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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Where should the pins be placed to decrease the failure rate after
fixation of a Mayo IIA olecranon fracture? A biomechanical analysis
Kaiyang Wang a,1, Ye Lu b,1, Yifan Shen a, Weijie Cai a, Shi Zhan c,∗, Jian Ding a,∗
a
Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai 200233, PR China
b
Department of Sports Medicine, Shanghai Sixth Hospital East Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 200233, PR China
c
Department of Orthopedic Surgery and Orthopedic Biomechanical Laboratory, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai
200233, PR China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Clinically, treatment of Mayo IIA olecranon fractures (MIOF) using pins is associated with a
Accepted 13 April 2020 high rate of failure. The purpose of our study was to compare the biomechanical stability and strength of
Available online xxx
four different fracture fixation configurations and to recommend the best method for the clinical treat-
Keywords: ment of MIOFs.
Olecranon fracture Methods: Twenty synthetic ulnar models were created and equally divided into 4 different fracture fix-
Tension band wiring ation groups: a double cortical configuration using Kirschner (K) wires; a double cortical configuration
Pins
using transcortical pins; an intramedullary pin system; and an intramedullary pin system with a 3-mm
Fracture stability
Biomechanical tests
distance between the eyelet and the proximal end of the olecranon (loose fixation). The stiffness and
strength of all specimens were tested under a loading rate of 2 mm/min. Between-group differences were
evaluated using an independent t − test, with significance set at P < 0.05.
Results: Stiffness and strength were significantly better for the K-wire than intramedullary group:
stiffness, 63.467±14.063 N/mm and 36.243±5.625 N/mm, respectively (P=0.009); and strength,
624.293±148.728 N and 406.486±74.109 N, respectively (P=0.019). There was no difference in stiffness
(P=0.370) or strength (P=0.929) between the use of transcortical pins and K-wires. Moreover, a 3-mm
prominence of the pin at the olecranon did not have a negative effect on either stiffness (P=0.494) or
strength (P=0.391).
Conclusions: Our biomechanical analysis indicated that using a double cortical pin configuration provided
the best stability and strength and, thus, may lower the risk of fracture fixation failure. The use of either
K-wires or pins in the double cortical configuration did not influence fixation stability. A loose double
cortical configuration might decrease fracture stability, although there differences were not significant.
© 2020 Elsevier Ltd. All rights reserved.

Introduction widely used as a method of reliable fixation for these fractures,

Olecranon fractures are intra-articular fractures that account for
about 10% of all upper limb fractures [1,2]. These fractures re-
quire anatomical reduction to prevent the development of post-
traumatic arthritis and to restore the function of the triceps mus-
cle for elbow extension [3]. Tension band wiring (TBW) has been
∗
Corresponding author at: Department of Orthopedic Surgery, Shanghai Jiao Tong
University Affiliated Sixth People’s Hospital, NO. 600, Yishan Rd., Shanghai, PR
China.
E-mail addresses: zhanshi4890966@yeah.net (S. Zhan), dingjian3246@163.com (J.
Ding).
1 prove on the TBW technique, one of which is the Arbeitsgemein-
These two authors contributed equally to this work and should be considered
co-first authors.
particularly for simple transverse displaced fractures of the olecra-
non. Although the evidence for clinical and biomechanical stabil-
ity obtained using the standard TBW technique is excellent, there
remains a risk of loss of the fixation, pull-out of the Kirschner
(K) wires, and soft tissue interference [4]. Furthermore, in the re-
cent research [5], we identified a high failure rate (39.6%) for in-
ternal fixation using the standard TBW technique, including infec-
tion, non-union or malunion, and ulnar nerve palsy. The rate of
failure among our cases was higher than the rate previously re-
ported (10%) by Macko et al., [6] Romero et al., [7] and Chan et al.
[8]
In recent years, various methods have been proposed to im-
schaft für Osteosynthesefragen (AO) tension band technique. The

https://doi.org/10.1016/j.injury.2020.04.018
0020-1383/© 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: K. Wang, Y. Lu and Y. Shen et al., Where should the pins be placed to decrease the failure rate after fixation
of a Mayo IIA olecranon fracture? A biomechanical analysis, Injury, https://doi.org/10.1016/j.injury.2020.04.018
JID: JINJ
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2 K. Wang, Y. Lu and Y. Shen et al. / Injury xxx (xxxx) xxx

Fig. 1. Plain radiographs of the four types of tension band wiring technique: (A). double cortical configuration using pins; (B). double cortical configuration using Kirschner
wires; (C). intramedullary pin; and (D). intramedullary pin with a 3 mm distance between the eyelet and the proximal end of the olecranon (Loose fixation).

