What is the tension band technique?

First described by Frederic Pauwels in 1935, the tension band technique is a surgical method widely used in orthopedics that promotes bone healing by converting tensile forces into stable compressive forces across a fracture. This innovative approach provides a stable, biomechanically sound solution for specific types of fractures.

Quick Summary

The tension band technique is a surgical procedure that uses wires, sutures, or plates to convert muscle-induced tensile forces across a fracture into powerful compression, providing stability and promoting bone union during movement.

Key Points

• Converts Forces: The technique transforms muscle-induced tensile (distractive) forces into compressive forces across a fracture site.

• Promotes Healing: By providing dynamic compression, it creates a stable mechanical environment that actively encourages bone healing during movement.

• Common Applications: Primarily used for fractures influenced by strong muscle or ligament pull, such as those of the patella, olecranon, and medial malleolus.

• Hardware Components: Typically involves parallel Kirschner wires (K-wires) and a figure-of-eight wire or suture loop.

• Risk of Irritation: A common disadvantage is the potential for symptomatic hardware that may require subsequent removal surgery.

First described by Frederic Pauwels in 1935, the tension band technique is a surgical method widely used in orthopedics that promotes bone healing by converting tensile forces into stable compressive forces across a fracture. This innovative approach provides a stable, biomechanically sound solution for specific types of fractures.

The Biomechanical Principle of the Tension Band

At its core, the tension band principle is an elegant application of biomechanics to facilitate fracture healing. A curved bone under an eccentric load—such as the patella under the pull of the quadriceps muscle—experiences both a compression side and a tension side. This tensile force can cause the fracture fragments to pull apart, leading to instability and poor healing. The genius of the tension band is its ability to neutralize this distractive, or pulling, force and convert it into a compressive one.

To achieve this, a fixation device, typically a figure-of-eight wire loop, is placed on the tension (convex) side of the bone. When the muscle contracts or the joint moves, it pulls on the implant. This pulling force, instead of distracting the fracture, creates a hinge effect that drives the fracture fragments together, providing excellent stability for bony union.

There are two main types of tension bands based on their effect during movement:

• Static Tension Band: Creates compression at the time of surgical application, with forces remaining relatively constant during movement. An example is the fixation of a medial malleolus fracture.
• Dynamic Tension Band: The compressive force increases with motion and physiological loading, actively promoting healing. This is seen in fractures influenced by strong muscle groups, like the patella or olecranon.

Common Applications in Orthopedic Surgery

The tension band technique is highly versatile and is a common treatment for several specific fractures where muscle or ligament pull is a significant factor in potential instability.

Patella Fractures

Transverse fractures of the patella are a classic indication for tension band wiring. The powerful quadriceps muscle and patellar tendon constantly pull on the kneecap, creating strong tensile forces. A figure-of-eight wire placed on the anterior (tension) surface of the patella converts this distractive pull into compression on the posterior articular surface during knee flexion, stabilizing the fracture fragments and allowing early motion.

Olecranon Fractures

The olecranon, or bony tip of the elbow, is another textbook case. Fractures here are under constant distractive tension from the triceps muscle pull. Tension band wiring, often using Kirschner wires (K-wires) and a figure-of-eight wire loop, effectively counters this muscle pull. During active elbow flexion and extension, the construct maintains compression across the fracture site.

Medial Malleolus Fractures

Avulsion fractures of the medial malleolus, where the bone is pulled away by the deltoid ligament, can also be treated with a tension band. The principle is the same: the wire loop converts the distracting force from the ligament into a compressive force at the fracture line, securing the fragment.

The Surgical Procedure: A Step-by-Step Overview

While specific details vary by fracture type, the general procedure for a tension band wiring includes these key steps:

1. Fracture Reduction: The surgeon first uses clamps to carefully align the bone fragments to their anatomical position.
2. K-wire Insertion: Two smooth Kirschner wires (K-wires) are inserted parallel to each other across the fracture line, exiting the far bone cortex. These pins prevent rotational instability and provide an anchor for the wire loop.
3. Figure-of-Eight Wire Application: An 18-gauge stainless steel wire is passed in a figure-of-eight pattern around the K-wires. For patellar fractures, the wire passes anteriorly. For olecranon fractures, it passes behind the K-wires and through a hole in the ulna.
4. Tightening the Wire: The wire is twisted to create tension, which draws the fracture fragments together. It must be tightened uniformly to ensure even compression.
5. Finishing the Construct: After tightening, the K-wires are bent to prevent them from migrating out of the bone and are then impacted into the bone, burying them beneath the soft tissue to minimize irritation.

For a visual guide to the procedure, you can consult resources like the AO Foundation Surgery Reference.

