SURGICAL TECHNIQUE
Triceps Tendon Repair James B. Bennett, MD,* Thomas L. Mehlhoff, MD†
Complete triceps tendon rupture is relatively rare, but more commonly seen in the athletic population. Loss of extension strength is the functional deficit for the elbow after rupture of the triceps tendon. Although partial tears may be treated conservatively, complete tears of the triceps tendon must be repaired to provide active extension at the elbow. Our preferred surgical technique for repair of the acute triceps tendon rupture is presented, as well as strategies for reconstruction of the triceps tendon with an Achilles tendon allograft. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Achilles allograft, bone tunnels, triceps reconstruction, triceps repair, triceps tear.
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reported in 1868 by Partridge. The age of occurrence for a triceps tendon rupture is usually between 30 and 50 years, but has been reported in children, as well as older adults in the eighth decade. The maleto-female ratio is generally 3:2. Systemic diseases such as diabetes mellitus, renal osteodystrophy, and secondary hyperparathyroidism may compromise the tendon insertion and result in a triceps rupture. Chronic olecranon bursitis, triceps olecranon spurring, and intratendinous steroid injections have been associated with triceps ruptures. The use of anabolic steroids can predispose to rupture of the tendon. Poor handling of the triceps tendon during fracture repair surgery or implant arthroplasty may also result in a triceps extension deficit. Severe triceps deficiency may follow repeated elbow surgery, such as revision total elbow arthroplasty.2 RICEPS TENDON RUPTURE WAS FIRST 1
ANATOMY The triceps brachii muscle includes the long, lateral, and medial heads. The long head originates from the From the *Department of Orthopedic Surgery, and Division of Plastic Surgery, Baylor College of Medicine, Houston; and †Fondren Orthopedic Group, 7401 South Main, Houston, TX. Received for publication February 6, 2015; accepted in revised form May 22, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: James B. Bennett, MD, Department of Orthopedic Surgery, and Division of Plastic Surgery, Baylor College of Medicine, Fondren Orthopedic Group, 7401 South Main, Houston, TX 77030; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.05.016
infraglenoid tuberosity, whereas the medial and lateral heads arise from the posterior humerus. A variant fourth head may arise between the triceps and the latissimus dorsi proximally. The insertion of the triceps tendon onto the olecranon has a dome-shaped footprint.3 This footprint covers the width of the olecranon and extends distally into the anconeus and flexor forearm fascia. The radial nerve supplies the triceps muscle. The vascular supply to the triceps muscle is the profunda brachii artery. EVALUATION Triceps tendon rupture may follow an uncoordinated fall on an outstretched arm, or a sudden failure of the triceps with weightlifting or pushing. The physical examination for an acute tear should focus on tenderness to palpation, ecchymosis, and pain with resisted extension. A palpable defect will be present with a complete tear. Inability to extend against gravity will also suggest a complete tear. The modified Thompson squeeze test with the elbow at 90 can be performed to assess triceps tendon integrity. Diagnostic imaging should include x-rays. These x-rays may demonstrate a proximal olecranon triceps traction spur, a small retracted bone avulsion fracture (Fig. 1) or a displaced olecranon fracture (Fig. 2). Magnetic resonance imaging is used for the definitive radiological diagnosis of the triceps injury, and can be used to assess the degree of injury (Fig. 3). INDICATIONS Triceps rupture most commonly occurs at the osseous tendon insertion site. The triceps tendon injury may
Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
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FIGURE 1: Flake bone avulsion from the olecranon with a triceps rupture. The arrow demonstrates a small bone avulsion attached to the triceps tendon.
be a partial musculotendinous tear, an incomplete interstitial laminal tear, or a complete insertional rupture.4 Partial triceps tear may be successfully treated with extension splinting. The expectation for recovery of strength is approximately 3 to 6 months depending on the degree of tear. Tears of 50% or less for the triceps tendon may be treated nonoperatively.5 Complete ruptures need to be addressed through surgical repair of the triceps tendon. Strategies to address acute complete ruptures include repair with nonabsorbable sutures through drill holes or the use of suture anchors. Yeh et al compared the biomechanical strength of 3 repair techniques.5 They determined that greater approximation of the triceps tendon to the bony footprint resulted in better restoration of the anatomy and less motion at the repair site. The anatomical repair they described used both the transosseous cruciate repair technique and bioabsorbable anchors. A single anchor is felt to be insufficient for repair. Chronic tears with retraction may require tendon autograft or allograft reconstruction. Smaller defects may be reconstructed through the V-Y advancement flap as described by Abraham and Pankovich.6 The anconeus rotation flap has also been described and used successfully for smaller tears as described by Sanchez-Sotelo and Morrey.7 Tendon autografts such as the semitendinosus, gracilis, or palmaris tendons have been described but are less successful because of size mismatch to the triceps tendon. The Achilles J Hand Surg Am.
