Fixation of Olecranon Fractures Using a Hybrid Intramedullary Screw and Tension Band Construct

Introduction Olecranon fractures are common injuries that require surgical intervention for optimal outcomes. Various fixation methods have been described in the literature, including the use of intramedullary proximal ulna screws in combination with tension band augmentation. Limited research has compared this hybrid technique to other established methods of fixation. This study compared complication and reoperation rates between multiple groups. Methods A retrospective review was conducted on patients with olecranon fractures who underwent internal fixation at a level 1 trauma center between January 1st, 2013, and April 22nd, 2023. Data was collected using CPT codes, and patients were categorized into five groups based on the method of fixation received: no implant, tension band only, locking olecranon plate, intramedullary screw and tension band hybrid, and others. Variables such as patient demographics, Mayo fracture classification, open vs. closed injury, implant type, reoperation rates, and postoperative complications were recorded. Results A total of 217 patients were included in the study. No difference was found with implant choice and reoperation rate (p = 0.461). There was a significant difference found with reoperation and fracture type (p = 0.027) and open fracture (p = 0.002). Conclusion The primary findings of this study indicate no significant difference in implant choice and reoperation rates among the various fixation methods used for olecranon fractures. These findings suggest that the hybrid fixation technique, utilizing intramedullary proximal ulna screws in combination with tension band augmentation, is a viable and comparable treatment option when evaluated against other well-documented methods of fixation. This study also reiterates that severity of initial injury is often the most important factor related to poorer outcomes. Further discussion and analysis of the data will provide a comprehensive understanding of implications and recommendations for olecranon fracture fixation.

In addition to the previously discussed techniques, intramedullary screws have been described as a fxation construct for olecranon fractures, either alone or in hybrid constructs with plate or tension band augmentation (Figure 2) [7,8,[13][14][15].Biomechanical studies have demonstrated that intramedullary proximal ulna screws in combination with tension band augmentation provide superior fxation when compared to TBW or PF alone [7,14].Although this hybrid technique has been described previously, there is a limited amount of data comparing hybrid intramedullary screw constructs to isolated TBW and PF constructs [8,15].
Te purpose of this study was to fll a gap in evidence comparing hybrid intramedullary screw/tension band fxation to the frequently described standards of care.Although TBW alone has a high rate of prominent hardware irritation, fxing the wire in place beneath a large diameter cortical screw and washer may prevent proximal migration and soft tissue irritation.Tis study compared complication and reoperation rates between multiple constructs used for simple olecranon fracture fxation.

Materials and Methods
A retrospective chart review was conducted on patients with olecranon fractures who underwent internal fxation at a single level 1 trauma center between January 1st, 2013, and April 22nd, 2023.Data from the electronic medical record were collected using CPT codes, and patients were categorized into fve groups based on the method of fxation received: no implant, tension band only, locking olecranon plate, intramedullary screw and tension band hybrid, and others.Te "others" classifcation was given to fxations not ftting into previous categories.Tis included other hybrid constructs (i.e., cannulated screw with adjunct plate fxation), or an intramedullary screw alone.Specifc exclusion criteria included those less than 18 years of age or skeletally immature patients.
Variables such as patient demographics, Mayo fracture classifcation, open versus closed injury, implant type, reoperation rates, and postoperative complications were recorded.Secondary variables included diabetes and smoking status, operative time, and estimated blood loss.Statistical analysis was performed using IBM SPSS Statistics software (version 29.0,IBM Corp., Armonk, NY, USA).

Operative Technique.
Patients are placed under general endotracheal anesthesia per the anesthesia providers.All patients are positioned in lateral decubitus with the operative extremity up.A radiolucent arm board is connected to the operating table anterior to the patient's chest/abdomen.Te operative arm is draped over the arm board to rest at approximately 90 °.C-arm fuoroscopy is then able to approach parallel to the operating table to obtain imaging.Te operative extremity is prepped and draped.
A direct longitudinal approach to the olecranon is performed.Fracture is identifed, debrided, and reduced.Te reduction tool of choice is pointed reduction clamps.A guidewire is then inserted directly through the tip of the olecranon and into the medullar canal of the ulna to facilitate a 5.0 cannulated drill bit.Either a 6.5 mm or 7.3 mm partially threaded cannulated screw may be used.Screw size is determined by premeasured ulnar medullary canal diameter as well as intraoperative cortical ft.
Te selected screw is then inserted with a washer and left approximately 1 cm proud at the tip of the olecranon.A Luque wire is then used to create a tension band construct, placing the midpoint of the wire beneath the washer.A transverse bicortical hole is drilled approximately 3 cm distal to the fracture site.Te wire is crossed in a fgure-of-eight confguration.A loop is created on either the medial or lateral wire, and the contralateral side is passed through the previously drilled hole.Te remaining free wire ends are twisted to tighten the construct while the screw and washer are simultaneously tightened.Te free ends of the wire can then be clipped at the ends of the twist, which may be tamped down into the bone to prevent prominence.

