Comparison of Outcomes and Costs of Tension-Band and Locking-Plate Osteosynthesis in Transverse Olecranon Fractures: A Matched-Cohort Study
To determine if there are significant differences in outcomes and costs between tension-band and locking-plate fixation of transverse olecranon fractures in adults, we retrospectively compared functional outcomes, complications, and costs in 2 cohorts of displaced transverse olecranon fractures. These cohorts (10 patients each) were matched on age and length of follow-up.
There were no significant differences between the groups in range of motion, functional scores, or arthrosis. There were no infections or nonunions in either group. There was no significant difference in rate of implant removal or symptomatic implants, though a trend was found toward a higher rate of both with tension bands. Operative time was significantly (P = .025) less for tension-band than locking-plate fixation (55 vs 85 minutes). In the tension-band group, charges were significantly less for implant, index procedure, and overall operative charges including reoperations ($6598.36 vs $14,333.46; P = .001). If all tension bands and no locking plates had been removed, tension-band fixation still would have cost significantly less ($7307.31 vs $14,160.26; P = .0005).
Our findings also suggest a trend toward fewer implant-related symptoms and less need for implant removal in patients treated with locking plates. Although both implants have high rates of prominence requiring removal, most studies support our findings that tension bands are more prominent than locking plates. Fixation has been reported to cause prominence requiring removal in 42% to 82% of patients with tension bands7-14 and 0% to 47% of patients with locking plates.1,8,17,18,20-22,28 It is important to note that many earlier studies either were conducted before the advent of precontoured locking plates or were not comparative.1,7,9-14,17,18,20-22,28 In one recent study, however, Edwards and colleagues19 surveyed 138 patients and found very similar implant removal rates: 63.6% for tension bands and 62.5% for locking plates. Nevertheless, implant removal rates for fixation of olecranon fractures remain high, regardless of implant used.
Our data did not reveal any difference in ROM or functional outcomes between patients who had and did not have implants removed. This suggests, first, that QDASH and MEPS may not be sensitive in identifying patients with implant prominence, as neither questionnaire incorporates implant prominence into its scoring, and, second, that implant removal does not significantly impair ROM. As a result, surgeons should consider asking patients specifically about symptoms of prominent implants once there is convincing evidence of union and counseling them about implant removal if appropriate.
To our knowledge, the differences in cost and operative time between tension-band and locking-plate fixation have not been previously reported. Our data suggest that the financial differences resulted mainly from implant charges; overall, tension-band fixation was roughly half the cost of locking-plate fixation. In addition, in patients who eventually had implants removed, the cost of implant removal was relatively small compared with the cost of the initial fixation in both cohorts. As a result, even if all patients in the tension-band cohort and no patients in the locking-plate cohort had implants removed, tension-band fixation and subsequent implant removal would still cost half as much as locking-plate fixation without implant removal. Moreover, fixation with a tension band took roughly 30 minutes less than fixation with a plate. Less time in the operating room likely contributed to the additional cost savings realized with tension-band fixation beyond those directly resulting from implant cost.
The strength of this study lies in the homogeneity of cohorts. Each cohort was matched primarily on age and secondarily on length of follow-up. All patients had closed, proximal, transverse fractures without comminution, and we excluded olecranon osteotomies as these represent an entity different from true fractures. Fractures with comminution or distal extension may represent more severe injuries, and functional scores, complications, hardware prominence, and operative time might have been affected by inclusion of these fractures. Further, there were no infections in either group to skew the rate of implant prominence or removal.
The weaknesses of the study lie in its limited sample sizes, retrospective design, and lack of long-term follow-up. Group size was limited by our attempts to create homogenous cohorts. As a result, some patients were not included as participants because of strict exclusion criteria. Most notably, we excluded any fracture not appropriate for tension-band fixation, as well as open fractures and osteotomies. Despite the retrospective nature of the study, all patients were examined by the investigators at final follow-up (minimum, 2 years) for the purpose of this study. It is possible that these functional results may not be sustained over the long term, as the risk for posttraumatic arthrosis in articular injuries builds with time. Although some patients may want to have implants removed later, all our study patients who had implants removed had them removed within 1 year, and all 20 patients were reached at minimum 2-year follow-up. Thus, it is unlikely but possible that some of the other study patients will elect to have implants removed.