FIGURE 2: Olecranon displaced fracture with triceps functional deficit.
tendon allograft is well suited in shape and size to augment acute repairs or to reconstruct large retracted chronic tears of the triceps when direct repair cannot be performed. Associated avulsion fractures of the olecranon with a large bone fragment will require open reduction and internal fixation of the bone with intramedullary fixation, plate fixation, or tension band wiring techniques, depending on surgeon preference and fracture location. CONTRAINDICATIONS Acute infection of the soft tissues or a joint infection is a contraindication to acute or reconstructive repair. Major neurologic dysfunction of the triceps muscle will negate surgery for a triceps repair. Psychological issues may influence the decision for any surgical repair. Any medical condition that precludes anesthesia would also be a contraindication to surgery. Relative contraindications to surgery could include the poor quality of the skin or soft tissues. Skin loss or soft tissue loss needs to be addressed before surgical repair of tendon rupture or reconstructive triceps tendon surgery. r
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FIGURE 3: Magnetic resonance imaging sagittal image that demonstrates an insertional triceps tendon rupture. The arrow demonstrates the retracted triceps tendon.
FIGURE 4: Acute repair of the triceps tendon using bone tunnels.
TECHNIQUE FOR REPAIR OF THE ACUTE TRICEPS TENDON RUPTURE Complete ruptures of the triceps tendon with extensor weakness should be repaired with surgery. Acute tears should be advanced to the olecranon and repaired with heavy sutures through bone tunnels (Fig. 4). Surgery is performed under general anesthesia with the patient in the supine position on the table. Prone or lateral decubitus position may be alternatively used. Two pillows are placed across the chest to support the arm for surgery. A sterile pneumatic tourniquet is used on the arm, and applied after sterile draping. A 10-cm longitudinal incision is used over the posterior aspect of the elbow. The skin is incised and full thickness subcutaneous flaps are elevated. Seroma fluid from the triceps tendon rupture is usually encountered. Tendon retraction will be noted, and a small bone fragment may be present with the tendon. Occasionally, a laminated tear of the long and the lateral heads is present, with some of the medial head tendon still intact (Fig. 5). The ulnar nerve is identified at the medial aspect of the triceps muscle. Release of the fascia of the upper arm is performed to identify and protect the ulnar nerve, particularly if the triceps muscle needs to be mobilized or advanced for repair. The fascia at the cubital tunnel is also released, although usually without transposition of the ulnar nerve. If a triceps traction spur is still present on the proximal olecranon, the spur is excised. The proximal J Hand Surg Am.
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FIGURE 5: Acute laminated triceps tendon tear.
ulna is then exposed in a subperiosteal fashion, elevating muscle fibers from both sides of the shaft. A 2.4-mm drill is used to create 2 cross-tunnels in the proximal ulna, as well as 1 transverse tunnel. A Hewson suture passer or large Keith needle can be used to pull large sutures from the triceps tendon through the bone tunnels. A #2 Ethibond suture is then weaved into the distal end of the triceps tendon to serve as a traction suture (Fig. 6). This traction suture will assist mobilization of the tendon and will later be passed through the transverse tunnel for repair. #5 Ethibond sutures X 2 are weaved through the medial and lateral aspects of the triceps tendon. Hewson suture passers are then used to pull the large #5 Ethibond sutures through the crossr
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FIGURE 7: Hewson suture passer placed through the bone crosstunnel.
FIGURE 6: Traction suture for the retracted triceps tendon.
tunnels (Fig. 7). The elbow is extended and the triceps tendon is advanced to the olecranon with the traction suture. The #5 Ethibond sutures are tied and the knots are buried. The #2 Ethibond traction suture is passed through the transverse tunnel and also tied. Excellent approximation of the triceps to the olecranon should be achieved (Fig. 8). The fascia of the ulna is then reapproximated with interrupted #1 Ethibond sutures. All suture knots should be buried. The tourniquet is released to evaluate hemostasis. The subcutaneous tissue and skin is then closed in the usual fashion. The incision is dressed with Xeroform and sterile dressings. A posterior fiberglass splint is applied with the elbow in extension.
FIGURE 8: Repair of the acute triceps tendon to the olecranon.
