Comparison of two fixation techniques of olecranon osteotomy after reconstruction of intra-articular distal humerus fractures

Abstract

BACKGROUND

Accurate surgical fixation of intra-articular distal humerus fractures require olecranon osteotomy. Repair of osteotomy is achieved with a variety of techniques but no consensus has been achieved regarding the optimum technique for fixing the olecranon osteotomy. In this retrospective study, we compared the functional and radiological outcome of the two commonly used techniques of fixing olecranon osteotomy after fixing distal humerus intra-articular fractures. We hypothesized that olecranon osteotomy fixed with 6.5 mm cancellous intramedullary screw alone yielded better radiological and functional outcome than fixation with cerclage wire over cancellous screw applied in figure of eight as tension band wiring (TBW).

AIM

To determine the radiological and functional outcome of olecranon osteotomy fixation with cancellous screw alone vs cancellous screw combined with cerclage wiring applied as TBW.

METHODS

This retrospective study was conducted in Lady Reading Hospital Peshawar Pakistan. Intra-articular distal humerus fractures fulfilling the inclusion criteria and operated during 2023 to 2025 were included. Olecranon osteotomy fixation with 6.5 mm cancellous screw alone was labelled as group A while cerclage wire over cancellous screw in figure of eight as TBW were labelled as group B. The demographics, radiological and functional outcome in both groups were compared at one year using Mayo Elbow Performance Score and Quick Disabilities of the Arm, Shoulder, and Hand Score.

RESULTS

We included 32 patients in this study. The mean age of group A patients was 34 ± 5.5 years while group B had a mean age of 34 ± 6.2 years. Radiological union of olecranon osteotomy was achieved in all cases in both groups. Functional outcome however was significantly better in group A than in group B (P < 0.05). The Mayo Elbow Performance Score was excellent in 14 (87.5%) and good in 2 (12.5%) patients in group A while 7 (43.47%) patients had excellent outcome, 5 (31.25%) good and 4 (25%) had fair outcome in group B. The mean Quick Disabilities of the Arm, Shoulder, and Hand Score was 24.5 ± 2.1 and 78.1 ± 12.1 in group A and B respectively (P < 0.05).

CONCLUSION

Similar radiological union was achieved in all patients of olecranon osteotomy treated with intramedullary screw alone and intramedullary screw with TBW. Functional outcome however was significantly better in intramedullary screw alone than in intramedullary screw with TBW.

Key Words: Intra-articular distal humerus fractures; Olecranon osteotomy; Mayo Elbow Performance Score; Tension band wiring; Quick Disabilities of the Arm, Shoulder, and Hand

Core Tip: In this retrospective study, we compared the radiological and functional outcomes of the two commonly used techniques for fixing olecranon osteotomy after fixing intra-articular distal humerus fractures. Fixation of olecranon osteotomy with intramedullary cancellous screw and washer yielded significantly better functional outcome and minimal complications than intramedullary screw and tension band wiring in young patients.

INTRODUCTION

Distal humerus fractures accounts for 1% to 6% of all fractures and 30% of elbow fractures while complex intercondylar distal humerus fractures [Arbeitsgemeinschaft fur Osteosynthesefragen (AO) type C fractures] constitute less than 1%[1,2]. AO type C fractures have bimodal distribution with younger patients sustain comminuted fractures due to high energy trauma while older patients present with relatively simple fractures due to low energy fall[3,4]. The gold standard for good exposure to comminuted intercondylar distal humerus fractures is the olecranon osteotomy[5]. Although olecranon osteotomy is associated with potential complications like delayed union, nonunion, discomfort with prominent implants and re-surgeries yet it facilitates anatomic reduction and accurate fixation by providing 63% more exposure to the intra-articular fracture fragments than other techniques[6]. Olecranon osteotomy is conventionally fixed with tension band wiring (TBW), but plates and intramedullary cancellous screw fixation and hybrid construct is also employed[7]. All these fixation techniques are associated with variable complications particularly TBW removal is often needed in majority of cases due to discomfort caused by prominence Kirschner wires (K-wires) or cerclage[8].

