Defining Technical Competence in Olecranon Fracture Fixation: An International Delphi Consensus on Tension Band Wiring Assessment

BACKGROUND: Tension band wiring (TBW) is a widely used technique for displaced olecranon fractures but carries a substantial risk of complications, often due to technical errors. Despite being a designated core competency in orthopedic curricula, no standardized, procedure-specific tool exists to assess technical performance in TBW. This study aimed to establish international expert consensus on assessment parameters for evaluating surgical competence in TBW of simple transverse olecranon fractures.

METHODS: A modified four-round Delphi process was conducted with 98 orthopedic trauma surgeons, primarily AO faculty. In Round 1, panelists proposed key performance parameters and typical errors. Responses were analyzed and processed by a steering committee. In Round 2, 46 parameters were rated for importance using a 5-point Likert-like scale; parameters with mean scores ≥3.0 were retained. In Round 3, specific score ranges were determined for each bone and fracture model; these results are not presented in this study. In the final round, experts assigned scores (1-10) to each retained parameter to reflect its impact on procedural quality. Descriptive statistics were used, and Pearson's correlation coefficient assessed the relationship between importance ratings and scores.

RESULTS: A total of 43 parameters were retained, covering fracture reduction (8 items), K-wire placement (14), cerclage wire configuration (18), and end-of-procedure verification (3). The highest scoring parameter was "achieving anatomical fracture reduction" (mean score: 9.7), followed by "placement of the cerclage wire in a figure-of-8 configuration" (9.4). A very strong correlation was observed between importance and final scores (r = 0.91, p < 0.001), indicating internal consistency.

CONCLUSIONS: This international consensus study defines a comprehensive set of assessment parameters for TBW of olecranon fractures. The tool supports both structured evaluation and high-specificity feedback-key drivers of skill acquisition in competency-based surgical training. It may be used directly in feedback settings or adapted for simulation platforms and structured curricula.

LEVEL OF EVIDENCE: Level V, Treatment Study, Delphi Process.