SURGICAL TECHNIQUE FOR REINFORCEMENT AND AUGMENTATION OF TRICEPS TENDON REPAIR WITH AN ACHILLES TENDON ALLOGRAFT When the triceps repair is questionable due to poor soft tissues, or high demand is expected such as in a competitive weightlifter, the repair can be reinforced and augmented with an Achilles tendon allograft (Fig. 9). A 20-cm longitudinal incision is placed on the posterior aspect of the elbow. The skin is incised in a longitudinal manner, elevating large subcutaneous flaps to expose the triceps mechanism. The triceps tendon will be retracted and the tissues may be more fibrotic. Decompression of the ulnar nerve should routinely be performed for chronic retracted tears. The fascia of the upper arm, as well as the cubital tunnel, will need to be released to mobilize the triceps muscle and protect the ulnar nerve. The triceps tendon traction suture with #2 Ethibond is placed into the remaining tendon
available. This traction suture is used to pull on the triceps tendon while mobilizing the muscle and assessing the excursion to the olecranon. The proximal ulna cross-tunnels are then performed as for the acute repair. A 2.4-mm drill is used to create the 2 cross-tunnels at the proximal ulna exiting on each side of the shaft. The #5 Ethibond sutures X 2 are then weaved through the triceps tendon. The #5 Ethibond sutures are passed through the bone tunnels in the ulna with Hewson suture passers. The sutures are tied over bone with the elbow in the extended position. The #2 Ethibond suture is passed through the transverse tunnel and tied. The sutures are left long after tying the knot so they can be later used to secure the distal aspect of the Achilles tendon allograft over the proximal ulna. It is preferable for the triceps tendon to dock to the olecranon, if possible, before placing the allograft. If not possible, the allograft will have to bridge the defect to the muscle.
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FIGURE 10: Achilles tendon allograft placed over the ulna.
FIGURE 9: Augmentation of the triceps repair using an Achilles tendon allograft. FIGURE 11: Achilles tendon allograft patched over the triceps muscle.
A fresh frozen Achilles tendon allograft is thawed and cut to shape. If bone is present on the allograft, this is removed. If an olecranon bone defect is present, the calcaneal bone of the allograft may be left in place with the Achilles tendon, and secured to the proximal ulna with an intramedullary screw, plate, or tension band technique.4 The distal allograft is placed over the proximal ulna and incorporated with the closure of the proximal ulna fascia over the allograft with inverted #1 Ethibond sutures (Fig. 10). The sutures from the bone tunnels can be passed through the allograft and tied for further fixation of the graft to the ulna. All suture knots are buried, so as not to be symptomatic. The allograft is then sutured to the triceps tendon with interrupted #1 Ethibond sutures along the medial and ulnar aspects of the tendon. Finally, the Achilles tendon allograft is sutured to the triceps muscle as a patch with a running #2 Ethibond suture (Fig. 11). The tourniquet is released. Hemostasis is verified. A Hemovac drain can be used if desired. Closure of the subcutaneous tissue and skin is performed, followed by the application of sterile dressings and a posterior fiberglass splint with the elbow in extension. J Hand Surg Am.
TECHNIQUE FOR LARGE DEFECT OF THE TRICEPS TENDON USING THE ACHILLES TENDON ALLOGRAFT AS A BRIDGING GRAFT When there is no triceps tendon, or the muscle has significant proximal retraction, the Achilles tendon allograft will need to be used as a bridging graft (Fig. 12). The triceps muscle should be mobilized for excursion as best possible. The ulnar nerve will require decompression for protection of the nerve, and to mobilize the medial aspect of the triceps muscle. The proximal olecranon will be exposed in a subperiosteal fashion, elevating the fascia and muscle from the sides of the shaft of the ulna. The olecranon bone cross-tunnels will not be required. #1 Ethibond sutures can be passed transversely through the proximal ulna with large Keith needles. These #1 Ethibond sutures can then be used to secure the distal aspect of the Achilles tendon allograft over the proximal ulna. The fascia of the ulna will then be tied over the Achilles tendon allograft. r
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Competitive athletes may require a full year to maximize extension strength.8 Bracing might be considered for athletic competition during the first year after surgical repair. COMPLICATIONS Infection, acute or chronic, must be addressed with proper diagnosis, debridement, and antibiotics. Associated fractures and dislocations may complicate the repair process and the rehabilitation of the elbow.9 Extensor weakness or extensor lag may follow incomplete rehabilitation or inadequate splinting postop. Failure of the repair may result from a suture pullout or an anchor failure, and must be addressed with the consideration of a repeat repair or augmentation with an allograft. Incomplete fracture fixation or a nonunion of the olecranon fracture will lead to a poor result, and may require revision. Return to full contact sports activity before 6 months may result in a repeat rupture or attenuation of the repair. Neurovascular injury is rare with isolated triceps surgery. PEARLS AND PITFALLS FIGURE 12: Reconstruction of the triceps using an Achilles tendon allograft as a bridging graft.
