Reduction of the olecranon fracture is assessed by imaging in full extension to check for possible implant impingement. Last, we apply the previously harvested fracture callus to the fracture site. Layered closure is performed, and bulky soft dressings are applied. Postoperative immobilization with a splint is used. Gentle range-of-motion exercises begin in about 2 weeks and progress as pain allows.
A case example with preoperative and postoperative images taken at 3-month follow-up is provided in Figure 4. The entire surgical technique can be viewed in the Video.
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Clinical Cases
Between July 2007 and February 2011, 7 patients with displaced olecranon fractures underwent osteosynthesis using the isoelastic tension band (Table 1). According to the Mayo classification system, 5 of these patients had type 2A fractures, 1 had a type 2B fracture with an ipsilateral nondisplaced radial neck fracture, and 1 had a type 3B fracture. There were 4 female and 3 male patients. The injury was on the dominant side in 3 patients. All patients gave informed consent to evaluation at subsequent office visits and completed outcomes questionnaires by mail several years after surgery. Mean follow-up at which outcome measures questionnaires were obtained was 3.3 years (range, 2.1-6.8 years). Exclusion criteria were age under 18 years and inability to provide informed consent, fracture patterns with extensive articular comminution, and open fractures. Permission to conduct this research was granted by institutional review board.
At each visit, patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) functional outcome survey and were evaluated according to Broberg and Morrey’s elbow scoring system.13,14 Chart review consisted of evaluation of medical records, including radiographs and orthopedic physician notes in which preoperative examination was documented, mechanism of injury was noted, radiologic fracture pattern was evaluated, and time to bony union was recorded. Elbow motion was documented. Grip strength was measured with a calibrated Jamar dynamometer (Sammons Preston Rolyan) set at level 2, as delineated in Broberg and Morrey’s functional elbow scoring system.
Results
The 7 patients were assessed at a mean final follow-up of 19 months after surgery and received a mean Broberg and Morrey score of good (92.2/100) (Table 2). Restoration of motion and strength was excellent; compared with contralateral extremity, mean flexion arc was 96%, and mean forearm rotation was 96%. Grip was 99% of the noninjured side, perhaps the result of increased conditioning from physical therapy. Patients completed outcomes questionnaires at a mean of 3.3 years after surgery. Mean (SD) DASH score at this longest follow-up was 12.6 (17.2) (Table 2). Patients were satisfied (mean, 9.8/10; range, 9.5-10) and had little pain (mean, 0.8/10; range, 0-3). All fractures united, and there were no infections. One patient had a satisfactory union with complete restoration of motion and continued to play sports vocationally but developed pain over the locking clip 5 years after the index procedure and decided to have the implant removed. He had no radiographic evidence of K-wire or implant migration. Another patient had a minor degree of implant irritation at longest follow-up but did not request hardware removal.
Discussion
Stainless steel wire is often used in TBW because of its widespread availability, low cost, lack of immunogenicity, and relative strength.7 However, stainless steel wire has several disadvantages. It is susceptible to low-cycle fatigue failure, and fatigue strength may be seriously reduced secondary to incidental trauma to the wire on implantation.15,16 Other complications are kinking, skin irritation, implant prominence, fixation loss caused by wire loosening, and inadequate initial reduction potentially requiring revision.10,12,17-21
Isoelastic cable is a new type of cerclage cable that consists of UHMWPE strands braided over a nylon core. The particular property profile of the isoelastic tension band gives the cable intrinsic elastic and pliable qualities. In addition, unlike stainless steel, the band maintains a uniform, continuous compression force across a fracture site.22 Multifilament braided cables fatigue and fray, but the isoelastic cerclage cable showed no evidence of fraying or breakage after 1 million loading cycles.22,23 Compared with metal wire or braided metal cable, the band also has higher fatigue strength and higher ultimate tensile strength.7 Furthermore, the cable is less abrasive than stainless steel, so theoretically it is less irritating to surrounding subcutaneous tissue. Last, the pliability of the band allows the surgeon to create multiple loops of cable without the wire-failure side effects related to kinking, which is common with the metal construct.
In 2010, Ting and colleagues24 retrospectively studied implant failure complications associated with use of isoelastic cerclage cables in the treatment of periprosthetic fractures in total hip arthroplasty. They reported a breakage rate of 0% and noted that previously published breakage data for metallic cerclage devices ranged from 0% to 44%. They concluded that isoelastic cables were not associated with material failure, and there were no direct complications related to the cables. Similarly, Edwards and colleagues25 evaluated the same type of cable used in revision shoulder arthroplasty and reported excellent success and no failures. Although these data stem from use in the femur and humerus, we think the noted benefits apply to fractures of the elbow as well, as we observed a similar breakage rate (0%).