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Technique

Loop Anchor Tension Band Fixation for Olecranon Fractures and Chevron Olecranon Osteotomy

Ho, Wei MD*; Yao, Shu-Hsin MD*; Chen, Chun-Ho MD*,†,‡

Author Information
Techniques in Hand & Upper Extremity Surgery: May 05, 2022 - Volume - Issue - 10.1097/BTH.0000000000000394
doi: 10.1097/BTH.0000000000000394

Abstract

Olecranon fractures are intra-articular fractures with an incidence of 12 per 100,000 individuals.1 These fractures are commonly encountered in elderly patients, caused by an indirect injury owing to the application of a distraction force to the triceps brachii muscle during a fall from a standing height.2,3 Olecranon fractures are classified using the Schatzker classification, Mayo classification, and Orthopaedic Trauma Association (OTA) classification proposed by the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Foundation.4 Schatzker type IV and Mayo IIIA/IIIB fractures are associated with poor outcomes, but most olecranon fractures are Mayo type IIA/IIB, with favorable surgical outcomes. Among the various treatment options, tension band wiring remains the gold standard of treatment for displaced olecranon fractures without comminution and severe bone loss.5 The AO-modified tension band wiring surgical technique comprises anatomical reduction of articular surface, parallel K-wire fixation, and figure-of-eight wiring augmentation. Transcortical fixation is recommended that the K wires anchored in the opposing cortex to prevent K-wire posterior migration. The proximal end of the K wires are bent 180 degrees, cut, and impacted into the proximal bone fragment.6 However, some complications have been reported after tension band wiring, the most frequent of which are posterior elbow pain because of hardware and rare but devastating neurovascular injury.7 The “loop anchor tension band” technique reportedly yields favorable surgical outcomes in treating patella fractures, with significantly reduced hardware migration rate.8 The same concept could be applied for treating olecranon fractures. Different from transcortical fixation, the K wires are all placed intramedullary using this technique and the K wires are locked with the figure-of-eight metal wire through the loops. The loop anchor tension band technique has some theoretical advantages including lower K-wire migration rate, intramedullary K-wire position that leads to minimal neurovascular damage rate, ability to fix smaller fragments, and reduced fluoroscopy exposure.

ANATOMY

The olecranon of the proximal ulna articulates with the trochlea of the distal humerus as the ulnohumeral joint. The triceps tendon attaches to the proximal part of the olecranon, providing most of the deforming force. Olecranon fractures are intra-articular fractures. Anatomical reduction with adequate fixation strength may benefit these patients to allow early range of motion (ROM) to avoid stiffness and to prevent subsequent elbow joint osteoarthritis.9 Some vulnerable neurovascular structures are at risk during osteosynthesis of the olecranon, including the ulnar nerve, anterior interosseous nerve over the volar cortex of the ulna and the ulnar artery (Fig. 1). Because of the subcutaneous nature of the olecranon, symptomatic hardware is the most common problem requiring removal with or without K-wire migration or prominence.10

F1
FIGURE 1:
Illustration of the positional relationship between the anterior interosseous nerve, ulnar artery, and the volar cortex of the ulna.

INDICATIONS/CONTRAINDICATIONS

The loop anchor tension band technique is mostly suitable for stable ulnohumeral joint fractures, including AO/OTA classification 2U1B1.d or Mayo type IIA olecranon fractures. We have also treated some multifragmentary olecranon fractures classified as AO/OTA 2U1B1.e or Mayo type IIB fracture and ulnohumeral unstable olecranon fracture Mayo type IIIA/IIIB (Figs. 2 and 3). This technique can also be used to fix the chevron olecranon osteotomy as an extensive surgical approach for complex distal humerus fractures. Contraindications include comminuted fractures with severe bone loss requiring bridge plate osteosynthesis and distal olecranon fractures involving the coronoid processes, such as Schatzker classification type D fractures.

F2
FIGURE 2:
Preoperative lateral and anteroposterior radiographs indicating a Mayo type IIB olecranon fracture.
F3
FIGURE 3:
Postoperative radiograph after open reduction and internal fixation with loop anchor tension band technique.

Surgical Technique

Setup

Patients are placed in the lateral decubitus position or supine position after general anesthesia, ensuring full ROM of the elbow joint and that intraoperative fluoroscopy can be obtained during the procedure.

Exposure

A posterior approach is used, starting with a curvilinear skin incision at the radial side to prevent painful scarring over the tip of the olecranon. After the whole subcutaneous tissue with overlying skin is carefully raised as a single flap, the fracture site is debrided, spread, evaluated, and anatomically reduced.

