A novel fragment specific classification of complex olecranon fractures: 3-dimensional model design, radiological validation, and proposed surgical algorithm.

BACKGROUND: Current classifications for proximal ulna fracture patterns rely on qualitative data and cannot inform surgical planning. We propose a new classification system based on a biological and anatomical stress analysis. Our hypothesis is that fragment types in complex fractures can be predicted by the tendon and ligament attachments on the proximal ulna. METHODS: First, we completed a literature review to identify quantitative data on proximal ulna soft tissue attachments. On this basis, we created a 3-dimensional model of ulnar anatomy with SliceOMatic and Catia V5R20 software and determined likely locations for fragments and fracture lines. The second part of the study was a retrospective radiological study. A level-1 trauma radiological database was used to identify computed tomography scans of multifragmentary olecranon fractures from 2009 to 2021. These were reviewed and classified according to the "fragment specific" classification and compared to the Mayo and the Schatzker classifications. RESULTS: Twelve articles (134 elbows) met the inclusion criteria and 7 potential fracture fragments were identified. The radiological study included 67 preoperative computed tomography scans (mean 55 years). The fragments identified were the following: posterior (40%), intermediate (42%), tricipital (100%), supinator crest (25%), coronoid (18%), sublime tubercle (12%), and anteromedial facet (18%). Eighteen cases (27%) were classified as Schatzker D (comminutive) and 21 (31%) Mayo 2B (stable comminutive). Inter-rater correlation coefficient was 0.71 among 3 observers. CONCLUSION: This proposed classification system is anatomically based and considers the deforming forces from ligaments and tendons. Having a more comprehensive understanding of complex proximal ulna fractures would lead to more accurate fracture evaluation and surgical planning.

The medial forearm fascia and lateral forearm fascia contribute to overhead elbow extension in displaced olecranon fractures: a biomechanical study.

BACKGROUND: In nonoperative management of displaced olecranon fractures, patients are able to maintain overhead extension despite a persistent nonunion. It has been hypothesized that this is feasible because of an intact lateral cubital retinaculum. The purpose of this biomechanical study was to determine the contribution of the medial and lateral cubital retinacula to overhead extension in the setting of a displaced olecranon fracture. METHODS: Eight fresh-frozen cadaveric upper-extremity specimens were used in this study. The triceps muscle was loaded through a pulley system operated by an Instron 8874 Biaxial Servohydraulic Fatigue Testing System at a rate of 10 mm/second to simulate overhead elbow extension. Each specimen was tested in 4 states: (1) native state with an intact olecranon; (2) transverse olecranon fracture; (3) transection of 1 cubital retinaculum (medial or lateral); and (4) transection of both medial and lateral cubital retinacula. The primary outcome was the ability to perform overhead extension. The secondary outcome was the force needed to generate extension. RESULTS: Elbow extension was noted in each specimen for trials 1, 2, and 3. Only when both the lateral fascia and medial fascia were transected was elbow extension not achieved. There was no significant difference in the force required to generate extension in the first 3 trials (P = .99). There was no significant difference in the change in the maximum force required to achieve extension between the specimens with only the medial side transected and the specimens with only the lateral side transected (P = .07). DISCUSSION: In the setting of an olecranon fracture, this biomechanical study suggests that if either the lateral or medial cubital retinaculum remains in continuity with the distal ulna, active overhead extension can be maintained. This finding may explain the positive clinical outcomes of nonoperative management of displaced olecranon fractures in the elderly patient population. Determining the integrity of the fascial structures preoperatively may help select candidates for nonoperative treatment of displaced olecranon fractures.

Percent articular exposure of the distal humerus with triceps fascial tongue approach compared with olecranon osteotomy.

BACKGROUND: Distal humerus fractures are common and can be difficult to treat. No one approach to the distal humerus has been shown to be superior to another; however, the olecranon osteotomy remains the gold standard for complex, intra-articular fractures. Understanding the percent of articular exposure with approaches to the distal humerus is important for success. The goal of this study is to show the percent of articular exposure of the triceps fascial tongue approach as compared with the olecranon osteotomy. METHODS: Twelve fresh frozen cadavers were separated randomly into 2 groups of 6 each. The first group of 6 specimens was allocated to the triceps fascial tongue approaches with the collaterals maintained and with the collaterals released off the ulna and elbow dislocated. The second group of 6 was allocated to the triceps fascial tongue approach while maintaining the collaterals followed by an olecranon osteotomy. The articular exposure was marked after performing each approach, and the percent of articular exposure was quantified by using 3D scanning. Standard deviations were calculated for each. RESULTS: The average percent visualization of the distal humerus articular surface in the fascial tongue approach while maintaining the collaterals was 36% in the first cohort and 37% in the second cohort with a standard deviation of 5% in both cohorts. The average percent of the distal humerus articular surface exposed in the fascial tongue approach with the collaterals released off the ulna and elbow dislocated was 85.09% with a standard deviation of 4%. The average percent of the distal humerus articular surface exposed in the olecranon osteotomy group was 57.9% with a standard deviation of 5%. CONCLUSION: The triceps fascial tongue approach allows for visualization of about one-third of the joint, which may be adequate for many intra-articular distal humerus fractures. For added exposure of the articular surface, the collaterals may be elevated from the ulna and the elbow dislocated allowing for a substantial increase in percent of articular exposure compared with the collateral retaining fascial tongue approach and the olecranon osteotomy.