AO technique was initially performed by implanting two K-wires
into the proximal medullary cavity of the ulna. The technique was
subsequently modified to use K-wires passed through the distal
volar cortex of the coronoid process. The latter approach has been
reported to provide a more reliable fixation, reducing the risk of
pull-out of the K-wires through the skin and the failure of fracture
stabilization [9]. However, implantation of K-wires through the an-
terior cortex of the coronoid process can restrict forearm rotation,
as well as increase the risk of heterotopic ossification and neu-
rovascular injury [6,10,11]. As a solution to these clinical complica-
tions of the AO technique, Netz and Stromberg designed a needle-
pin (with pin-holes) system for intramedullary fixation of olecra-
non fractures [12]. Currently, although there is evidence of suc-
cessful clinical outcomes for the different fixation methods used
for olecranon fractures, the best fracture fixation technique remains
an issue of controversy [13–15]. In addition, in our daily clinical
work, we identified that in some cases, the intramedullary pin can-
not be placed sufficiently close to the olecranon cortex either due
to structural features of the pin or the barrier caused by the tri-
ceps tendon. In these cases, it would be necessary to evaluate if
this gap between the bone and the pin modifies the biomechanical
strength and stability of the fixation [16]. Therefore, our aim was
to compare the biomechanical stability and strength of four differ-
ent fracture fixation configurations for the treatment of Mayo IIA
olecranon fractures (MIOFs) to determine the best fixation method.
Materials and Methods
Specimen preparation and surgical procedures
figuration using pins (Acumed, Hillsboro, Oregon, United States),
forming the transcortical group; B. double cortical configuration
using K-wires (Acumed, Hillsboro, Oregon, USA), forming the K-
wire group; C. intramedullary fixation, using a pin system, forming
the intramedullary group; and D. intramedullary fixation, but with
a 3-mm distance between the eyelet and the proximal end of the
olecranon, forming the loose intramedullary group.
All fracture fixations were performed according to the AO Foun-
dation guidelines [17]. With group A, for the transcortical fixation
was performed using point-resetting forceps, with the fragments
fixed using two parallel pins, with a horizontal spacing of 2 cm be-
tween the two pins. The parallel pins are placed subcutaneously in
the ulna, angled slightly anteriorly and perpendicular to the frac-
ture line. A 2-mm bone hole was drilled in the ulna, and a 1-mm
wire placed through the hole, forming a figure 8 fixation of the
distal end of the olecranon, under the triceps tendon. When the
appropriate tension was achieved, a knot was tied and excess steel
wire cut and the knot bent down (Fig. 2). Group B is very similar to
group A, and the only difference is that needle-pins were replaced
by the k-wires. Group C: The needle-pins were used to replace k-
wires to finish the standard TBW technique. Two parallel 2.0-mm
needle-pins were employed in a longitudinal direction going from
the dorsocranial tip of the olecranon into the ulna distally. Care
was also taken to ensure that the pins were placed into ulnar bone
marrow cavity totally. Group D: Before the wire was tightened, the
needle holder was filled between the bone surface of the olecranon
and the pin eyelet to simulate 3-mm interspace. Once the tension
band was built up, the needle holder was removed to form the
loose intramedullary group.

Twenty identical synthetic ulnar models of a MIOF (Sawbone, Biomechanical testing

model 1026-3 synthetic bone, Pacific Research Laboratories, Vashon
Island, Washington, United States) were used as bone substitutes
for biomechanical testing. All models were of the right ulna, hav-
ing the same weight, density and size, as well as the same fracture
pattern. Five synthetic models were evaluated for each of the fol-
lowing four fracture fixation groups (Fig. 1): A. double cortical con-
Fixation stability and strength was evaluated under an axial
tensile load using the Instron test system (Instron, Norwood, MA,
USA). The ulna was fixed using a customised frame, and the ole-
cranon was pulled vertically using a K-wire to simulate the natu-
ral extension pulling force on the olecranon by the triceps tendon.

Please cite this article as: K. Wang, Y. Lu and Y. Shen et al., Where should the pins be placed to decrease the failure rate after fixation
of a Mayo IIA olecranon fracture? A biomechanical analysis, Injury, https://doi.org/10.1016/j.injury.2020.04.018
JID: JINJ
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K. Wang, Y. Lu and Y. Shen et al. / Injury xxx (xxxx) xxx 3

Table 1
Stiffness and strength measurements for the four fracture fixation groups.

