Comminuted, intra-articular fractures of the distal humerus represent complex and difficult-to-treat fracture patterns. These challenging fractures are uncommon, have intricate surrounding anatomy, and have limited bone stock available for their fixation. In the active patient, open reduction and internal fixation (ORIF) remains the standard of care for such fractures.1 Several posterior approaches have been described in the literature for fixing the distal humerus, all variations on 3 principal distal humerus approaches: triceps sparing,2,3 triceps splitting,4–6 and olecranon osteotomy.7
Given its superior articular surface exposure, maximum exposure of the surgical site, and minimal impact on extensor muscle mechanisms, the posterior transolecranon approach is common when treating intra-articular distal humerus fractures.8 However, its associated olecranon osteotomy has been cited with a number of complications, including high rates of olecranon hardware prominence and osteotomy nonunion.9 This osteotomy-related complication rate is poorly defined in the literature, and there is controversy regarding the optimal method of fixation for the olecranon osteotomy. Despite this lack of consensus, no study has directly compared methods of olecranon osteotomy fixation immediately following transolecranon ORIF of the distal humerus. As such, this study compares the clinical results of tension band wiring (TBW) and plate fixation (PF) of olecranon osteotomy following transolecranon ORIF of comminuted, intra-articular distal humerus fractures.
Materials and Methods
A retrospective chart review was conducted to identify all patients with comminuted, intra-articular distal humerus fractures (AO types 13-C2 and 13-C3) treated operatively using a transolecranon approach by 1 of 3 orthopedic trauma surgeons (S.R.K., N.C.T., K.A.E.) from January 2007 to January 2017 at 1 academic medical center. In each case, the associated intra-articular, chevron-type olecranon osteotomy was fixed with either TBW or PF (Figure 1). Patients treated with elbow arthroplasty, those treated without osteotomy, and those younger than 18 years were excluded. Patients with less than 6 months of clinical follow-up or those who had not yet healed at the time of final follow-up were likewise excluded. For all remaining eligible patients, patient charts and radiographs were retrieved and reviewed following local institutional review board approval for full retrospective review.
Lateral radiographs following distal humerus open reduction and internal fixation with olecranon osteotomy fixed with tension band wiring (A) and plate fixation (B).
Collected data included patient demographics, injury details, operative details, functional outcomes, reoperations, and complications. Patient demographics included sex, body mass index, age, Charlson Comorbidity Index (CCI), smoking status, and mechanism of initial injury. Time to radiographic healing of both the humerus fracture and the olecranon osteotomy site was also recorded. Collected operative details included surgical approach, treatment of the ulnar nerve, and method of olecranon fixation. At all postoperative follow-up visits, elbow flexion/extension and pronation/supination were measured using a goniometer. Both lateral and anteroposterior radiographs of the affected elbow were obtained at all follow-up visits to assess fracture healing. Final function was further assessed with Mayo Elbow Performance Index (MEPI) scores obtained for all patients using the functional information recorded in their latest clinical note. This retrospective data collection was performed by 2 independent observers (J.M.H., D.N.K.) not involved with patient care.
Operative Osteotomy Details
The olecranon osteotomy was performed via a chevron osteotomy using a microsagittal saw and osteotome. The osteotomized portion of the olecranon and the triceps were reflected proximally, exposing the comminuted intra-articular fracture fragments. Following acceptable articular reduction and fixation of the distal humerus, the olecranon osteotomy was repaired. For patients fixed with TBW, two 1.6-mm Kirschner wires were drilled in parallel from the dorsal cortex to the anterior cortex of the ulna across the osteotomy site. Next, a 2-mm drill hole was made transversally distal to the osteotomy, where either an 18-gauge or a 20-gauge tension wire was passed. A second tension wire was passed through the triceps dorsal to the Kirschner wires. The wires were tensioned in a figure-of-8 fashion and were cut short, bent, and impacted into the proximal ulna. For patients fixed with PF, the olecranon osteotomy was repaired with either a 4-hole or a 6-hole precontoured proximal ulna plate, or an intraoperatively contoured one-third tubular plate, fixed with 3.5-mm screws.
Data and outcomes were compared between olecranon fixation cohorts using independent t tests, chi-square tests, Fisher's exact tests, and Mann–Whitney U tests, with P<.05 considered significant. All statistical analyses were conducted using SPSS, version 23.0, software (SPSS, Inc).
