Comparative efficacy and safety of tension band wiring versus plate fixation for olecranon fractures: a meta-analysis and trial sequential analysis of randomized clinical trials.

BACKGROUND

Management of displaced olecranon fractures remains controversial. Surgeons must weigh the lower cost of tension band wiring (TBW) against the stability of plate fixation (PF). This study utilizes recent Level I evidence and Trial Sequential Analysis (TSA) to determine if cumulative data are sufficient to draw preliminary conclusions based on the available randomized controlled trial (RCT) evidence.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant meta-analysis of RCTs was conducted using PubMed, Scopus, and Web of Science through January 2025. Eligible studies compared TBW versus PF in adults with displaced fractures. Outcomes included functional scores (Disabilities of the Arm, Shoulder and Hand [DASH], Mayo Elbow Performance Score [MEPS]), complications, reoperation rates, and costs. TSA was employed to control for Type I/II errors and evaluate the futility of further testing. Several outcomes, including MEPS, forearm rotation arc, and total complications, are derived from only 2 studies and should be considered exploratory rather than definitive pooled estimates.

RESULTS

Three high-quality RCTs (Mayo 2A/2B) were included. No statistically significant differences appeared for DASH (P = .84), MEPS, or range of motion. TSA for DASH reached the required information size, suggesting functional equivalence. However, TBW was associated with significantly higher risks of total complications (risk ratio = 1.53; P = .01) and reoperation (risk ratio = 1.47; P = .01). While TBW had shorter operative times and lower implant costs, total patient-level health-care costs at one year showed no significant difference (P = .131).

CONCLUSION

Current randomized evidence suggests that TBW and PF may yield similar functional outcomes for displaced olecranon fractures; however, these findings are based on a limited number of RCTs, with several secondary outcomes derived from only 2 studies. TSA supports functional equivalence for DASH and forearm rotation arc, though evidence is insufficient for other functional parameters. TBW is associated with higher rates of secondary surgery, largely driven by symptomatic hardware removal rather than true fixation failure, with no significant increase in revision surgery rates. No statistically significant difference in overall health-care costs was observed. Given the limited RCT evidence, heterogeneity in fracture types, and variability in cost reporting, these findings should be interpreted with caution and further high-quality, fracture-subtype-stratified trials are needed.