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C OPYRIGHT Ó 2017 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Plate Versus Tension-Band Wire Fixation for

Olecranon Fractures
A Prospective Randomized Trial
Andrew D. Duckworth, BSc, MBChB, MSc, FRCSEd(Tr&Orth), PhD, Nicholas D. Clement, FRCSEd(Tr&Orth), PhD,
Timothy O. White, MD, FRCSEd(Tr&Orth), Charles M. Court-Brown, MD, FRCSEd(Orth),
and Margaret M. McQueen, MD, FRCSEd(Orth)

Investigation performed at the Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Background: The aim of this single-center, single-blinded, prospective randomized trial was to compare the outcomes
of tension-band wire (TBW) and plate fixation for simple isolated, displaced fractures of the olecranon.
Methods: We performed a prospective randomized trial involving 67 patients who were ‡16 to <75 years of age and had
an acute isolated, displaced fracture of the olecranon. Patients were randomized to either TBW (n = 34) or plate fixation (n = 33)
and were evaluated at 6 weeks, 3 months, 6 months, and 1 year following surgery. The primary outcome measure was the
Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year.
Results: The baseline demographic and fracture characteristics of the 2 groups were comparable, except for age, which
was lower in the TBW group. The 1-year follow-up rate was 85% (n = 57), with 84% (n = 56) completing the DASH. There was
a significant improvement in the DASH score over the 1-year period following surgery (p < 0.001). At 1 year, the DASH
score for the TBW group (12.8) did not differ significantly from that of the plate group (8.5) (p = 0.315). The groups also did
not differ significantly in terms of range of motion, the Broberg and Morrey score, the Mayo Elbow Score, or the DASH at all
assessment points over the 1 year (all p ‡ 0.05). Complication rates were significantly higher in the TBW group (63%
compared with 38%; p = 0.042), predominantly because of a significantly higher rate of metalwork removal in symptomatic
patients (50.0% compared with 22%; p = 0.021). Four infections occurred, all in the plate group (0% versus 13%; p =
0.114), as did 3 revision surgeries (0% versus 9.4%; p = 0.238).
Conclusions: Among active patients with a simple isolated, displaced fracture of the olecranon, no difference was
found between TBW and plate fixation in the patient-reported outcome at 1 year following surgery. The complication rate
was higher following TBW fixation and was due to a higher rate of implant removal in symptomatic patients. However, the
more serious complications of infection and the need for revision surgery occurred exclusively following plate fixation in
this trial.
Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

T
ension-band wire (TBW) fixation is the most commonly
employed technique for the treatment of simple isolated,
displaced fractures of the olecranon. In contrast, plate
fixation is thought to provide superior fracture reduction and
fixation for comminuted, unstable, distal, and/or oblique frac-
tures1-9. Despite advocates for alternative surgical techniques
including intramedullary nailing10 and suture fixation11, TBW
fixation remains the standard management for simple isolated,
displaced fractures of the olecranon (Mayo type 2A)12-14.
Retrospective comparative studies of TBWand plate fixation,
for both simple and comminuted displaced fractures of the olec-
ranon, have noted comparable functional outcomes15-17. It remains
unclear, however, whether the initial higher cost of plate fixation is
offset by the cost associated with the higher rate of TBW construct
removal. A recent Cochrane meta-analysis of 244 surgically man-
aged olecranon fractures in 6 randomized controlled trials con-
cluded that further work is essential in order to determine the
optimal surgical management of simple isolated fractures of the

Disclosure: The Scottish Orthopaedic Research Trust into Trauma (SORT-IT) research charity supported the running of this trial through its research team;
A.D.D. served as a fellow from 2010-2011. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article
(http://links.lww.com/JBJS/D418).

