies
Study | MINORS Scale Domain |
---|
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | Total |
---|
Gartsman et al, 1981 | 0 | 2 | 0 | 1 | 0 | 2 | 2 | 0 | 2 | 2 | 0 | 0 | 11 |
Murphy et al, 1986 | 2 | 2 | 1 | 1 | 0 | 2 | 0 | 0 | 2 | 2 | 0 | 0 | 12 |
Mullett et al, 2000 | 2 | 2 | 2 | 1 | 0 | 0 | 2 | 0 | 2 | 2 | 2 | 0 | 15 |
Karlsson et al, 2002 | 2 | 2 | 2 | 1 | 2 | 2 | 0 | 0 | 2 | 2 | 0 | 2 | 17 |
Aslam et al, 2003 | 2 | 2 | 0 | 1 | 0 | 2 | 0 | 0 | 2 | 2 | 0 | 1 | 12 |
Ruden et al, 2011 | 2 | 2 | 0 | 1 | 0 | 0 | 0 | 0 | 2 | 2 | 1 | 0 | 10 |
Lan et al, 2013 | 2 | 2 | 0 | 1 | 0 | 2 | 2 | 0 | 2 | 2 | 1 | 2 | 16 |
Tarallo et al, 2014 | 2 | 2 | 2 | 1 | 0 | 2 | 2 | 0 | 2 | 2 | 1 | 2 | 18 |
Snoddy et al, 2014 | 2 | 2 | 2 | 1 | 0 | 2 | 2 | 1 | 2 | 2 | 2 | 2 | 20 |
Schliemann et al, 2014 | 2 | 2 | 1 | 1 | 0 | 2 | 0 | 1 | 2 | 2 | 1 | 2 | 16 |
Amini et al, 2015 | 2 | 1 | 1 | 1 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 2 | 17 |
Chan et al, 2015 | 2 | 2 | 1 | 1 | 0 | 2 | 2 | 0 | 2 | 2 | 1 | 2 | 17 |
Del Sole et al, 2016 | 2 | 0 | 2 | 1 | 0 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 19 |
Powell et al, 2018 | 2 | 2 | 2 | 1 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 2 | 19 |