//

Repair of triceps rupture

    Overview

    Learn the Repair of triceps rupture surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Repair of triceps rupture surgical procedure.
    Triceps tendon ruptures are rare injuries and account for less than 1% of tendinous injuries. They usually occur as an avulsion from the olecranon, although intramuscular and musculotendinous ruptures have also been described.
    These injuries are more common in males and usually occur as a result of a forceful eccentric contraction in a flexed elbow. This occurs for example when weightlifting or falling onto an outstretched arm.
    It has been associated with systemic diseases including metabolic bone disorders, anabolic steroid use, local steroid injection, fluoroquinolone use, chronic olecranon bursitis and previous triceps surgery. Due to the rarity of these injuries the published literature contains mainly case reports, although there are some case series. Numerous surgical techniques for repair have been described in the literature which are predominantly variations involving either a trans-osseous suture repair or suture anchors.
    My preferred technique (based on its biomechanical robustness ) is as described by Clark et al.
    This involves running 2 locking Krakow stitches to the distal triceps tendon and passing them through two parallel bone tunnels in the olecranon. This is then re-passed through the bone tunnels to provide a double row type repair before securing the sutures using a 4.75mm Swivelock anchor.
    I favour this technique as it has a higher strength in load at yield, higher peak load, and less displacement of the repair on cyclical loading when compared to a transosseous ruciate suture repair (Clark et al. Distal Triceps Knotless Anatomic Footprint Repair Is Superior to Transosseous Cruciate Repair: A Biomechanical Comparison Arthroscopy. Arthroscopy 2014). It also minimises the foreign material at the triceps tendon footprint when compared to techniques using suture anchors. This is to optimise conditions for integration of the primary repair. It is theoretically more biomechanically robust than techniques using anchors orientated in the direction of pull of the triceps tendon.
    Author : Mr Samuel Chan FRCS (Tr & Orth)
    Institution :The Queen Elizabeth Hospital, Birmingham ,UK.
    Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.
    In the USA contact: fda.gov
    In the UK contact: gov.uk
    In the EU contact: ema.europa.e

    Indications

    INDICATIONS
    Indications for surgery include full thickness tears of the distal triceps tendon. These can be defined as acute or chronic. In a multicentre retrospective review by Giannicola et al., acute ruptures were defined as tears diagnosed and operated on within 30 days. Chronic ruptures were defined as those undergoing surgery over 30 days. If there is a significant delay with concern regarding the amount of tendon retraction, it is important to have a reconstruction option available. Giannicola et al. noted that 18% of distal triceps tendon ruptures were initially missed.
    Superficial partial thickness tears with significant clinical weakness are also an indication for surgery.
    SYMPTOMS & EXAMINATION
    Patients will usually present having had a fall from standing height or from a forced extension during weightlifting. They may complain of a ‘pop’ or giving way. They will complain of pain and weakness on extension.
    It is important to ascertain from the history whether there were any prodromal symptoms, history of metabolic bone conditions, steroid use and any previous injections or surgery.
    Clinical assessment will confirm swelling and bruising over the extensor surface of the elbow, along with tenderness over the tip of the olecranon. There may be a palpable gap just proximal to the olecranon tip.
    There may be an inability to extend against gravity with likely significant weakness against resisted extension with gravity eliminated. If unsure, it is useful to compare with the contralateral side.
    It is important to document the neurological and vascular status of the upper limb, with particular reference to the ulna nerve.
    IMAGING
    AP and lateral radiographs of the elbow help to identify any avulsion fragments of the olecranon. This can help assess the amount of retraction of the triceps tendon. If a bony fragment is identified, CT scanning is useful in defining the fragment and to look for associated bony injuries including radial head fractures, terrible triad injuries and distal humeral fractures.
    If a distal triceps tendon rupture is suspected, an ultrasound performed by an experienced musculoskeletal radiologist is needed to confirm the diagnosis and is usually readily accessible. An MRI of the elbow is desirable to delineate the extent of the tear and for surgical planning.

    ALTERNATIVE OPERATIVE TREATMENT
    As mentioned before, alternative methods of fixation include transosseous sutures and suture anchor fixation. Current literature suggests that there is no significant difference in clinical outcomes between the two types of fixation.
    In chronic ruptures, tendon allograft reconstruction has to be considered if the gap is too large to bridge.
    NON-OPERATIVE MANAGEMENT
    For full thickness tears of the distal triceps tendon, conservative management is largely reserved for patients with low functional demand with significant co-morbidities.
    For partial thickness tears, a clinical assessment needs to be made. If the patient is able to extend against gravity, conservative management may be considered.
    CONTRAINDICATIONS
    As described, the main contra-indications are usually down to patient factors and their anaesthetic fitness for surgery. In this age group, concerns regarding compliance can be an issue, and it is important to ensure informed consent is obtained particularly with regard to post-operative rehab regimes and their expected recovery.