J Bone Joint Surg Am. 2017;99:1261-73 d http://dx.doi.org/10.2106/JBJS.16.00773


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Fig. 1
Consolidated Standards of Reporting Trials (CONSORT) diagram for the recruitment and flow of participants through the trial.
olecranon18. Of the 6 trials included, 2 were quasi-randomized
and only 1 directly compared plate and TBW fixation and it used
nonvalidated patient-reported outcome measures in a hetero-
geneous group3. Regarding lower-demand elderly patients,
retrospective case series have demonstrated good short-term
and long-term patient-reported outcomes when employing
primary nonoperative management for simple isolated, dis-
placed olecranon fractures19-22.
The aim of the current trial was to determine if any differ-
ence exists between TBW and plate fixation with respect to the
TABLE I Inclusion and Exclusion Criteria
Inclusion Criteria
Age of ‡16 to <75 yr
Displaced fracture of the olecranon
Minimal or moderate fragmentation of the olecranon
Presentation within 2 weeks of olecranon fracture
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primary outcome measure, the Disabilities of the Arm, Shoulder
and Hand (DASH) score, at 1 year post-surgery for simple isolated,
displaced fractures of the olecranon among active patients. The
null hypothesis was that there would be no difference in functional
outcome, as measured by the DASH, at 1 year post-surgery.
Materials and Methods
T his was a registered single-center, prospective randomized trial including
active adult patients with an isolated, displaced fracture of the olecranon
(ClincalTrials.gov ID NCT01391936). The study center is a level-I trauma
Exclusion Criteria
Pregnant women with predetermined treatment
Patients unable to give informed consent or unable to comply with follow-up
Associated fractures of the coronoid, radial head, and/or distal aspect of the
humerus
Associated ligamentous injury, dislocation, or subluxation of the elbow
Open fracture of the olecranon
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TABLE II Baseline Characteristics of Study Participants by Treatment Group

TBW, N = 34 Plate, N = 33 P Value

Age (yr) 0.028*

Mean and std. dev. 43 ± 16 52 ± 17
Range 19-73 18-74
95% CI 37-49 46-58
Sex (no. [%]) 0.397†
Male 21 (61.8) 17 (51.5)
Female 13 (38.2) 16 (48.5)
Dominant hand (no. [%]) 0.614‡
Left 1 (2.9) 2 (6.1)
Right 33 (97.1) 31 (93.9)
Side of injury (no. [%]) 0.889†
Left 19 (55.9) 19 (57.6)
Right 15 (44.1) 14 (42.4)
Associated injury (no. [%]) 9 (26.5) 7 (21.2) 0.614†
Smoker (no. [%]) 13 (38.2) 12 (36.4) 0.874†
Alcohol consumption§ (no. [%]) 0.708‡
£21 units/wk 30 (90.9) 28 (84.8)
>21 units/wk 3 (9.1) 5 (15.2)
‡1 comorbidity (no. [%]) 17 (50) 23 (69.7) 0.100†
SIMD quintile (no. [%]) 0.099†
1 8 (23.5) 4 (12.1)
2 7 (20.6) 2 (6.1)
3 7 (20.6) 5 (15.2)
4 4 (11.8) 10 (30.3)
5 8 (23.5) 12 (36.4)
ASA grade (no. [%]) 0.149†
1 19 (55.9) 11 (33.3)
2 11 (32.4) 18 (54.5)
3 4 (11.8) 4 (12.1)
Mechanism of injury (no. [%]) 0.609†
Fall from standing height 20 (58.8) 20 (60.6)
Fall from height 3 (8.8) 1 (3.0)
Other 0 (0) 2 (6.1)
Motor vehicle collision 7 (20.6) 6 (18.2)
Sports 2 (5.9) 3 (9.1)
Fight/assault 2 (5.9) 1 (3.0)
Pre-injury DASH§ 0.135#
Mean and std. dev. 1.1 ± 5.5 2.3 ± 6.2
Range 0-31.7 0-30
95% CI 0-3 0-4.5

*Student unpaired t test. †Chi-square test. ‡Fisher exact test. §N = 33 for the TBW group. #Mann-Whitney U-test.

center. Between October 2010 and October 2014, 67 patients who were ‡16
to <75 years of age with an acute (within 2 weeks of injury), simple isolated,
13,14
displaced Mayo type-2A fracture of the olecranon (OTA/AO fracture
23
type 21-B1.1) were recruited into the study (Fig. 1). The inclusion and
exclusion criteria are listed in Table I. Displacement of >2 mm of the articular
7,24
surface on standard radiographs was used as the definition of displacement .
25,26
The primary outcome measure was the DASH score at 1 year post-surgery .
The appropriate ethical and clinical trial committees authorized the study.
Demographic data were collected at initial presentation (Table II). Pa-
tients were asked to complete a retrospective pre-injury DASH questionnaire
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Fig. 2 Fig. 3
Fig. 2 A lateral radiograph of an olecranon fracture managed with tension-band wire fixation. Fig. 3 A lateral radiograph of an olecranon fracture
managed with plate fixation.

