How to improve tension band

wiring technique project

Subodh Deshmukh
Gemma Smith
Ziyun Ding
Duncan Shepherd
Mode of action of traditional TBW
• Tension band principle
– A bending force applied eccentrically to a column causes
tension and compression within that column

– A ‘tension band’ absorbs the force and the compression

cortex becomes stable

– Makes use of the functional movement of the limb

– Tension forces are converted into compression forces

provided the compression cortex is not deficient
 Traditional tension band wiring
• Indications
– Eccentrically loaded articular surfaces
= Absolute stability, interfragmentary compression, direct bone
healing

• Commonly olecranon and patella

• Other indications are tuberosity of the humerus, of
the lateral and medial malleoli, and of the trochanter
of the femur
 Traditional tension band wiring
• Olecranon and patella
 Olecranon fracture

• Technique
• A simple transverse fracture can be held accurately by:
• Insert a K-wire through fracture line
• Insert a second K-wire parallel to the first one to prevent
fragment rotation
• Tension band is provided by figure-of-eight looped wire over the
tension surface, anchored around the K-wire ends proximally,
and a transverse hole through ulna distally
• Wire is tightened equally on both sides by twisting to apply
compression
• Once fixed, any pull on the triceps muscle increases the
dynamic compression across fracture site
 Patella fracture
A study of TBW biomechanics in the weight-
bearing activities such as walking, staring-up
and standing up from the chair.
• Technique
• Provided the fracture is a simple transverse fracture and there is no
fragmentation of the deep articular cortex.
• Can be reduced with pointed forceps and held with two parallel K-wires
• A wire, inserted around the ends of these wires (deep to the quadriceps
tendon), crossed over the front of the patella, and then around the
lower ends of the K-wires is tightened to provide compression. Achieved
by tightening a loop on each limb of the wire
• The pull of the hamstrings then increases dynamic compression across
the fracture as the knee flexes and extends
• No one has demonstrated what happens to TBW or the forces across the
traditional TBW when there is active extention of the Knee against
gravity or against resistance
 Complications associated with
traditional TBW technique
• Incorrect technique for fracture configuration
• Failing tension band wire
– K wires backing out
– Cerclage wire slips from around k wire
– No compression at fracture site
• Implant failure
– Cerclage wire breaks
• High implant removal rates due to symptomatic implants
• Infection
Failing TBWs
Failing TBWs
 What we know already
• Can improve technique
• 1)Placing two twists at corners rather than in an
arbitrary fashion
• 2)Placing the figure-of-8 loop in transverse
orientation.
• 3)Increasing the diameter of the wire used to
make the figure-of-8 loop
• 4)Increasing the number of strands in the
figure-of-8 loop
 New concepts to:
• Improve technique
– Increasing distance between k wires
• ? Improve stability of construct
– Optimal distance of k wires to articular surface
• ? Improve compression at fracture site
 New concepts to:
• Improve hardwear used
– Orthocord rather than cerclage wire
– Device to ‘lock’ tension band into k wires
– Device other than k wire
• Smooth and can back out
• Sharp and bent ends can cause prominence and
infection
• Can orthocord be fed through horizontal drill holes
through the bone to hold into place?
 New concepts
• New type of
hardware
• Patellar plate
• Tensioned wires going
longitudinally through
the patella and four
extra flexible holes in
the plate
 What needs to be done
• Assess stability of construct with k wires in a
varying positions and the forces going through
the fracture site
– Increasing distance between k wires
– Altering k wire position in relation to articular
surface
 What needs to be done
• Assess the material properties of orthocord in
comparison to cerclage wire
• Measure the forces going through a new
orthocord only construct
• Consider other design techniques to ‘lock’
tension band to device than passes
perpendicular to fracture site
• Work on biomechanics of the Plate and
Through patella tensioned wire technique
 A Pilot Parametric Study
 Parameters:
• Positioning of the K-wires
• Material properties of the cerclage wires: increasing
the diameter of the wire;
• Shape variations of the patella: thickness, width and
length

 Outcome measures ：
• Fracture site displacement
• Wire stress
 FE model
• Constrains and boundary
conditions: Fq, Fpf, and
Fpt, which are calculated
based on the motion and
the ground reaction force;
• Geometry: the shape of
patella; contact points of
Fq, Fpf, and Fpt and the
two K-wires:
• Material properties:
Patella, K-wires and
cerclage wires