The use of a long partially threaded intramedullary cancellous screw alone with a washer or screw in combination with a stainless steel wire in figure of eight TBW configuration is a relatively new technique and providing extra compression of olecranon osteotomy[8,9]. Fixation of olecranon osteotomy with intramedullary screw is technically simple and less time consuming than conventional TBW or plate[9]. The advantages of olecranon osteotomy fixation with intramedullary screw include less soft tissue dissection and least prominence of implant which results in lower postoperative complications and revision surgeries[10]. Biomechanical studies have revealed that the stability provided by intramedullary screw, plate and K-wires with TBW construct for fracture compression and load to failure in olecranon osteotomy is equivalent[10,11]. Similar functional outcome of intramedullary screw, plate and K-wires with TBW construct have been reported by recent studies[12]. Due to the subcutaneous location and complex proximal ulna anatomy the optimum consensus technique of fixing olecranon osteotomy is still controversial[13].

The objective of our study was to determine the radiological and functional outcome of olecranon osteotomy fixation with intramedullary cancellous screw alone vs cancellous screw combined with cerclage wiring applied in figure of eight TBW. We hypothesized that olecranon osteotomy fixed with 6.5 mm cancellous intramedullary screw alone yielded better radiological and functional outcome than fixation with cancellous screw and TBW.

MATERIALS AND METHODS

This retrospective study was conducted in Lady Reading Hospital Peshawar Pakistan. The study protocols were approved by the Institutional Review Board Lady Reading Hospital (approval No. 145/LRH/MTI). The sample size for this study was calculated using Naing et al[14] formula: n = Z²P(1-P)/d² where n denotes sample size, Z is level of confidence (5%/1.96), P is expected prevalence/proportion (2% or 0.028)[1,2] and d is precision (5% or 0.05). The calculated sample size was 29. By adding possible lost to follow up (10% or 2.96), our final total sample size was 32. All adults patients of both gender and any age with closed intra-articular distal humerus fractures (AO type 13-C)[2], operated with open reduction and internal fixation with dual precontoured locking plates and olecranon osteotomy fixation with intramedullary screw with or without TBW were included. The included subjects had a complete record with minimal postoperative follow up of one year. All patients were operated during March 2023 to May 2025. All were operated by same surgical team (all three authors). The relevant regular controlled data was retrieved from hospital management information system. Patients with pathological distal humerus fractures, metabolic bone disease vascular injury and revision surgery were excluded. Preoperative radiographs [anteroposterior (AP) and lateral views], 3D computed tomography scan elbow and postoperative radiographs were reviewed in each case for fracture classification, and type of fixation. All the included subjects were contacted and requested for consent and for controlled up-to-date radiological and functional assessment in our Orthopaedic Out Patient Department.

Operative technique

Standard identical protocol was adopted for olecranon osteotomy and fixation of intra-articular distal humerus fractures. All the surgeries were performed under general anaesthesia and pneumatic tourniquet control. All the surgeries were performed by the same surgical team (all three authors). All the operating surgeons were experienced trauma surgeons with more than ten years of treating complex elbow fractures. The patient was placed lateral decubitus position with the affected arm in arm holder. Preoperative intravenous antibiotics (injection cefuroxime) was administered at induction before tourniquet inflation. A straight incision on the posterior midline of elbow was given about 5 cm below the tip of olecranon and 5 cm above the olecranon. After soft tissue dissection ulnar nerve was identified and protected to one side with a sling. The site of olecranon osteotomy was marked with cautery about 2-2.5 cm distal to the tip of olecranon. A 2.8 mm guide wire was inserted intramedullary from tip of olecranon distally into the ulna and checked under image intensifier in AP and lateral views. A drill bit of 4.8 mm was inserted over guide wire till it touched the cortex of ulna. An appropriate size 6.5 mm partially threaded cancellous screw with washer was inserted into the medullary canal of ulna. Once ensured that the screw had a strong grip in diaphysis of ulna it is retracted back and engaged with tip of olecranon leaving only few threads inside the tip of olecranon. We performed transverse olecranon osteotomy with an oscillating power saw and completed with a chisel. The olecranon osteotomy along with triceps tendon was elevated to expose the intra-articular distal humerus fracture. The intra-articular distal humerus fracture is fixed with two locking compression plates on lateral and medial column and inter fragmentary screws when needed (Figures 1 and 2). The proximal olecranon osteotomy piece was placed on its original position and reduced with reduction a clamp. The cancellous screw was advanced intramedullary and tightened to achieve compression. The osteotomy reduction and screw positioning was confirmed in image intensifier.

