Is Tension Band Wire Fixation Superior to Plate Fixation for Simple Displaced Olecranon Fractures? A Randomized Trial With Median Follow-up of 7.5 Years

Abstract Background Surgeons disagree about the best surgical treatment for simple, displaced olecranon fractures. Although the tension band wiring technique and plate fixation are the most common surgical options for fixation, studies comparing both are limited. To date, there have been no randomized trials comparing patient-reported outcomes and complications at more than 5 years of follow-up. Questions/purposes (1) Does tension band wiring or plate fixation result in better ROM and patient-reported outcome scores for simple displaced olecranon fractures? (2) What is the risk of complications associated with each technique? Methods Between November 2012 and October 2017, 68 patients were treated for acute, displaced olecranon fracture in a hand and upper extremity surgery unit at a tertiary-care center. Patients 18 years or older with traumatic, nonpathologic, simple olecranon fractures who presented within 2 weeks of injury were considered potentially eligible. Based on that, 74% (50) of patients met the inclusion criteria; 16% (11) of patients declined to participate in the study, and another 10% (seven) were excluded because they did not meet the prespecified inclusion criteria. Patients were randomized on a 1:1 basis to either tension band wiring or plate fixation and were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery. At the final follow-up interval, 16% (eight) were lost to follow-up: 4% (two) in the tension band wiring group and 12% (six) in the plate fixation group. The median follow-up time was 8 years (IQR 7 to 9 years). We evaluated complications at a minimum of 6 years after surgery. The primary outcome measure was the 1-year postoperative DASH score. Additional outcome measures included the patient-reported Oxford Elbow Score, ROM, and the proportion of patients in each group who reported hardware-related symptoms and had subsequent implant removal or postoperative infection. Results No differences were observed in the DASH score (tension band wiring 18 [range 3 to 65] versus plate fixation 24 [range 3 to 52], median difference -6 [95% CI -12.7 to 14.9]; p = 0.73), Oxford Elbow Score (tension band wiring 36 [range 10 to 48] versus plate fixation 39 [range 17 to 47], median difference -3; p = 0.53), or all ROM measurements (p > 0.05) between the groups at 1 year of follow-up. The odds of having surgery for symptomatic implant removal were lower for plate fixation than for tension band wiring (one of 19 versus eight of 23, OR 9.6 [95% CI 1.08 to 85.7]; p =0.02); the odds of infection, however, were higher in the plate group (three of 19 versus 0 of 23; p = 0.048). Conclusion No differences were observed between the two techniques in terms of ROM or patient-reported outcomes. Surgeons should consider that although the risk of implant removal is higher in tension band wiring, patients older than 85 years undergoing plate fixation for simple olecranon fractures are at a greater risk of postoperative infection. Level of Evidence Level I, therapeutic study.