Of the 107 consecutive intra-articular distal humerus fractures treated during this time period, a total of 48 adult patients met inclusion criteria. The 59 patients who failed to meet inclusion criteria either underwent total elbow arthroplasty (n=16), underwent ORIF through an approach other than olecranon osteotomy (n=41), or failed to follow up postoperatively (n=2). All included patients were treated for intra-articular AO type 13-C2 or 13-C3 fractures via a transolecranon approach. Eight fractures were open and 40 were closed. Of this cohort, 27 (56.3%) patients had fixation of their olecranon osteotomy with TBW using Kirschner wires, and 21 (43.8%) had fixation of their olecranon osteotomy with PF. Mean follow-up among included patients was 20.5±16.1 months (range, 13–62 months). Fixation groups did not significantly differ regarding any demographic or injury type (Table 1).
All distal humerus fractures healed by a mean of 19.4±6.6 weeks. All olecranon osteotomies healed by a mean of 16.9 weeks, although 2 TBW patients underwent olecranon delayed union repair with iliac crest bone grafting to achieve healing. Clinically, there were no differences in olecranon osteotomy mean time to union, mean elbow arc of motion at any period, mean pronation/supination arc of motion at any period, or mean patient MEPI score at final follow-up. However, patients with TBW had greater elbow extension at both 6-month (P=.023) and final follow-up when compared with the PF cohort (P=.001) (Table 2). There was no difference in complication rate between the 2 cohorts (Table 3). There was also no significant difference in reoperation rate, because 6 patients from the TBW group and 4 patients from the PF cohort underwent reoperation for various procedures (Table 4).
There were no differences in the rates of olecranon delayed union requiring intervention, delayed union not requiring intervention, painful/prominent olecranon hardware without hardware removal, or removal of painful/prominent olecranon hardware. Two patients in the TBW group required symptomatic delayed union repair with iliac crest bone grafting of their olecranon following failure to heal at an average of 19.4 weeks following initial operation, compared with none in the PF cohort (P=.181). Both TBW patients were converted to PF as part of the delayed union repair and went on to heal. Of note, both TBW patients with olecranon delayed union requiring reoperation were daily smokers. A subanalysis comparing daily smokers to nonsmokers demonstrated a significantly longer time to olecranon union among smokers (39.3±18.4 weeks) compared with nonsmokers (13.8±4.7 weeks; P<.001). A similar subanalysis was performed comparing open fractures with closed, and no significant differences were observed. A third subanalysis was performed to compare all outcomes across each of the 3 treating surgeons included in the study, and this analysis revealed no differences between surgeons across any outcome measure.
Likewise, patients who underwent reoperation of any type were compared with patients who did not undergo reoperation. The only measured difference between these cohorts was a longer mean time to olecranon union among the reoperation cohort (22.9±17.4 weeks among patients with reoperation vs 15.0±6.9 weeks among those without reoperation; P=.041).
Three TBW and 4 PF patients developed posttraumatic arthritis. Of these 7 patients developing posttraumatic arthritis, all of them originally had an AO type 13-C3 fracture. One PF patient developed wound breakdown and dehiscence over the olecranon plate and underwent irrigation and debridement with removal of all hardware and secondary closure. Four PF patients and 1 TBW patient developed ulnar nerve neuropathy symptoms postoperatively, which resolved by 1 year. Of these patients, 1 PF patient and 1 TBW patient concurrently developed posttraumatic elbow contracture with heterotopic ossification about the osteotomy site; both elected operative treatment in the form of open elbow release with ulnar nerve transposition and removal of all hardware. One PF patient with ulnar neuropathy symptoms underwent removal of olecranon hardware with ulnar nerve transposition. One PF patient developed nonsymptomatic heterotopic ossification about the osteotomy site. Two PF patients and 1 TBW patient had symptomatic olecranon hardware at their last follow-up but elected not to undergo hardware removal. One PF patient developed a seroma over his olecranon, which was treated with aspiration in the outpatient clinic. In total, 7 (25.9%) TBW and 4 (19.0%) PF patients had olecranon hardware removed (P=.834). Of these, 1 TBW patient and 2 PF patients underwent removal solely for symptomatic olecranon hardware, whereas all other hardware removals involved removal of humeral plates and were performed concomitantly with other procedures.
This study demonstrated that repair of an intra-articular chevron osteotomy with either a tension-band construct or a plate-and-screw construct provided for reliable healing in the setting of distal humerus repair. All patients had their humerus fractures heal, and there were no differences regarding olecranon osteotomy time to union. Further, there were no differences regarding total arc of motion or final elbow function evaluated by patient MEPI score between patients who had their olecranon osteotomy fixed with a plate and patients who had their olecranon fixed with TBW.
