SpeedBridge Technique for Open Distal Triceps Tendon Repair

Abstract

Background:

Distal triceps tendon ruptures occur most commonly in middle-aged males, with possible rupture locations including the musculotendinous junction, mid-tendon, or most commonly, at the tendinous insertion. This surgical technique video demonstrates a hybrid distal triceps tendon repair construct utilizing transosseous sutures, SpeedBridge compression, and knotless suture anchor fixation.

Indications:

Indications for this procedure include an acute injury with complete avulsion of the distal triceps tendon from the olecranon and extension weakness. The goals of surgical repair include restoration of the tendon footprint on the olecranon and the creation of a strong fixation construct that balances tension to optimize healing and restore functional range of motion.

Technique Description:

The proximal avulsed tendon is prepared with two number 2 suture tapes placed in a locking Krackow fashion. The locking stitch exit point is determined at a distance proximal to the distal end of the tendon to optimize tension after the reduction of the tendon to the footprint. Two looped sutures are then passed through the tendon at the same exit level as the locking stitch, 1 on the medial and lateral sides of the locking stitch, respectively. Two transosseous tunnels are drilled obliquely, from proximal to distal, through the olecranon. A 4.75-mm suture anchor is then drilled and tapped in the proximal ulna, in between 2 transosseous tunnel exit points, for lateral placement. The medial and lateral locked stitches are passed through the medial and lateral transosseous tunnels, respectively. The SpeedBridge construct is formed by passing one suture from each locking stitch limb back through the tendon using the previously placed looped sutures as shuttling devices. After appropriate tensioning, the sutures are secured into the previously drilled 4.75-mm suture anchor in a specific fashion.

Results:

Current literature suggests that the SpeedBridge technique for triceps tendon repair demonstrates good functional and clinical outcomes with high satisfaction rates, elbow functional scores, and rates of returning to work/activity, coupled with low complication rates.

Conclusion:

The hybrid SpeedBridge construct is an effective technique for acute distal triceps tendon repair.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

SpeedBridge Technique for Open Distal Triceps Tendon Repair, presented by Steve Marcaccio and Dr Albert Lin.

Here are our disclosures.

Background

Distal triceps tendon ruptures are rare injuries with a reported incidence of less than 1% of upper extremity tendon injuries. ⁸ The most common demographic affected is middle-aged males between 30 and 50 years old, ¹⁰ and the most common mechanism of injury is due to an eccentric load with the elbow in flexion, ¹ such as from a fall or weightlifting.

The distal triceps can rupture at the musculotendinous junction, mid-tendon, or at the tendinous insertion, which is the most common, as 96% of cases occur here. Acute injuries can present as a partial versus complete rupture of the tendon. ¹ In the setting of complete avulsion of the tendon from the olecranon and weakness with extension, surgical management is indicated. The goal of surgery is to restore the tendon footprint on the olecranon and optimize healing and elbow extension.

There are three commonly described repair methods including direct repair of tendon to the periosteum, transosseous suture tied over a bone bridge, or suture anchor fixation.^2,3,8 Few biomechanical and clinical outcome studies exist comparing suture anchor versus transosseous fixation, and evidence is inconclusive as to which repair method is superior.

In this surgical technique video, we will present a clinical case of acute distal triceps tendon rupture and demonstrate a hybrid repair strategy utilizing transosseous sutures, SpeedBridge compression, and knotless suture anchor fixation.

Indications

This case focuses on a 62-year-old right-hand dominant male who presented with left elbow pain after a ground level fall. On examination, he had a palpable defect over the distal triceps, 4/5 triceps strength, and was unable to extend his elbow overhead against gravity. Based on this examination, our clinical suspicion for a complete triceps tendon rupture was high.

An magnetic resonance imaging (MRI) was obtained, and relevant images are shown here. From left to right across the screen, sequential sagittal slices progress from medial to lateral. The MRI demonstrates a complete rupture with approximately 4 cm of tendon retraction from the tip of the olecranon.

In our case the injury was acute and likely amenable to primary repair. Current literature shows primary repair is ideally performed within 3 weeks of injury but has been demonstrated to be possible as far as 12 weeks after injury.