    Setup

    The procedure is performed under general anaesthetic and supplemented with a nerve block performed by the anaesthetist. It is usually necessary to supplement this with local anaesthetic and adrenaline infiltrted to the operative field to optimise pain relief and to optimise the field of view.
    The patient is placed in a lateral decubitus position with the affected arm uppermost. The position of the shoulder is checked to ensure it is in an appropriate and comfortable postion. The arm is placed in a short ulnar gutter support. Care is taken to ensure that chest wall is well protected from any clamps and metal equipment using gel pads and padding. The elbow can be manipulated during the procedure and can cause pressure areas if not appropriately protected. A surgical prescrub prior to routine skin preparation may be performed.
    Intermittent calf compression Flotron devices are used during surgery to reduce the risk of thromboembolic disease unless there are any contraindications. Intravenous antibiotics are administered by the anaesthetist. The skin is prepared using Chlorohexidine solution starting at the hand, then onto the whole of the upper limb, up to and including the shoulder. Standard adhesive drapes are used and a sterile tourniquet is applied but not inflated after a later of sterile wool is applied. This is to allow adequate mobilisation of the triceps tendon if it is significantly retracted.

    Operation – 1

    MRI images of triceps tendon rupture (TTR) from left to right:
    Sagittal T2 image
    Coronal T1 image
    Coronal fat saturated image
    O – Olecranon

    The patient is set up in a lateral decubitus position with the body stabilised. The alignment of the spine is perpendicular to the table but is set close to the edge of the table as is practicable. This is to allow clearance of the table as well as for access to fluoroscopy if indicated.
    A short ulna gutter is used to support the arm. Care is taken to ensure the arm is set up in a stable position and that there is enough clearance to flex and extend the elbow.
    This is usually with the humerus in a position parallel to the floor and level with the shoulder.
    The height of the table is set to ensure a comfortable operating position.

    The whole arm is prepped and U drapes are applied at the level of the shoulder to maximise the sterile field. A sterile tourniquet is applied but not inflated to allow mobilisation of the triceps muscle.
    The hand is covered in a stockinette and wrapped with four inch crepe to isolate the hand. This also keeps the hand clear of any blood.

    The radial and ulnar aspect of the upper arm is marked as a aide for orientation during the surgery.
    The landmarks are identified, including the medial and lateral epicondyles denoted by the 2 circles. The ulnar nerve (UN) is palpated and marked to ensure that it is protected. The outline of the olecranon is palpated and marked.
    A longitudinal posterior midline incision is marked, centred over the distal triceps tendon. When extending distally, it is curved radially avoid aligning the incision over a weightbearing surface.

    The incision is made using a 15 surgical blade through skin and subcutaneous fat down to the level of the triceps fascia.

    This deep exposure is developed through the whole length of the incision.
    West retractors help to expose the field of view. Diathermy to bleeding vessels is applied to achieve haemostasis.

    Once the appropriate plane at the level of the triceps fascia is identified, fasciocutaneous flaps are raised to allow adequate exposure of the triceps.
    As depicted, the surgical blade is applied obliquely against the tissues to stay in the correct plane and to not incise into the triceps fascia.
    If done correctly, the areolar tissue lifts off easily with very little bleeding.

    This dissection is continued to the lateral edge of the triceps (A) at the level of the lateral intermuscular septum.

    Similarly, the medial fasciocutaneous flap is developed with care taken to remain on the muscle fascia as the flap is raised. If this plane is not maintained, there is always a risk of buttonholing through the skin.
    When progressing medially, one should take note by palpation or visual inspection of the ulnar nerve to ensure that it is not damaged in the approach.
    At the level of the olecranon, the nerve is usually safe if the FCU fascia is not breached.

    At the medial edge of the triceps rupture (TTR), the tissues are very scarred. Time is taken to bluntly dissect out the anatomy.
    A cautious approach is recommended due to the close proximity of the ulnar nerve.

    Number 1 vicryl stay sutures can be passed through the skin and secured to aid exposure of the anatomy.
    As noted in the previous slide, the tissue planes are difficult to define due to the scar tissue (area B)
    Note, in this case, anconeus epitrochlearis (AE), an accessory muscle, is present at the level of the cubital tunnel.

    Once the medial edge of triceps is defined, the ulnar nerve (UN) can be located and exposed.
    In this view, the lateral head of triceps (C) is well defined, whereas the long head of triceps (D) is more indistinct due to the rupture and scar tissue formation.