Comparison of clinical outcomes between the olecranon osteotomy approach and the Bryan-Morrey approach for total elbow arthroplasty.

BACKGROUND: This study aims to investigate the clinical efficacy of the olecranon osteotomy approach and the Bryan-Morrey approach in total elbow arthroplasty (TEA). METHODS: In this retrospective study, 49 patients with elbow disease were treated with TEA. A total of 22 patients with TEA by olecranon osteotomy approach were designated as group A, and 27 patients with TEA by Bryan-Morrey approach were designated as group B. There were 22 males and 27 females, aged 32-82 years with a mean age of 62 years. There were 44 cases of unilateral elbow joint, including 27 cases on the left elbow and 17 cases on the right elbow, and 5 cases of the bilateral elbow joint. There were 6 cases of osteoarthritis (7 elbows), 18 cases of rheumatoid arthritis (22 elbows), 14 cases of traumatic arthritis (14 elbows), 7 cases of distal humeral fractures (7 elbows), and 4 cases of elbow tuberculosis (4 elbows). For each group, we recorded the operative time, intraoperative bleeding, elbow flexion, extension, pronation, supination, postoperative complication rates, and Mayo Elbow Performance Score after surgery. RESULTS: Operative time and intraoperative bleeding were less in group A than in group B (53-120 min [70 (62.5, 78) min] vs. 64-105 min [77 (73, 87) min], and 10-200 ml [50 (20, 90) ml] vs. 5-250 ml [100 (50, 150) ml], P < .028). The elbow flexion, pronation activity, and Mayo Elbow Performance Score were higher in group A than in group B, [(121 ± 12)° vs. (112 ± 10)°, 85 (85,85)° vs. 80 (77,85)°, and (94 ± 3) points vs. (91 ± 4) points, P < .036], while elbow extension and supination activity and complication rates were not statistically significant in either group. CONCLUSION: Compared to Bryan-Morrey approach, the olecranon osteotomy approach to TEA provides adequate visualization, saves operative time and reduces bleeding, provides better flexion activity, effectively improves elbow function, and achieves satisfactory clinical outcomes.

Outcomes of Adolescent T-condylar Fractures: Kids Do Not Always Make You Look Good.

BACKGROUND: Optimal treatment for pediatric and adolescent T-condylar fractures remains poorly understood. We sought to assess how functional outcomes and range of motion (ROM) after surgical fixation of T-condylar fractures are affected by patient and surgical factors. METHODS: This is a retrospective cohort study of 52 patients with operatively treated T-condylar fractures at a single tertiary pediatric referral center between 2003 and 2021. All patients younger than 18 at the time of injury with a radiographically confirmed diagnosis were included. RESULTS: Fifty-two T-condylar fractures were included, with a mean patient age of 12.9 years (SD, 2.8). The cohort was 65% male. Nine (19%) fractures were open, 46% (24/52) were AO type C2, and 33% (17/52) occurred in skeletally mature individuals. The surgical approach was through olecranon osteotomy in 29% (15/52) of patients, and fixation included anatomically specific plates and screws in 42% (22/52) of patients. In our cohort, 46% (24/52) achieved good outcomes based on Jarvis ROM criteria and 42% (22/52) achieved good to excellent results based on Roberts functional criteria. The median loss of ROM was 58 degrees at 6 weeks, 20 degrees at 3 and 6 months, and 8 degrees at 1 year postoperatively. We observed a complication rate of 54% (28/52). Patients undergoing adult-type plate fixation had better postoperative range of motion at 6 weeks (ROM loss 52 vs. 80 degrees, P =0.03) and 3 months (10 vs. 35 degrees P =0.004) compared with pediatric-type fixation and trended towards better functional outcomes. We did not identify significant differences in functional outcome scores or complication rates with respect to surgical approach or skeletal maturity. CONCLUSIONS: Surgical fixation of pediatric and adolescent T-condylar fractures achieved a good to excellent functional outcome in only a minority of patients (46% Jarvis / 42% Roberts) with a high rate of postoperative complications (54%). Future work is needed to elucidate optimal treatment to minimize complications and achieve the best functional outcomes in these challenging fractures. LEVEL OF EVIDENCE: Level-IV.