Figure 1 Preoperative and postoperative X-ray films of distal humerus fractures and images of olecranon osteotomy fixation. A and B: Preoperative anteroposterior (A) and lateral radiographs (B) showing intra-articular distal humerus fracture; C and D: Postoperative anteroposterior (C) and lateral radiographs (D) showing healed fracture distal humerus and healed olecranon osteotomy fixed with cancellous screw and washer; E and F: Preoperative and postoperative radiographs showing fixation of olecranon osteotomy with intramedullary screw and cerclage. Preoperative anteroposterior and lateral radiographs showing intra-articular distal humerus fracture (E). Fixation with pre-contoured locking plates and olecranon osteotomy fixation with intramedullary screw and cerclage (F).

Figure 2 Peroperative photographs. Peroperative photographs showing ulnar nerve dissection, separation and securing it safely to one side with a sling. Olecranon osteotomy was retracted proximally to facilitated fracture reduction. Accurate anatomical fracture reduction with provisional Kirschner-wires fixation of fracture fragments followed by application of contoured locking plates on both columns of distal humerus. A: Ulnar nerve dissection, separation and securing it safely to one side with a sling; B: Olecranon osteotomy was retracted proximally to facilitated fracture reduction. Accurate anatomical fracture reduction was achieved with provisional Kirschner-wires fixation of fracture fragments; C: Application of definitive pre-contoured locking plates on both columns of distal humerus.

In patients with intramedullary screw and TBW construct two horizontal superficial holes in both cortices diaphysis of ulna was made with 3.2 drill bit about 4 cm distal to the osteotomy. An 18 gauge stainless steel cerclage is passed through these holes. The cerclage was applied around the tip of cancellous screw with washer in figure of eight as TBW. It is tightened firmly and screw is inserted over it (Figure 1E and F). The wound was closed in layers. An above elbow back slab was given for two weeks. At two weeks stitches were removed and slab discontinued. Identical supervised physical rehabilitation program was initiated which included initial range of motion exercises followed by gradual transition to active and passive elbow motion. Follow up visits were scheduled at four weeks initially for six months and then every third months thereafter.

In each visit radiological union of fracture and osteotomy was determined with X-ray AP and lateral view and functional assessment was done with Mayo Elbow Performance Score (MEPS)[15] and Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH)[16] Score. The MEPS is a validated outcome assessment tool covering pain, range of motion, stability and activity of daily living. It has total 100 points with 90 points to 100 points graded as excellent outcome, 75 points to 89 points good, 60 to 74 fair and less than 60 points as poor outcome. The Quick DASH is a validated outcome assessment tool with 11 items questionnaire utilizing 5-point Likert scale. The score ranges from 0 (no disability) to 100 (most sever disability). At one year postoperative follow up radiological and functional outcome was compared in our patients with olecranon osteotomy fixation with 6.5 mm cancellous screw alone (group A) with screw and cerclage wire in figure of eight TBW (group B).

Statistical analysis

We analysed our data with SPSS version 27. Quantitative variables like age, MEPS and Quick DASH are represented as mean ± SD, while qualitative variables like type of fracture, aetiology of fracture and side of fracture is represented as frequency and percentage. The mean MEPS and Quick DASH in both the groups are compared and P value calculated with independent sample t test. The categorical variables in both groups were compared and P value calculated with χ² test. P < 0.05 is considered significant. Data is presented in table where necessary.