27,28
to establish a baseline . The Scottish Index of Multiple Deprivation (SIMD) significantly different between the groups (p = 0.116). Antibiotics (routinely,
29
was used to assess socioeconomic deprivation . 1.5 g of cefuroxime unless contraindicated) were administered intravenously
prior to inflation. All operations were performed under image-intensifier
Randomization guidance.
After providing informed consent, patients were randomized to undergo A posterior longitudinal direct midline skin incision was routinely used.
either TBW or plate fixation. This was performed by block randomization Lateral and medial fasciocutaneous flaps were raised to allow adequate exposure
(n = 4) using sequential closed opaque envelopes, which were prepared by of the fracture site, with the length dependent on the type of fixation being used
our statistician and contained a card detailing to which of the 2 groups and the fracture complexity. The ulnar nerve was not routinely dissected out or
(TBW or plate) the patient had been randomized. Randomization was on transposed. The triceps tendon was identified proximally inserting into the
a 1:1 basis. proximal fracture segment. Subperiosteal dissection was performed in the in-
terval between the flexor carpi ulnaris (FCU) and extensor carpi ulnaris (ECU) as
necessary to identify the fracture site and the proximal aspect of the ulna, with the
Radiographic Classification FCU and anconeus elevated as required off the medial and lateral aspects of the
All injuries were assessed and classified at the time of presentation by 1 of ulna to allow visualization of the joint and fracture fragments. The fracture was
the authors (A.D.D.) using standard anteroposterior and lateral elbow ra- prepared in a standard fashion and held reduced with a reduction clamp.
diographs. The OTA/AO fracture classification and Mayo classification for A standard TBW technique was used throughout the trial and employed
13,14,23
olecranon fractures were used . Initial radiographs were reviewed to 2 parallel 1.6-mm Kirschner wires in a longitudinal direction going from the
confirm fracture displacement, the absence of comminution necessitating
plate fixation, and the absence of an associated fracture and/or subluxation
or dislocation of the elbow. Fracture displacement was defined as the dis- TABLE III Concomitant Injuries and Management (N = 16)
tance or gap in the articular surface created by the fracture, using the
3
presentation lateral elbow radiograph . Measurements were carried out in a Injury Management
standardized fashion with a calibrated radiograph (Kodak picture archiving
communication system). Ipsilateral proximal humeral fracture Nonoperative
Ipsilateral nondisplaced acetabular Nonoperative
Management Protocol fracture
The median time to definitive surgery was 2 days (range, 0 to 14 days) and was Contralateral distal radial fracture Nonoperative
comparable between the 2 groups (p = 0.796). All fractures were operated on Contralateral 5th metacarpal fracture Nonoperative
under the supervision of a consultant orthopaedic trauma surgeon using well-
established standardized techniques. In 19 (28.4%) of the cases, the consultant Contralateral 3rd and 4th metatarsal Nonoperative
was the primary surgeon; a trauma fellow or senior trainee was the primary fractures
surgeon in the other 48 cases (71.6%). This was not significantly different Back injury (no fracture) Nonoperative
between the groups (p = 0.152). Because of the proximal nature of the fracture, Minor head injury (n = 7) Nonoperative
1 patient in the plate group underwent TBW fixation, and because of the
Ipsilateral femoral neck fracture Dynamic hip screw
unexpected comminution of the fracture, 1 patient in the TBW group under-
went plate fixation (Fig. 1). Ipsilateral acromioclavicular joint Open stabilization
Patients were placed in the lateral decubitus position with the arm over dislocation
a bolster and a tourniquet on the arm. The median tourniquet time was 42 Ipsilateral open tibial fracture Intramedullary nailing
minutes (range, 25 to 62 minutes; n = 61). The tourniquet time was not
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TABLE IV Functional, Patient-Reported, and Surgeon-Reported Outcomes at Each Assessment Point After Injury by Treatment Group*

TBW Plate
No. of Patients
Time Mean and Mean and
Point TBW Plate Outcome Std. Dev. Range 95% CI Std. Dev. Range 95% CI P Value†

6 wk 29 30
Elbow flexion 94 ± 30 45-150 83-106 97 ± 31 10-151 85-108 0.759
arc (°)
Forearm rotation 174 ± 19 80-180 167-181 171 ± 20 85-180 164-178 0.511
arc (°)
B & M score 68 ± 13 34-86 63-73 67 ± 14 32-91 62-72 0.932
MES 74 ± 15 25-95 68-79 77 ± 16 30-100 71-83 0.430
DASH 35 ± 23 0-90 27-44 36 ± 19 0.8-89 29-44 0.811
12 wk 29 31
Elbow flexion 120 ± 24 58-150 111-129 117 ± 21 50-149 109-125 0.566
arc (°)
Forearm rotation 174 ± 19 100-180 167-182 178 ± 6.5 150-180 175-180 0.332
arc (°)
B & M score 79 ± 13 52-100 74-84 78 ± 15 34-100 73-84 0.902
MES 83 ± 11 65-100 79-87 84 ± 17 30-100 78-90 0.801
DASH 21 ± 22 0-80 13-30 20 ± 16 0-66 14-26 0.831
26 wk 28 28
Elbow flexion 131 ± 17 90-160 125-138 130 ± 19 80-158 123-138 0.809
arc (°)
Forearm rotation 178 ± 8.6 135-180 175-181 178 ± 8.6 135-180 175-181 0.951
arc (°)
B & M score 84 ± 13 54-100 79-89 86 ± 12 52-100 82-91 0.572
MES 86 ± 11 65-100 82-91 86 ± 11 65-100 82-91 0.906
28 27 DASH 19.7 ± 20 0-82 11-28 15.9 ± 15 0-54 9.8-22 0.464
52 wk 28 29
Elbow flexion 137 ± 15 84-160 131-143 131 ± 15 95-158 126-137 0.169
arc (°)
Forearm rotation 178 ± 10 130-180 174-181 180 ± 2.0 170-180 179-180 0.344
arc (°)
B & M score 89 ± 15 35-100 84-95 95 ± 6.7 78-100 92-97 0.072
MES 90 ± 14 40-100 84-95 96 ± 6.8 85-100 93-98 0.050
28 28 DASH 12.8 ± 20 0-79 5.3-20 8.5 ± 10 0-41 4.4-12.5 0.315

