Olecranon Osteotomy vs. Triceps-Sparing Approach for Open Reduction and Internal Fixation in Treatment of Distal Humerus Intercondylar Fracture: A Systematic Review and Meta-Analysis
Distal humerus intercondylar fractures (DHIFs) represent complex intra-articular injuries that challenge orthopedic surgeons due to their comminuted nature and proximity to critical neurovascular structures. Open reduction and internal fixation (ORIF) remains the gold standard for managing these fractures, but the optimal surgical approach to facilitate ORIF—olecranon osteotomy (OO) or triceps-sparing (TS) techniques—remains debated. This systematic review and meta-analysis aimed to compare the efficacy and safety of OO and TS approaches in restoring elbow function, minimizing complications, and optimizing surgical outcomes.
Background and Clinical Context
DHIFs account for approximately 2% of adult fractures, often resulting from high-energy trauma or falls in older patients with osteoporotic bone. The fracture’s intra-articular nature necessitates precise anatomical reduction to preserve joint congruity and prevent post-traumatic arthritis. Surgical exposure must balance adequate visualization of fracture fragments with preservation of soft tissue integrity. Historically, OO has been favored for its ability to provide direct articular visualization, but concerns persist about complications like non-union at the osteotomy site and prolonged recovery. In contrast, TS approaches avoid osseous disruption but may limit exposure, particularly for complex fractures.
Study Design and Methodology
The meta-analysis followed PRISMA guidelines, systematically searching PubMed, EmBase, Cochrane Library, and Chinese National Knowledge Infrastructure from inception through December 2019. Keywords included combinations of “distal humerus intercondylar fracture,” “olecranon osteotomy,” and “triceps-sparing approach.” Inclusion criteria encompassed randomized controlled trials (RCTs) and observational studies comparing OO and TS techniques in adults with DHIF. Outcomes assessed included the incidence of excellent/good elbow function (primary endpoint), Mayo Elbow Performance Score (MEPS), operative duration, intraoperative blood loss, and complication rates.
Nine studies involving 637 patients met eligibility criteria. Four were RCTs, and five were observational studies. Study quality was evaluated using JADAD scores for RCTs (range: 1–3) and Newcastle-Ottawa Scale (NOS) scores for observational studies (range: 5–6). Heterogeneity was quantified via I² statistics, and sensitivity analyses tested the robustness of pooled estimates.
Key Findings
1. Elbow Functional Outcomes
The primary outcome—excellent/good elbow function—showed no significant difference between OO and TS groups (odds ratio [OR]: 1.37; 95% CI: 0.69–2.75; P = 0.371). However, sensitivity analysis excluding one outlier study (Liu et al., 2017) revealed a potential advantage for OO (OR: 1.81; 95% CI: 1.04–3.15; P = 0.035). Subgroup analyses suggested geographical variations: studies from Finland and Pakistan favored OO (OR: 3.55; 95% CI: 1.57–8.02), while Chinese studies showed no significant difference.
2. Mayo Elbow Performance Score
MEPS, a validated measure of pain, stability, motion, and function, demonstrated comparable results between approaches (weighted mean difference [WMD]: 0.17; 95% CI: −2.56 to 2.89; P = 0.904). Subgroup analyses of RCTs and observational studies confirmed this equivalence.
3. Operative Duration and Blood Loss
Pooled data revealed no significant differences in operative time (WMD: 4.04 minutes; 95% CI: −28.60 to 36.69; P = 0.808) or blood loss (WMD: 33.61 mL; 95% CI: −18.35 to 85.58; P = 0.205). However, sensitivity analyses indicated OO might prolong surgery (WMD: 22.02 minutes; P < 0.001) and increase blood loss (WMD: 57.09 mL; P = 0.007) when excluding a low-quality RCT (Wang et al., 2017). Observational studies consistently associated OO with longer operative times and greater hemorrhage.
4. Complications
Overall complication rates did not differ significantly (OR: 1.93; 95% CI: 0.49–7.60; P = 0.349). However, sensitivity analysis excluding the same outlier study suggested higher risks with OO (OR: 3.78; 95% CI: 1.85–7.74; P < 0.001). Specific complications included non-union (OO: 3.2% vs. TS: 1.1%), superficial infections (OO: 4.5% vs. TS: 2.8%), and ulnar neuropathy (OO: 2.7% vs. TS: 1.9%).
Discussion
Interpretation of Findings
The meta-analysis highlights equipoise between OO and TS approaches for DHIF management. While OO provides superior articular visualization, its theoretical benefits did not translate into significantly better functional outcomes in the primary analysis. The sensitivity analyses, however, suggest that OO might offer a marginal advantage in restoring elbow function, albeit at the cost of longer operative times, increased blood loss, and higher complication risks. These findings align with biomechanical studies emphasizing the trade-off between exposure and iatrogenic injury.
Mechanistic Considerations
OO involves creating an intentional osteotomy of the olecranon to mobilize the triceps and improve articular access. This technique facilitates direct visualization of the trochlea and capitellum, enabling precise reduction of complex fractures. However, the additional osteotomy site introduces risks of non-union, hardware irritation, and delayed mobilization. TS approaches, such as the paratricipital or triceps-splitting methods, preserve the olecranon but may compromise visualization in highly comminuted fractures.
Clinical Implications
The choice between OO and TS should be individualized based on fracture complexity, surgeon expertise, and patient factors. For simpler fractures (AO/OTA type C1), TS approaches may suffice, minimizing soft tissue disruption. For complex intra-articular comminution (type C3), OO’s enhanced exposure could justify its risks. Surgeons must weigh the benefits of anatomical reduction against potential complications, particularly in osteoporotic patients or those with compromised healing capacity.
Limitations and Future Directions
The study’s limitations include heterogeneity in fracture classification, surgical techniques, and outcome measures across studies. Most included studies were retrospective and underpowered, with only four RCTs. Additionally, variations in postoperative rehabilitation protocols may have influenced functional outcomes. Future research should prioritize prospective RCTs with standardized outcome measures, longer follow-up, and subgroup analyses based on fracture severity and patient demographics.
Conclusion
This meta-analysis found no definitive superiority of OO over TS approaches in treating DHIFs. While OO may marginally improve functional outcomes in select populations, it is associated with longer operative times, greater blood loss, and higher complication rates. Surgeons should tailor their approach to fracture complexity and patient-specific factors, prioritizing techniques that balance anatomical restoration with minimal iatrogenic harm.
doi.org/10.1097/CM9.0000000000001393
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