Place 2 pillows across the chest under the drapes to
The elbow is then extended and the Achilles tendon allograft is tubed with #2 Ethibond sutures to create a robust tendon. The broader portion of the Achilles tendon allograft is then placed onto the muscle of the mobilized triceps. If there is a tendon stump, this is passed through the Achilles tendon allograft and sutured with a Pulvertaft repair technique, if possible. The remaining allograft is then positioned as a patch over the triceps muscle with a running #2 Ethibond suture.
REHABILITATION After triceps repair or reconstruction, the elbow is immobilized in extension for 6 weeks. The patient is initially casted in 20 to 30 of extension for 2 weeks, then 60 of extension for 2 weeks, and then 90 of flexion for 2 weeks. The patient may then have a removable splint for the active range of motion. Extension and flexion is encouraged, but without resistance. Light resistive exercises may then begin after 12 weeks, emphasizing isometric and eccentric kick-back exercises with a light weight or tubing. At 6 months, full activity is allowed for the noncompetitive athlete, with no lifting restrictions for the gym or work. J Hand Surg Am.
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facilitate access to the posterior elbow with the patient in supine position and decrease the difficulty of holding the arm. Do not operate through abrasions or unhealed skin. Wait for open wounds to heal before surgery. Poor soft tissues may need to be addressed with a flap or other coverage before reconstruction. Always identify and protect the ulnar nerve. This is the nerve most at risk for the triceps repair or reconstruction, especially if scar tissue is present. Mobilize the triceps muscle and tendon to reach the olecranon, even if the elbow needs to be in extension. Contact of the triceps tendon to the proximal olecranon bone is always better than a bridging allograft, if possible. Use large nonabsorbable sutures for the repair. The triceps is a large tendon and will carry heavy loads. Bury all suture knots over the proximal ulna, so as to be less symptomatic. A fresh frozen Achilles tendon allograft is mechanically preferable to a freeze-dried allograft. The elbow can be tight in extension after repair. The triceps muscle will stretch with serial casting during rehabilitation after surgery. The flexion of the elbow recovers over time. Splint the elbow in extension to protect the repair and the posterior skin incision. Do not be in a hurry
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to advance the range of motion after surgery. Contracture of the elbow is rare after this surgery. The use of lightweight eccentric exercises after 3 months should be emphasized during recovery to strengthen the triceps tendon. Avoid deep elbow dip or pushup exercises against resistance for at least 6 months.
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5. 6.
7.
REFERENCES 1. Partridge A. A case report of a case of ruptured triceps cubiti. Medical Times Gazette. 1868;1:175. 2. Celli A, Arash A, Adams RA, Morrey BF. Triceps insufficiency following total elbow arthroplasty. J Bone Joint Surg Am. 2005;87(9): 1957e1964. 3. Yeh PC, Stephen KT, Solovyova O, Obopilwe E, Smart LR, Mazzocca AD, Sethi PM. Distal triceps tendon footprint in a
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9.
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biomechanical analysis of three repair techniques. Am J Sports Med. 2010;38(5):1025e1033. Morrey BF. Rupture of the triceps tendon. In: Morrey BF, ed. The Elbow and Its Disorders. 4th ed. Philadelphia: Saunders; 2009: 536e546. Yeh PC, Dobbs SD, Smart LR, Mazzocca AD, Sethi PM. Distal triceps rupture. J Am Acad Orthop Surg. 2010;18(1):31e40. Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon: treatment by V-Y tendinous flap. J Bone Joint Surg Am. 1975;57(2): 253e255. Sanchez-Sotelo J, Morrey BF. Surgical techniques for reconstruction of chronic insufficiency of the triceps: rotation flap using anconeus and tendo-Achilles allograft. J Bone Joint Surg Br. 2002;84(8): 1116e1120. Tom JA, Kumar NS, Cerynik DL, Mashru R, Parrella MS. Diagnosis and treatment of triceps tendon injuries: a review of the literature. Clin J Sport Med. 2014;24(3):197e204. Yoon MY, Koris MJ, Ortiz JA, Papandrea RF. Triceps avulsion, radial head fracture, and medial collateral ligament rupture about the elbow. J Shoulder Elbow Surg. 2012;21(2):12e17.