Long-term Functional Consequences of Surgically Treated Pediatric and Adolescent Olecranon Fractures: Does the Presence of Associated Fractures and Surgical Procedure Affect the Results?

BACKGROUND: Olecranon fractures are rare conditions in childhood. The aim of this study was to investigate the factors affecting the results in surgically treated pediatric and adolescent olecranon fractures. METHODS: The orthopaedic trauma database of a large academic tertiary center was retrospectively searched for patients who had sustained an olecranon fracture and were treated surgically between 2005 and 2021. Data related to demographic features, additional fractures, and the presence of any disease were obtained from the patient files. Mayo elbow performance score and the Turkish-language version of the shortened version of the disabilities of arm, shoulder, and hand scale were the main functional outcome measurements. RESULTS: The study included 37 elbows of 34 patients with an average age at the time of surgery of 10.9±3.1 years. The mean follow-up period was 78.2±48.0 months (range, 12 to 196 mo). The 1-year fracture rate of contralateral olecranon was 75% in osteogenesis imperfecta patients. Concomitant fractures were 7 proximal radius, 1 medial epicondyle, and 2 capitellum fractures. The surgical treatment methods were tension band wiring (TBW), open reduction and isolated K-wire fixation, closed reduction and percutaneous fixation (CR-PP), and open reduction-plate fixation. The mean implant removal time in patients treated with closed reduction and percutaneous fixation was 2.2 months, open reduction and isolated K-wire fixation 4.7 months, and TBW 12.7 months ( P =0.004). The mean disabilities of arm, shoulder, and hand scale was 1.9. The mean Mayo elbow performance score was 100. Grade 1 elbow arthritis was determined in 3 patients. No patient underwent revision surgery. CONCLUSIONS: All treatment modalities provided excellent long-term functional results and low complication rates without the need for revision. Closed reduction-percutaneous fixation and open reduction-isolated K-wire fixation were associated with shorter implant removal times compared with TBW. LEVEL OF EVIDENCE: Level III.

Biomechanical impact of elbow motion in elbow stiffness.

BACKGROUND: A mechanical block in the elbow due to osteophytes in the olecranon fossa is a common clinical symptom for elbow stiffness. PURPOSE/HYPOTHESIS: This study aims to understand the biomechanical characteristics or changes in the stiff elbow in the resting (or neutral) and swing position of the arm using a cadaveric model. The hypotheses included the following: (1) a difference exists in the articular contact pressure of the elbow by comparing the non-stiff and stiff models in in vivo studies; (2) the degree of stiffness would affect the increase of the joint loading of the elbow. STUDY DESIGN: Controlled laboratory study, cadaveric study. METHODS: Eight fresh-frozen specimens from individuals of both sexes were included in the biomechanical study. The specimen was mounted on a custom-designed jig system with gravity-assisted muscle contracture to mimic the elbow in a standing position. The elbow was tested in two conditions (the resting and passive swing). Contact pressure was recorded for three seconds in the resting position, which was the neutral position of the humerus. By dropping the forearm from 90° of the elbow flexion, the passive swing was performed. The specimens were tested sequentially in three stages of stiffness (stage 0, no stiffness; stage 1, 30° of extension limitation; and stage 2, 60° of extension limitation). After data collection was completed in stage 0, a stiff model was sequentially created for each stage. The stiff model of the elbow was created by blocking the olecranon by inserting a 2.0 K-wire into the olecranon fossa horizontally with the intercondylar axis. RESULTS: The mean contact pressures were 279 ± 23, 302 ± 6, and 349 ± 23 kPa in stages 0, 1, and 2, respectively. The increases in the mean contact pressure in stages 2 versus 0 were significant (P < 0.0001). The mean contact pressures were 297 ± 19, 310 ± 14, and 326 ± 13 kPa in stages 0, 1, and 2, respectively. The peak contact pressures were 420 ± 54, 448 ± 84, and 500 ± 67 kPa in stages 0, 1, and 2, respectively. The increases in mean contact pressure in stage 2 versus 0 were significant (P = 0.039). The increases in peak contact pressure in stages 0 versus 2 were significant (P = 0.007). CONCLUSIONS: The elbow bears the load created by gravity and muscle contracture in the resting and swing motion. Moreover, extension limitation of stiff elbow increases the load bearing in the resting position and swing motion. Careful surgical management should be considered for meticulous clearance of bony spur around olecranon fossa to resolve the extension limitation of the elbow.

The conundrum of olecranon aperture and its relation to the distal end of the humerus in a modern Indian population: An anatomical and surgical perspective.