RESULTS

We retrieved the hospital management information system data of 40 patients who were operated for intra-articular distal humerus fractures. Amongst these 3 (7.5%) patients were not fulfilling our inclusion criteria, 3 (7.5%) patients could not come to our Orthopaedic Out Patient Department for up-to-date radiological and functional assessment, 1 (2.5%) patient had deficient record and 1 (2.70%) patient was recently operated with follow up time less than one year. We therefore reviewed the record of 32 eligible and enrolled patients. A comparison of demographic and clinical variables of group A (olecranon osteotomy fixation with intramedullary screw and washer alone) and group B (olecranon osteotomy fixation with intramedullary screw and washer and TBW) is shown in Table 1.

Table 1 Comparison of demographic and clinical variables of both groups, n (%)/mean ± SD.

No.	Demographic and clinical variables	Group A	Group B	P value
1	Gender
	Male	12 (75)	13 (81.25)	0.10
	Female	4 (25)	3 (18.75)
2	Side
	Right	10 (62.5)	11 (68.75)	0.09
	Left	6 (37.5)	5 (31.25)
3	Fracture classification
	AO 13-C1	5 (31.25)	5 (31.25)	0.08
	AO 13-C2	7 (43.75)	6 (37.5)
	AO 13-C3	4 (25)	5 (31.25)
4	Aetiology of fracture
	RTA	12 (75)	13 (81.25)	0.20
	Fall	4 (25)	3 (18.75)
5	Age, years	34 ± 5.5	34 ± 6.2	0.30
6	Diabetes mellitus	1 (6.25)	2 (12.5)	0.10
7	Hypertension	1 (6.25)	3 (18.75)	0.20
8	Ischemic heart disease	1 (6.25)	1 (6.25)	0.50
9	Follow up months	16 ± 1.2	15.4 ± 2	0.32
10	6.5 mm intramedullary screw length, mm	95.4 ± 3	95 ± 2.1	0.12
11	MEPS	92.3 ± 4.1	78.1 ± 12.1	0.03
12	Quick DASH score	24.5 ± 2.1	56.2 ± 4.8	0.001
13	Distal humerus fracture union	16 (100)	16 (100)	-
14	Olecranon osteotomy union	16 (100)	16 (100)	-
15	Complications
	Superficial infection	3 (18.75)	7 (43.75)	0.01
	Discomfort due to prominent implant	-	9 (56.25)	0.004
	Osteotomy implant removal	-	7 (43.75)	0.002

AO: Arbeitsgemeinschaft fur Osteosynthesefragen; RTA: Road traffic accident; MEPS: Mayo Elbow Performance Score; Quick DASH: Quick Disabilities of the Arm, Shoulder, and Hand.

We achieved radiological union of distal humerus fractures and olecranon osteotomy in all of our cases in both groups at minimum of one year follow up. Loss of articular reduction was not noticed in any case. We did not find any delayed union and non-union in our patients. The functional outcome however was significantly better in group A than group B with mean MEPS score of 92.3 ± 4.1 in group A vs 78.1 ± 12.1 in group B (P < 0.05). The MEPS was excellent in 14 (87.5%) and good in 2 (12.5%) patients in group A while 7 (43.47%) patients had excellent outcome, 5 (31.25%) good and 4 (25%) had fair outcome in group B. The mean Quick DASH score was also significantly better (P < 0.05) in group A (24.5 ± 2.1) than in group B (78.1 ± 12.1). Subgroup analysis revealed mean MEPS score of 85.3 ± 3, 91.4 ± 5 and 90.1 ± 2 in patients with AO 13-C1 fracture, AO 13-C2 and AO 13-C3 fractures respectively in group A (P > 0.05). In group B patients with AO 13-C1 fracture had MPES score of 75 ± 6, AO 13-C2 had 61.3 ± 4 and AO 13-C3 fracture had 90 ± 1 score (P > 0.05). The mean Quick DASH score was 22.4 ± 2, 24 ± 1.4, 26 ± 1 in patients of group A with fractures classified as AO 13-C1 fracture, AO 13-C2 and AO 13-C3 fractures respectively (P > 0.05). The mean Quick DASH score of group B was 55.3 ± 4, 60 ± 2.1, 50.5 ± 5 in patients with 13-C1 fracture, AO 13-C2 and AO 13-C3 fractures respectively (P > 0.05). The functional outcome was not significantly associated with age, gender, side of fracture, length of screw and individual type of fracture (P > 0.05). No significant association of radiological and clinical outcome was noted for diabetes mellitus, hypertension and ischemic heart disease. Olecranon osteotomy fixation with intramedullary screw and TBW was significantly associated with discomfort due to prominent implant (56.25%, n = 9) and removal of TBW (43.75%, n = 7) in most cases (P < 0.05). We did not document delayed union and nonunion of osteotomy and any implant failure requiring revision in our study.