Reconstruction

Reduction is achieved through elbow extension, and the fragments are approximated by 2 pin-pointed reduction forceps on both sides. Two parallel 1.25-mm K wires are inserted along the intramedullary axis of the ulnar shaft (Fig. 4). A transverse drill hole is then made over the dorsal cortex of the ulna with a 2.0-mm K-wire or drill bit. Make sure that the bone tunnel is dorsal to the intramedullary K wires and is 2 to 4 cm distal to the fracture site. Subsequently, a 1.0-mm stainless steel wire is passed through the transverse drill hole. Fluoroscopy is used to ensure a suitable entry point and intramedullary placement of 1.25-mm K wires along with the reduction, followed by preparation of the loop anchor.

F4
FIGURE 4:
Lateral view of fracture fixation using the loop anchor tension band technique. A, Parallel intramedullary K-wire fixation. B, Making of loop anchor. C, Engaging the anchor to the cortex. D, Figure-of-eight wiring fixation.

The parallel 1.25-mm K-wire tips are meticulously bent into a loop shape with a Fergusson Suction Tube (Aesculap, Tuttlingen, Germany) and a wire twister (Aesculap, Tuttlingen, Germany). Through the use of the wire twister, the loop is adjusted to a proper size and shape, facing the triceps tendon (Fig. 5). During these procedures, additional temporary K wires may be used to maintain the reduction. The triceps tendon is then split along the bone over the entry points of K wires with separate incisions. Subsequently, the loop anchors are advanced into the triceps tendon with bone contact. A 16-gauge needle is used as a guidance after it penetrates both sides of the triceps tendon and the loop anchors. Under the guidance of the 16-gauge needle, the 1.0-mm stainless steel wire is passed through the route (Fig. 6). It is then tightened with a single radially placed twist or bilateral double twists (Fig. 7). The reduction and stability are immediately assessed through elbow ROM and fluoroscopy (Supplemental Video, which demonstrates the making of loop anchor tension band, Supplemental Digital Content 1, https://links.lww.com/BTH/A175).

F5
FIGURE 5:
Image showing the K-wire bent into a loop shape with a wire twister and suction tip. The loop was then adjusted to the desired shape with the wire twister.
F6
FIGURE 6:
Anteroposterior view of the loop anchor tension band technique. A and B, Making of loop anchors. C, Passing of the stainless wire with the help of a 16-gauge needle through the loop anchors. D, Tightening into twists and approximating the triceps.
F7
FIGURE 7:
Intraoperative image of the loop anchors and the loop anchor tension band technique.

Closure

The split triceps tendon is approximated with a 3–0 absorbable suture, ensuring that the loop anchor is deeply buried under the tendon. Finally, the wound is closed using a 2–0 absorbable suture for the subcutaneous layer and a 3–0 absorbable running suture for the subcuticular skin layer. The wound is then covered by a gauze and a compression bandage. A sling is applied without any plaster splint for immobilization.

Rehabilitation

After the operation, those who underwent the loop anchor tension band technique without splint immobilization are encouraged to perform immediate active ROM exercises. They are instructed to avoid full weight-bearing and heavy exercises until evidence of bony union is observed on postoperative follow-up imaging.

Outcome

Our case series included 10 patients (7 men and 3 women). Among these patients, 6 of them were classified as Mayo type IIA, 3 patients as type IIB and 1 patient as type IIIA (Table 1). These patients were treated from February 2017 to July 2020 by 1 orthopedic trauma surgeon. The mean age of the patients was 49.0 (range: 19 to 85) years. All the K wires were placed intramedullary, with no case of violation of the volar ulnar cortex. The mean operative time was 35.2 (range: 32 to 41) minutes, and the mean hospital length of stay was 2.9 (range: 1 to 6) days. One patient initially underwent conventional tension band wiring for proximal K-wire fixation for Mayo type IIB fracture; the most proximal fragment was too small, and hence, the K wires could only be placed intramedullary (Fig. 8). However, after the splint was removed during follow-up, we observed that the implant had migrated and was protruding out of the skin (Fig. 9). Thus, the patient underwent revision surgery using the loop anchor tension band technique and received empirical intravenous antibiotics for 6 days because of implant exposure. Fracture union was observed at 4 months after the surgery (Fig. 10).