*B & M score = Broberg and Morrey score, MES = Mayo Elbow Score, and DASH = Disabilities of the Arm, Shoulder and Hand. †Student unpaired
t test.

proximal fragment of the olecranon into the ulna distally. Care was also taken to
ensure that the wires were extra-articular, and it was up to the discretion of the
surgeon whether these were placed in the anterior cortex or straight down the
shaft of the ulna. If they were placed in the anterior cortex, care was taken to
prevent them from penetrating too far anteriorly, with length allowed for the
final burying of the trimmed wires in the proximal aspect of the ulna. A
transverse tunnel was then placed distally in the ulna using a drill at ;4 cm
distal to the fracture site. A 1.2-mm flexible cerclage wire was then passed pos-
terior to the 2 Kirschner wires and through the triceps tendon proximally; the 2
ends were then crossed, and 1 end was placed through the distal tunnel in a figure-
of-8 technique. The wire was then tensioned in the standard fashion, and all wire
ends were trimmed and buried at the conclusion of the procedure (Fig. 2).
For plate fixation, Kirschner wires were sometimes used initially to
supplement the fracture reduction and then removed once stability was
achieved. Once the fracture was reduced, a precontoured, nonlocking dorsal
proximal ulnar plate (Zimmer) was applied in a standard fashion. Initially, a
long longitudinal screw entering the medullary canal distally was placed to hold
fracture reduction. Once the construct was stable, distal screws were then
placed to stabilize the construct (Fig. 3). The median number of screws used
per case was 5 (range, 3 to 7).
Following surgery, patients were routinely immobilized with the use of
either an above-elbow backslab or a crepe bandage dressing with thick synthetic
wool padding for 10 to 14 days. A physiotherapy exercise regime was initiated
for each patient. The time frame for the initiation of active range of motion and
functional activities varied among the patients and was individualized ac-
cording to surgeon preference as well as patient and fracture characteristics.
Although lifting and strengthening were typically allowed at 6 to 8 weeks fol-
lowing surgery, this was also individualized to the patient. It is not routine in
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Fig. 4
Mean DASH score, and 95% confidence interval, at each assessment point according to randomization group.
our unit to remove internal fixation following olecranon fracture fixation unless
the patient is symptomatic.
Outcome Assessment
Clinical and functional evaluations were performed prospectively at 2 weeks, 6
weeks, 3 months, 6 months, and 1 year post-surgery. Radiographic evaluations
were performed at the same time points, although at 1 year only if clinically
indicated. Patients were evaluated outside of these times as clinically indicated,
with clinical and radiographic assessment performed as required, and this was
recorded as part of the cost analysis. The development of complications and
the need for subsequent surgeries were also recorded.
A full clinical outcome assessment was completed by a blinded research
physiotherapist or research fellow not involved in the patient’s management.
Range of motion in the unaffected and affected elbows (flexion, exten-
sion, supination, and pronation) was measured using a standard full-circle
goniometer. The primary outcome measure was the DASH score 1 year post-
25,26
surgery . Secondary outcome measures included surgeon-reported measures,
pain, complications, radiographic assessment, and cost. The surgeon-reported
30
outcome measures were the Mayo Elbow Score (MES) and the Broberg and
31,32
Morrey score . Because of logistical issues, 3 patients (all in the plate group)
had their final 1-year outcome evaluation performed over the telephone. There
are data to validate the verbal administration of the QuickDASH (an abbreviated
version of the DASH questionnaire), with written scores correlating well with
33
verbal scores . For these patients, the most recent range-of-motion measure-
ments were carried forward, as all had regained full elbow motion by 6 months.
Complications were defined as the loss of fracture reduction, prominent
and problematic metalwork, further surgery including the removal of metal-
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work, superficial or deep wound infections, and the onset of symptoms and/or
signs of neurological impairment following surgery. Removal of internal fixa-
tion would routinely be due to pain or loss of function secondary to the device,
with or without loss of position and/or prominence. Superficial infection was
defined as a wound infection that was treated successfully with antibiotics and
required no surgical intervention. Deep infection fulfilled the criteria as set
34
out by Horan et al. .
Radiographic assessment (anteroposterior and lateral views of the el-
bow) determined the quality of initial reduction, metalwork failure, and loss of
reduction as well as progression to union. The quality of reduction was con-
sidered satisfactory if the articular surface was reduced to within 2 mm, with no
evidence of a step-off or gap of >2 mm3. Fracture union was defined as en-
dosteal healing, with ‡75% of organized trabecular bridging at the fracture
35,36
site .
Statistical Analysis
A power analysis was performed to determine the requirements for detecting a
clinically relevant mean difference of 10 points (DASH) between the 2 groups at
26,37-40
1 year after surgery . This indicated that a total sample size of 50 patients
(25 per group) would provide 80% power to detect a significant difference (a =
0.05) in the DASH score, assuming an effect size of 0.8 (mean difference [and
26,37-40
standard deviation] of 10 ± 12 ) using an unpaired t test. To account for
a possible loss to follow-up of 25%, the intention was to enroll 35 subjects in
each arm (total sample size of 70).
Data were analyzed using the intention-to-treat principle. Chi-square
(all numbers in cell ‡5) or Fisher exact (1 cell <5) tests were used to analyze
binary variables. A Student t test (2 groups) or analysis of variance (ANOVA;
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Fig. 5
Mean elbow flexion arc (in degrees), and 95% confidence interval, at each assessment point according to randomization group.