The olecranon osteotomy has historically been the standard approach for fixing complex fractures of the distal humerus.7,8 However, reports with this approach have been mixed, largely due to the high rate of reported osteotomysite complications following a transolecranon approach. The posterior transolecranon approach used in this study carries several advantages, especially when treating comminuted and complex fractures of the distal humerus.10–15 The primary benefit is maximized visualization of the distal humeral articular surface. In a cadaveric study, Wilkinson and Stanley16 demonstrated that a transolecranon approach to the distal humerus allows for a 63% and 24% increase to visualization of the humeral articular surface when compared with triceps-splitting and triceps-sparing approaches, respectively. This approach also carries less risk for postoperative triceps weakening or evulsion17,18 and allows for earlier elbow joint mobilization postoperatively, reducing the risk of fibrous tissue formation and stiffness.19
Despite these advantages, studies have reported high complication rates related to the osteotomy site.20,21 Specifically, Henley et al20 and Henley22 reported a 31% complication rate with regard to the olecranon osteotomy in their studies, with delayed union/nonunion in 10.3% of patients, and symptomatic hardware about the olecranon in another 21%. Similar findings were reported by McKee et al,21 citing a 27% reoperation rate for hardware removal among olecranon osteotomies following distal humerus ORIF. Further, Gofton et al23 reported an olecranon nonunion rate of 9% among their 22 patients operated with a transolecranon approach.
These results differ from those of Coles et al,18 who reported no olecranon nonunions and an 8% isolated olecranon hardware removal rate among their large 67-patient cohort using an intramedullary screw with supplemental dorsal wire construct to achieve olecranon fixation. This rate of hardware removal is consistent with that of Ring et al,24 who report a 13% isolated olecranon hardware removal rate with a total 27% hardware removal rate, attributing success to their modified K-wire TBW technique for osteotomy fixation. This technique involves drilling of the K-wires obliquely across the osteotomy site with a slight anterior angle, as to engage the anterior ulnar cortex on placement. This anterior angling was used among the current authors' TBW patients.25
These rates reported in the literature are consistent with those observed in the current study. There were 2 olecranon delayed unions requiring intervention in this study, both following TBW of the olecranon osteotomy.
Heterotopic ossification,23 ulnar nerve neuropraxia,17,26 and elbow contracture27,28 are the most common complications associated with comminuted distal humerus fractures and were similarly observed among both PF and TBW patients and occurred at rates similar to those in the literature.7
Further, there was no difference among the overall rate of complications, reoperations, or individual complication rate between cohorts. Additionally, there was no difference in total arc of elbow motion or arc of pronation/supination at any time point, mean time to olecranon union, or final elbow function as evaluated by patient MEPI score. However, the TBW cohort demonstrated significantly greater elbow extension at both 6-month and final follow-up when compared with the PF cohort. The greater extension loss among the PF cohort in this study may be attributable to the increased bulk of the proximal plate along the distal ulna in the olecranon fossa. However, this did not affect total arc of motion when compared with TBW patients, and its clinical import is likely negligible.
Although several studies have compared outcomes for TBW and PF for fixation of isolated olecranon fractures,29,30 this is the first study to directly compare fixation methods following olecranon osteotomy with distal humerus fractures. The study highlights the outcomes achievable following complex intra-articular distal humerus fractures using a posterior transolecranon approach with either PF or TBW fixation of the associated olecranon osteotomy. The need for hardware removal was not uncommon among this cohort and has been considered a drawback to the olecranon osteotomy in the literature. However, the final outcomes among patients who underwent reoperation in this study were not different from those who did not undergo reoperation, and the authors believe the risk of reoperation is balanced against the need to visualize and fix the articular surface, given the complexity of these fractures. Fully addressing the initial distal humerus fracture to the best of the surgeon's ability should take priority with complex fractures of the distal humerus, because residual complications to the distal humerus are associated with much greater morbidity than the potential for secondary olecranon hardware removal.
This study had several limitations. First, this study was subject to inherent weaknesses of a retrospective study, because data were reliant on complete and accurate medical records. Further, elbow flexion/extension and pronation/supination measurements were assessed by 3 different providers, and some degree of inconsistency may exist. It is also difficult to assess the true effect of symptomatic olecranon hardware on hardware removal, because any hardware removal performed concomitantly with another procedure likely had varying degrees of symptom severity and indication for removal. Finally, longer follow-up might have led to more patients developing complications. However, length of follow-up was limited by the retrospective study design, because follow-up was reliant on clinic visits or documentation. Therefore, patients without follow-up beyond their last asymptomatic visit likely went on to experience good function with their elbow, and the follow-up for healthy patients may be under-representative.
