Triceps Tendon Repair

Abstract

Background:

Triceps tendon tear has a low incidence. Therefore, surgical repair of the triceps tendon is performed only by a small number of orthopedic surgeons.

Indications:

To provide information regarding the current treatment algorithm and surgical technique.

Technique Description:

The triceps tendon is exposed through a posterior approach. The tendon is then longitudinally split to expose the deep degenerated tissue. The degenerated tissue and any existing osteophytes are removed. The superficial layer of the tendon is sewn back down to the deeper layer of the tendon. The tendon is advanced distally, and the split incision is closed. This is followed by double–row repair with suture anchors.

Results:

Excellent clinical outcomes have been reported with re–rupture rates of around 7% at a 4–year follow–up.

Discussion/Conclusion:

Partial and complete ruptures of the triceps tendon require surgical treatment. Current surgical treatment options yield excellent clinical outcomes.

Graphical Abstract

This is a visual representation of the abstract.

VIDEO TRANSCRIPT

This is Dr. Mark Schickendantz, and I will be speaking to you today about triceps tendon injuries and their subsequent repair.

I do have a disclosure; I am a consultant for Arthrex.

Triceps injuries tend to be rare. They are most often seen in men in their 4th to 6th decade. They are typically an acute injury, such as a fall on an outstretched hand. We also see this in weight–lifting and football. We sometimes see this as the result of a direct blow to the back of the elbow. Overuse, anabolic steroid use, and systemic corticosteroid use, or injections are all considered risk factors for a triceps tendon rupture. Comorbid conditions are also commonly seen in some of our older patients.

Patients typically complain of pain, swelling, ecchymosis, and one of the hallmarks is weakness with active elbow extension.

Routine workup includes a history, physical examination, and radiologic evaluation.

Clinically, we are looking for swelling and ecchymosis around the backside of the elbow. There is typically a palpable gap at the proximal olecranon and an inability to actively extend against gravity, particularly in a high–grade injury with complete rupture. The modified Thompson test can be useful as well. The examiner squeezes the muscle belly of the triceps in an attempt to passively extend the elbow against gravity—a positive test is an inability to do that.

On imaging, the telltale sign is called the “flake” sign, where a piece of the tip of the olecranon—oftentimes associated with an olecranon spur—is seen proximal to the typical location of the triceps attachment on the olecranon. Ultrasound can also be useful, it is very operator–dependent, but it can be used as well. On magnetic resonance imaging (MRI), you will see a defect in the tendon of the triceps—you can see that in the middle image here on our right—the deepest fibers of the triceps tendon remain attached—that is a very typical finding where the more superficial fibers delaminate away and leave this fluid–filled gap. That is very characteristic in acute rupture of the triceps tendon.

This is what it looks like up close. We can see that olecranon spur on the lateral x–ray of the elbow, and you can see the 2 little flecks of bone—the “flake” sign—up in the triceps tendon as it has been retracted away from its attachment at the olecranon. On the MRIs above, particularly on the sagittal view, you get a nice look at the rupture of that outer layer of the triceps tendon. You can see that on the axial view as well—the disruption in the normal course of the tendon.

This is a 50-year-old, otherwise healthy man who had a slip and fall 6 days ago, landing backward and bracing himself from falling. He complained of bruising and swelling in the elbow. He does have a history of a left elbow injury 16 years ago that was associated with pain and swelling. It resolved without any further issues. On examination at this presentation, he had a visible and palpable defect on the distal triceps attachment above the olecranon. There was ecchymosis in this region. The elbow is noted to have a full range of motion and weakness with active elbow extension. The radiographs that you saw earlier showed a large traction spur at the olecranon and the ossification or “flake” sign in the proximal triceps tendon itself. The MRI shows classic findings of avulsion of the triceps with a 4–cm gap between the attachment site and the end of the tendon.

Surgery is often recommended for treatment of complete rupture of the triceps tendon, particularly in the acute setting. It can be more challenging in the chronic setting. We found that the best way to do this is in the lateral decubitus position with the arm supported on an arm holder, and we do this under tourniquet.

This is a triceps tendon repair in a left elbow. The patient is in the lazy lateral decubitus position with the arm held in a saddle–like arm holder. It is important when we are working around the elbow to know where the ulnar nerve is. We have marked the lateral and the medial side, outlining our bony landmarks. There is the radial head. The incision is going to start about 4 cm proximal to the tip of the olecranon and gently curve laterally around the olecranon tip. We are going to avoid going medial—as that is where the ulnar nerve is. Typically, you do not have to expose the ulnar nerve—just understand where it is located.

The exposure is done sharply with a 15 blade. As you get down to the olecranon tip, you may run into the bursa—you saw a little bursal fluid right there. We will go ahead and incise this and create some pretty good–sized skin flaps—this is amenable to that. Once we have created those skin flaps, we will go ahead and feel our triceps tendon. What we are feeling here and seeing is that the tendon itself has been torn and delaminated, but the deeper portions are still attached. The superficial portion is what is torn and retracted proximally.