Materials and Hardware

Historically, the technique has relied on stainless steel wire combined with K-wires. However, advancements in materials science have introduced alternative fixation options:

• Stainless Steel Wire: The traditional and cost-effective option, offering high tensile strength.
• Absorbable Sutures: Non-absorbable, high-tensile strength sutures (e.g., FiberWire) are increasingly used, particularly for patellar fractures. They offer comparable fixation strength with the significant advantage of reducing symptomatic hardware and the need for future removal.

Advantages and Disadvantages

As with any surgical procedure, the tension band technique has distinct benefits and potential drawbacks.

Advantages

• Cost-Effective: Compared to plate fixation, the hardware and procedure for tension band wiring are generally less expensive.
• Simple Technique: It is a relatively straightforward procedure for trained surgeons, minimizing technical difficulty.
• Early Mobilization: The dynamic compression created by the technique allows for earlier joint movement and functional rehabilitation, which can prevent joint stiffness.

Disadvantages

• Symptomatic Hardware: The wire and K-wires can sometimes irritate the surrounding soft tissues, causing pain and requiring a second surgery for removal. This is a significant drawback, reported in up to 60% of patellar fracture cases.
• Hardware Migration: The K-wires can migrate or back out over time, leading to complications such as joint impingement or skin irritation.
• Limited Applicability: The technique is not suitable for all fracture types, particularly those with significant comminution (fragmentation) where there is no solid opposing cortex to absorb the compressive forces.

Comparison: Tension Band Wiring vs. Plate Fixation

For certain fractures, surgeons may choose between tension band wiring and plate fixation. The choice depends on several factors, including the fracture pattern, bone quality, and surgeon experience.

Feature	Tension Band Wiring	Plate Fixation
Mechanism	Converts tensile forces to compression during movement.	Applies static compression and provides buttressing.
Stability	Excellent for simple, transverse fractures under muscular load.	High stability, suitable for a wider range of complex fractures.
Cost	Relatively low-cost hardware.	Significantly higher cost due to complex plates and screws.
Hardware Prominence	High risk of hardware becoming prominent and irritating soft tissue.	Lower risk of symptomatic hardware when properly contoured.
Surgical Complexity	Less complex and invasive than plating.	More complex, with greater surgical exposure often required.
Fracture Type	Best for simple, articular avulsion fractures.	Versatile, effective for complex, comminuted fractures.

Postoperative Care and Rehabilitation

Rehabilitation is a crucial component of recovery following a tension band procedure. For dynamic constructs, early and active motion is often encouraged to leverage the compressive benefits of the implant. Physical therapy will focus on regaining range of motion and strength. The rehabilitation protocol, however, is tailored to the specific fracture, its stability, and the patient's individual needs. Close monitoring for hardware complications is essential during the recovery period.

Conclusion

In summary, the tension band technique is a time-tested orthopedic procedure that offers a robust and cost-effective solution for specific fracture patterns. By converting muscle-induced tension into stabilizing compression, it facilitates a conducive environment for bone healing and allows for early rehabilitation. While risks like hardware irritation exist, careful surgical technique and adherence to postoperative protocols can lead to excellent functional outcomes, making the tension band a valuable tool in a surgeon's armamentarium.

Frequently Asked Questions

What is the main purpose of the tension band technique?

The primary purpose is to convert tensile forces, which can pull a fracture apart, into compressive forces that push the bone fragments together. This provides stability, promotes healing, and allows for earlier joint movement.

Which specific types of fractures are treated with the tension band technique?

The technique is best suited for simple, transverse, or avulsion fractures influenced by strong muscle or ligamentous pull. Common examples include fractures of the patella (kneecap), olecranon (elbow), and medial malleolus (ankle).

Are there alternatives to metal wire for tension band procedures?

Yes, surgeons increasingly use high-tensile strength, non-absorbable sutures as an alternative to stainless steel wire. These sutures offer comparable stability with a reduced risk of irritating soft tissues and needing a second surgery for removal.

What are the common risks or complications of tension band wiring?

The most common complication is irritation from the hardware, which can cause pain and necessitate removal. Other risks include hardware migration, infection, and failure of the construct if the opposite bone cortex is compromised.

Does the technique allow for early rehabilitation?

Yes, for dynamic tension band constructs, early and active motion is often encouraged as it helps increase the compressive forces at the fracture site, which can prevent joint stiffness and accelerate recovery.

What is the difference between a static and a dynamic tension band?

A static tension band creates compression at the time of surgery that remains constant. A dynamic one, however, increases compression across the fracture site during physiological loading, such as muscle contraction or weight-bearing.

Is the tension band technique suitable for highly fragmented (comminuted) fractures?

No, it is not typically suitable for comminuted fractures. The technique requires a strong, intact opposite bone cortex to act as a hinge. In a fragmented fracture, this buttressing effect is lost, increasing the risk of mechanical failure.