Patients undergoing TBW or PF of their olecranon osteotomy following ORIF of intra-articular distal humerus fractures had similar outcomes in this study. Patients undergoing olecranon osteotomy fixed with PF may experience less terminal elbow extension when compared with those fixed with TBW. With either method, reoperation for removal of symptomatic hardware is not uncommon, but good results can be expected even if reoperation is necessary. Given the similar clinical outcomes between the 2 methods of olecranon fixation following distal humerus ORIF, either modality may be considered when selecting a construct for olecranon osteotomy repair as part of comminuted distal humerus fracture repair.
- Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus: an operative approach. J Bone Joint Surg Am. 1985;67(2):226–239. doi:10.2106/00004623-198567020-00008 [CrossRef] PMID:3968114
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|Characteristic||Total cohort (N=48)||TBW (n=27)||PF (n=21)||P|
|Age, mean±SD, y||48.8±15.9||46.1±18.1||52.6±14.8||.201|
|Male, No.||22 (45.8%)||12 (44.4%)||10 (47.6%)||.613|
|Female, No.||26 (54.2%)||15 (55.6%)||11 (52.4%)|
|BMI, mean±SD, kg/m2||23.9±3.3||23.7±3.6||24.3±3.0||.668|
|AO type 13-C2 fracture pattern, No.||12 (25.0%)||7 (25.9%)||5 (23.8%)||.887|
|AO type 13-C3 fracture pattern, No.||36 (75.0%)||20 (74.1%)||16 (76.2%)|
|Follow-up, mean±SD, mo||20.5±16.1||19.0±9.2||20.9±16.7||.371|
|TBW (n=27)||PF (n=21)|
|Time to olecranon union, wk||17.0±11.9||16.8±8.4||.867|
|3-mo elbow arc of motion||86.8°±18.2°||74.6°±29.8°||.131|
|3-mo pronation/supination arc of motion||127.0°±15.1°||125.1°±13.7°||.679|
|3-mo elbow extension deficit||23.8°±14.2°||31.3°±17.2°||.111|
|6-mo elbow arc of motion||110.1°±15.2°||103.6°±12.9°||.221|
|6-mo pronation/supination arc of motion||134.8°±17.0°||132.0°±16.1°||.723|
|6-mo elbow extension deficit||14.9°±7.1°||20.7°±7.3°||.023|
|Final elbow arc of motion||120.1°±12.1°||115.6°±13.8°||.113|
|Final pronation/supination arc of motion||142.7°±17.0°||141.1°±14.6°||.876|
|Final elbow extension deficit||9.5°±6.6°||17.4°±7.4°||.001|
|MEPI score at last follow-up||88.7±7.2||84.7±9.9||.149|
|Olecranon delayed union requiring reoperation||Isolated osteotomy hardware removal||Associated osteotomy hardware removala||Olecranon delayed union||Superficial infection with dehiscence||Ulnar nerve neuropathy||Elbow contracture|
|TBW (n=27)||2 (7.4%)||1 (3.7%)||6 (22.2%)||1 (3.7%)||0 (0%)||1 (3.7%)||1 (3.7%)|
|PF (n=21)||0 (0%)||2 (9.5%)||2 (9.5%)||1 (4.8%)||1 (4.8%)||4 (19.0%)||1 (4.8%)|
|Total (N=48)||2 (4.2%)||3 (6.3%)||7 (14.6%)||2 (4.2%)||1 (2.1%)||5 (10.4%)||2 (4.2%)|
|TBW (n=27)||PF (n=21)||Total (N=48)|
|Required reoperation||7 (25.9%)||4 (19.0%)||11 (22.9%)|
|Olecranon delayed union repair with ICBG and olecranon fixation exchange||2 (7.4%)||0 (0%)||2 (4.2%)|
|Irrigation and debridement with removal of all hardware||0 (0%)||1 (4.8%)||1 (2.1%)|
|Elbow contracture release with HO excisiona||1 (3.7%)||1 (4.8%)||2 (4.2%)|
|Removal of all hardware||3 (11.1%)||0 (0%)||3 (6.3%)|
|Removal of olecranon hardware only||1 (3.7%)||2b (9.5%)||3 (6.3%)|