The purpose of this video is to demonstrate the surgical technique of olecranon osteotomy with tension band wire repair. A patient with a comminuted, intra-articular distal humerus fracture requiring ORIF is presented in this video demonstration of the surgical technique of an olecranon osteotomy. The olecranon osteotomy is an established technique for approaching the distal humerus for surgical repair of fracture. In the video, the patient is positioned laterally allowing a dorsal incision. The ulnar nerve is identified and protected. A chevron osteotomy, apex distally based, is created in the proximal ulna using osteotomes, centering the osteotomy within the sulcus of the proximal ulna. Once the osteotomy has been completed, the proximal ulna is reflected proximally to allow access to the distal humerus. At the conclusion of the video, the osteotomy is repaired with a tension band technique.
Surgical treatment of intra-articular distal humerus fractures routinely requires a transolecranon approach for necessary visualization and access for fixation. Over time, various modifications of the technique have emerged. Some of these modifications include the location of the osteotomy, the details of cutting the bone, and the technique of osteotomy repair.
Patients are routinely positioned in the lateral position as is shown in this video demonstration. The midline dorsal incision is appropriate; however, some will advocate for keeping the incision away from the tip of the olecranon so that the incision does not lie over both hardware and a bone prominence. The osteotomy is routinely made through the center of the olecranon sulcus, wherein the cartilage is thinnest if present, and the bone is thinnest. Making the cut more proximally, closer to the tip, may be less destabilization to the elbow but compromises the visualization of the anterior aspect of the trochlea. A more distal osteotomy can destabilize the elbow joint and necessitate plate fixation.
The osteotomy can be performed with either an osteotomy or an oscillating saw. In this video, an osteotome is used. An oscillating saw can be used alternatively; however, this will cause a small amount of bone loss equal to the thickness of the sawblade and may cause thermal injury to the remaining bone. A chevron cut, apex distal, is recommended over a transverse cut through the proximal ulna as the chevron pattern of the osteotomy provides superior intrinsic translational and rotational stability at the time of repair.
The most controversial aspect of the osteotomy remains the repair. This video demonstrates a tension band repair using longitudinal K-wires (0.062 inches) with an 18-gauge cerclage wire. A key aspect of this technique is the engagement of the volar cortex of the ulna with the distal tips of the longitudinal K-wires to add stability to the repair. And by impacting the folded tips of the K-wires underneath the triceps tendon, prominence and back out of the pins is virtually eliminated. In this demonstration, the cerclage wire is only tensioned from one side, whereas others do recommend tensioning using a twisting wire loop on both sides of the osteotomy site. Alternative choices for repair include the use of an intramedullary screw, the use of a custom olecranon nail, or the use of a plate with screws. All of these choices add cost to the standard K-wire construct that is demonstrated in this video. Immediate range of motion should be allowed with any of these fixation techniques. Fluoroscopy was not used in this video presentation and is not necessary for successful execution of this procedure. Some surgeons may prefer intraoperative imaging to confirm location of the osteotomy, reduction of the osteotomy at the time of repair, and hardware positioning. Complications of olecranon osteotomy can include hardware prominence necessitating reoperation and nonunion.
Performing an olecranon osteotomy is a technically demanding procedure, and attention to surgical detail is necessary. High success rates with predictable healing can be expected with a technically well-performed olecranon osteotomy.
REFERENCES
1. Ring D, Gulotta L, Chin K, et al. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma. 2004;18:446–449.
2. Coles CP, Barei DP, Nork SE, et al. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006;20:164–171.