PURPOSE: We aimed to clarify the morphology of the olecranon aperture (OA) of the humerus with its relationship to the distal end of the humerus (epicondylar width) and the width of the medullary canal. METHODS: In total, 156 dry adult humeri were examined for the presence of OA. When present, we reported their shape, measured transverse (TD) and vertical diameter (VD), the distance from its medial border to the tip of medial epicondyle (D1), lateral border to the tip of lateral epicondyle (D2) and lower border to the tip of trochlea (D3). The epicondylar width (EW) and the width of the medullary canal were also measured in all the humeri. RESULTS: OA was reported in 32 humeri (20.6%) with left side predominance, translucent septum in 35.8%, and opaque septum in 43.6%. The most typical shape noted was oval. On right side, mean VD and TD was 4.30±0.54mm and 5.85±0.45mm, respectively, whereas on left, these value were 4.21±0.56mm and 5.64±0.43mm, respectively. The mean of D1, D2 and D3 was 25.86±0.43mm, 26.50±0.28mm and 15.07±0.53mm on right and 24.80±0.41mm, 26.84±0.21mm and 15.81±0.31mm on left with significant difference (P<0.05). The medullary canal was significantly smaller in humeri with OA. CONCLUSION: Topographic location of OA may have possible role in determining safe zone for retrograde nailing in supracondylar humeral fractures. Since OA has a direct relation to the size of the intramedullary canal, it is crucial during preoperative planning and choosing an adequate surgical approach involving lower segment of humerus.

Clinical comparison of double-plate fixation by the perpendicular plate method versus parallel plate method for distal humeral fracture: a multicenter (TRON group) study.

INTRODUCTION: Double-plating methods are popular, with perpendicular and parallel plate methods being widely used surgical method for the rigid fixation of distal humeral fracture (DHF). However, which plate method is better for DHF remains controversial. The aim of this study was to compare patient outcomes including the incidences of complications and reoperation between the two plate methods. METHODS: We extracted 383 patients with DHF undergoing surgery between 2011 and 2020 from our multicenter database, which is named TRON. We divided the subjects into two groups: perpendicular plating group (Group A) and parallel plating group (Group B). To adjust for baseline differences between the groups, patients were matched for age, sex, olecranon osteotomy, AO type, and type of injury. We assessed the Mayo Elbow Performance Score (MEPS) at 3 and 6 months and the last follow-up month as the clinical outcome. We investigated the incidences of complications and reoperations in both groups. RESULTS: After matching, each group comprised 50 patients. There was no significant difference between Group A versus Group B in MEPS score at each time point. The incidence of implant removal in Group B was higher than that in Group A (26.5% vs 50%, p = 0.023). DISCUSSION: Although there were no significant differences in clinical outcomes or complications between the two groups, the incidence of implant removal was higher in Group B than in Group A. In the parallel plate technique, where the plates have to be placed in areas with thin subcutaneous soft tissue, the incidence of implant removal might be high due to the discomfort caused by the implant.

Risk factors for revision surgery in operative treatment of traumatic injuries of the olecranon and prepatellar bursa.

INTRODUCTION: Traumatic lacerations of the prepatellar (PB) and olecranon bursa (OB) are common injuries. The aim of this study was to gain descriptive data and to identify risk factors associated with complications that made revision surgery after primary bursectomy necessary. MATERIAL AND METHODS: In this retrospective monocentric study at a level I trauma center, all patients with traumatic lacerations of the PB or OB who were treated with primary surgical bursectomy from 2015 to 2020 were analyzed. RESULTS: 150 consecutive patients were included. In 44% of cases, the PB was affected (n = 66), in 56% the OB (n = 84). The reoperation rate after surgical bursectomy was 10.7% (n = 16). The main cause of reoperation was wound infection (50%; n = 8). The most common pathogen of postoperative infections was Staphylococcus aureus (87.5%). Several comorbidities have been identified as risk factors for reoperation after primary surgical bursectomy, such as heart diseases, arterial hypertension, the use of antihypertensives and anticoagulation. In contrast, surgical expertise, use of drains, postoperative immobilization, and postoperative antibiotics had no statistically significant effect. A significantly higher postoperative infection rate (17.6%) was observed in patients who were operated more than 48 h after initial trauma. CONCLUSIONS: Given the limited recommendations for therapy of these common injuries, further investigations should focus on standardized therapeutic options for lacerations of the PB or OB. Delayed surgical interventions after trauma were associated with higher complication rates. Therefore, urgent surgery within 48 h after trauma may help to prevent revisions. LEVEL OF EVIDENCE: Level of evidence IV.

Comparison of clinical outcomes of three internal fixation techniques in the treatment of olecranon fracture: a retrospective clinical study.

