Technique Using Isoelastic Tension Band for Treatment of Olecranon Fractures
The isoelastic ultrahigh-molecular-weight polyethylene tension band may be considered an alternative to stainless steel wire for tension band fixation of olecranon fractures.
In this article, we present our technique using this isoelastic tension band and describe the outcomes of 7 patients who underwent open reduction and internal fixation of closed, displaced olecranon fractures with minimal or no articular surface comminution. We reviewed medical records and performed physical examinations and functional assessments.
Anatomical reduction was maintained in all elbows through union. Physical examination measurements indicated nominal side-to-side differences in motion and strength. Mean Broberg and Morrey elbow score was good (92/100), and mean (SD) Disabilities of the Arm, Shoulder, and Hand score was 12.6 (17.2). One patient had a minor degree of hardware irritation at longest follow-up but did not request hardware removal. One patient underwent implant removal for a symptomatic implant 5 years after surgery.
This easily reproducible technique yields excellent physical and functional outcomes.
Various studies have addressed the clinical complaints and reoperation rates associated with retained metal implants after olecranon fixation. Traditional AO (Arbeitsgemeinschaft für Osteosynthesefragen) technique involves subcutaneous placement of stainless steel wires, which often results in tissue irritation. Reoperation rates as high as 80% have been reported, and a proportion of implant removals may in fact be caused by factors related to the subcutaneous placement of the metallic implants rather than K-wire migration alone.5,12,18 A nonmetallic isoelastic tension band can provide a more comfortable and less irritating implant, which could reduce the need for secondary intervention related to painful subcutaneous implant. One of our 7 patients had a symptomatic implant removed 5 years after surgery. This patient complained of pain over the area of the tension band device clip, so after fracture healing the entire fixation device was removed in the operating room. If reoperation is necessary, removal of intramedullary K-wires is relatively simple using a minimal incision; removal of stainless steel TBW may require a larger approach if the twisted knots cannot be easily retrieved.
A study of compression forces created by stainless steel wire demonstrated that a “finely tuned mechanical sense” was needed to produce optimal fixation compression when using stainless steel wire.26 It was observed that a submaximal twist created insufficient compressive force, while an ostensibly minimal increase in twisting force above optimum abruptly caused wire failure through breakage. Cerclage cables using clasping devices, such as the current isoelastic cerclage cable, were superior in ease of application. Furthermore, a clasping device allows for cable tension readjustment that is not possible with stainless steel wire. The clasping mechanism precludes the surgeon from having to bury the stainless steel knot and allows for the objective cable-tensioning not possible with stainless steel wire. Last, the tensioning device is titratable, which allows the surgeon to set the construct at a predetermined quantitative tension, which is of benefit in patients with osteopenia.
One limitation of this study is that it did not resolve the potential for K-wire migration, and we agree with previous recommendations that careful attention to surgical technique may avoid such a complication.10 In addition, the sample was small, and the study lacked a control group; a larger sample and a control group would have boosted study power. Nevertheless, the physical and functional outcomes associated with use of this technique were excellent. These results demonstrate an efficacious attempt to decrease secondary surgery rates and are therefore proof of concept that the isoelastic tension band may be used as an alternative to stainless steel in the TBW of displaced olecranon fractures with minimal or no comminution.
Conclusion
This easily reproducible technique for use of an isoelastic tension band in olecranon fracture fixation was associated with excellent physical and functional outcomes in a series of 7 patients. The rate of secondary intervention was slightly better for these patients than for patients treated with wire tension band fixation. Although more rigorous study of this device is needed, we think it is a promising alternative to wire tension band techniques.