DISCUSSION

In our study, we documented that olecranon osteotomy fixation with intramedullary screw with washer was more effectively and safely than intramedullary screw with TBW. This technique had minimal complications. Our results are supported by literature. Cañete San Pastor et al[9] treated 26 patients of olecranon osteotomy with 6.5 mm long and 102 mm thick intramedullary screw and washer. Complications were infection noted in one patient, delayed union in two cases, wound dehiscence in one patient and implant failure in one patient. At 12 months follow up, all cases achieved union. Cañete San Pastor et al[9] also shared their two cases of olecranon osteotomies fixation with shorter and thinner intramedullary screws and TBW which were failed and revised with long intramedullary screws alone. They concluded that intramedullary screw with washer alone is a safe and an effective technique of fixing olecranon osteotomy but longer and thicker intramedullary screws are preferable than shorter and thinner screws. Yıldız et al[5] treated a total of 37 patients including 20 patients treated with K-wires and TBW and intramedullary screw and TBW, plate fixation (8 patients) and intramedullary nail fixation (9 patients). The mean age of their patients was 37 years old. At an average duration of 44 months the mean MEPS was 84 and mean DASH score was 22 and mean visual analogue scale was 3. They concluded that no technique of olecranon osteotomy fixation was superior to the other as no statistically significant difference was found amongst the various fixation methods of olecranon osteotomy in terms radiological and functional outcome.

In our study, we were able to avoid the screw related complications mentioned in literature by using a cancellous screw of adequate diameter (6.5 mm diameter) and length (95.4 ± 3 mm long) for fixing olecranon osteotomy. In a systematic review, Feinstein et al[8] revealed that 6.5 mm cancellous screw with TBW was used for fixing olecranon osteotomy in six studies with 382 patients. He noted great variations of screw diameter and use of washer amongst the surgeons delayed union with cancellous screw alone was noted in 7.7% (n = 2) patients, while cancellous screw and TBW had delayed union of 7.5% (n = 15). Nonunion was 6.9% (n = 5) in screw alone and 3.9% (n = 12) in screw plus TBW. The frequency of implant removal was similar (19.4%) in both groups. Revision surgery was required for implant failure in screw alone in 7.7% (n = 3) and 4.5% (n = 8) in screw with TBW. The infection rate was 4.6% (n = 3) in screw alone and 7% (n = 13) in screw plus TBW. This review however preferred chevron osteotomy over transverse olecranon osteotomy.

Meldrum et al[7] treated 10 patients of olecranon osteotomy with intramedullary screw and achieved union in all cases. Similar to our study none of their patients needed removal of osteotomy screw because of infection, painful irritation or discomfort. According to the study[7], K-wires with TBW needs removal more often than intramedullary screw (odds ratio = 3.29). Woods et al[13] treated 58 patients with screw and TBW and 39 with screw alone. They reported better union rates with minimal complications in screw alone group. The infection rate was 8.5% (n = 5) in screw with TBW and 5.1% (n = 2) in screw alone. Removal of hardware was needed in 19% (n = 10) in screw with TBW and 15.4% (n = 6) in screw alone. Nonunion was 10.3% (n = 4) in screw alone vs 8.6% (n = 5) in screw and TBW, but the difference was not statistically significant. They pointed out that regardless of fixation technique of olecranon osteotomy patients having non-union of olecranon osteotomy had a high Charlson comorbidity index score than others (0.56, P = 0.04). No significant difference was noted in the rates of non-union between screw fixation alone and screw with TBW. This study concluded that intramedullary screw fixation is a safe and effective technique for fixing olecranon osteotomy[13].