OBJECTIVE: The application of double plating in olecranon fractures is becoming increasingly widespread. There is no research comparing this technique with traditional tension band wiring (TBW) and the single plate technique. The purpose of this study was to compare the efficacy of three fixation techniques in olecranon fractures. MATERIALS AND METHODS: From March 2016 to May 2020, we collected the clinical data of 95 patients with olecranon fractures who underwent surgical treatment. Thirty-five patients received TBW surgery (TBW Group), 32 patients received a 3.5 mm locking compression plate (LCP, 3.5 mm LCP Group), and 28 patients received double mini-locking plate treatment (DP Group). The operation time, fracture union time, time of return to work, range of motion (ROM), soft tissue stimulation to remove internal fixation, and patient-related functional results (the Weseley score, Mayo Elbow Performance Score [MEPS], and Disabilities of Arm, Shoulder and Hand Score [DASH]) were recorded. The clinical results and complications of the three internal fixation techniques were compared. RESULTS: The average follow-up time was 15.011.82 months (12-18 months). All patients' fractures healed by first intention. There were no statistically significant differences in the operation time, fracture union time, ROM, Weseley score, MEPS or DASH scores of the three groups of patients. The postoperative return time for patients in the TBW group was 10.002.15 weeks, the 3.5 mm LCP group was 9.561.93 weeks, and the DP group was 8.432.38 weeks (P = 0.014); 12 patients in the TBW group required removal of plant due to soft tissue stimulation, the 3.5 mm LCP group had 8 cases, and the DP group had 2 cases (P = 0.038). CONCLUSION: The postoperative clinical results and elbow joint function of patients with olecranon fractures fixed by tension band wiring, 3.5 mm LCP and double mini-locking plate are similar, which indicates that double-plate technology can be used as an alternative to the two groups of traditional techniques. In addition, double-plate technology also helps patients return to work earlier and has a lower incidence of soft tissue stimulation.

Cost Assessment of Plating Versus Tension Band Wiring Constructs for Treating Mayo Type 2A Olecranon Fractures.

PURPOSE: Tension band wiring (TBW) or plating may be used for fixation with similar clinical outcomes for adults with displaced Mayo 2A olecranon fractures. The primary hypothesis is that total direct costs (TDCs) for surgery are lower for TBW than plating. Our secondary hypothesis is that combined surgical TDCs are lower for TBW even with a 100% rate of subsequent tension band hardware removal and a 0% rate of plate removal. METHODS: Patients who underwent TBW or plating of an isolated unilateral Mayo 2A olecranon fracture between July 2011 and January 2020 at a single academic medical center were identified. Then, TDC for each surgery on plate fixation, TBW, and hardware removal was obtained and converted to 2020 US dollars using information technology cost tools provided by our institution. Finally, relative TDCs were compared between plate fixation and TBW groups using univariate and multivariable generalized estimating equations with log-link. RESULTS: Of the 97 included patients, the mean age was 50 ± 21 years, and 48% were female. Tension band wiring and plate fixation were performed on 18% (17/97) and 82% (80/97) of male and female patients, respectively. Demographics were similar between groups, although the finding that plate fixation cost 2.6 times that of TBW within the index surgery was significant in the multivariable model, independent of potential confounders (coefficient 2.55, 95% confidence interval: 2.09-3.10). Additionally, mean TDC remained significantly greater for plate fixation even under the hypothetical situation where 100% TBW were removed, and the plate removal rate was 0% (cost difference 181%). CONCLUSIONS: Using TBW relative to plate fixation may improve the cost of care for operative Mayo 2A olecranon fractures. Furthermore, this finding was robust to the rate of hardware removal. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analyses III.

Proximal Ulna Osteotomy for Complex Fractures of the Distal Humerus: A 3-Dimensional Laser Analysis and Comparison With Olecranon Osteotomy.

PURPOSE: The current methods of distal humerus (DH) articular surface visualization only allow a limited view of the joint. This study describes an osteotomy procedure that increases the visualization of and access to the DH articular surface for fixation without compromising ligaments. METHODS: Eighteen fresh-frozen human elbows (9 matched pairs) underwent proximal ulna osteotomy (PUO) or transverse olecranon osteotomy (OO) contralaterally. The visualized articular surface of the DH was demarcated, and the surface areas of the DH, capitellum, and trochlea were measured using 3-dimensional scanning. The angular arc of the articular surface of the capitellum and trochlea was measured using a goniometer. RESULTS: The 3-dimensional scans showed that 87.6% of the total DH surface area was visualized using PUO versus 65.6% using OO. When the trochlea and capitellum surface areas were separated, 94.0% versus 75.9% of the trochlea and 74.8% versus 44.7% of the capitellum were visualized using PUO and OO, respectively. The goniometric angles demonstrated that 98.2% versus 70.9% of the trochlea and 75.1% versus 43.5% of the capitellum articular surface arc angles were visualized using PUO and OO, respectively. After PUO with further release of the flexor-pronator mass was performed, 100% of the DH articular surface was visualized. CONCLUSIONS: Proximal ulnar osteotomy improves the visualization of the DH articular surface. CLINICAL RELEVANCE: Proximal ulna osteotomy spares ligaments, avoids osteotomizing the greater sigmoid notch, involves more robust metaphyseal bone for potentially better fixation, and may permit DH arthroplasty without compromising primary ligamentous elbow stabilizers. Further clinical studies are needed to assess the utility of this type of osteotomy.

