Original Research

Comparison of Outcomes and Costs of Tension-Band and Locking-Plate Osteosynthesis in Transverse Olecranon Fractures: A Matched-Cohort Study

Am J Orthop. 2015 July;44(7):E211-E215

References

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Anteroposterior and lateral radiographs of the elbow were obtained at follow-up and were examined for maintenance/integrity of implants, radiographic union, and posttraumatic arthrosis. Arthrosis was graded using the Broberg and Morrey²⁴ classification: grade 0 (normal elbow), grade 1 (slight joint-space narrowing with minimal osteophyte formation), grade 2 (moderate joint-space narrowing with moderate osteophyte formation), grade 3 (severe degenerative changes with gross destruction of joint).

Medical records were examined to determine surgery time. Billing information was examined to determine charges related to each operation, specifically the charge for the implants and the overall charge for the operation, which included anesthesia charges. Subsequent operations were included as applicable.

Student t test was used to compare differences in normative data, and Pearson χ² test to compare differences in categorical data. Differences with P < .05 were considered significant.

Results

There were no clinically or statistically significant differences in ROM or functional outcomes (Table 2). According to MEPS, results were excellent in 8 and good in 2 patients in the tension-band group and excellent in 7 and good in 3 patients in the locking-plate group.

In patients who had implants removed, average time to subsequent procedure was 6.2 months, and all patients who underwent implant removal did so before 1-year follow-up. Implant removal was required in 4 tension-band patients and 1 locking-plate patient (P = .12). Similarly, 7 tension-band patients (including those with implants removed) and 3 locking-plate patients had implant-related symptoms, with the difference trending (P = .07) toward significance (Table 2).

Patients who elected to have their implants removed tended to be younger than those who did not (45.7 vs 56.0 years); the difference (P = .14) was not significant. Worker’s compensation status did not affect the decision to undergo implant removal. At final follow-up, there were no differences in ROM or functional outcomes between patients who had implants removed and those who did not. No variable predicted which patients had implants removed or not (Table 3).

Implant charges were $207.97 for the tension-band cohort and $6688.52 for the locking-plate cohort (P < .0001). Operative charges for the index procedures were $5171.06 for tension-band fixation and $14,160.26 for locking-plate fixation (P < .0001). Overall operative charges, including charges for subsequent operations, were $6598.36 in the tension-band cohort and $14,333.46 in the locking-plate cohort (P = .001). In a comparison of combined charges for index procedure and implant removal (excluding other repeat operations), charges were $6025.56 for the tension-band cohort and $14,333.46 for the locking-plate cohort (P = .0002). Even if all patients with tension-band fixation and no patients with locking-plate fixation had implant removal, mean charges for all operative care would still be significantly (P = .0005) less in the tension-band cohort than in the locking-plate cohort ($7307.31 vs $14,160.26) (Table 4).

Surgery time was significantly (P = .025) less for tension-band fixation than for locking-plate fixation (55.3 vs 85.4 minutes) (Table 2).

Four tension-band patients and 3 locking-plate patients had radiographic evidence of grade 1 posttraumatic arthrosis (P = .64). None required subsequent procedures. Patients with posttraumatic arthrosis had slightly less flexion, but there was no difference in overall flexion-extension arc or functional outcomes between patients with and without arthrosis (Table 5).

The locking-plate cohort had no other complications, and the tension-band cohort had 3. In 1 tension-band patient, the wire disengaged from the Kirschner wires. The fracture healed, but a subsequent procedure was required for symptomatic implant prominence (Figures 2A–2C). Another tension-band patient developed both posttraumatic arthrofibrosis and cubital tunnel syndrome, in addition to a prominent implant. She underwent capsular release, ulnar nerve transposition, and implant removal. At final follow-up, motion was improved, and ulnar nerve symptoms were resolved. There were no infections in either group. Overall, there were no statistically significant differences in complications between groups.

Discussion

We conducted this study to determine differences between tension-band and locking-plate fixation of isolated, closed, noncomminuted, transverse olecranon fractures. Few studies have directly compared tension-band and locking-plate fixation,^8,10,19,25 particularly in reference to outcomes of functional scores, implant prominence, complications, operative time, and cost-effectiveness. We found no study that clinically compared these implants since the advent of precontoured locking plates, and no study that compared results in similar fracture patterns. In our study, we found no differences in functional or radiographic outcomes between groups, but significant differences in charges and overall cost of care.

Our findings suggest that patients return to high functional level an average of 4.3 years after fixation of an olecranon fracture with either a tension band or a locking plate. Both cohorts achieved QDASH scores equivalent to normative values for the general population,²⁶ and all patients in both cohorts achieved either good or excellent results based on MEPS values.²³ This is comparable to reported functional outcomes in the literature, with previous reports suggesting 86% to 92% of patients obtain good or excellent results.^{1,7,8,12,14,17,18,27} The rate of posttraumatic arthrosis in both cohorts was low, and, when present, arthrosis was radiographically mild (no patient had grade 2 or 3 arthrosis). Patients with and without radiographic evidence of arthrosis had similar ROM and functional outcomes.