Distal Triceps Repair

Prevalence of Biceps rupture

• Fall on the hand with elbow in extension
  • Sports¹
• Excessive load
  • Weightlifters and athletes²
• Patients with diseases involving collagen structure and tendon quality³
  • Ex. rheumatoid arthritis, Marfan's syndrome
• Patients undergoing elbow arthroplasty³

• http://pathologies.lexmedicus.com.au/pathologies/radial-head-fracture
• https://www.bodybuilding.com/content/6-best-triceps-workouts-for-men.html

1. Sollender JL, Rayan GM, Barden GA (1998) Triceps tendon rupture in weight lifters. J Shoulder Elbow Surg 7(2): 151-153.
2. Mair SD, Isbell WM, Gill TJ, Schlegel TF, Hawkins RJ (2005) Triceps Tendon Ruptures in Professional Football Players. Am J Sports Med 32(2): 431-434.
3. Demirhan M, Ersen A. Distal triceps ruptures. EFORT Open Rev. 2017;1(6):255–259. Published 2017 Mar 13. doi:10.1302/2058-5241.1.000038

Anatomy of Triceps

• Consisting of 3 muscular heads that gather into a single insertion on the olecranon
  • long head
  • lateral head
  • medial head
• Presence of distinct footprint areas in the olecranon for
  • posterior elbow capsule
  • medial head of the triceps
  • common tendon of the long and lateral head of the triceps

• https://www.yoganatomy.com/triceps-brachii-muscle/

Triceps Insertion

Area: 466 mm²

Width: 1.6 – 4.2 cm

Starts 12 mm from olecranon tip

Primary Acute Repair Technique Complete and Partial

• Complete ruptures should always be treated surgically
• Partial ruptures can be treated conservatively or surgically
  • Surgical repair recommended when patient experiences loss of strength or is symptomatic

Case Example–

• Patient history
  • 73 yr old gentleman elbow injury while swinging golf club
  • Constant dull elbow pain and weakness
  • Inability to workout and play golf
• Clinical examination
  • Palpable defect
  • Marked weakness with elbow extension

Imaging

Methods of Repair - Transosseous bone tunnel Repair

• Bunnell technique
• Krakow technique
• Suture and wire

• Krakow locking-type sutures placed through drill holes
• Bunnell Technique

Methods of Repair - Suture Anchor Repair

• Triceps Pulley-Pullover Technique
• Double Row Repair
  • Knotless
  • Knotted

• Suture Anchor placement
• Suture Anchors
• Double Row technique
• Pull-over technique

• Combination technique using drill holes & single suture anchor

Outcomes from Distal Triceps Tendon Repairs

Outcomes from Distal Triceps Tendon Repairs

• Primary repair: Good outcomes (strength and function) in majority of patients.
• Low complication and re-rupture rates.
• No differences between technique/method of repair!

What about Biomechanical Evidence?

• No significant difference in post-procedure biomechanical strength between transosseous cruciate repair and suture anchor repair.

• Final Transosseous cruciate repair construct
• Final suture anchor construct

• Distal triceps knotless anatomic footprint repair resulted in greater biomechanical strength and resistance to displacement at the tendon-bone interface compared to traditional transosseous cruciate repair.

Knotless Anatomic footprint final fixation

• Transosseous cruciate techniqueWeakness Construct
• knotless suture-bridge technique
• V-Shaped Techniquehighest load to failure

Bottom Line

• Suture anchor augmented repair probably biomechanically superior to traditional transosseous repair.
• Any technique can work if executed well!

My Preferred Setup & Equipment

• Supine (Arm holder or bump)
• Lateral with arm holder
• Suture Anchors
  • 3.0 double loaded suture anchors for proximal row (two anchors)
  • 4.5-5.0 mm knotless suture anchors for lateral row (two anchors)
• No C-arm necessary for primary repair
• Rongueur to prepare olecranon, no burr needed

Double Row Surgical Technique

Case Study – Triceps Repair

2 Year Outcome

Pros- Cons Suture Only vs Suture Anchor

Pearls of Treatment

• Look for fleck sign - use it to your advantage and don’t excise it
• Don’t place your incision directly over the olecranon process!
• Beware of the Ulnar nerve!
• Use a hinged elbow brace to protect the repair

How To Rehab?

• Splint 60-90 degrees posterior slab plaster splint for 10 days
• Transition to hinged elbow brace
• Increase flexion by 30 per week
• Passive/gravity extension and active flexion
• At 8-12 weeks depending on patient and repair factors may begin light strengthening
• Typically 6-12 months before return to play depending on sport/demands

Chronic/Failed Triceps Repairs

Case Example

• 50 yr. old male carpenter presented with right elbow pain and swelling
• A history of 3 prior repair surgeries (approx 12 months since last surgery)
• Pain, weakness and symptomatic bursitis
• Performed olecranon bursectomy and revision repair with suture anchors
• However, patient developed increased pain in the weeks afterwards and reported several instances of elbow swelling

Imaging

Revision/Chronic Triceps Reconstruction Options

• Two basic ideas:
  • Salvage with various rotational flaps
  • Reconstruction with allograft/autograft tissue
    • Achilles tendon reconstruction
    • Semitendinosus reconstruction

Reinforcement with a reflected slip of fascia from the posterior forearm

Tendon graft passed through bone tunnels and reinforced using flap of fascia detached from forearm

Use of Flaps

• Anconeus Muscle Rotation Flap
• Triceps Tendon Flap
• Olecranon periosteal flap

• Anconeus Rotation Flap
• Triceps Tendon Flap (Patient with Olecranon Bursitis)
• Olecranon periosteal Flap

Use of musculotendinous/periosteum sleeve

Methods of Repair - Achilles tendon allograft

• Proximal suture of the allograft
• Completed proximal suture of the allograft

Triceps tendon reconstruction with semitendinosus graft

• Semitendinosus grafts woven through triceps
• Hamstrings graft

• Transosseous tunnels and anchor positioning
• Final suture construct

Autograft tendon woven through triceps tendon using Bunnell technique

Autograft Semitenidonsus & Gracillis Recon – Docking Technique

Autograft Semitenidonsus & Gracillis Recon – Docking Technique

3 Year Outcome

Reconstruction Pearls

• For athletes/high demand be prepared to perform reconstruction
• Anticipate tissue loss
• Use autograft
• Consider anatomic repair
• Match the reconstruction with the tissue loss

Case Study

• 37 y.o. right hand dominant male
• Avid weightlifter
• History of failed prior triceps repair
• Presents with left elbow pain from lifting weights
  • Pain is 7/10 at worst, 4/10 on average
  • Has been treated with anti-inflammatories and rest
• Exam
  • ROM 0° to 130°
  • 90°/90° pronation/supination
  • Tender to palpation over distal triceps
  • 4/5 strength with elbow extension, 5/5 with flexion

Case Study

• Obtained x-rays and MRI
  • X-rays show osteophytes or HO involving distal triceps
  • MRI scan shows partial tear of the triceps with 1.9cm of retraction

Case Study

• Elected to proceed with a left elbow triceps repair
• At one year follow-up, patient has made excellent progress
  • Lifting weights without restriction
  • No pain
  • ROM from 0° to 130°
  • 5/5 triceps strength