Biomechanical Comparison of Dual and Posterior Locking Plates in an Ex Vivo Comminuted Olecranon Fracture Model.

PURPOSE: Comminuted olecranon fractures are commonly fixed with posterior locking plates (PLPs). Though biomechanically validated, this method comes with risks of symptomatic implant prominence and wound breakdown. Dual locking plates (DLPs) placed on the medial and lateral surfaces of the olecranon theoretically avoid these risks and allow for fixation of proximal fracture fragments in multiple planes. A biomechanical comparison of DLP and PLP fixation would help to validate the use of DLPs in comminuted olecranon fractures. METHODS: Seven matched pairs of cadaveric upper extremities were evaluated with quantitative computed tomography scans to evaluate bone mineral density (BMD). Osteotomies simulating comminuted olecranon fractures (Mayo Type IIB) were created and the specimens were fixed either with variable angle PLPs or variable angle DLPs. The specimens were then cyclically loaded and loaded to failure. The ultimate strength, fracture displacement, and mechanism of failure were recorded and compared across groups. The correlation between BMD and ultimate strength was analyzed. RESULTS: The mean total BMD was 0.79 g/cm2 (SD, 0.14 g/cm2). No specimen failed during cyclic testing. Five of 7 PLP specimens and 5 of 7 DLP specimens failed by fracture through the proximal screws though in different planes (sagittal vs axial splits, respectively). The mean ultimate strengths of the PLP (1077 N [SD, 462 N]) and DLP (1241 N [SD, 506 N]) groups were similar. There was a linear relationship between ultimate strength and BMD (R2 = 0.33). CONCLUSION: Dual locking plates display biomechanical properties that suggest that they can be used in the fixation of comminuted olecranon fractures. Catastrophic failure of the fixation constructs occurs around stress risers at the proximal screws rather than due to displacement at the fracture itself. CLINICAL RELEVANCE: Dual locking plate constructs can be considered for use in the fixation of comminuted olecranon fractures.

Open Excision of Olecranon Melorheostosis to Relieve Elbow Extension Block.

We report a 34-year-old man who presented with hyperostosis of his right elbow associated with an inability to fully extend his elbow. The radiographic assessment revealed a classical dripping candle wax appearance of his proximal ulna suggestive of melorheostosis. Computed tomography was performed to identify the impingement point and aid in surgical planning. A targeted open excision biopsy via a Boyd incision was performed to excise the exophytic component that was causing the functional block. After surgery, he achieved full elbow extension and was able to return to his usual activity.

Hardware complications and reoperations following precontoured plate fixation of the olecranon: a population-based study.

BACKGROUND: Several fixation techniques have been described to treat acute olecranon fractures. Plate fixation is often used because of its superior mechanical properties. The reported rates of reoperation after olecranon plate fixation have been quite heterogeneous. The purpose of this study was to establish an updated reoperation rate based on modern precontoured plate constructs. METHODS: This retrospective cohort study used population-level administrative data to identify all surgically treated adult patients with olecranon fractures at 4 hospitals in Edmonton, AB, Canada, between 2010 and 2015. Radiographic review was conducted to identify patients who underwent precontoured olecranon plate fixation. Fracture characteristics including Mayo fracture classification and other concomitant upper-extremity injuries were identified. Chart reviews were performed to determine patient characteristics and patients who required reoperation. The primary reason for and type of reoperation were determined. RESULTS: Six hundred patients were surgically treated for olecranon fractures. Precontoured plate fixation was used in 321 patients. The average age of included patients was 56 years (standard deviation [SD], 19.4 years), and there were 173 female patients (53.9%). Reoperation was required in 90 patients (28%). For 50 patients, implant-related irritation was the primary reason for reoperation, representing 55.6% of the patients who underwent reoperation (50 of 90) and 15.6% of the total cohort (50 of 321). Other reasons for reoperation included hardware failure in 17 patients (5.3%), infection in 9 (2.8%), and contracture in 9 (2.8%). Patients who required reoperation were significantly younger (52.9 years [SD, 18.1 years] vs. 57.7 years [SD, 19.4 years]; P = .048) and had significantly higher rates of type III olecranon fractures (17.8% [16 of 90] vs. 8.2% [19 of 231]; P = .04) and Monteggia fractures (13.3% [12 of 90] vs. 4.8% [11 of 231]; P = .008). A multivariate logistic regression model also demonstrated increased odds ratios (ORs) for overall reoperation in patients with Monteggia fractures (OR, 2.99 [95% confidence interval, 1.25-7.17]; P = .014) and for reoperation due to implant-related irritation in younger patients (OR, 0.98 [95% confidence interval, 0.96-0.996]; P = .018). No discerning factors were identified for the 50 patients who underwent hardware removal for implant-related irritation compared with the whole reoperation group (n = 90). CONCLUSION: This study found that patients with olecranon fractures treated with precontoured plates experienced a hardware removal rate of 15.6% for implant-related irritation. Patients who sustained more complex fractures, such as Monteggia injuries, demonstrated higher rates of reoperation. Increasing age may be associated with lower rates of reoperation. In patients who required reoperation, there were no identifiable radiographic or clinical characteristics that were associated with implant-related irritation as their primary reason for reoperation.