We planned to have allograft available for tendon reconstruction in case of excessive retraction or limited mobilization prohibiting primary repair. The pre-operative fixation strategy was for passage of transosseous sutures, with the formation of a SpeedBridge construct, and knotless fixation with a suture anchor distally to restore the insertion footprint.

Technique Description

Before providing a step-by-step guide for our technique, we wanted to provide 2 summary illustrations that depict the overall plan for our construct. The image on the left shows a posterior view of the elbow, with the triceps tendon prepared with 2 stitches in Krakow fashion, which are passed through the 2 transosseous tunnels as shown with the arrows. Once this is completed, 1 limb from each transosseous tunnel will be passed back through each tunnel through the use of the shown looped sutures to create the SpeedBridge construct. The image on the right shows a lateral view of the elbow, demonstrating the ideal trajectory of the transosseous tunnels, following the force vector of the triceps tendon while also avoiding penetration of the elbow joint.

A curvilinear, longitudinal incision was made centered around the olecranon. Thick skin flaps were elevated medially and laterally and the distal triceps paratenon was incised. The triceps tendon was found retracted approximately 4 cm proximally, consistent with our pre-operative imaging findings.

The proximal, avulsed tendon was identified and secured with Allis clamps.

The avulsed triceps tendon was prepared with 2 number 2 suture tapes placed in a locking Krackow fashion. These 2 locking stitches were placed in parallel, traveling up the medial and lateral sides of the tendon, respectively, starting 1 cm proximal to the distal end of the tendon and extending for a minimum of 4 throws proximally, being careful to remove any slack from the stitch with each throw. Furthermore, we planned for these stitches to exit 1 cm proximal to the distal extent of the tendon based upon our evaluation of the tendon footprint, as provisional reduction demonstrated that this location would optimize reduction of the tendon to the footprint with appropriate tension. Careful evaluation of the tendon footprint on the olecranon is paramount in planning the Krackow stitch exit point to optimize reduction of the tendon.

We then take two number 2 Fiber-Link sutures and place them at the distal end of the Krackow sutures using a Keith needle to pass the non-looped end deep to the triceps tendon. One Fiber-Link suture is passed just lateral to the lateral Krackow stitch exit point, and the other is passed just medial to the medial Krackow stitch exit point. It is important to pass these Fiber-Links at the same level as the exit point of the previous Krackow sutures, as these will be incorporated into the SpeedBridge construct and maintaining balanced tension of the sutures is paramount to appropriately distribute tension across the construct.

In our technique, these sutures will be passed through transosseous tunnels drilled through the proximal ulna to recreate the distal triceps insertion site. The triceps insertion on the olecranon was identified and freshened to a cortical bleeding surface using a rongeur.

Next, 2 transosseous tunnels were drilled through the olecranon from proximal to distal using a 2.0 drill bit, being careful to avoid intra-articular penetration with our tunnel trajectory.

We then use the drill bit for the 4.75 mm Bio-SwiveLock anchor to prepare the site for fixation in between the distal exiting points of the 2 transosseous tunnels, aiming distally to avoid the joint.

Next, using a Hewson suture passer, the lateral number 2 suture tape exiting limbs and the corresponding lateral Fiber-Link passing suture are passed from proximal to distal through the lateral transosseous tunnel. This process is repeated for the medial aspect of the construct, passing the medial tendon sutures through the medial transosseous tunnel. Regarding tunnel placement, while the olecranon fossa is often directly visualized through the triceps tendon tear, intraoperative fluoroscopy can be utilized to confirm extra-articular tunnel trajectory, though this technique is not routinely utilized in our practice.

After passage, initial tensioning of the sutures can be performed to approximate the distal tendon to its insertion site on the proximal ulna.

To form the SpeedBridge construct, 1 limb from each of the medial and lateral Krackow stitch is taken from their distal tunnel exit point and passed back through the lateral transosseous tunnel. This was done by passing both limbs through the looped end of the lateral Fiber-Link suture and shuttling the sutures through the tunnel by pulling on the non-looped end of the Fiber-Link distally. This process is repeated with the remaining Krackow suture limbs being shuttled through the medial tunnel using the medial Fiber-Link suture.

The SpeedBridge construct is then appropriately tensioned to optimize uniform compression of the tendon to its proximal ulnar footprint.

