Olecranon nail disengagement: a case report

J Shoulder Elbow Surg (2012) 21, e11-e15 www.elsevier.com/locate/ymse Olecranon nail disengagement: a case report E. Christopher Casstevens, MDa,*, Thorsten Jentzsch, MDb, Michael T. Archdeacon, MD, MSEa, Mohab B. Foad, MDc a Department of Orthopaedic Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA Department of Traumatology, Universitaetsspital Zuerich, Z€urich, Switzerland c Beacon Orthopaedics and Sports Medicine, Cincinnati, OH, USA b Olecranon osteotomy is often used for visualization and fixation of intra-articular supracondylar humerus fractures.1,2,16 For Orthopaedic Trauma Association (OTA) type 13-C fractures, which have a higher likelihood of nonunion, trans-olecranon approaches continue to be more popular than other options, such as triceps splitting, Bryan-Morrey triceps reflecting, triceps reflecting anconeus pedicle, and paratricipital approaches.1,14,15 Despite the advantages of olecranon osteotomy, concern remains in regard to the complications associated with osteotomy fixation. Fixation of the olecranon can be achieved through tension band wiring, intramedullary fixation or plating.8 Commonly encountered problems are prominence and pain related to the extra hardware, backing out of Kirschner wires, breakage of tension band wires, and olecranon nonunion.3,5,6,13 Because of the high reoperation rate with hardware prominence, intramedullary nails have been developed.7 Olecranon osteotomy nonunion has been reported to occur in up to 7% in patients with transverse osteotomies.7,13,16 We are not aware of any published report of olecranon nail disengagement associated with olecranon osteotomy nonunion. Case report A seventy-year-old male presented with an open comminuted T-shaped bicondylar distal humerus fracture after a high fall The Institutional Review Board of the University of Cincinnati reviewed this work and approved the submission for publication. *Reprint requests: E. Christopher Casstevens, MD, PO Box 670212, Cincinnati, OH 45267-0212, USA. E-mail address: chris.casstevens@uc.edu (E.C. Casstevens). (Fig. 1). The fracture was classified as 13C1 according to the OTA classification.10 The patient’s past medical history was significant for type 2 diabetes mellitus, hypertension, and coronary artery disease. Physical exam demonstrated no evidence of neurovascular compromise or an impending compartment syndrome. The patient was treated with urgent surgical debridement of the fracture and open reduction and internal fixation via a standard posterior approach with an olecranon osteotomy.12 The osteotomy was repaired with an intramedullary olecranon nail (Synthes Olecranon Nail, West Chester, PA, USA) (Fig. 2). On examination at 2 months postoperative, the elbow had an arc of motion of 10130 with supination and pronation of 85 . Five months after the index procedure, the patient presented with pain and decreased elbow motion. Radiographs demonstrated failure of fixation and nonunion of the olecranon osteotomy with complete disengagement of the olecranon nail (Fig. 3). Revision surgery was performed via the same posterior approach. The distal humerus was well united, and there was no evidence of infection. Deep tissue biopsies were obtained to rule out septic nonunion. The olecranon nail had failed at the threaded junction and stripping of the threads along the proximal component was noted; however, the fixation screws for the nail remained intact (Fig. 4). The proximal component of the nail was easily removed; however, the distal segment required an extraction device. Revision repair of the osteotomy nonunion included curettage of the canal and cancellous allograft bone chips combined with demineralized bone matrix putty (DBX; Synthes, West Chester, PA, USA) and internal fixation with a locking olecranon plate (Olecranon Plate; Smith and Nephew, Memphis, TN, USA) (Fig. 5). At final follow-up, 36 months after the index procedure, the patient’s only subjective complaint was of pain while swinging a hammer. Elbow range of motion ROM showed a flexion/ extension arc from 5 to 135 with supination of 90 and pronation of 90 . He had no neurovascular deficits, and final radiographs showed interval healing with some persistent lucency at the osteotomy site and complete healing of the distal humerus fracture (Fig. 6). Despite the excellent ROM and minimal subjective 1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2012.05.039 e12 E.C. Casstevens et al. Figure 1 Anteroposterior (A) and lateral (B) demonstrate a comminuted T-shaped bicondylar distal humerus fracture. Figure 2 Anteroposterior (A) and lateral (B) plain radiographs after first surgery. complaints, his DASH (Disabilities of the Arm, Shoulder and Hand) score was 45.8 out of 100 (0 representing no disability and 100 representing complete disability). This represents a moderate degree disability in the affected upper extremity. The patient was informed and consented to the submission of his clinical data for publication in the form of a case report. Discussion Surgical treatment for intra-articular distal humerus fractures with open reduction and internal fixation utilizing bicolumnar plating is strongly supported in the literature, as is olecranon osteotomy for improved surgical exposure.1-3,6,8,11,13,14,16 Techniques for the repair of the osteotomy consist of tension band wire fixation, plate stabilization, intramedullary screw fixation with or without tension band, and olecranon nail fixation.5-8,15 The proposed advantages of an intramedullary nail device include minimal surgical exposure, hardware that is less prominent than other forms of fixation, as the nail can be buried in the canal, and a biomechanically superior fixation construct. In a cadaveric study, Molloy et al Olecranon nail disengagement Figure 3 Figure 4 e13 Anteroposterior (A) and lateral (B) plain radiographs of olecranon nonunion and nail failure. Intraoperative photographs demonstrating the proximal part of the failed olecranon nail (A) and the components after removal (B). Figure 5 Open reduction and internal fixation with a plate and screws after removal of the failed hardware. concluded that intramedullary nail fixation was significantly