Lateral epicondyle osteotomy approach vs. olecranon osteotomy approach: an anatomic study of cadavers.

BACKGROUND: Exposure of the articular surface is the key to successful open reduction and internal fixation treatment for coronal shear fractures of the distal humerus. The olecranon osteotomy approach has previously been described as one of the most effective exposure approaches. Nevertheless, this approach cannot expose the anterior trochlea, and it is impossible to reduce and fix the capitellum under direct vision. The purpose of this study was to compare the exposure of the articular surface of the distal humerus between the lateral epicondyle osteotomy approach (group L) and the olecranon osteotomy approach (group O). METHODS: Each approach was performed on 8 freshly frozen upper limbs of adult cadavers. After each approach was completed, a 0.5-mm Kirschner wire is inserted along the edge to mark the visible part of the articular surface. Then, the soft tissue of each elbow is removed, and a surface-scanning system is used to create a digital 3-dimensional model. The visible part of the articular surface obtained by each surgical approach was mapped and quantified using markers created by Kirschner wires. RESULTS: The lateral epicondyle osteotomy approach and the olecranon osteotomy approach exposed 0.8 ± 0.0 and 0.6 ± 0.0 of the distal humeral articular surface (P < .001), 1.0 ± 0.0 and 0.3 ± 0.1 of the capitellum (P < .001), 0.6 ± 0.0 and 0.7 ± 0.0 of the trochlea (P < .001), 0.7 ± 0.0 and 0.5 ± 0.1 of the anterior trochlea (P < .001), and 0.5 ± 0.0 and 1.0 ± 0.0 of the posterior trochlea, respectively (P < .001). CONCLUSION: Compared with the olecranon osteotomy approach, the lateral epicondyle osteotomy approach could more fully expose the total articular surface of the distal humerus, capitellum, and anterior trochlea, but the olecranon osteotomy approach could more fully expose the trochlea and posterior trochlea.

A new all-suture tension band tape fixation technique for simple olecranon fractures versus conventional tension band wire fixation: a comparative biomechanics study.

HYPOTHESIS: Simple transverse or short oblique olecranon fractures without articular comminution are classified as Mayo type IIA fractures and are typically treated with a tension band wire construct. Because of the high reoperation rates, frequently because of prominent hardware, all-suture tension band constructs have been introduced. It was the purpose to compare the biomechanical performance of conventional tension band wire fixation with a new all-suture tension band tape fixation for simple olecranon fractures. METHODS: Mayo type IIA olecranon fractures were created in 20 cadaveric elbows from 10 donors. One elbow of each donor was randomly assigned to the tension band wire technique (group TBW) or tension band tape (Arthrex, 1.3-mm SutureTape) technique (group TBT). Both groups were cyclically loaded with 500 N over 500 cycles, after which a uniaxial displacement was performed to evaluate load to failure. Data were analyzed for gap formation after cyclic loading, construct stiffness, and ultimate load to failure, where failure was defined as fracture gap formation greater than 4.0 mm. RESULTS: There was no significant difference in gap formation after 500 cycles between the TBW (1.8 mm ± 1.3 mm) and the TBT (1.9 mm ± 1.1 mm) groups (P = .854). The TBT showed a tendency toward greater construct stiffness compared with the TBW construct (mean difference: 142 N/mm; P = .053). Ultimate load to failure was not significantly different comparing both groups (TBW: 1138 N ± 286 N vs. TBT: 1126 N ± 272 N; P = .928). In both groups, all repairs failed because of >4.0-mm gap formation at the fracture site and none because of tension band construct breakage. CONCLUSIONS: Our study shows that the TBT technique produces equivalent or superior biomechanical performance to the TBW for simple olecranon fractures. The TBT approach reduces the risk of hardware prominence and as a result mitigates against the need for hardware removal. The TBT technique offers a clinically viable alternative to TBW.

Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study.

BACKGROUND: There are various approaches to the distal humerus when managing a distal humeral fracture, and controversy exists regarding which approach is optimal. The purpose of this study was to report the outcomes of the triceps tongue (TT) approach when used for osteosynthesis of AO type 13-A, B, and C distal humeral fractures. Secondarily, we aimed to compare the outcomes of the TT approach vs. olecranon osteotomy (OO) when used for osteosynthesis of AO type 13-C distal humeral fractures. METHODS: We performed a retrospective review of patients with distal humeral fractures treated with open reduction-internal fixation by either a TT or OO approach between 2007 and 2019 at 2 separate institutions. TT patients with AO type 13-C fractures were matched to OO patients at a 1:1 ratio based on age, sex, and fracture characteristics. Surgical time, intraoperative blood loss, elbow motion, fracture union, complications, and Disabilities of the Arm, Shoulder and Hand scores were compared. RESULTS: A total of 28 patients treated with the TT approach were assessed, and the matched TT and OO cohorts each comprised 15 patients. The TT group showed less blood loss (119.3 mL vs. 268.5 mL, P = .03), had greater maximal flexion (126° vs. 116°, P = .03), and achieved a larger flexion-extension arc (108° vs. 93°, P = .05) than the OO group. In the OO cohort, 27% of patients had complications directly related to the OO, and OO patients had a higher rate of postoperative ulnar nerve neuritis (33% vs. 0%, P = .04). There was no difference in Disabilities of the Arm, Shoulder and Hand score (P = .08), procedure time (P = .2), total number of patients with ≥1 complication (P = .5), difficulty with union (P = .7), or number of patients requiring revision surgery (P = .7). CONCLUSIONS: The TT approach is a safe and effective approach for the treatment of distal humeral fractures. When compared with the OO approach for AO type 13-C fractures, the TT approach did not differ regarding functional outcomes but showed increased range of motion, decreased intraoperative blood loss, and a lower rate of postoperative ulnar nerve neuritis. The TT approach should be considered as a safe and reliable first-line approach for intra-articular distal humeral fractures because it allows adequate visualization of the articular surface, eliminates complications related to osteotomy including delayed union or nonunion and hardware failure or irritation, and allows for easy conversion to total elbow arthroplasty.

Reduction of olecranon fractures with no or minimal dorsal cortex comminution based on the contour of the posterior ulnar cortex: does it restore the greater sigmoid notch?

INTRODUCTION: When treating olecranon fractures surgically, surgeons rely on the contour of the posterior cortex of the proximal ulna. However, it is unclear whether the greater sigmoid notch (GSN) is restored anatomically by this method. We analyzed whether reduction of fractures based on the posterior ulnar cortex contour is reliable for restoration of the GSN contour in displaced olecranon fractures with no or minimal dorsal cortex comminution. MATERIALS AND METHODS: We performed a retrospective review of 23 patients with Mayo type 2 olecranon fractures with no or minimal dorsal cortex comminution who were treated surgically. We analyzed pre- and postoperative elbow CT images and measured the interfragmentary distance (IFD), articular step-off, articular gap, contour defect and GSN angle to evaluate the restoration of the GSN contour. RESULTS: The mean preoperative IFD and contour defect were 16.5 mm (range 4.3-35.6 mm) and 4.3 mm (range 0.7-13.3 mm), respectively. Postoperatively, there was no residual IFD, and the mean contour defect decreased significantly to 1.4 mm (range 0-3.7 mm). The residual articular step-off and gap were 0.2 mm (range 0-3.8 mm) and 1.0 mm (range 0-5.9 mm), respectively. Acceptable GSN restoration was achieved in 14 of 23 patients (60.9%). Sixteen patients had > 2 mm of preoperative contour defect, and 7 (43.8%) achieved acceptable GSN restoration; the remaining 7 patients (100%) who had < 2 mm of the contour defect achieved acceptable GSN restoration. Patients whose preoperative contour defect was > 2 mm had a higher risk of unacceptable GSN restoration, with an odds ratio of 2.29 (p = 0.019). CONCLUSIONS: In displaced olecranon fractures without significant dorsal cortex comminution, reduction based on the posterior ulnar cortex could be reliable for fractures with under 2 mm of preoperative contour defect, but not for those with > 2 mm of contour defect. LEVEL OF EVIDENCE: IV.