In our study, intramedullary screw with TBW was associated with significant postoperative complications than screw alone (P < 0.05). In a systematic review of 41 articles, Spierings et al[17] documented that olecranon osteotomy fixation with intramedullary screw and TBW had a number of complications. These include delayed union in 2.8% patients, heterotrophic ossification in 9% patients, removal of implant in 28.3% and postoperative infection in 4.3% patients. Ocalan et al[18] treated 36 patients with K-wires and TBW, plate and intramedullary screw. Intramedullary screw was applied in 11 (29.7%) patients. Implant removal was done in 4 patients in K-wires and TBW, 3 patients in plating and 2 patients in intramedullary screw. Plate removal was 2.6 times more likely to done than screw removal. Overall MEPS score was excellent in 22 (59.5%), good in 7 (18.9%) and fair in 8 (22.6%). These authors concluded that both K-wires with TBW and intramedullary screw with or without TBW can be done to achieve good results, but because of the simplicity of intramedullary screw fixation, these authors preferred to use intramedullary screw. Tak et al[19] treated 93 olecranon osteotomies with intramedullary screws. Only four cases had delayed union but ultimately all united at 20 weeks. The olecranon screw was prominent in 25.9% of patients and presence of a painful olecranon bursa was noted in 19.1% patients. The osteotomy screw was removed in 32.6% of patients after healing of the osteotomy. Postoperative functional outcome was graded as excellent (90 points to 100 points) in 36 (40.4%) patients, good (75 points to 85 points) in 40 (45%), fair (50% to 65%) in 10 (11.2%) and poor (less than 50 points) in 3 (3.4%). Contrary to our results which favored intramedullary screw fixation of olecranon osteotomy, Wagener et al[20] demonstrated in a biomechanical study using roentgen stereophotogrammetry, analysis that fixation of olecranon osteotomy with intramedullary screw and TBW was superior to the screw alone and K-wires and TBW, as it can bear greater triceps forces and can safely allow postoperative elbow range of motion.

Variations and innovations of intramedullary screw fixation alone and screw with TBW for olecranon osteotomies have been reported in literature. Instead of intramedullary cancellous screw fixation of olecranon osteotomy, Han et al[21] treated 14 olecranon osteotomies with cannulated intramedullary screw and TBW, and achieved osteotomy union in all cases without any complication. Batihan et al[22] suggests that an intramedullary cannulated headless screw is better biomechanically than TBW, plating and cannulated screw as it resists olecranon osteotomy displacement more efficiently at higher tensile foresee than other constructs. Wagener et al[23] treated 19 patients of olecranon osteotomy with intramedullary screw washer and suture Fibrewire in TBW configuration. All cases achieved union without any major complications.

In our study, we documented similar osteotomy union rates but significantly better functional outcome in patients treated with intramedullary screw alone than screw with cerclage as indicated by MEPS score of 92.3 ± 4.1 vs 78.1 ± 12.1 and Quick DASH score of 24.5 ± 2.1 vs 56.2 ± 4.8 respectively (P < 0.05). The similar osteotomy union rates between the two techniques can be explained by the appropriate size screw, optimum technique and primary perfect compression caused by the intramedullary screw at the osteotomy site during surgery. In the screw plus TBW construct the TBW component (we may call it “the risk component” in this case) did not produce any additional advantage. The low rates superficial surgical site infection, no irritation of soft tissues or symptomatic hardware and no need for early unplanned hardware removal in intramedullary screw are the major causes of increased patient satisfaction ensuring early and uninterrupted rehabilitation, and can be attributed to excellent functional outcome in our patients treated with intramedullary screw alone. However, Yıldız et al[5] compared 20 patients treated with K-wires and TBW and intramedullary screw and TBW, 8 patients with plates and 9 patients with intramedullary nails. They did not report any significant difference amongst the three construct regarding functional outcome as assessed with visual analogue scale score, disabilities of the arm, shoulder and hand score and Mayo score. Yıldız et al[5] concluded that no technique of osteotomy fixation was superior to the other.

