DEFINITION

Elbow extension against gravity or resistance may be difficult or impossible when the distal triceps tendon is ruptured or avulsed from the olecranon insertion.

Complete ruptures of all three heads tendon insertion (long, lateral, and medial heads) generally require surgical treatment.

Partial lesions are functionally well tolerated in patients with low functional demand.

 

 

ANATOMY

Origin

 

The triceps brachii (FIG 1) has three heads:

 

 

The long head arises from the infraglenoid tubercle of the scapula.

 

The lateral head has a linear attachment from the upper margin of the radial grove of the humerus.

 

 

 

FIG 1 • Triceps brachii anatomy.

 

 

The medial head originates below the lateral margin of the radial groove that contains the radial nerve. Its insertion covers the entire rear surface of the lower part of the humerus.

 

Insertion

 

In the distal third of the posterior aspect of the arm, the lateral head joins with the long head to form the superficial tendinous part of the insertion on the posterior surface of the olecranon. The medial head (deep part of the triceps) inserts through muscular and tendinous fibers directly onto the olecranon.

 

The superficial tendon forms two components as it approaches its insertion area (FIG 2):

 

 

A lateral part that is more expansive and relatively thin and in continuity with anconeus muscle and fascia

 

 

 

FIG 2 • The distal triceps tendon insertion (superficial and deep components): The lateral aspect of the tendon is more expansive, relatively thin, and in continuity with anconeus muscle and fascia. The medial part is thicker than the lateral aspect and forms the proper triceps tendon. It inserts directly onto olecranon.

 

 

P.3918

 

A medial part of the tendon that is thicker than the lateral aspect and forms the proper triceps tendon and inserts directly onto olecranon

 

In some cases, a well-defined interval is located between the lateral triceps expansion and medial triceps tendon just proximal to the olecranon. This interval is located along the crest of the ulna and is well known as triceps decussation.

 

The deep tendon is covered by a thin layer of muscle fibers both medially and laterally.

 

The deep medial head of the triceps shows a broad and flat tendon centrally and laterally, whereas medially is a narrow thickened tendon.22

 

Medially, the superficial and deep tendons are confluent and form the proper triceps tendon that insert into the

medial olecranon footprint.

 

Magnetic resonance imaging (MRI) often demonstrates a bipartite insertion between the deep and superficial tendon of the triceps into the olecranon7 (FIG 3).

 

However, all three heads of the triceps contribute to the formation of the triceps olecranon dome-shaped footprint1 (FIG 4).

Olecranon Footprint

 

The mean medial to lateral width of the insertion area is about 20 mm and the mean proximal to distal length22 is about 13 mm.

 

The mean distance from the olecranon tip to the most proximal aspect of the medial head insertion4,22 is between 14.8 and 16 mm.

 

The mean width (medial to lateral distance) of the medial head footprint is 16 mm and the mean thickness is 4 mm.

 

 

 

FIG 3 • The MRI demonstrating a bipartite insertion between the deep (a) and superficial (b) components of the triceps tendon into the olecranon.

 

 

 

FIG 4 • The mean width (A) of the medial head footprint is about 16 mm and the mean thickness is 4 mm. The mean width of the common superficial tendon footprint is 19 mm and the mean thickness is 8 mm (B).

 

 

The mean width of the common superficial tendon footprint is 19 mm and the mean thickness4 is 8 mm.

 

Understanding the anatomy of the triceps tendon is the key to good outcomes following posttraumatic triceps repair or triceps reinsertion after deep surgical exposure.

 

PATHOGENESIS

 

Triceps tendon injuries are probably one of the rarest tendon injuries in the body. There is a male predominance (3:1, male to female) with a wide range of age in which it can occur.56

 

Triceps tendon ruptures can be simply classified into one of four groups:

 

 

 

Traumatic lesion (most common) Spontaneous rupture

 

Overuse injury

 

Following total elbow arthroplasty

 

Traumatic Lesions

 

Triceps tendon ruptures most commonly occur acutely when a patient falls on an outstretched hand with the elbow in some flexion and a forced load is applied to the contracting triceps. Traumatic tears can occur at several different anatomic regions, but they are most commonly observed at the insertion of the tendon such

as an olecranon avulsion. More rarely, they can occur at the musculotendinous junction or within the muscle belly.3,5,39

 

The traumatic distal tendon lesions can be partial or total5,23 and are often isolated. Associated lesions of the radial head,30,31 the medial collateral ligament (MCL),24,32,49 and the capitellum57 have been described.

 

Partial traumatic tendo-osseous avulsions with one small fragment of bone visible proximal to the olecranon (flake sign) often occur associated with the radial head fractures31 or simultaneous radial head and MCL-associated injuries.57

 

The combination of a triceps avulsion, radial head fractures, and MCL rupture were reported by Yoon et al57 as triad injury.

