Olecranon fractureOlecranon fracture

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

Rigshospitalet, Copenhagen University HospitalRigshospitalet, Copenhagen University Hospital

�� 20% of forearm fracture20% of forearm fracture

�� 12 per 100.000 persons per year12 per 100.000 persons per year

�� LowLow--energy fallenergy fall

�� Increased risk >50 yearsIncreased risk >50 years

�� 90% AO 21.B1.190% AO 21.B1.1

�� Dickworth et al. Injury 2012;43:343Dickworth et al. Injury 2012;43:343--346 346

�� Why operate?Why operate?

�� Methods of fixationMethods of fixation

–– KK--wire, cerklagewire, cerklage

–– PlatingPlating

�� OutcomeOutcome

�� SummarySummary

Why operate?Why operate?

�� Restore articular surfaceRestore articular surface

�� Achieve absolute stabilityAchieve absolute stability

�� Commence early active movementCommence early active movement

�� Preservation of range of motion and Preservation of range of motion and

powerpower

�� 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 to Loads applied comparable to clinical situationsclinical situations

�� Displacements measuredDisplacements measured

Fyfe et al. Jour Bone Joint Surg (Br).1985. 67B;3:367Fyfe et al. Jour Bone Joint Surg (Br).1985. 67B;3:367--372372

Methods of fixation?Methods of fixation?

Fracture typeFracture type

TransverseTransverse

ObliqueOblique

ComminutedComminuted

Fixation techniqueFixation technique

Tension band 1.0 mm, 1 Tension band 1.0 mm, 1

knot, Kknot, K--wire 2.0 mmwire 2.0 mm

Tension band 1.0 mm, 2 Tension band 1.0 mm, 2

knots, Kknots, K--wire 2.0 mmwire 2.0 mm

Tubular plateTubular plate

Cancellous screw, washerCancellous screw, washer

Cancellous screw, washer, Cancellous screw, washer,

tension bandtension band

Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367--372372

Methods of fixation?Methods of fixation?

Fracture typeFracture type Fixation techniqueFixation technique

TransverseTransverse Tension band, 2 knotsTension band, 2 knots

ObliqueOblique Tension band, 2 knotsTension band, 2 knots

or tubular plateor tubular plate

ComminutedComminuted Tubular plateTubular plate

Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367Fyfe et al. Jour Bone Joint Surg (Br). 1985. 67B;3:367--372372

KK--wire and cerklagewire and cerklage

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

�� Proximal ulnar canal?Proximal ulnar canal?

�� Anterior cortex?Anterior cortex?

�� Distal ulnar canal?Distal ulnar canal?

Huang et al. J Trauma. 2010.68;1:173Huang et al. J Trauma. 2010.68;1:173--176176

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

Proximal ulnar Proximal ulnar

(n=24)(n=24)Anterior cortexAnterior cortex

(n=28)(n=28)

Distal ulnar Distal ulnar

(n=26)(n=26)

Average followAverage follow--

up/monthsup/months34.5 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 removalimplant removal8 (33%)8 (33%)

*p=0.03*p=0.03

3 (11%)3 (11%) 2 (8%)2 (8%)

Proximal Proximal

migration of Kmigration of K--

wire/mmwire/mm

4.08 s.d. 1.894.08 s.d. 1.89

*p=0.001*p=0.001

1.53 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 KHow to place the K--wires?wires?

�� Inserted as close as possible to the Inserted as close as possible to the articular surfacearticular 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

�� KK--wires are impacted into ulnawires are impacted into ulna

Newman et al. 2009. Injury; 40(6): 575Newman et al. 2009. Injury; 40(6): 575--581581

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

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

Prayson et al. Shoulder Elbow Surg. Prayson et al. Shoulder Elbow Surg. 2008.17;1:1212008.17;1:121--125125

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

FailureFailure

(> 2 mm movement (> 2 mm movement

across osteotomy)across osteotomy)

CompressionCompression

Stainless steel wireStainless steel wire 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 appropriateTension band is not appropriate

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

midpoint of the troclear notchmidpoint of the troclear notch

–– CoCo--existing coronoid fractureexisting coronoid fracture

–– Associated with Monteggia Associated with Monteggia

fracture dislocationfracture dislocation

Newman et al. 2009. Injury; 40(6): 575Newman et al. 2009. Injury; 40(6): 575--581581

Which kind of plate?Which kind of plate?

�� Cadaveric studyCadaveric study

�� Comminute fractureComminute fracture

�� 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;130:459Surg.2010;130:459--464464

Which kind of plate?Which kind of plate?

�� Advantage of locking compression Advantage of locking compression

plate to conventionel plate:plate to conventionel plate:

–– Angular and axial stabilityAngular and axial stability

–– Preserves periosteal blood supplyPreserves periosteal blood supply

–– No toggling of unlocked screws (improves No toggling of unlocked screws (improves

fixation in osteoporotic fractures and fixation in osteoporotic fractures and

comminution)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

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

Outcome Outcome –– Cochrane reviewCochrane review

Veillette et al. Orthop Clin N Am. 2008;39:229Veillette et al. Orthop Clin N Am. 2008;39:229--236236

Short termShort term

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

*only plate fixation*only plate fixation

LongLong--termterm

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

PainPain 1 1

(VAS score)(VAS score)

6% severe daily 6% severe daily

symptomssymptoms

Motion compared to Motion compared to

nonnon--affected armaffected armDecreased supinationDecreased supination Decreased flexion and Decreased flexion and

extension extension

(5 degrees)(5 degrees)

Radiographic Radiographic

evaluationevaluation8% OA8% OA 5% OA5% OA

1% non1% non--unionunion

PatientPatient--rated outcomerated outcome 9.79.7

(VAS score)(VAS score)

96% excellent or good96% excellent or good

Summary Summary –– Tension band Tension band

fixationfixation

�� Fracture: Transverse or Fracture: Transverse or

obliqueoblique

�� KK--wire: Anterior cortex or wire: Anterior cortex or

distal ulnar canaldistal ulnar canal

�� KK--wire penetration: <10 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 Summary -- PlatingPlating

�� Fractures: Distal to the Fractures: Distal to the

midpoint of the troclear midpoint of the troclear

notch, conotch, co--existing coronoid 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