TABLE 1 - Demographics and Summary of Outcomes for Patients Treated With Loop Anchor Tension Band
Patients Age Sex Injury Pattern Associated Injury Mayo AO Schatzker FUtime Union Hardware Removal Extension Lag
1 24.0 Female GLF n IIA 2U1B1.d C 13.5 3 mo Cosmetic concern 15*
2 19.0 Female MVC n IIA 2U1B1.d A 12.0 2 mo Cosmetic concern 0
3 37.0 Male MVC Humerus IIA 2U1B1.d A 13.6 3 mo Simultaneous ROI 0
4 54.0 Female GLF n IIA 2U1B1.d A 11.5 2 mo Painful hardware 0
5 61.0 Female GLF n IIA 2U1B1.d A 10.5 2 mo Painful hardware 0
6 22.0 Female MVC n IIB 2U1B1.e B 13.2 2 mo Cosmetic concern 0
7 55.0 Male GLF n IIB 2U1B1.e D 24.0 3 mo No 15
8 60.0 Male GLF n IIB 2U1B1.e D 13.2 4 mo Painful hardware 10*
9 85.0 Female GLF Radial neck IIIA 2U1B1.d F 15.0 3 mo No 0
10 73.0 Female MVC n IIA 2U1B1.d C 12.5 3 mo No 0
Average 49.0 13.9 2.7 mo 4 (0-15)
*Full ROM at final f/u.
AO indicates Arbeitsgemeinschaft für Osteosynthesefragen; GLF, ground-level fall; MVC, motor vehicle collision; ROI, removal of implants.

F8
FIGURE 8:
Preoperative radiographs showing a Mayo type IIB olecranon fracture.
F9
FIGURE 9:
Radiographs and intraoperative image showing wire migration after conventional tension band wiring fixation.
F10
FIGURE 10:
Radiographs of revision surgery using loop anchor tension band technique. In this case, the bone tunnel was placed volar to the intramedullary K wires because of technique error. The metal wire should be placed as dorsal as possible to covert tensile forces on the posterior side of the olecranon into compression forces at the joint line during flexion. Eventually, fracture union was observed without K-wire migration.

The mean follow-up time was 13.9 months, with a minimum follow-up duration of 1 year. All patients achieved full ROM, except 1 patient who had spurs and osteoarthritis, with limited ROM before surgery. The QuickDASH score and Mayo elbow performance scores were collected for outcome analysis. The mean QuickDASH score was 15.4 (range: 13.6 to 18.2) and the mean Mayo elbow performance score was 94 (range: 85 to 100). None of the patients experienced K-wire migration. Seven patients had hardware removal secondary to implant associated pain or cosmetic appearance.

Complications

All patients achieved clinical and radiographic union without malunion and K-wire migration. No damage to the neurovascular structure was noted. Three patients complained about hardware irritation. Only 1 patient exhibited permanent extension lag because of existing elbow joint osteoarthritis while 2patients reported temporary extension lag only during early follow-up.

DISCUSSION

The goal of olecranon fracture treatment is achieving anatomical reduction of the articular surface and stable construct fixation. Various treatment options have been suggested for simple and comminuted olecranon fractures, including AO-modified tension band wiring with parallel K wires, intramedullary screw with or without tension band augmentation, intramedullary nailing, fiber wire suture, posterior plating, and olecranon excision with triceps advancement.3,11,12 Conventional AO-modified tension band wiring remains a popular option for Mayo type IIA and some of the IIB olecranon fractures.5 The most common complication is elbow pain because of painful hardware, leading to a high reoperation rate of up to 71.7% for implant removal.13 Several surgical techniques have been developed to reduce the complications related to metal implant migration and prominence, including transcortical K-wire position, bioabsorbable intramedullary screws, and high-strength braided suture only.14,15 Although transcortical positioning of the K-wire reduces the migration rate and affords a more superior biomechanical result, it can cause anterior interosseous nerve injury, ulnar artery injury, restriction of elbow ROM, and radioulnar synostosis on extrusion to undesired areas.7

The loop anchor tension band technique reduces the rates of these potential complications and the amount of fluoroscopy exposure owing to the long intramedullary K wires. This technique enables the fixation of smaller proximal fragments, which are otherwise difficult to fix because of limited space when aiming for bicortical fixation. With the tensioning of the twists, the loop anchor is further compressed against the bone surface of the proximal fragment, closing the articular gap and minimizing implant prominence to the triceps tendon. A similar commercialized construct has been reported in a previous study.16 No pin migration, restriction of ROM, or neurovascular injury was observed in that study. Although these pins with eyelets are simple to use, their use is limited owing to concerns regarding availability and high cost at local hospitals. The loop anchor tension band is cost effective and can be easily duplicated using a wire twister, suction tube, and wire cutting forceps alone (Fig. 11). In addition, the surgical time can be minimized because frequent adjustments of the K-wire and intraoperative image confirmation are not required in this technique. Although in this case series we observed a high hardware removal rate, not all the patient experienced painful hardware. Among these 7 patients underwent implant removal surgery, 3 patients decided for hardware removal because of implants irritation, 3 of them were young women with cosmetic concerns about the hardware beneath the skin; the last patient’s wires were removed along with his distal humerus implant. Overall, patients who underwent fracture reduction using this technique reported favorable maintenance of reduction, early ROM, and short hospital stay, except for 1 patient who required prolonged hospitalization because of complications of previous surgery. Moreover, no implant migration was noted in our series.