Vol. -, - 2015
Triceps Tendon Repair James B. Bennett, MD,* Thomas L. Mehlhoff, MD†
Complete triceps tendon rupture is relatively rare, but more commonly seen in the athletic population. Loss of extension strength is the functional deficit for the elbow after rupture of the triceps tendon. Although partial tears may be treated conservatively, complete tears of the triceps tendon must be repaired to provide active extension at the elbow. Our preferred surgical technique for repair of the acute triceps tendon rupture is presented, as well as strategies for reconstruction of the triceps tendon with an Achilles tendon allograft. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Achilles allograft, bone tunnels, triceps reconstruction, triceps repair, triceps tear.
T
reported in 1868 by Partridge. The age of occurrence for a triceps tendon rupture is usually between 30 and 50 years, but has been reported in children, as well as older adults in the eighth decade. The maleto-female ratio is generally 3:2. Systemic diseases such as diabetes mellitus, renal osteodystrophy, and secondary hyperparathyroidism may compromise the tendon insertion and result in a triceps rupture. Chronic olecranon bursitis, triceps olecranon spurring, and intratendinous steroid injections have been associated with triceps ruptures. The use of anabolic steroids can predispose to rupture of the tendon. Poor handling of the triceps tendon during fracture repair surgery or implant arthroplasty may also result in a triceps extension deficit. Severe triceps deficiency may follow repeated elbow surgery, such as revision total elbow arthroplasty.2 RICEPS TENDON RUPTURE WAS FIRST 1
ANATOMY The triceps brachii muscle includes the long, lateral, and medial heads. The long head originates from the From the *Department of Orthopedic Surgery, and Division of Plastic Surgery, Baylor College of Medicine, Houston; and †Fondren Orthopedic Group, 7401 South Main, Houston, TX. Received for publication February 6, 2015; accepted in revised form May 22, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: James B. Bennett, MD, Department of Orthopedic Surgery, and Division of Plastic Surgery, Baylor College of Medicine, Fondren Orthopedic Group, 7401 South Main, Houston, TX 77030; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.05.016
infraglenoid tuberosity, whereas the medial and lateral heads arise from the posterior humerus. A variant fourth head may arise between the triceps and the latissimus dorsi proximally. The insertion of the triceps tendon onto the olecranon has a dome-shaped footprint.3 This footprint covers the width of the olecranon and extends distally into the anconeus and flexor forearm fascia. The radial nerve supplies the triceps muscle. The vascular supply to the triceps muscle is the profunda brachii artery. EVALUATION Triceps tendon rupture may follow an uncoordinated fall on an outstretched arm, or a sudden failure of the triceps with weightlifting or pushing. The physical examination for an acute tear should focus on tenderness to palpation, ecchymosis, and pain with resisted extension. A palpable defect will be present with a complete tear. Inability to extend against gravity will also suggest a complete tear. The modified Thompson squeeze test with the elbow at 90 can be performed to assess triceps tendon integrity. Diagnostic imaging should include x-rays. These x-rays may demonstrate a proximal olecranon triceps traction spur, a small retracted bone avulsion fracture (Fig. 1) or a displaced olecranon fracture (Fig. 2). Magnetic resonance imaging is used for the definitive radiological diagnosis of the triceps injury, and can be used to assess the degree of injury (Fig. 3). INDICATIONS Triceps rupture most commonly occurs at the osseous tendon insertion site. The triceps tendon injury may
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
TRICEPS TENDON REPAIR
FIGURE 1: Flake bone avulsion from the olecranon with a triceps rupture. The arrow demonstrates a small bone avulsion attached to the triceps tendon.
be a partial musculotendinous tear, an incomplete interstitial laminal tear, or a complete insertional rupture.4 Partial triceps tear may be successfully treated with extension splinting. The expectation for recovery of strength is approximately 3 to 6 months depending on the degree of tear. Tears of 50% or less for the triceps tendon may be treated nonoperatively.5 Complete ruptures need to be addressed through surgical repair of the triceps tendon. Strategies to address acute complete ruptures include repair with nonabsorbable sutures through drill holes or the use of suture anchors. Yeh et al compared the biomechanical strength of 3 repair techniques.5 They determined that greater approximation of the triceps tendon to the bony footprint resulted in better restoration of the anatomy and less motion at the repair site. The anatomical repair they described used both the transosseous cruciate repair technique and bioabsorbable anchors. A single anchor is felt to be insufficient for repair. Chronic tears with retraction may require tendon autograft or allograft reconstruction. Smaller defects may be reconstructed through the V-Y advancement flap as described by Abraham and Pankovich.6 The anconeus rotation flap has also been described and used successfully for smaller tears as described by Sanchez-Sotelo and Morrey.7 Tendon autografts such as the semitendinosus, gracilis, or palmaris tendons have been described but are less successful because of size mismatch to the triceps tendon. The Achilles J Hand Surg Am.