    The ulnar nerve is identified and mobilised to protect it from potential iatrogenic injury.
    If it is not seen, it can be palpated at the medial edge of the triceps distally between the medial epicondyle and the olecranon.
    Be aware of anatomical variants including:
    A subluxing ulnar nerve, which occurs in 2% of the population. This can course anterior to the medial epicondyle.
    The anconeus epitrochlearis (AE) – an accessory muscle that lies between the olecranon and medial epicondyle and overlies the cubital tunnel. In this case, AE has been incised to mobilise the ulnar nerve.

    The lateral edge of triceps is defined, lifted and bluntly dissected down to bone.
    Blunt dissection is continued across to the medial triceps window.

    The McIndoe scissors are used to mobilise the distal triceps tendon cirumferentially.
    The superficial lateral head portion (C) appears ruptured and any residual fibres have subluxed laterally.
    The superficial long head of triceps (D) portion of the distal triceps tendon is ruptured and retracted proximally.
    The deep medial head contribution to the distal triceps tendon appears to be intact.

    The fact that the deep medial head contribution to the distal triceps tendon is intact becomes even clearer once the medial to lateral window is completed.

    The long head of triceps (D) portion is isolated and mobilised.

    As the scar tissue is dissected, the anatomic planes become clearer. The superficial triceps layer (held in Kocher’s) is dissected and mobilised from the deeper medial layer of triceps (indicated by forceps).

    One freed, the ruptured distal triceps tendon is mobilised and its excursion and reducibility to the footprint is assessed.

    Note that due to the chronicity of this particular injury, it is not possible to reduce the tendon to its original insertion in flexion.

    The tendon appear to be reducible in extension.
    A judgement call is required at this stage as to whether a primary repair is possible, or whether a triceps reconstruction using synthetic material or allograft will be needed.

    A locking Krakow stitch is passed incorporating the long head contribution of the superficial triceps tendon.

    A locking Krakow stitch is passed from distal to proximal and back down the lateral head portion of the distal triceps tendon using a number 2 Fibrewire suture.
    Care is taken assess the starting and end point of the distal triceps tendon for the suture. These should correspond with the insertion of the triceps on the oecranon footprint.

    The running locking stitch is passed 4-5 times up the ascending limb and similarly down the descending limb.
    The image shows the proximal extent of the ascending running locking stitch before descending down the lateral aspect of the tendon.

    The triceps footprint on the olecranon is defined using a scalpel to excise any residual tendon or scar tissue.

    Operation – 2

    Once passed, any slack is taken out of the suture.
    These sutures are used to plan the insertion on the triceps footprint of the olecranon.

    A burr is used to freshen the triceps footprint on the olecranon.
    The burr is used just to abrade the cortical surface and any bony debridement is strictly limited.

    A 2mm drill is used to drill 2 parallel channels starting at the most anterior aspect of the triceps footprint, exiting on the dorsal cortex around 6-8cm distal to the tip of the olecranon.
    Care is taken to ensure that there is an adequate bone bridge between the medial and lateral channels to minimise the risk of fracture and to allow insertion of a suture anchor to secure the fixation.

    A Fibre-loop suture on a straight needle is passed through the distal triceps tendon just proximal to where the Krakow sutures exit. This is used to shuttle sutures through the tendon.

    This “Fibre-loop” step is repeated for the long head side.

    Once passed, all the sutures for the lateral head are gathered together and the same is repeated for the long head side.
    Once orientated there should be 2 main bundles of sutures

    A large bore cannula is passed down the channels to ascertain the entry point and the exit point on the dorsal cortex.
    It is usually necessary to incise the fascia of anconeus laterally (as shown with the blade of the scalpel), and the fascia of FCU medially.

    Once the channel is determined, the lateral head sutures (2 limbs of Fibrewire and Fibreloop) are loaded on a straight needle with loop. These are passed down the channel and delivered.
    Retractors can help expose the exit point and aid retrieval of sutures.

    This image shows the long head sutures being pulled though and the excess slack is removed.

    The same is repeated on the lateral side.
    Each bundle of sutures consist of 2 limbs of Fibrewire suture and 2 limbs of a cut Fibreloop suture. It is important to ascertain which suture correlates to which.
    Note to leave enough Fibreloop suture proximally and care needs to be taken when delivering the sutures so that they are not pulled through.
    A Fibrelink can be used as a alternative to a Fibreloop and may be easier to pass as it only has 1 limb at one end of the suture.
    Note, in this case, a Fibreloop is used for the lateral head and a Fibrelink used for the long head.

    One Fibrewire suture is taken from each of the long head and lateral head bundle and passed through the loop of the Fibrelink proximally on the medial side.
    Once passed, it is important to hold onto the ends of the sutures to ensure safe redelivery back down the channels.