F11
FIGURE 11:
Photograph of the required instruments. A, BAUMGARTNER DUROGRIP TC Wire Twister, Aesculap. B, Fergusson Suction Tube, Aesculap. C, TC Wire Cutting Forceps, Aesculap.

A limitation of our study is the small sample size and lack of a control group. Further biomechanical studies and comparative studies with larger groups may be required to confirm the advantages of this technique. Finally, our hardware removal rate is not lesser than previous report since removal surgery was requested by asymptomatic patients because of culture influence and cosmetic concern. But in our experience, those patients who had wire migration will suffered from greater elbow pain requiring removal surgery. Further effort will be made to prevent subcutaneous prominence of the implants such as replacement of metal wire using nonabsorbable, braided Polyester Suture.

ACKNOWLEGEMENTS

The authors thank Ditmanson Medical Foundation Chia-Yi Christian Hospital for assisting this project.

REFERENCES

1. Duckworth AD, Clement ND, Aitken SA, et al. The epidemiology of fractures of the proximal ulna. Injury. 2012;43:343–346.
2. Newman SDS, Mauffrey C, Krikler SJ. Olecranon fractures. Injury. 2009;40:575–581.
3. Baecher N, Edwards S. Olecranon fractures. J Hand Surg [Am]. 2013;38:593–604.
4. Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium—2018. J Orthop Trauma. 2018;32(suppl 1):S1–S170.
5. Chalidis BE, Sachinis NC, Samoladas EP, et al. Is tension band wiring technique the “gold standard” for the treatment of olecranon fractures? A long term functional outcome study. J Orthop Surg Res. 2008;3:9.
6. Buckley RE, Moran CG, Apivatthakakul T. AO Principles of Fracture Management: Vol 2: Specific fractures. New York, NY: George Thieme Verlag; 2017:637–656.
7. Catalano LW, Crivello K, Lafer MP, et al. Potential dangers of tension band wiring of olecranon fractures: an anatomic study. J Hand Surg [Am]. 2011;36:1659–1662.
8. Yao S-H, Lin S-F, Lin C-H, et al. Loop anchor tension band technique for patella fractures lowers the rate of Kirschner migration. Injury. 2021;52:1556–1562.
9. Duckworth AD, Clement ND, McEachan JE, et al. Prospective randomised trial of non-operative versus operative management of olecranon fractures in the elderly. Bone Joint J. 2017;99-B:964–972.
10. Bugarinovic G, McFarlane KH, Benavent KA, et al. Risk factors for hardware-related complications after olecranon fracture fixation. Orthopedics. 2020;43:141–146.
11. Powell AJ, Farhan-Alanie OM, Bryceland JK, et al. The treatment of olecranon fractures in adults. Musculoskelet Surg. 2017;101:1–9.
12. Das AK, Jariwala A, Watts AC. Suture repair of simple transverse olecranon fractures and chevron olecranon osteotomy. Tech Hand Up Extrem Surg. 2016;20:1–5.
13. Romero JM, Miran A, Jensen CH. Complications and re-operation rate after tension-band wiring of olecranon fractures. J Orthop Sci. 2000;5:318–320.
14. Mullett JH, Shannon F, Noel J, et al. K-wire position in tension band wiring of the olecranon—a comparison of two techniques. Injury. 2000;31:427–431.
15. Crozier-Shaw G, Mahon J, Bayer TC. The use of bioabsorbable compression screws & polyethylene tension band for fixation of displaced olecranon fractures. J Orthop. 2020;22:525–529.
16. Kim JY, Lee YH, Gong HS, et al. Use of Kirschner wires with eyelets for tension band wiring of olecranon fractures. J Hand Surg [Am]. 2013;38:1762–1767.
Keywords:

olecranon fractures; chevron osteotomy; open reduction and internal fixation; loop anchor tension band; tension band wiring

Supplemental Digital Content

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