FIGURE 2: Olecranon displaced fracture with triceps functional deficit.
tendon allograft is well suited in shape and size to augment acute repairs or to reconstruct large retracted chronic tears of the triceps when direct repair cannot be performed. Associated avulsion fractures of the olecranon with a large bone fragment will require open reduction and internal fixation of the bone with intramedullary fixation, plate fixation, or tension band wiring techniques, depending on surgeon preference and fracture location. CONTRAINDICATIONS Acute infection of the soft tissues or a joint infection is a contraindication to acute or reconstructive repair. Major neurologic dysfunction of the triceps muscle will negate surgery for a triceps repair. Psychological issues may influence the decision for any surgical repair. Any medical condition that precludes anesthesia would also be a contraindication to surgery. Relative contraindications to surgery could include the poor quality of the skin or soft tissues. Skin loss or soft tissue loss needs to be addressed before surgical repair of tendon rupture or reconstructive triceps tendon surgery. r
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FIGURE 3: Magnetic resonance imaging sagittal image that demonstrates an insertional triceps tendon rupture. The arrow demonstrates the retracted triceps tendon.
FIGURE 4: Acute repair of the triceps tendon using bone tunnels.
TECHNIQUE FOR REPAIR OF THE ACUTE TRICEPS TENDON RUPTURE Complete ruptures of the triceps tendon with extensor weakness should be repaired with surgery. Acute tears should be advanced to the olecranon and repaired with heavy sutures through bone tunnels (Fig. 4). Surgery is performed under general anesthesia with the patient in the supine position on the table. Prone or lateral decubitus position may be alternatively used. Two pillows are placed across the chest to support the arm for surgery. A sterile pneumatic tourniquet is used on the arm, and applied after sterile draping. A 10-cm longitudinal incision is used over the posterior aspect of the elbow. The skin is incised and full thickness subcutaneous flaps are elevated. Seroma fluid from the triceps tendon rupture is usually encountered. Tendon retraction will be noted, and a small bone fragment may be present with the tendon. Occasionally, a laminated tear of the long and the lateral heads is present, with some of the medial head tendon still intact (Fig. 5). The ulnar nerve is identified at the medial aspect of the triceps muscle. Release of the fascia of the upper arm is performed to identify and protect the ulnar nerve, particularly if the triceps muscle needs to be mobilized or advanced for repair. The fascia at the cubital tunnel is also released, although usually without transposition of the ulnar nerve. If a triceps traction spur is still present on the proximal olecranon, the spur is excised. The proximal J Hand Surg Am.
3
FIGURE 5: Acute laminated triceps tendon tear.
ulna is then exposed in a subperiosteal fashion, elevating muscle fibers from both sides of the shaft. A 2.4-mm drill is used to create 2 cross-tunnels in the proximal ulna, as well as 1 transverse tunnel. A Hewson suture passer or large Keith needle can be used to pull large sutures from the triceps tendon through the bone tunnels. A #2 Ethibond suture is then weaved into the distal end of the triceps tendon to serve as a traction suture (Fig. 6). This traction suture will assist mobilization of the tendon and will later be passed through the transverse tunnel for repair. #5 Ethibond sutures X 2 are weaved through the medial and lateral aspects of the triceps tendon. Hewson suture passers are then used to pull the large #5 Ethibond sutures through the crossr
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FIGURE 7: Hewson suture passer placed through the bone crosstunnel.
FIGURE 6: Traction suture for the retracted triceps tendon.
tunnels (Fig. 7). The elbow is extended and the triceps tendon is advanced to the olecranon with the traction suture. The #5 Ethibond sutures are tied and the knots are buried. The #2 Ethibond traction suture is passed through the transverse tunnel and also tied. Excellent approximation of the triceps to the olecranon should be achieved (Fig. 8). The fascia of the ulna is then reapproximated with interrupted #1 Ethibond sutures. All suture knots should be buried. The tourniquet is released to evaluate hemostasis. The subcutaneous tissue and skin is then closed in the usual fashion. The incision is dressed with Xeroform and sterile dressings. A posterior fiberglass splint is applied with the elbow in extension.
FIGURE 8: Repair of the acute triceps tendon to the olecranon.