    There can be significant resistance when trying to pass the sutures through the triceps fascia.
    Therefore, it is important to maintain control of the limbs of the suture. This is to all running the sutures back and forth to minimise any friction and resistance.
    This image shows how the sutures lay in a cris-cross pattern over the triceps footprint to hopefully allow greater surface area contact and to optimise healing.

    Once passed, the Fibrelink/Fibreloop is pulled through and discarded.
    The image nicely shows the reduction of the tendon back to its footpint.
    It is useful at this stage to cycle the elbow to retension the fixation and minimise risk of gapping.

    Before final tightening, it is useful to adjust how the tissues lie under the double row type fixation.

    A pilot hole is sited for insertion of the suture anchor using the 2mm drill.
    I use this additional step when anchoring into cortical bone. This, I think minimises the risk of fracture compared to using the tap directly.
    The siting of the anchor is usually between the medial and lateral suture channels at the level of the exit point.
    If there is concern that the anchor may enter the joint, it can be angled proximally or distally.

    The Arthrex tap for Swivelock anchors is advanced using a mallet.
    It is important to tap down to the second laser mark to ensure that the anchor can be seated flush with the bone.

    The image shows the 4.75mm Swivelock anchor (Arthrex), which comes preloaded on the green handle.
    All 4 limbs of the Fibrewire sutures are passed through the anchor distal using the suture passer (orange tab).
    As there can be significant internal friction, I tend to stabilise the tip of the anchor when performing this step to minimise the risk of the anchor bending or breaking.

    Once passed, the sutures are pulled through and the anchor is advanced.

    The tip of the anchor is engaged in the pilot hole.

    Each individual suture is tightened and secured on the paddle once the tension is appropriate.
    Note that some slack is required as advancing the anchor into the hole will further increase tension.
    Too much tension will restrict advancement of the anchor.

    Once the tip in engaged in the hole, the anchor is tapped down with a mallet…

    …until the threads are just engaged with the bone.
    The thumb paddle is held and the threads are advanced by turning the handle clockwise
    Once it is clear that it is fully advanced and flush with the bone, the top suture is unwound and disengaged from the handle.

    The handle can then be removed by pulling it away.
    Ensure that the sutures are disengaged from the thumb paddle.

    The sutures are now locked and secure.
    The excess Fibrewire suture can be cut with a scalpel blade.

    This shows the final construct, which appeared to be solid and robust on stressing.

    Operation – 3

    The para-tricipital windows can be sutured with number 1 vicryl.

    The soft tissues are closed in layers.

    3-0 monocryl is used to close the skin and supplemented with steristrips.

    A backslab is applied in a position of comfort and relative extension so as to not overload the triceps repair.

    Post Operative

    This rehab protocol was proposed by Kocialkowski et al in Shoulder & Elbow 2018.
    Mobilise with physio as per regime of:
    0-2 weeks – backslab, no weightbearing, wrist and finger exercises
    2-4 weeks – hinged elbow brace 0-90, avoid passive flexion beyond 90 when out of brace and resited extension, for active supination/pronation and anconeus strengthening exercises, active elbow flexion as tolerated with gravity eliminated
    4-6 weeeks – brace increased to 0-120, avoid resisted extension, progress to open chain shoulder exercises and loaded supination/pronation
    6-12 weeks – brace removed and commence full ROM, avoid heavy lifting, for strengthening and kinetic chain exercises, isometric elbow extension at different angles, progression to wall pressups
    >12 weeks – return to sporting activity

    Recommended Reading

    Giannicola G, Bullitta G, Rotini R, Murena L, Blonna D, Iapicca M, Restuccia G, Merolla G, Fontana M, Greco A, Scacchi M, Cinotti G. Results of primary repair of distal triceps tendon ruptures in a general population. Bone Joint J. 2018 May 1;100-B(5):610-616. doi: 10.1302/0301-620X.100B5.BJJ-2017-1057.R2.
    Cinotti et al showed satisfactory results for primary triceps repairs (either acute or chronic) in 93% of patients in a multicentre trial.
    In 27 patients with a mean FU of 47.5 months (12 to 204), mean scores were:
    MEPS 94 (60 to 100)
    QuickDASH 10 (0 to 52)
    m-ASES 94 (58 to 100).
    Muscle strength was 5/5 and 4/5 in 18 and 10 distal triceps tendon repairs respectively.
    The rehab programme is described in:
    Kocialkowski C, Carter R, Peach C. Triceps tendon rupture: repair and rehabilitation. Shoulder Elbow. 2018 Jan;10(1):62-65. doi: 10.1177/1758573217706358. Epub 2017 May 3.

    Reference

    • orthoracle.com

    Tags:

    You might be interested in

    Dark mode powered by Night Eye