Tension band wiring, with its technique gradually evolving including individualized 3D-printed navigation [17], is the most commonly used surgical technique in managing olecranon fracture [8]. There were also attempts using a hook plate to achieve anatomical reduction [12,13,14]. Due to the nature of olecranon fracture as an intra-articular fracture, open procedure including careful reduction of the fracture fragments is of necessity in obtaining satisfactory clinical outcomes [18]. In our study, a comparison of these two distinctive surgical techniques was conducted in terms of clinical outcome and complication. The HPF group and the TBW group achieved similar ROM in flexion-extension and rotation, as well as the MEPS and the DASH scores at the last follow-up with no statistically significant difference in duration of follow-up. Notably, the HPF group had a significantly lower re-operation rate(44.4% vs. 80.0%, P< 0.01).

The tension band wiring technique has been shown to achieve satisfactory clinical outcomes in the treatment of olecranon fractures in terms of ROM and the MEPS [19,20,21], which are compatible with our findings. However, the symptomatic prominence of the Kirschner wires [10] and a high re-operation rate are concerns of the tension band wiring technique. There has been research indicating a re-operation rate as high as 71.7% [11].

There has been limited literature comparing HPF and TBW techniques, which reported an excellent functional outcome with follow-up durations of 13.5 ± 9.7 and 14.4 ± 11.6 months for TBW and HPF groups, respectively [22]. This result is consistent with our findings except a lower re-operation rate. In our study, a relatively longer follow-up time of 37.4 ± 10.1 and 35.6 ± 9.2 months for the TBW and the HPF group, which could have an impact on re-operation rate. Thus, different structure of hooks may also contribute to this inconsistency.

It shall be noted that in the previous studies involving hook plate fixation, the structure of the ‘hooks’ evolves in different forms. In the firstly applied cases, the hooks was made in two right-angle at the end of the plate [12]. Later, its modification form appears in two 180-degree bending hooks [13]. Single hook in a sharp appearance of the central tension plate has been applied as well [18]. In our study, two 90–90° bending hooks were featured to be able to penetrate olecranon to prevent rotational and translational movement (Fig. 2).

The 90–90° configuration provides better fracture fragment grip, with screws providing additional stabilization of the reduction. Therefore, HPF can achieve favorable clinical outcomes. In our study, the flexion-extension ROM and pronation-supination ROM were 143.0 ± 15.4 and 172.2 ± 6.9, respectively. The MEPS, and the DASH score were 90.9 ± 13.5 and 7.4 ± 5.0. The hook plate features an integrated design with a proximal notch minimizes implant migration, thereby reducing the need for removal. Consequently, the re-operation rate is significantly lower in the HPF group than the TBW group (44.4% vs. 80.0%, p < 0.01) in our study. Furthermore, there has been study examining the stability of olecranon osteotomy in distal humerus fracture, olecranon hook plate exhibits significantly higher stability compared with tension band wiring [23], which could give a hint in its potential benefit.

There are several limitations in our study. Firstly, intramedullary pins were applied in all of our cases and may not represent tension band wiring technique using double cortical pins, which was reported to be able to provide better stiffness [24]. Double cortical pins were also reported to be relative stronger against loading than multifilament cable in TBW [25]. Secondly, selection bias might be existed due the nature as a retrospective cohort study. In term of sample size, though our sample size is comparable to the available research, a larger sample size is still needed. Furthermore, there could be studies to investigate the biomechanical properties of this specific type of hook plate to provide more evidence in its application.

The principal finding of our study indicate that while achieving similar functional outcomes and complication rates compared to the gold standard [26], the use of hook plates provides a lower re-operation rate. This suggests that hook plate fixation may be an ideal alternative in managing olecranon fractures and may bring potential benefit.