multiple groups) was used to assess linear variables between groups for
parametric data. A Mann-Whitney U-test (2 groups) or Kruskal-Wallis test
(multiple groups) was used to assess linear variables between groups for
nonparametric data. Linear regression was used to analyze the relationship
between 2 continuous variables. Multivariate regression analysis was used to
assess the independent effect of the surgical group on the DASH when
controlling for confounding variables. Two-tailed p values are reported, and
significance was defined as p < 0.05, with 95% confidence intervals (CIs)
presented.
Cost Analysis
Standardized costs were used with regard to the total number of days in the
hospital, the cost of treatment, clinical evaluation appointments attended,
and any complications including subsequent surgeries and antibiotics for
infection. Social and productivity costs were not evaluated. The standardized
costs were obtained from the National Health Service Lothian. Antibiotic
costs were calculated from the current edition of the British National
41
Formulary .
Results
ixty-seven patients were randomized to TBW (n = 34) or
S plate (n = 33) fixation (Fig. 1, Table II). The overall mean
age was 47 ± 17 years (range, 18 to 74 years). Thirty-eight
(57%) of the patients were male and 29 (43%) were female
(p = 0.272). One or more comorbidities were documented in
40 (60%) of the patients, and a majority of the patients were
classified as ASA (American Society of Anesthesiologists)
grade 1 (n = 30) or 2 (n = 29). The most frequent mechanism
of injury was a fall from standing height (n = 40). All fractures
were classified radiographically as Mayo type 2A (OTA/AO
21-B1.1). Three fractures had notable articular comminution
at the time of surgery: 2 randomized to plate fixation and 1 to
TBW fixation. The mean fracture displacement was 13 mm
(range, 4 to 32 mm). Sixteen (24%) of the patients had con-
comitant injuries (Table III).
The baseline demographic and fracture characteristics of
the 2 treatment groups are shown in Table II. Patients in the
TBW group were younger (43 versus 52 years; p = 0.028), but
all other characteristics were comparable.
Primary Outcome
Fifty-seven (85%) of the patients were evaluated at 1 year,
with 56 (84%) of the patients having completed a valid
DASH questionnaire. At 1 year following surgery, the overall
mean DASH was 10.6 ± 16 (range, 0 to 79; n = 56). Overall,
among patients who completed a valid DASH at both 6 weeks
and 1 year (n = 53), scores improved significantly (mean score of
35.2 at 6 weeks and 9.2 at 1 year; p < 0.001) (Table IV, Fig. 4).
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Mean Broberg and Morrey score, and 95% confidence interval, at each assessment point according to randomization group.
There was no difference between the groups in terms of the
DASH at any assessment point following surgery (p ‡ 0.05)
(Table IV, Fig. 4). The mean DASH score at 1 year was 12.8 in the
TBW group and 8.5 in the plate group (p = 0.315).
Secondary Outcomes
Surgeon-Reported and Functional Outcomes
At 1 year following surgery, the overall mean Broberg and
Morrey score was 92 (range, 35 to 100; n = 57), with 89% of
the patients achieving an excellent (n = 30) or good (n = 21)
outcome. Five patients had a fair outcome and 1, a poor
outcome. At 1 year, the overall mean MES was 93 (range, 40 to
100; n = 57), with 93% achieving an excellent (n = 36) or good
(n = 17) outcome. Three patients had a fair outcome and 1,
poor. The mean elbow flexion arc at 1 year was 134° ± 15°
(range, 84° to 160°), and the mean forearm rotation arc was
179° ± 6.8° (range, 130° to 180°). The 2 treatment groups did
not differ significantly in terms of range of motion (Fig. 5), the
Broberg and Morrey score (Fig. 6), or the MES (Fig. 7) at any
assessment point following surgery (all p ‡ 0.05) (Table IV).
Complications
Complications were assessed in 62 patients (Table V). There
were 41 complications in 31 (50%) of the patients, including
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removal of metalwork in symptomatic patients (n = 22,
35.5%), loss of fracture reduction (n = 12, 19.4%), infection
(n = 4, 6.5%), and the need for revision surgery (n = 3,
4.8%).
Complications were significantly higher in the TBW
group (63% compared with 38%; p = 0.042), predominantly
because of a significantly higher rate of removal of metalwork
in symptomatic patients (50% compared with 22%; p = 0.021).
One patient in the TBW group underwent an early manipu-
lation under anesthesia (MUA) for stiffness and subsequently
underwent implant removal following union. Loss of reduction
was twice as common in the TBW group (27% compared with
13%), although this difference between the groups was not
statistically significant (p = 0.206).
Four infections occurred in the plate group (13% com-
pared with 0% in the TBW group; p = 0.114), as did 3 revision
surgeries (9.4% compared with 0%; p = 0.238). Of the 4 in-
fections, 2 were superficial (resolved with oral antibiotic therapy)
and 2 were deep. One deep infection was managed successfully
with antibiotics and plate removal once the fracture had healed,
and the other resulted in revision to a TBW construct. In that
case, the infection was successfully treated following a prolonged
course of antibiotics and further surgery to remove the TBW
construct, but a fibrous nonunion developed. Two other revision
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Fig. 7
Mean Mayo Elbow Score, and 95% confidence interval, at each assessment point according to randomization group.