We are going to go ahead and release the remaining tendon off the olecranon footprint to mobilize the triceps tendon as much as we possibly can. We will come in and clean out any areas of degenerative tendon that does not look too viable. We will come in with a rongeur for this, and then we will take a curette and clean the remaining tissue off of the olecranon. We will bring our tension proximal, which you are seeing here is the area of delamination, and you see the torn edges of the tendon starting to come into our view. Again, the deeper fibers seem to be attached. There is the area of delamination, you can see the damaged tissue that we are encountering now, and we are going to want to make sure that we get this nice and mobile so we can excise this area of degeneration and then advance our tendon distally as much as we can. We are going to go ahead and open this up a little further, and you will see how damaged this is. This is delaminated away from itself. This is pretty typical for these triceps tendon ruptures. You can see the real poor quality of this tissue as you open this up more proximally. An important tip to make sure that you take this up as proximal as you can. Make sure you do not miss any of this diseased tendon. What we are going to want to do is cut this diseased tendon out of here. This is not going to be something you can just repair primarily. This tissue is very unhealthy. It is very friable, as you can see coming out quite easily with our rongeur.

Once we have cleaned out those layers, we are going to then close that layer, that delaminated area. The superficial layer of the tendon is going to be sewn back down to the deeper layer of the tendon. We are going to try and advance that tendon distally as we go as much as we possibly can. You can see this has been retracted up proximally quite a bit. We are not going to be able to get all of it back down, but we will advance it as much as we possibly can. We are using No. 2 permanent sutures to do this part of the closure of the delaminated area. Once we are happy that we have got this closed, we will go ahead and close that split that we made, again using a No. 2 permanent suture. You can probably run that suture here, but we have elected to do an interrupted stitch.

Finally, as we get on toward the olecranon, I am going to mark 4 areas on the olecranon where our drill is going to go to recreate our footprint. We are going to pass 4 suture anchors into this olecranon footprint to give us really nice coverage and great fixation. These are single–loaded anchors. You can also use a double–loaded anchor. Here it has got a No. 2 permanent suture on it. This is a single–loaded suture anchor, and again we are going to put 4 of these in here. We will place all 4 of these anchors prior to doing any suture passage. This drill has a positive stop which is about 12 mm in depth, so it should keep you out of the joint as long as you are reasonably centered on the bone. Once we get all 4 of these anchors placed, we are then going to pass these sutures in a mattress–stitch fashion. We start proximally passing each limb of the suture through each flap of tissue here in a mattress–stitch fashion—so you will have 8 strands of suture coming through your triceps tendon. Once those are passed, we will go ahead and tie these mattress sutures over each of the anchors, and it gives us nice secure fixation. We are going to keep those limbs long, and then we will tie those together, so we will tie those ones proximal, medial, and lateral and then distal, medial, and lateral. You can see that brings that down nicely and gives you excellent coverage over the olecranon footprint. Closure is going to be routine with interrupted subcutaneous sutures, and then as this is an extensor area, the elbow can flex, we are going to want to use nylon sutures for the skin.

Potential complications following surgery can include re–rupture, infection is rare, persistent pain is not typical, calcifications in the tendon can be seen, subcutaneous adhesions can occur in patients who have had a lot of dissection and advancement of a retracted tendon.

Following surgery, the first week is spent in a postoperative splint, mobilized at typically 30° of flexion. Complete extension is difficult for the patients to tolerate, so we usually allow them some flexion in their elbow. Beginning at week 2, we will bring them out of the splint and put them in a hinged elbow orthosis, gradually increasing their flexion a week at a time at 15° increments as tolerated. Our goal is to get 90° by week 5 and hopefully you are looking at full flexion by about week 6. Once they gain their range of motion back, we will allow active extension against gravity at week 6. Usually, we do not start any actual resistance strengthening until 12 weeks postoperative.

Return to sports guidelines include unrestricted activity and return to sports typically at about 6 months.

What are the outcomes in the literature? Actually, the results are pretty good. This is a retrospective cohort, level 3 study published in The Journal of Shoulder and Elbow Surgery in 2017 looking at 56 patients with a mean age of about 53. Two different repair techniques, transosseus and suture anchor, repair both leading to good improvement in the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder, and Hand (DASH) Score. The DASH score was a little lower in the transossesus repairs but it was not felt to be clinically relevant. Rerupture was about 7% in this group of 56 patients.

Another level 4 case series published in The Orthopedic Journal of Sports Medicine in 2019 looks at transosseus repair, suture anchor repair, and primary repair. They had similar outcomes in multiple scores across all 3 groups and did not see any reruptures in this case series of 69 patients.