Stiffness (N/mm)

Group Mean Maximum Minimum SD

(A) Transcortical 71.445 87.017 58.046 5.558

(B) Material 63.467 74.573 41.800 6.289
(C) Intramedullary 36.243 43.083 30.196 5.625
(D) Loose intramedullary 32.122 39.596 18.639 8.368

Strength (N)

Group Mean Maximum Minimum SD

(A) Transcortical 634.039 863.587 415.494 186.027

(B) Material 624.293 743.681 372.053 148.728
(C) Intramedullary 406.487 487.068 311.013 74.109
(D) Loose intramedullary 433.444 480.582 394.345 36.583

SD, standard deviation.

transcortical K-wire configuration provided greater stiffness and

Fig. 2. Biomechanical testing of the stiffness and strength of the four different fix-
ation techniques for Mayo type IIA fractures of the olecranon was evaluated using
a sawbone model. (A). lateral view, and (B). anteroposterior view.
A vertical tensile force was applied to the wire to pull the distal
end of the olecranon, at a rate of 2 mm/min (Fig. 3). Stiffness was
quantified by the slope of the load-displacement curve, measured
using a load sensor, providing a proxy measure of stability of the
fracture fixation. The ultimate strength of the fracture fixation was
defined by the magnitude of the load at the point of failure.
Statistical analysis
strength than intramedullary fixation: stiffness, 63.467±14.063
N/mm and 36.243±5.625 N/mm, respectively, P=0.009; and
strength, 624.293±148.728 N and 406.486±74.109 N, respectively,
P=0.019. For transcortical fracture fixation, pins provided greater
stiffness than K-wires (71.444±12.429 N/mm and 63.467±14.063
N/mm, P=0.370), although the strength was not significantly dif-
ferent between the two fixation methods (634.039±186.027 N and
624.293±148.728 N, P=0.929). Inserting a 3-mm gap between the
bone and the prominence of the pin reduced the strength and
stiffness of the intramedullary fixation: strength, 406.487±74.109
N and 433.444±36.583 N, respectively, P=0.494; and stiffness,
36.243±5.625 N/mm and 32.123±8.368 N/mm, P=0.391. Therefore,
a 3-mm gap can lead to overall elbow joint dysfunction (Fig. 4).

Analyses were performed using the SPSS software (SPSS Version
20; SPSS Inc., Chicago, IL, United States). Differences in stiffness
and strength among the four fracture fixation groups were eval-
uated using Student’s t − test, with significance set at P < 0.05.
Results
The measured stiffness and strength values for the four fix-
ation groups are reported in Table 1. The transcortical fixa-
tion, using either K-wires or pins, was the main factor influ-
encing the stability and strength of the internal fixation. The
Discussion
TBW for MIOFs provide several advantages, including simplic-
ity of the surgical technique, precise fixation and early mobili-
sation. The technical advantage to TBW lies in the fact that the
two K-wires or pins act as inner splints, dispersing the forces ap-
plied to the fracture through the range of elbow joint motion.
Moreover, the inclusion of the figure 8 configuration with K-wires
offsets the tension applied to the elbow, providing dynamic in-
ternal fixation and continuous pressurisation to promote fracture
healing [18]. The continuous improvements in the TBW technique

Fig. 3. The experimental conditions: (A). model tested with the model simulating 90° of elbow flexion; and (B). a vertical load was applied using the Instron test system to
measure stiffness and strength.

Please cite this article as: K. Wang, Y. Lu and Y. Shen et al., Where should the pins be placed to decrease the failure rate after fixation
of a Mayo IIA olecranon fracture? A biomechanical analysis, Injury, https://doi.org/10.1016/j.injury.2020.04.018
JID: JINJ
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4 K. Wang, Y. Lu and Y. Shen et al. / Injury xxx (xxxx) xxx

Fig. 4. Difference in the mean stiffness and strength between the four types of fracture fixation. ∗ , statistical significance.

Fig. 5. (A). Mayo type IIA fractures intramedullary pin fixation with a 2.5 mm distance between the eyelet and the proximal end of the olecranon and the fractures fit tightly
(arrow). (B). Rehabilitation training was performed after surgery. There was a 1 mm distance at 8 weeks and the fracture line remains clear. It is worth noting that elbow
flexion was limited and the elbow flexion at 90 degrees cannot be complete because of the elbow’s discomfort and pain.

