Purpose <p>This study aimed to compare reoperation rates and additional clinical outcomes among three methods of olecranon osteotomy fixation: intramedullary screw (IMS), tension band wire (TBW), and plate fixation (PF).</p> Methods <p>A retrospective review was conducted of all AO/OTA class 13 distal humerus fractures treated at a single academic Level 1 trauma center between January 1, 2005, and July 31, 2021. Inclusion criteria included patients treated using an olecranon osteotomy fixed via IMS, TBW, or PF. The primary outcome was the need for reoperation with secondary outcomes including complications (nonunion, implant prominence, wound dehiscence, or infection) and patient-reported outcome measures—Single Assessment Numeric Evaluation (SANE) score and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score. Outcomes were compared across the 3 fixation modalities using multivariable logistic regression.</p> Results <p>In total, 86 patients met the inclusion criteria: 47 had IMS fixation of their osteotomy, 15 had TBW, and 24 had PF. Reoperations were required in 31 patients overall, yielding 32%, 33%, and 46% reoperation rates for IMS, TBW, and PF, respectively. There was no significant difference in the risk of reoperation (<i>p</i> = 0.32) or complications (<i>p</i> &gt; 0.05). All three methods demonstrated similar times to union (<i>p</i> = 0.09), and there were no significant differences in SANE score (<i>p</i> = 0.53) or QuickDASH score (<i>p</i> = 0.58).</p> Conclusion <p>Olecranon osteotomy fixation by IMS, TBW, and PF yields similar rates of reoperation, regardless of root cause, and results in equivalent SANE and QuickDASH scores. Implant choice should be made on a case-by-case basis with respect to patient and surgeon preference.</p> <p><i>Level of evidence</i></p> <p>Level III, Retrospective comparative study</p>