surgeries were in the plate group: 1 failed fixation that was
successfully converted to a TBW construct, and the other, an
exchange of a long screw that was blocking forearm rotation.
Radiographic Outcomes
In the 57 of 62 patients who progressed to radiographic union,
the median time to union was 12 weeks (range, 6 to 52 weeks).
Three patients in the plate group and 2 patients in the TBW group
progressed to a functional fibrous nonunion (Fig. 8). These
patients had a loss of reduction, 2 associated with infection.
Cost Analysis
Costs were assessed for 62 patients. The median number of
days in the hospital was 2 (range, 1 to 38). The overall median
cost per patient was £5,529 (UK) (range, £2,961 to £27,936;
interquartile range [IQR], £3,487 to £6,224) or $8,349 (US)
(range, $4,471 to $42,183; IQR, $5,265 to $9,398). No signifi-
cant difference between the 2 groups was found in the cost per
patient (p = 0.131) (Table VI), despite a significantly higher
median cost for the primary intervention in the plate group
(p < 0.001).

TABLE V Complications within 1 Year Following Injury by Treatment Group

TBW, N = 30* Plate, N = 32* P Value

Total complications 19 (63.3) 12 (37.5) 0.042†

Infection 0 (0) 4 (12.5) 0.114‡
Loss of reduction 8 (26.7) 4 (12.5) 0.206‡
Subsequent surgeries
Removal of metalwork 15 (50) 7 (21.9) 0.021†
Revision 0 (0) 3 (9.4) 0.238‡

*The values are given as the number of patients, with the percentage of the group in parentheses. †Chi-square test. ‡Fisher exact test.
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pre-injury DASH score (p < 0.001; r = 0.45). On multivari-

ate linear regression analysis, controlling for age, sex, SIMD
quintile, comorbidities, and ASA grade, the treatment arm
was not predictive of the 1-year DASH, with increasing ASA
grade being the only independent predictor of a poorer out-
come (Table VII). A post-hoc power analysis of the regression
model for predictors of outcome as assessed by the DASH
score at 1 year, using an R2 value of 0.273, a sample size of
56, 6 predictors in the model, and an a value of 0.05, of-
fered 91% power.