SURGICAL TECHNIQUE FOR REINFORCEMENT AND AUGMENTATION OF TRICEPS TENDON REPAIR WITH AN ACHILLES TENDON ALLOGRAFT When the triceps repair is questionable due to poor soft tissues, or high demand is expected such as in a competitive weightlifter, the repair can be reinforced and augmented with an Achilles tendon allograft (Fig. 9). A 20-cm longitudinal incision is placed on the posterior aspect of the elbow. The skin is incised in a longitudinal manner, elevating large subcutaneous flaps to expose the triceps mechanism. The triceps tendon will be retracted and the tissues may be more fibrotic. Decompression of the ulnar nerve should routinely be performed for chronic retracted tears. The fascia of the upper arm, as well as the cubital tunnel, will need to be released to mobilize the triceps muscle and protect the ulnar nerve. The triceps tendon traction suture with #2 Ethibond is placed into the remaining tendon
available. This traction suture is used to pull on the triceps tendon while mobilizing the muscle and assessing the excursion to the olecranon. The proximal ulna cross-tunnels are then performed as for the acute repair. A 2.4-mm drill is used to create the 2 cross-tunnels at the proximal ulna exiting on each side of the shaft. The #5 Ethibond sutures X 2 are then weaved through the triceps tendon. The #5 Ethibond sutures are passed through the bone tunnels in the ulna with Hewson suture passers. The sutures are tied over bone with the elbow in the extended position. The #2 Ethibond suture is passed through the transverse tunnel and tied. The sutures are left long after tying the knot so they can be later used to secure the distal aspect of the Achilles tendon allograft over the proximal ulna. It is preferable for the triceps tendon to dock to the olecranon, if possible, before placing the allograft. If not possible, the allograft will have to bridge the defect to the muscle.
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FIGURE 10: Achilles tendon allograft placed over the ulna.
FIGURE 9: Augmentation of the triceps repair using an Achilles tendon allograft. FIGURE 11: Achilles tendon allograft patched over the triceps muscle.
A fresh frozen Achilles tendon allograft is thawed and cut to shape. If bone is present on the allograft, this is removed. If an olecranon bone defect is present, the calcaneal bone of the allograft may be left in place with the Achilles tendon, and secured to the proximal ulna with an intramedullary screw, plate, or tension band technique.4 The distal allograft is placed over the proximal ulna and incorporated with the closure of the proximal ulna fascia over the allograft with inverted #1 Ethibond sutures (Fig. 10). The sutures from the bone tunnels can be passed through the allograft and tied for further fixation of the graft to the ulna. All suture knots are buried, so as not to be symptomatic. The allograft is then sutured to the triceps tendon with interrupted #1 Ethibond sutures along the medial and ulnar aspects of the tendon. Finally, the Achilles tendon allograft is sutured to the triceps muscle as a patch with a running #2 Ethibond suture (Fig. 11). The tourniquet is released. Hemostasis is verified. A Hemovac drain can be used if desired. Closure of the subcutaneous tissue and skin is performed, followed by the application of sterile dressings and a posterior fiberglass splint with the elbow in extension. J Hand Surg Am.
TECHNIQUE FOR LARGE DEFECT OF THE TRICEPS TENDON USING THE ACHILLES TENDON ALLOGRAFT AS A BRIDGING GRAFT When there is no triceps tendon, or the muscle has significant proximal retraction, the Achilles tendon allograft will need to be used as a bridging graft (Fig. 12). The triceps muscle should be mobilized for excursion as best possible. The ulnar nerve will require decompression for protection of the nerve, and to mobilize the medial aspect of the triceps muscle. The proximal olecranon will be exposed in a subperiosteal fashion, elevating the fascia and muscle from the sides of the shaft of the ulna. The olecranon bone cross-tunnels will not be required. #1 Ethibond sutures can be passed transversely through the proximal ulna with large Keith needles. These #1 Ethibond sutures can then be used to secure the distal aspect of the Achilles tendon allograft over the proximal ulna. The fascia of the ulna will then be tied over the Achilles tendon allograft. r
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Competitive athletes may require a full year to maximize extension strength.8 Bracing might be considered for athletic competition during the first year after surgical repair. COMPLICATIONS Infection, acute or chronic, must be addressed with proper diagnosis, debridement, and antibiotics. Associated fractures and dislocations may complicate the repair process and the rehabilitation of the elbow.9 Extensor weakness or extensor lag may follow incomplete rehabilitation or inadequate splinting postop. Failure of the repair may result from a suture pullout or an anchor failure, and must be addressed with the consideration of a repeat repair or augmentation with an allograft. Incomplete fracture fixation or a nonunion of the olecranon fracture will lead to a poor result, and may require revision. Return to full contact sports activity before 6 months may result in a repeat rupture or attenuation of the repair. Neurovascular injury is rare with isolated triceps surgery. PEARLS AND PITFALLS FIGURE 12: Reconstruction of the triceps using an Achilles tendon allograft as a bridging graft.
