Tension suture fixation of olecranon fractures

Background: Mayo type-IIA olecranon fractures are characterized by a transverse or short oblique fracture without articular comminution or ulnohumeral instability. Traditionally, these fractures are treated with a tension-band wiring technique. Despite good rates of fracture union, tensionband wiring is associated with a reoperation rate of 30% to 60%, usually for removal of prominent metalwork. The tension suture technique was developed as an alternative method of fixing Mayo type-IIA fractures using only hightensile braided nonabsorbable number-2 sutures, with the aim of reducing the reoperation rate associated with tension-band wiring without compromising outcomes. The tension suture technique has subsequently become the only technique we use when treating these fractures. Description: The patient is positioned in the lateral decubitus position under general or regional anesthesia.Adirect posterior approach ismade, centered over the fracture. The fracture is identified, cleared of hematoma, and reduced with use of a large,pointedreductionclamptoprovide interfragmentary compression. A2.5-mmtransverse drill hole ismade through the ulna distal to the fracture site. Two sets of number-2 braided nonabsorbable sutures are utilized. The first sutures are passed lateral to medial through the drill hole and used to grasp the medial triceps insertion onto the proximal fragment, then passed back through the transverse drill hole frommedial to lateral and used to grasp the lateral triceps insertion onto the proximal fragment. The suture ends are tensioned to remove slack and tied on the lateral aspect of the olecranon. The second sutures are then passed lateral to medial through the transverse drill hole but this time used to grasp the posterolateral triceps insertion on the proximal fragment, then repassed through the transverse drill hole frommedial to lateral, and finally used to grasp the posteromedial triceps insertion. The suture limbs are tensioned and tied onthe lateral aspect of the ulnanext to the first suture.The clamp is removed, and the construct is tested under full range of motion to ensure there is no evidence of gapping. Fluoroscopy is utilized to confirm reduction before the wound is irrigated and closed in a standard fashion. Alternatives: Mayo type-IIA fractures may be treated nonoperatively in frail or low-demand patients. Surgical treatment is traditionally performedwith the tensionband wiring technique, but plate or intramedullary fixation may also be utilized.