Fig. 8
Fibrous nonunion associated with infection following plate fixation.
Predictors of Primary Outcome Measure
Comorbidities (p = 0.023) and increasing ASA grade (p <
0.001) were predictive of the 1-year DASH score. There was
also an association with fracture nonunion (score of 34 for
those who developed a nonunion versus 9 for those demon-
strating union; p = 0.002) and a moderate correlation with the
Discussion
o our knowledge, this is the first prospective randomized
T trial comparing TBW and plate fixation for isolated, dis-
placed fractures of the olecranon using location-specific plates,
strict inclusion and exclusion criteria, and a validated patient-
reported outcome measure. The data demonstrated that TBWand
plate fixation provide comparable patient and surgeon-reported
outcomes in the year following surgery. Although the overall
complication rate was higher following TBW fixation, because
of an increased rate of symptomatic implant removal, the more
serious complications of infection and revision surgery were
exclusive to the plate group.
Hume and Wiss performed the only other prospective
randomized trial that we are aware of in the literature com-
paring TBW (n = 19) and plate fixation (n = 22) for displaced
olecranon fractures3. Comminuted and open fractures were
included, and no validated patient-reported outcome mea-
sures were used. Despite this, the results of their study were

TABLE VI Cost Analysis by Treatment Group*

TBW, N = 30 Plate, N = 32 P Value†

Median no. of days in 2 (1-38) [1-3] 2 (1-30) [1-5] 0.446

hospital (range) [IQR]‡
Median cost of primary 32 (—) [—] 552 (32-563) [547-558] <0.001
intervention (range) [IQR]§ (£)
Median no. of clinical 6 (5-8) [5-6] 5 (5-12) [5-6] 0.610
evaluations (range) [IQR]#
Median cost of antibiotics 0 0 (0-141) [0-0] 0.047
(range) [IQR] (£)
Total no. of extra trips to 16 10
operating room
Median cost of further 0 (—)[—] 0 (0-32) [0-0] 0.088
implants (range) [IQR] (£)
Overall median cost/patient 5,546 (2,961-27,936) [2,961-5,654] 5,174 (3,476-23,056) [3,492-6,828] 0.131
(range) [IQR] (£)
Overall median cost/patient 8,374 (4,471-42,183) [4,471-8,538] 7,812 (5,249-34,815) [5,273-10,310]
(range) [IQR] ($)

*Exchange rate of £1 = $1.51. †Mann-Whitney U-test. ‡Inpatient stay was £675/day ($1,021/day). §TBW construct: £12.24 ($18.53);
plate: £505.60 ($765.48) and £5.36 ($8.12) per screw; and above-elbow backslab/cast: £20 ($30.28). Does not include a standard
operating room cost of £1,824 ($2,761), which was included in the overall cost per patient #Each surgical outpatient consultation was
£86 ($130).

