Olecranon fractureOlecranon fracture

Lonnie Froberg, MD, Ph.DLonnie Froberg, MD, Ph.D

Odense University HospitalOdense University Hospital

20% of forearm fracture20% of forearm fracture 12 per 100.000 persons per year12 per 100.000 persons per year Low-energy fallLow-energy fall Increased risk >50 yearsIncreased risk >50 years 90% AO 21.B1.190% AO 21.B1.1

Duckworth et al. Injury 2012;43:343-346 Duckworth et al. Injury 2012;43:343-346

Why operate?Why operate? Methods of fixationMethods of fixation

– K-wire, cerklageK-wire, cerklage– PlatingPlating

OutcomeOutcome SummarySummary

Why operate?Why operate?

Restore articular surfaceRestore articular surface Achieve absolute stabilityAchieve absolute stability Commence early active Commence early active

movementmovement Preservation of range of motion Preservation of range of motion

and powerand power Avoidance of complicationsAvoidance of complications

Methods of fixation?Methods of fixation?

Methods of fixation?Methods of fixation?

Cadaveric elbow jointCadaveric elbow joint Standard osteotomiesStandard osteotomies Five different fixation Five different fixation

techniquestechniques

Loads applied comparable Loads applied comparable to clinical situationsto clinical situations

Displacements measuredDisplacements measured

Fyfe et al. Jour Bone Joint Surg (Br).1985. 67B;3:367-372Fyfe et al. Jour Bone Joint Surg (Br).1985. 67B;3:367-372

Methods of fixation?Methods of fixation?

Fracture typeFracture type

TransverseTransverse

ObliqueOblique

ComminutedComminuted

Fixation Fixation techniquetechniqueTension band 1.0 mm, 1 Tension band 1.0 mm, 1 knot, K-wire 2.0 mmknot, K-wire 2.0 mm

Tension band 1.0 mm, 2 Tension band 1.0 mm, 2 knots, K-wire 2.0 mmknots, K-wire 2.0 mm

Tubular plateTubular plate

Cancellous screw, Cancellous screw, washerwasher

Cancellous screw, Cancellous screw, washer, tension bandwasher, tension bandFyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372

Methods of fixation?Methods of fixation?

Fracture Fracture typetype

Fixation Fixation techniquetechnique

TransverseTransverse Tension band, 2 Tension band, 2 knotsknots

ObliqueOblique Tension band, 2 Tension band, 2 knotsknots

or tubular plateor tubular plateComminutedComminuted Tubular plateTubular plate

Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367-372

K-wire and cerklageK-wire and cerklage

K-wire with or without K-wire with or without eyelets?eyelets?

No significant No significant difference in difference in postoperative pain postoperative pain or in rate of hard or in rate of hard ware removalware removal

Kim et al. Kim et al. J Hand Surg Am. 2013.Jul 9

How to place the K-wires?How to place the K-wires?

Proximal ulnar canal?Proximal ulnar canal? Anterior cortex?Anterior cortex? Distal ulnar canal?Distal ulnar canal?

Huang et al. J Trauma. 2010.68;1:173-176Huang et al. J Trauma. 2010.68;1:173-176

How to place the K-wires?How to place the K-wires?

Proximal ulnar Proximal ulnar (n=24) (n=24)

Anterior Anterior cortexcortex

(n=28)(n=28)

Distal ulnar Distal ulnar (n=26)(n=26)

Average Average follow-up/monfollow-up/monthsths

34.5 s.d 7.234.5 s.d 7.2 34.0 s.d 5.934.0 s.d 5.9 29.6 s.d 7.229.6 s.d 7.2

Symptomatic Symptomatic implant implant removalremoval

8 (33%)8 (33%)

*p=0.03*p=0.033 (11%)3 (11%) 2 (8%)2 (8%)

Proximal Proximal migration of K-migration of K-wire/mmwire/mm

4.08 s.d. 1.894.08 s.d. 1.89

*p=0.001*p=0.0011.53 s.d 0.561.53 s.d 0.56 1.31 s.d 0.541.31 s.d 0.54

Satisfactory Satisfactory functionel functionel outcomeoutcome

21 (88%)21 (88%) 26 (93%)26 (93%) 26 (100%)26 (100%)

How to place the K-wires?How to place the K-wires?

Inserted as close as possible to Inserted as close as possible to the articular surfacethe articular surface

Back 1 cm from final position, cut Back 1 cm from final position, cut obliquely, bent obliquely, bent

Incisions with lines in tricepsIncisions with lines in triceps K-wires are impacted into ulnaK-wires are impacted into ulna

Newman et al. 2009. Injury; 40(6): 575-581Newman et al. 2009. Injury; 40(6): 575-581

How to place the K-wires?How to place the K-wires?