Although K-wires and TBW construct is the most frequently used technique for fixation of olecranon osteotomy, but due to the higher rate of complications and revisions, it is losing popularity. Dumartinet-Gibaud et al[24] documented 56% revision rate of TBW construct in his series of 39 patients. These top three reasons for revision were implant impingement (44%), fixation failure (24%) and nonunion of osteotomy (16%). In literature, many biomechanical studies tested the effectiveness of various construct for fixing olecranon osteotomy. In one biomechanical study conducted by Calisal and Uğur[25], three fixation techniques were compared including fixation with traditional TBW technique, intramedullary screw and double screws. They noted that TBW has the lowest pull out strength of 55.10 N followed by intramedullary screw (70.08 N) and double screw (84.28 N). This can be the possible reason for relatively higher complication rate associated with TBW and the reason for shifting from traditional TBW to intramedullary screw fixation of olecranon osteotomy. In another biomechanical study, Reising et al[26] tested TBW, olecranon osteotomy nail and olecranon hook plate for fixing olecranon osteotomy, and noted higher postoperative osteotomy displacement with traditional TBW than with newer nail and hook plate. These authors concluded that nail and hook plate provide more stability than TBW but in vivo complications of these newer implants need to be monitored. Similarly, Kia et al[27] conducted a biochemical study comparing low profile continuous loop tension band with intramedullary screw and TBW, and found no difference in biomechanical strength of the two except that low profile continuous loop tension band had a lower prominence of hardware. Meldrum et al[7] reported that amongst the fixation techniques of olecranon osteotomy TBW were more commonly required removed than others (P < 0.05). One reason for this increased frequency of TBW removal is the reason of prominence of implants more than 1 mm above the tip of olecranon (odds ratio = 3.29). Petraco et al[28] randomized 18 upper limb cadaveric specimens into transverse olecranon osteotomy and fixation with K-wires and TBW, chevron osteotomy and fixation with intramedullary cancellous screw and TBW and oblique osteotomy fixed with lag screws and TBW. After periodic cyclical loading of variable loads no significant differences was noted in osteotomy displacement or stability in any construct. Petraco et al[28] concluded that fixation of olecranon osteotomy should be left to the operating surgeon preferences and expertise. Cole et al[29] treated 46 patients of olecranon osteotomy with intramedullary screw and TBW. Union was achieved in all cases. However, two cases required early revision with plate because of osteotomy displacement on early postoperative radiographs. According to the study, initial osteotomy fracture reduction is more important than fixation technique[29]. Furthermore, the orientation of olecranon osteotomy should be perfectly transverse rather than oblique, because the screw and TBW would not be able to neutralize the shearing forces across the longitudinal axis of ulna. To ensure optimum olecranon osteotomy cuts, cutting jigs are now in the process of designing, to minimize such complications of olecranon osteotomy[30]. Our study had few limitations. Our study was single center and retrospective. Our patients were young with good quality bone. We recommend multicenter prospective randomized controlled trial with larger sample size and diverse population age to verify our results.

CONCLUSION

Similar radiological union was achieved in all patients of olecranon osteotomy treated with intramedullary screw alone and intramedullary screw with TBW. However, functional outcome was significantly better in intramedullary screw alone than in intramedullary screw with TBW. The complication rate of intramedullary screw and TBW is significantly higher than intramedullary screw alone. Fixing olecranon osteotomy with intramedullary screw alone is simple, easy and with minimal minor complications. Therefore, we recommend this as the technique of choice for fixing olecranon osteotomy in young patients.