Abstract
Background:
Triceps tendon ruptures typically result from a forceful elbow eccentric contraction. The goal of a distal triceps tendon repair is to reattach the torn tendon back to the olecranon. Surgery is indicated for patients with complete rupture of the triceps tendon or symptomatic partial tears with failed conservative management. The complication rate occurs in 22% of patients postoperatively; however, only 0% to 4% of patients suffer a re-rupture of the tendon.
Indications:
We present a case of a highly active 38-year-old right-hand dominant man with acute onset of left posterior elbow pain following 1-handed pushup resulting in a complete distal triceps avulsion with 1.5 cm retraction.
Technique:
The distal triceps avulsion was repaired in a double row fashion using 2 double-loaded all-suture anchors in the medial row and anchor in the lateral row through a posterior approach.
Results:
Full anatomic footprint coverage was able to be achieved intraoperatively, and gentle range of motion from 0 to 90 degrees of flexion did not result in gap formation.
Discussion/Conclusion:
Successful outcomes with full anatomic footprint coverage of the distal triceps tendon can be achieved through a double row repair configuration.
This is a visual representation of the abstract.
Video Transcript
Distal Triceps Tendon Injury presented by Dr John Matthews and co-authors Ryan Paul and Dr Kevin Freedman.
None of the authors have a disclosure to mention.
The triceps is a pennate muscle composed of 3 heads: the long head originating from the infra-glenoid tuberosity, lateral head originating off the posterior humerus proximal to the spiral groove, and the medial head which is the deepest and originates distal to the spiral groove off. It is innervated by the radial nerve with the main function of providing elbow extension.
All 3 heads of the triceps converge to insert on the proximal olecranon. Cadaveric studies demonstrated the insertion begins 12 mm distal to the tip of the ulna and is domeshaped measuring on average 21 mm wide by 13mm long. There is also a lateral triceps expansion that occasionally remains intact despite a full thickness tendon tear which can provide elbow extension, although significantly weaker.
Typically, triceps injuries occur in men between 30 and 50 years old. Injury usually occurs due to a forceful elbow eccentric contraction and frequently occurs at the insertion site. On rare circumstances, the injury occurs at the musculotendinous junction or within the muscle belly.
Clinically, triceps ruptures may present with a history of a popping sensation with associated pain and bruising.
On examination, it is important to inspect for deformity or asymmetry. Acutely, patients may have ecchymosis and swelling overlying the olecranon. There may be a palpable defect and weaker extension. Elbow range of motion and neurologic status should be documented. Modified Thompson squeeze test can be performed through a firm compression of the mid-portion of the triceps. A positive test equates to a lack of elbow extension suggestive of a complete rupture of the tendon and the lateral expansion.
X-rays should be obtained to evaluate for associated fracture or avulsion. A magnetic resonance imaging (MRI)/ultrasound should also be considered to confirm the diagnosis or for evaluation of a partial tear, but it is not always necessary if there is clinical evidence of a full thickness tear.
Treatment options depend on the degree of tear, location, and patient's demands. Nonoperative management can be considered in partial tears involving <50% of the tendon with maintained strength, muscle belly disruptions, and low demand patients or those that are poor surgical candidates.
Operative indications include acute complete tears or partial tears over >50% with associated weakness and those that have failed non-operative management.
There are a variety of published operative techniques; the suture anchor fixation is the described technique in this case, but other techniques include trans-osseous cruciate, anatomic-trans-osseous equivalent, knotless anatomic footprint repair, and speed bridge technique.
For this case, the patient was a highly active 38-year-old right-hand-dominant man weight lifter who sustained an injury while attempting a 1-handed pushup.
On examination, he was 5′8′′, 160 pounds. Visual inspection of the elbow demonstrated ecchymosis over the olecranon with swelling and a notable deformity. He had a palpable defect along the distal triceps and 2/5 strength with resisted elbow extension.
The patient presented with a video recording of his injury. While attempting a 1-handed pushup, the patient sustained a distal triceps injury with the elbow at 15 degrees of flexion and eccentric load. An audible pop is heard with associated discomfort.
Plain radiographs were obtained and did not demonstrate any osseous abnormality.
A sagittal T2 MRI demonstrated a complete distal triceps avulsion with 1.5 cm retraction and associated edema.
Surgical intervention was recommended for this patient due to his age, activity level, and degree of tear.
The patient was taken to the operating room and positioned in the lateral decubitus position and a nonsterile tourniquet applied as far proximally as possible. The arm was prepped and draped in the usual sterile fashion.
An M and L were marked on the elbow to represent the medial and lateral aspects in consideration of the ulnar nerve.