K-wire penetration K-wire penetration more than 10 mm more than 10 mm beyond the beyond the anterior cortex anterior cortex increases risk for increases risk for penetration of penetration of median nerve and median nerve and ulnar arteryulnar artery

Prayson et al. Shoulder Elbow Surg. Prayson et al. Shoulder Elbow Surg. 2008.17;1:121-1252008.17;1:121-125

Which kind of tension band?Which kind of tension band?

FailureFailure

(> 2 mm (> 2 mm movement across movement across osteotomy)osteotomy)

CompressionCompression

Stainless steel Stainless steel wirewire

0% 0% 71%71%

Ethibond No. 2Ethibond No. 2 100%100% 66%66%

Ethibond No. 5Ethibond No. 5 40%40% 40%40%

Fiber wireFiber wire 0%0% 43%43%

Lalliss et al. Jour Bone Joint Surg (Br).2010.92B;2:315-319

PlatingPlating

PlatingPlating

When to plate?When to plate?– Tension band is not Tension band is not

appropriateappropriate– Oblique fractures distal to the Oblique fractures distal to the

midpoint of the troclear notchmidpoint of the troclear notch– Co-existing coronoid fractureCo-existing coronoid fracture– Associated with Monteggia Associated with Monteggia

fracture dislocationfracture dislocation

Newman et al. 2009. Injury; 40(6): 575-581Newman et al. 2009. Injury; 40(6): 575-581

Which kind of plate?Which kind of plate?

Cadaveric studyCadaveric study Comminute Comminute

fracturefracture

No difference in No difference in failure rate (>2 mm failure rate (>2 mm gap of fracture)gap of fracture)

Buijze et al. Arch Orthop Trauma Buijze et al. Arch Orthop Trauma Surg.2010;130:459-464Surg.2010;130:459-464

Which kind of plate?Which kind of plate?

Advantage of locking Advantage of locking compression plate to compression plate to conventionel plate:conventionel plate:– Angular and axial stabilityAngular and axial stability– Preserves periosteal blood supplyPreserves periosteal blood supply– No toggling of unlocked screws No toggling of unlocked screws

(improves fixation in osteoporotic (improves fixation in osteoporotic fractures and comminution)fractures and comminution)

Which kind of plate?Which kind of plate?

Stainless steel or titanium?Stainless steel or titanium?

More screw in proximal fragment More screw in proximal fragment better than fewer screws?better than fewer screws?

Larger screws better than small Larger screws better than small screws?screws?

Which kind of plate?Which kind of plate?

Accumed stainless stellAccumed stainless stell

Synthes stainless stellSynthes stainless stell

Synthes titaniumSynthes titanium

US ImplantsUS Implants

ZimmerZimmer

Edwards et al. J Orthop Trauma 2011;25(5):306-Edwards et al. J Orthop Trauma 2011;25(5):306-311311

Which kind of plate?Which kind of plate?

No statistical difference between No statistical difference between maximum load and cycles survivedmaximum load and cycles survived

Edwards et al. J Orthop Trauma 2011;25(5):306-311Edwards et al. J Orthop Trauma 2011;25(5):306-311

Outcome – Cochrane reviewOutcome – Cochrane review

Veillette et al. Orthop Clin N Am. 2008;39:229-236Veillette et al. Orthop Clin N Am. 2008;39:229-236

Short termShort term

(2-3 years)(2-3 years)

*only plate fixation*only plate fixation

Long-termLong-term

(15-25 years)(15-25 years)

PainPain 1 1

(VAS score)(VAS score)6% severe daily 6% severe daily symptomssymptoms

Motion compared to Motion compared to non-affected armnon-affected arm

Decreased Decreased supinationsupination

Decreased flexion Decreased flexion and extension and extension

(5 degrees)(5 degrees)

Radiographic Radiographic evaluationevaluation

8% OA8% OA 5% OA5% OA

1% non-union1% non-union

Patient-rated Patient-rated outcomeoutcome

9.79.7

(VAS score)(VAS score)96% excellent or 96% excellent or goodgood

Summary – Tension band Summary – Tension band fixationfixation

Fracture: Transverse or Fracture: Transverse or obliqueoblique

K-wire: Anterior cortex or K-wire: Anterior cortex or distal ulnar canaldistal ulnar canal

K-wire penetration: <10 K-wire penetration: <10 mm beyond the anterior mm beyond the anterior cortex cortex

Tension band: 1.0 mm Tension band: 1.0 mm stainless steel wire, 2 stainless steel wire, 2 knotsknots

Summary - PlatingSummary - Plating

Fractures: Distal to the Fractures: Distal to the midpoint of the troclear midpoint of the troclear notch, co-existing coronoid notch, co-existing coronoid fracture, Monteggia fracture, Monteggia

Locking compression plate Locking compression plate theoretically superior to theoretically superior to conventionel plateconventionel plate

Thank youThank you

TechniqueTechnique

TechniqueTechnique

TechniqueTechnique