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TABLE VII Multivariate Linear Regression Analysis*
Regression
Variable Coefficient 95% CI
Age 20.09 20.39 to 0.20
Sex 2.25 26.61 to 11.12
SIMD quintile 20.68 23.83 to 2.47
Comorbidities 22.96 215.50 to 9.59
ASA grade 14.15 4.20 to 24.09
Management 26.27 214.40 to 1.86
*To identify significant predictors of the 1-year DASH score when
controlling for confounding factors. R2 = 0.273.
comparable with the data presented here. Those authors
reported that elbow motion at 6 months was comparable
between treatment groups, but with loss of fracture reduction
and prominent metalwork in symptomatic patients more
common following TBW, as our trial also reported. Hume
and Wiss found that the overall clinical outcome was far su-
perior in the plate-fixation group, with 86% obtaining a good
result compared with 47% in the TBW group3. In contrast,
our trial demonstrated no significant difference in outcome
at 1 year, but there was a trend toward superior outcomes in
the plating group for patient and surgeon-reported outcome
measures.
The main perceived complication of plate fixation is
prominent hardware, given the position of the plate on the
dorsal aspect of the ulna42. However, the literature quotes lower
rates of plate removal (5% to 20%) when compared with re-
moval following TBW3,5,7,16, which is consistent with our trial
(22%). In the Hume and Wiss study 3, prominent or prob-
lematic metalwork was seen in 42% of patients who underwent
TBW compared with 5% in the plate group. Our trial found an
equivalent rate for TBW, but a higher rate for plate fixation that
is more in keeping with current data3,5,7,16. Interestingly, all
other complications occurred in the TBW group in the original
trial by Hume and Wiss3, which is not consistent with our trial,
in which infection and revision surgery occurred exclusively
in the plate group.
Retrospective studies comparing TBW with plate fixa-
tion15-17 have consistently reported comparable functional
outcomes, with a higher rate of metalwork removal for TBW
fixation and increased costs with plate fixation. We have dem-
onstrated comparable overall costs for TBW and plate fixation
due to the much higher rate of implant removal in the TBW
group. In contrast, Amini et al.15 retrospectively compared
TBW (n = 10) and plate (n = 10) fixation for simple isolated,
transverse olecranon fractures and found that overall costs
were significantly higher for plate fixation ($6,598.36 versus
$14,333.46), despite a higher rate of metalwork removal for
TBW (40% versus 10%). This discrepancy is likely due to
smaller patient numbers, no consideration of other costs (e.g.,
length of stay), and most importantly, the higher implant cost
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for plates compared with that in our trial ($6,688.52 versus
$836.72 in our trial).
The rate of loss of reduction in the TBW group is
P Value consistent with both the limited available clinical data,
ranging from 33% to 53%3,43,44, as well as biomechanical ev-
0.528 idence that questions the validity of this construct to maintain
0.612 fracture stability and reduction. Wilson et al. performed a
0.667 biomechanical comparison of TBW and plate fixation in 20
0.638 models with identical transverse fractures of the olecranon45.
0.006 They found that the modern precontoured location-specific
0.128 plates were significantly better at providing fracture com-
pression, particularly at the articular surface. However, we
found that the loss of reduction does not seem to influence
patient-reported outcome at 1 year following surgery, pro-
vided the patient progresses to union. Nonunion was asso-
ciated with an inferior outcome in our trial of younger active
patients. There is a growing body of evidence to support the
role of nonoperative management for displaced olecranon
fractures in low-demand elderly patients19-21. Nonunion is com-
mon in these cases, but with a negligible re-intervention rate
and no correlation found with the long-term functional out-
comes reported22.
The primary strengths of this trial are the large number
of patients recruited, a good level of compliance with >90% of
patients receiving their allocated treatment, and the high
follow-up rate at 1 year. The numbers recruited in each group
were greater than required according to our initial power
calculation. Although multiple surgeons of different experi-
ence levels were involved in the surgery for these patients, this
scenario is most representative of day-to-day clinical practice,
i.e., pragmatic.
A primary limitation of the study was the lack of
blinding of both the surgeon and the patient to the allocated
treatment arm. It is argued that this is pragmatic in that, in
routine clinical practice, patients would always be aware of
their proposed treatment46,47. The study was also limited by
the fact that multiple surgeons were involved over the study
period and that patients with concomitant injuries were in-
cluded, although again, this is pragmatic and reflective of day-
to-day clinical practice. We acknowledge the subjective nature
of the decision to remove an implant, and it could be argued
that these findings, including in relation to cost, are most
applicable to our center. However, it is not routine in our unit
to remove implants following olecranon fracture fixation
unless the patient is symptomatic, and the rate of metalwork
removal in our series is very consistent with that in the current
available literature.
A further limitation to acknowledge is the difference
found in age between the 2 groups despite randomization, with
the TBW group being 9 years younger, on average, than the
plate group. A superior (lower) DASH score was found in the
plate group at 1 year, and it is possible that a significant dif-
ference would have been apparent if the age of the groups were
more comparable. However, when controlling for age and
other confounding factors on multivariate linear regression
analysis, no difference was found between the 2 groups in the
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primary outcome measure. It is important to note that the
study was not originally powered for a multivariate regression
analysis and that this was a post-hoc analysis performed due to
the unexpected age discrepancy found between the groups.
In conclusion, the findings of this trial demonstrate no
clear patient or surgeon-reported benefit of plate fixation over
the current gold standard of TBW in active patients with a
simple isolated, displaced fracture of the olecranon. The more
serious complications of infection and revision surgery occurred
exclusively following plate fixation in this study. However, we
believe that patients should be counseled regarding the high
rate of metalwork removal in symptomatic patients following
the TBW technique. n
NOTE: The authors acknowledge the Scottish Orthopaedic Research Trust into Trauma (SORT-IT) for
assistance in performing this study. The authors also thank the trauma consultants and registrars
of the Edinburgh Orthopaedic Trauma Unit for their invaluable assistance and endless patience in
carrying out this trial; Mr. Paul Jenkins and Mr. Iain Murray for their production assistance for some
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Andrew D. Duckworth, BSc, MBChB, MSc, FRCSEd(Tr&Orth), PhD1
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Timothy O. White, MD, FRCSEd(Tr&Orth)1
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E-mail address for A.D. Duckworth: andrew.duckworth@ed.ac.uk
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