We then proceed with fixation of the construct by placing a 4.75 mm knotless Bio-SwiveLock anchor in our previously drilled hole in between the transosseous tunnel exit points. To complete this fixation, the 2 medial limbs from the construct are first passed through the anchor's eyelet from medial to lateral. The eyelet passing device can then be reloaded, and the 2 lateral limbs from the construct are then passed from lateral to medial.

The anchor is then placed through the previously drilled hole in the distal ulna, tensioning the sutures individually while inspecting the triceps tendon insertion to confirm adequate reduction of the tendon to the footprint. Of note, care must be taken to avoid over-inserting the anchor into the bone, as the anchor should remain flush with the ulnar surface to maintain optimal cortical bone purchase.

All suture ends are cut flush with the bone. Of note, using a knotless suture anchor avoids any prominent knots that could cause postoperative incisional irritation.

The final construct demonstrates a stable, anatomic repair of the distal triceps tendon.

The patient was immobilized in a posterior elbow splint in 60° of flexion and a standard sling.

We recommend positioning the patient in the lateral decubitus position with the elbow hanging. This allows full access to the posterior elbow. Adequate proximal dissection, with care and protection of the radial/ulnar nerve, is necessary to mobilize the tendon sufficiently. More dissection may be required in the setting of delayed surgery. This may involve longitudinal splitting of the heads of the triceps. When preparing to drill the transosseous tunnels, it is essential to consider the proximity to the articular surface. Tunnels should be directed obliquely and posteriorly across the tip of the olecranon. Ensure there is enough space between the transosseous tunnels to place a 4.75-mm anchor in between the tunnels without tunnel collapse. Finally, extending the elbow intraoperatively can assist with reduction of the tendon to its footprint and avoid over-tensioning the repair. An intraoperative examination may be performed to evaluate the comfortable elbow range of motion from 0° to 60° without tension on the repair.

Ulnar nerve neuropraxia can present as a complication of distal triceps tendon repair due to its close proximity as it courses along the medial elbow. Care should be taken with dissection of the superficial layer and retractor placement. As discussed on the last slide, appropriate tunnel trajectory is necessary to avoid joint penetration and tunnel exit point must be separated distally to limit risk of fracture. Finally, over-tensioning of sutures can be avoided with intraoperative examination of tendon excursion and reduction.

Our postoperative protocol outlined here involves brief immobilization in gentle flexion to protect the repair. At 1 week postoperatively, the splint is removed, and patients may begin physical therapy with very gradual advances in permitted degrees of flexion over subsequent weeks. Also starting 1 week postoperatively, patients may begin passive extension as tolerated, with the goal to achieve full extension by 2 to 4 weeks postoperatively.�Patients graduate from brace wear at 6 weeks, at which time they may begin very limited weightbearing. Gentle strengthening may begin at 3 months and at the 5- to 6-month mark, patients may return to sporting activities.

Results and Discussion

Overall, patients report high satisfaction rates, elbow functional scores, and rates of returning to work and activity after distal triceps tendon repair.^4,5,7,10 A study by Kokkalis et al ⁶ reports near full recovery for elbow extension strength after repair using both transosseous and suture anchor based techniques. However, it should be noted that the available literature evaluated either the suture anchor or the transosseous suture constructs, and our technique, which is a hybrid of these 2 techniques, has not been well studied.

Current literature shows that this repair technique has a lower overall complication rate compared to transosseous sutures without anchor use and direct repair. ¹ Re-rupture is an unfortunate complication for which comparative studies have demonstrated a slightly higher incidence in transosseous suture fixation compared to this technique.^1,8 Re-rupture most frequently occurred in the setting of a new trauma. A retrospective cohort study reported a 1.2% rate of ulnar neuropraxia in 184 distal triceps tendon repairs. ¹ In all cases this was temporary and resolved within 3 months. The preoperative finding of enthesophytes is an independent predictor of postoperative complications, most commonly persistent surgical site pain and paresthesia, as reported by Waterman et al. ¹⁰ Other surgical complications include prominent and symptomatic hardware due to superficial knots tied over the proximal olecranon. ⁹

Thank you for your attention, and we hope that you found this surgical technique video to be useful.