have improved the fixation effect on the olecranon fracture and
lowered the risk for postoperative complications, including a sig-
nificant reduction in the rate of fracture fixation failure [19,20].
Our study extends current knowledge regarding the TBW tech-
nique, using laboratory-based biomechanical analysis to measure
the strength and stiffness [21,22] of four different TBW configura-
tions, with the intent of providing basic knowledge to inform prac-
tice. All four TBW fixation configurations used (transcortical using
pin or K-wires, intramedullary, and loose intramedullary) met the
basic requirements of biomechanical stability (Fig. 4). At present,
the TBW technique for fixation of MIOFs is performed using ei-
ther intramedullary fixation or the modified double cortical fix-
ation. Our results indicate that the transcortical TBW technique,
using either K-wires or pins, provides significantly better fracture
stability and strength than the intramedullary fixation technique.
Intramedullary pins may provide insufficient stabilisation, which
would cause early loosening of the internal fracture configuration,
resulting in failure of the fixation. This mechanism of failure has
previously been proposed by Kim et al. [23] and Linden et al.
[24] In our practice, we also identified that early functional mobil-
isation after K-wire stabilisation of MIOFs can also lead to fixation
failure due to slippage or pull-out of the K-wires [3].
Several modifications to the transcortical fixation using K-wires
have been developed in an effort to lower the risk of fixation fail-
ure. Koslowsky et al. [22] used fine-threaded K-wires, while Kim
et al. [25] upgraded the technique from using one tension band
to using two bands. For their part, Huang et al. [26] pushed the
K-wires deeper into the distal medullary cavity. Various improve-
ments to the fixation technique itself have also been described.
Gruszka et al. [27] used an olecranon tension plate, while Dieterich
et al. [28] and Lovy et al. [29] used an olecranon sled. These modi-
fications to the TBW technique have reduced the volume of the in-
ternal fixation and the risk of K-wire pull-out, with the TBW tech-
nique remaining the most cost-effective treatment option [30,31].
With regard to cost and technical difficulty, we observed that the
use of either K-wires or pins, for transcortical fixation, provided
the same strength and stability of the fixation. We had identified
in our clinical practice that relaxation of the steel wire in TBW
influenced the strength and stability of the fixation. As such, we
did include an assessment of the effect of relaxing the tightness
of the TBW on the strength and stability of the fracture fixation.
We identified that a gap distance of 3 mm (of the end of the
pin from the ulnar cortex) slacked the TBW, resulting in a reduc-
tion of the internal fixation stiffness (from 36.243±5.625 N/mm
for correct intramedullar fixation to 32.123±8.368 N/mm for the
loose intramedullar fixation, P=0.391). This finding is consistent
with our clinical observations, indicating that the pin hole should
be placed as close to the back of the olecranon as possible, even
if the between-group difference in our study was not significant
(Fig. 5).
Three limitations in study design may have biased our final re-
sults and showed be acknowledged. First, although we used a stan-
dardised method to tighten the cable or steel and quantified the
applied force, the tensile force of the TBW may not be exactly
equal to the tensile force applied to the olecranon in vivo. There-
fore, further studies are warranted to validate our findings, includ-
ing biomechanical test to reflect the main properties of the tight-
ening in vivo [27,32]. Secondly, we tested only five models in each
of the four types of fixation. Although this sample size was suffi-
cient to identify differences in the strength and stability between
the four fixation types, a larger number of samples are needed to
prove the reliability of our findings. Lastly, we acknowledge that
previous studies [33–35]. have measured the relative displacement
of the fracture fragments, we only included measures of stiffness
and strength, due to the structural specificity of the elbow joint.
These two parameters may be sufficient to quantify the capacity
of the fixation to resist destabilising forces and, thus, of the whole
stability of the fixed structure [21,22].

Please cite this article as: K. Wang, Y. Lu and Y. Shen et al., Where should the pins be placed to decrease the failure rate after fixation
of a Mayo IIA olecranon fracture? A biomechanical analysis, Injury, https://doi.org/10.1016/j.injury.2020.04.018
JID: JINJ
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K. Wang, Y. Lu and Y. Shen et al. / Injury xxx (xxxx) xxx
Conclusions
According to our biomechanical analyses, the transcortical TBW
technique provides the best fracture fixation method to reduce the
rate of fixation failure for MIOFs, with the material used (K-wires
or pins) not having a significant effect on the strength and stabil-
ity of the fixation. Loosening of the intramedullary fixation showed
worse stability of the fracture fixation by the biomechanical re-
sults. However, further clinical research on this issue is warranted.
Funding
This study was sponsored by the Interdisciplinary Program of
Shanghai Jiao Tong University (YG2017QN14); Funding project of
Shanghai Sixth People’s Hospital (ynlc201617).
Data availability
The data used to support the findings of this study are available
from the corresponding author upon request.
Declaration of Competing Interest
The authors are not compensated and there are no other in-
stitutional subsidies, corporate affiliations, or funding sources sup-
porting this work unless clearly documented and disclosed.
Acknowledgments
The Authors gratefully acknowledge the support of Prof. Hai Hu,
the head of department of Orthopedic Biomechanical Laboratory of
Shanghai Jiaotong University affiliated Sixth People’s Hospital.
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