Results
217 patients were included in the study.No diference was found in sex (p � 0.660), presence of diabetes (p � 0.594), smoking status (p � 0.666), and laterality (p � 0.809) (Table 1).BMI, OR time, and blood loss were logarithmically transformed to produce parametric data confrmed with Q-Q plots and Shapiro-Wilk testing.Tese were then tested with one-way ANOVA and Bonferroni correction.Tere was no diference in BMI between groups (p � 0.05) (Table 1).OR time and blood loss were found to be higher in the locking plate group (p ≤ 0.001).Estimated blood loss was found to be higher in the locking plate group than in the other treatment groups (p � 0.013).Te locking plate group had an OR time signifcantly higher than the no-implant group (p ≤ 0.001) and the other treatment group (p � 0.003).No diference in OR time was found between the locking plate group and the intramedullary screw plus tension band group (p � 1.000) or the tension band group (p � 0.576).
Chi-squared tests were used to compare implant choice and our primary outcome, reoperation rate, and secondary outcomes of fracture type and presence of open fracture.No diference was found with implant choice and reoperation rate (p � 0.461) (Tables 1 and 2) (Figure 3).Tere was a signifcant diference found with reoperation and fracture type (p � 0.027) with increased reoperation rates in increasingly complex fracture patterns (Mayo 3B) (Figure 4).Tere also was a signifcant diference in reoperation rates between open vs. closed fractures, with open fractures having an increased reoperation rate (p ≤ 0.01) (Figure 5).

Discussion
Te primary fndings of this study indicate no signifcant diference in implant choice and reoperation rates among the various fxation methods used for olecranon fractures.Tese fndings suggest that the hybrid fxation technique, utilizing intramedullary proximal ulna screws in combination with tension band augmentation, is a viable and comparable treatment option when compared to other welldocumented methods of fxation.
A typical problem with tension band fxation of olecranon fractures is hardware prominence.Te proximity of the hardware to the skin in addition to the scant soft tissue envelope about the elbow creates a difcult working environment for fracture fxation.Te goal of hybrid fxation is to provide increased biomechanical stability to a fxation construct while also avoiding postoperative complications and need for reoperation due to hardware prominence and all causes.
Te intramedullary screw and tension band construct was implemented at our institution with the idea that fxation of the tension band wire beneath the washer of an intramedullary screw would prevent any proximal migration of the wire and ideally prevent hardware irritation requiring Tis study also reiterates that the severity of initial injury is additionally an important factor related to poorer outcomes.In this case, the most complex fracture patterns, as well as open fractures, required repeat surgeries more frequently.

4.1.
Limitations.Tis study is a retrospective study; therefore, no functional or subjective patient outcomes are included.Te treatment groups are small with unequal distribution of fxation constructs.While we did include the Mayo classifcation in order to diferentiate fracture severity, we did not correlate the fxation construct with the severity of fracture, which could represent a confounding relationship as more complex fracture patterns cannot be appropriately treated with all described fxation constructs.

Conclusions
Te goal of this study was to introduce a seldom-used hybrid fxation construct for simple olecranon fracture patterns.In the appropriate scenario, a hybrid intramedullary screw and tension band construct can be a safe, afordable option with no increase in complications when compared to previously described standards of care.Advances in Orthopedics

Figure 1 :
Figure 1: (a) Olecranon fracture repair with a tension band wire construct; (b) olecranon fracture repair with a locking plate/screw fxation.

Figure 2 :
Figure 2: Te hybrid construct used in this study consisted of an intramedullary proximal ulna screw and tension band construct.

Figure 5 :
Figure 5: Reoperation rate by open fracture status.Tere was a signifcant diference in reoperation rates between open vs. closed fractures, with open fractures having an increased reoperation rate.

Table 1 :
Treatment groups and relevant demographics.

Table 2 :
Reasons for reoperation.Reoperation rate by fxation construct.No diference was found with implant choice and reoperation rate.Reoperation rate by Mayo fracture classifcation.Tere was a signifcant diference found with reoperation and fracture type, with increased reoperation rates in increasingly complex fracture patterns (Mayo 3B).