stiffer and stronger than tension band wiring in simulated transverse olecranon fractures.7 Other studies have reported good outcomes using intramedullary fixation.15 When looking at the strength of fixation of displaced olecranon fractures, Nowak et al showed higher stability for intramedullary nailing systems than tension band wiring.9 In an angle-adjusted and linear-force adjusted engine with 14 cadaver elbows, the intramedullary nailing group showed significantly less displacement at the osteotomy site than the tension band group. Though our literature search yielded no direct comparison, the intramedullary nail contains interlocks that likely improve stability and reduce implant migration compared to a simple intramedullary screw for fixation of an olecranon osteotomy. In contrast to tension band and plate fixation, hardware failure has not been reported with intramedullary fixation. Tension band constructs have been noted to unwind or break.5,6 Reviewing a total of 320 patients with distal humerus fractures, of whom nearly 200 were approached through olecranon osteotomy, Robinson et al encountered 11 patients who had to undergo additional surgery due to hardware prominence after tension band wiring and screw fixation of the olecranon osteotomy.13 Repairing an e14 E.C. Casstevens et al. Figure 6 Anteroposterior (A) and lateral radiographs (B) at 36 months following the index procedure demonstrating intact hardware and incomplete healing of the olecranon osteotomy (black arrow). osteotomy with plate fixation remains a viable option despite a substantial reoperation rate for hardware prominence and pain.7 Good results with plate fixation compared to tension band wiring were obtained by Hume et al.5 Horner et al determined that screw and plate fixation offered superior resistance to biceps brachii and brachialis muscles forces in distal olecranon fractures when compared with tension band wires.4 Nonunions with other forms of device failure have been described in the literature. Reviewing OTA type C distal humerus fractures, Gofton et al found 2 olecranon nonunions of the 22 fractures approached through an olecranon osteotomy.3 One of the nonunions was repaired with a tension band plus a screw, whereas a tension band alone was used in the other. Overall, 14 osteotomies were repaired through a reconstruction plate, which produced the most consistent results and lowest complication rates. In another study by Robinson et al, only 3 nonunions were found after performing an osteotomy on nearly 200 patients.13 In the present case, the patient was at risk for nonunion due to the presence of an open fracture in the setting of medical comorbidities, particularly diabetes. The stripping of screw threads on the proximal component of the device suggests that it was adequately engaged during the initial surgery; but in light of the patient’s high risk for nonunion, the implant failure was likely secondary to nonunion of the olecranon osteotomy. In the presence of nonunion, the muscle forces of the triceps were likely transmitted across the nail upon mobilization. This may have led to the gradual stripping of the screw threads over the ensuing months until the components disengaged completely. Though a tension band or plate may also have failed in this setting, the removal of such implants during a revision procedure would likely have proven more straightforward, as there would be no need for the retrieval of an intramedullary component. Conclusion In conclusion, an intramedullary olecranon osteotomy nail may have some clinical and biomechanical advantages; however, the added difficulty in the event of hardware failure should be considered in fractures at high risk for nonunion. References 1. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res 1982;166: 188-92. 2. Dakoure PW, Ndiaye A, Ndove JM, Sane AD, Niane MM, Seve SI, et al. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat 2007;29:6714. http://dx.doi.org/10.1007/s00276-007-0263-8 3. Gofton WT, Macdermid JC, Patterson SD, Faber KJ, King GJ. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am 2003;28:294-308. http://dx.doi.org/10.1053/jhsu.2003. 50038 4. Horner SR, Sadasivian KK, Lipka JM, Saha S. Analysis of mechanical factors affecting fixation of olecranon fractures. Orthopedics 1989;12: 1469-72. 5. Hume MC, Wiss DA. Olecranon fractures. A clinical and radiographic comparison of tension band wiring and plate fixation. Clin Orthop Relat Res 1992;285:229-35. 6. Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg Am 1985;67:1396-401. Olecranon nail disengagement 7. Molloy S, Jasper LE, Elliott DS, Brumback RJ, Belkoff SM. Biomechanical evaluation of intramedullary nail versus tension band fixation for transverse olecranon fractures. J Orthop Trauma 2004;18:170-4. 8. Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr. Displaced olecranon fractures in adults. Biomechanical analysis of fixation methods. Clin Orthop Relat Res 1987;224:210-4. 9. Nowak TE, Mueller LP, Burkhart KJ, Sternstein W, Reuter M, Rommens PM. Dynamic biomechanical analysis of different olecranon fracture fixation devices–tension band wiring versus two intramedullary nail systems: an in-vitro cadaveric study. Clin Biomech (Bristol, Avon) 2007;22:658-64. http://dx.doi.org/10.1016/j.clinbiomech.2007.02.003 10. Fracture and Dislocation Classification Compendium - 2007. OTA Classification, Database and Outcomes Committee. J Orthop Trauma 2007;21:S1-160. e15 11. O’Driscoll SW. The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions. Orthop Clin North Am 2000;31:91-101. 12. O’Driscoll SW, Sanchez-Sotelo J, Torchia ME. Management of the smashed distal humerus. Orthop Clin North Am 2002;33:19-33. 13. Robinson CM, Hill RM, Jacobs N, Dall G, Court-Brown CM. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma 2003;17:38-47. 14. Schildhauer TA, Nork SE, Millis WJ, Henly MB. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma 2003;17:374-8. 15. Wadsworth TG. Screw fixation of the olecranon after fracture or osteotomy. Clin Orthop Relat Res 1976;119:197-201. 16. Wilkinson JM, Stanley D. Posterior surgical approaches to the elbow: a comparative anatomic study. J Shoulder Elbow Surg 2001;10:380-2.