A curvilinear incision was then marked over the distal humerus and proximal ulnar deviating radially to avoid the ulnar nerve.
After time out was performed, the arm was exsanguinated, and tourniquet inflated.
The curvilinear incision was made laterally based on the olecranon.
Dissection was carried down to the triceps fascia and skin flaps were made. Care was taken to avoid injury to the ulnar nerve.
The distal triceps tendon was then identified and mobilized. One tip in cases of semi-acute or chronic tears is to ensure full mobility of the triceps tendon is achieved with release of adhesive bands and scar tissue to allow for easier re-attachment and less tension repair.
The olecranon was prepared with a rougeur to remove any remaining soft tissue to a smooth bleeding base. The remaining tendon attached was left in place for over-sowing following repair.
Next the proximal ulna periosteum is incised in preparation for the lateral row anchor for the double row repair.
Next the drill guide was positioned along the distal ulna and held firmly in place to prevent skiving. It is important to ensure the trajectory of the drill is angled distally and posteriorly to avoid joint penetration and making sure to leave room for a second anchor on the lateral aspect.
After the tunnel is drilled, it is crucial to maintain the position of the guide to allow easy passage of the anchor. A double-loaded 2.8-mm all-suture anchor was then placed and the sutures unwrapped.
The process is repeated for the second anchor, and once again care is taken to ensure the drill is angled distally and posteriorly to avoid joint penetration.
Following anchor placement, one limp from each suture is passed through the distal end of the tendon in a mason allen fashion to lock within the tendon. The second limb is passed in simple suture fashion allowing the suture to slide and pulling the tendon down to the insertion site. It is important to keep the sutures organized for proper tying.
Next, each suture is tied individually using a surgeon's knot followed by 6 alternating half hitches. The simple pass suture is used as the post since the mason allen stitch is locked within the tendon which aides in reduction of the tendon and allowing for greater compression of the tendon against the ulna.
After tying, one limb from each suture is used to form the lateral row and pulled to evaluate reduction and location of the lateral row.
A free needle is then used to pass the suture limbs under the attached flap of tendon prior to placement of the lateral anchor. The attached flap of tendon will later be oversown to the tendon to add additional fixation.
A bovie is used to mark the location of the lateral anchor and remove remaining soft tissue prior to drilling. The cortical bone of the ulna tends to be fairly dense, so pre-drilling with a 4.5-mm drill bit and using an awl to dilate the tunnel and compress the trabecular bone is a useful tip to allow for easier placement of the 5.5-mm anchor. As the ulna is fairly superficial, hardware prominence may cause pain and discomfort in select patients. Therefore, it is crucial to ensure the anchor is fully seeded and flush with the cortex.
All the sutures were then passed through the anchor for the lateral row. One tip to provide easier suture passage is to turn the know counterclockwise a quarter turn to slightly enlarge the anchor islet.
Next the awl is removed and the anchor malleted in place. Attention should be placed on the trajectory of the awl prior to removal to ensure the anchor is placed in a similar fashion. This will ensure the anchor does not break or bottom out during insertion. Once the anchor is flush with the posterior ulna, each suture is individually tightened and cleated. This specific anchor allows for suture tensioning after placement.
The sutures were then cut. The remaining proximal sutures could then be utilized for a second lateral row fixation or cut depending on the quality of fixation and if any gap formation occurs during gentle elbow range of motion. For this case, the tendon was easily and adequately re-approximated to the ulna with no gap formation during elbow range of motion and therefore cut.
The remaining attached flap of tendon was then oversown to the repaired tendon using a No. 1 vicryl in a running fashion to provide additional fixation.
The wound was then copiously irrigated and subcutaneous layer closed with 2-0 vicryl.
The skin was subsequently closed with 3-0 nylon with simple interrupted stitches.
Once fully closed, Xeroform gauze (Covidien, Dublin) was applied followed by a sterile dry dressing.
Postoperatively, patients remain in the splint at 45 to 60° of flexion for 10 to 14 days after which the patient is seen in the office and the dressing is removed to evaluate the incision.
Patients are transitioned into a range of motion brace with passive range of motion allowed from full extension to 90° of flexion at 2 weeks and increased by 10 degrees per week until full range of motion is obtained.
Active range of motion is permitted at 8 weeks and strengthening at 12. Typical return to sport and manual labor is 4 to 6 months.
The most common complication following distal triceps repair is elbow stiffness which is typically successfully managed with physical therapy. Re-rupture rate and revisions are uncommon with a reported rate of 0% to 4%.
We recommend treating full thickness tears acutely as patients have superior outcomes when surgery is performed in the first 3 weeks.
These are the references.
Thank you.
Footnotes
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