Place 2 pillows across the chest under the drapes to
The elbow is then extended and the Achilles tendon allograft is tubed with #2 Ethibond sutures to create a robust tendon. The broader portion of the Achilles tendon allograft is then placed onto the muscle of the mobilized triceps. If there is a tendon stump, this is passed through the Achilles tendon allograft and sutured with a Pulvertaft repair technique, if possible. The remaining allograft is then positioned as a patch over the triceps muscle with a running #2 Ethibond suture.
REHABILITATION After triceps repair or reconstruction, the elbow is immobilized in extension for 6 weeks. The patient is initially casted in 20 to 30 of extension for 2 weeks, then 60 of extension for 2 weeks, and then 90 of flexion for 2 weeks. The patient may then have a removable splint for the active range of motion. Extension and flexion is encouraged, but without resistance. Light resistive exercises may then begin after 12 weeks, emphasizing isometric and eccentric kick-back exercises with a light weight or tubing. At 6 months, full activity is allowed for the noncompetitive athlete, with no lifting restrictions for the gym or work. J Hand Surg Am.
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facilitate access to the posterior elbow with the patient in supine position and decrease the difficulty of holding the arm. Do not operate through abrasions or unhealed skin. Wait for open wounds to heal before surgery. Poor soft tissues may need to be addressed with a flap or other coverage before reconstruction. Always identify and protect the ulnar nerve. This is the nerve most at risk for the triceps repair or reconstruction, especially if scar tissue is present. Mobilize the triceps muscle and tendon to reach the olecranon, even if the elbow needs to be in extension. Contact of the triceps tendon to the proximal olecranon bone is always better than a bridging allograft, if possible. Use large nonabsorbable sutures for the repair. The triceps is a large tendon and will carry heavy loads. Bury all suture knots over the proximal ulna, so as to be less symptomatic. A fresh frozen Achilles tendon allograft is mechanically preferable to a freeze-dried allograft. The elbow can be tight in extension after repair. The triceps muscle will stretch with serial casting during rehabilitation after surgery. The flexion of the elbow recovers over time. Splint the elbow in extension to protect the repair and the posterior skin incision. Do not be in a hurry
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to advance the range of motion after surgery. Contracture of the elbow is rare after this surgery. The use of lightweight eccentric exercises after 3 months should be emphasized during recovery to strengthen the triceps tendon. Avoid deep elbow dip or pushup exercises against resistance for at least 6 months.
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REFERENCES 1. Partridge A. A case report of a case of ruptured triceps cubiti. Medical Times Gazette. 1868;1:175. 2. Celli A, Arash A, Adams RA, Morrey BF. Triceps insufficiency following total elbow arthroplasty. J Bone Joint Surg Am. 2005;87(9): 1957e1964. 3. Yeh PC, Stephen KT, Solovyova O, Obopilwe E, Smart LR, Mazzocca AD, Sethi PM. Distal triceps tendon footprint in a
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biomechanical analysis of three repair techniques. Am J Sports Med. 2010;38(5):1025e1033. Morrey BF. Rupture of the triceps tendon. In: Morrey BF, ed. The Elbow and Its Disorders. 4th ed. Philadelphia: Saunders; 2009: 536e546. Yeh PC, Dobbs SD, Smart LR, Mazzocca AD, Sethi PM. Distal triceps rupture. J Am Acad Orthop Surg. 2010;18(1):31e40. Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon: treatment by V-Y tendinous flap. J Bone Joint Surg Am. 1975;57(2): 253e255. Sanchez-Sotelo J, Morrey BF. Surgical techniques for reconstruction of chronic insufficiency of the triceps: rotation flap using anconeus and tendo-Achilles allograft. J Bone Joint Surg Br. 2002;84(8): 1116e1120. Tom JA, Kumar NS, Cerynik DL, Mashru R, Parrella MS. Diagnosis and treatment of triceps tendon injuries: a review of the literature. Clin J Sport Med. 2014;24(3):197e204. Yoon MY, Koris MJ, Ortiz JA, Papandrea RF. Triceps avulsion, radial head fracture, and medial collateral ligament rupture about the elbow. J Shoulder Elbow Surg. 2012;21(2):12e17.
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