 

 

 

Spontaneous Ruptures

P.3919

 

Triceps injury can occur spontaneously due to attrition conditions if the tendon integrity is compromised. Loss of integrity can be caused by the following:

 

 

 

 

 

Rheumatoid arthritis Chronic renal failure Endocrine disorders Metabolic bone diseases

 

Steroid use (local or systemic corticosteroids or anabolic steroids)18

 

Tenosynovial pathologic tissue proliferation in the tendon combined with low local blood supply and mechanical attrition results in rupture of the tendon.

 

Overuse Injuries

 

The cumulative submaximal loading of the tissue is referred to as overuse injuries, and complete rupture often occurs through abnormal tendon with intrinsic pathologic disorders.19

 

A classification of progressive Achilles tendon disorders46 can be useful to understand the structural manifestations of triceps tendon overuse injury.

 

 

Peritendinitis

 

 

Tendinosis with or without peritendinitis Partial rupture

 

Total rupture

 

Triceps tendinosis during sporting activities is not infrequent. In cases of chronic tendon pain, the pathologic lesion is typical of a degenerative process with areas of marked degeneration and lack of local vascular

supply.2 These characteristic changes, especially if associated with a repetitive use of local corticosteroids, predispose to triceps tendon rupture, possibly by decreasing the tendon tensile strength.

 

Surgical treatment is recommended in chronic tendinosis when clinical and MRI assessments detect partial rupture of the tendon.

 

Following Total Elbow Arthroplasty

 

Failure of triceps reattachment can be seen following surgical treatment in which a triceps takedown is

performed.

 

When the total elbow arthroplasty is performed, the surgical triceps takedown or slide is usually well tolerated, but some patients have an unsuccessful postsurgical attenuation or ruptures of the triceps reattachment.

 

 

At the Mayo Clinic, this complication occurred in 16 elbows following 887 total elbow arthroplasties, about 2% of the procedures.10

 

Predisposing factors are inflammatory arthropathies with poor tissue quality.

 

 

The triceps weakening is a frequent and a well-recognized problem following the total elbow arthroplasty. The causes of the triceps weakness or rupture following arthroplasty may be related to the following:

 

Changes of the triceps moment arm which is a function of location of the axis of the prosthetic joint.14 The offset of the triceps tendon decreases (reducing the strength of the muscle) when the prosthesis design is not anatomic. Insufficient reinsertion related to poor quality of tendon tissue or tendon devascularization during the approach.

 

Aggressive rehabilitation program during the postoperative period with active exercises that can attenuate or detach the triceps reinsertion

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

In patients with suspected rupture of triceps tendon, the physician should gather a precise history including:

 

 

Age, dominant arm

 

 

Presence of preexisting pain from overuse injuries44

 

 

Repetitive use of local corticosteroids or systemic anabolic steroids12 Previous elbow surgery

 

The patient most commonly describes a sudden pain in the posterior aspect of the elbow after a history of direct blow or fall on outstretched hand.16,17,29,38 The usual mechanism of injury is a forceful sudden flexion of extended elbow.48,49,50

 

 

Laceration and open injuries with or without elbow fracturedislocation can also cause distal triceps rupture.27 In general, the triceps lesions is characterized by the following:

 

Tenderness and a palpable defect in the tendon that can be seen proximal to the olecranon

 

 

Swelling, ecchymosis, and body habitus can obscure the tendon defect in the acute stage. Once swelling subsides, most patients demonstrate a palpable gap in the tendon.

 

Active extension is typically diminished or absent, depending on whether or not there is a complete or partial tear.9,40

 

A partial rupture of the medial head is frequently undiagnosed. The diagnosis can be difficult, but care should be taken when evaluating radiographs to assess for the presence of the flake sign.

 

The clinical findings of the triceps insufficiency following total elbow arthroplasty are as follows10,11:

 

 

 

A change in the posterior contour of the elbow with visual and palpable prominence of the implant The presence of olecranon bursitis

 

Atrophy of the triceps muscle

 

Proximal retraction or lateral subluxation of the extensor mechanism

 

The most universal physical finding with a triceps rupture is the inability to extend the arm against gravity (FIG 5).

 

A tear can be seen and palpated in the tendon during attempts at resisted extension (FIG 6A,B).

 

Discerning between partial or complete ruptures can be a diagnostic challenge. The test to evaluate the triceps function against gravity and resistance is performed by the physician

 

P.3920

with the patient in the prone position with the elbow flexed to 90 degrees, the upper arm supported on the table, and the forearm hanging free (FIG 7).

 

 

 

 

FIG 5 • The triceps extension tests can be performed observing the ability of the patient to extend the elbow over his or her head, against gravity.

 

 

 

 

 

FIG 6 • A. The clinical findings of the triceps insufficiency are a change in the posterior contour of the elbow with visual and palpable prominence of bone. B. A tear can often be palpated in the triceps tendon.

 

 

A partial tendon lesion is manifested by weakness and ability to actively extend the elbow against the gravity but not against resistance. This finding is likely secondary to an intact lateral expansion or a compensating anconeus muscle.

 

A total tendon tear is manifested by loss of extension strength against gravity, and active elbow extension is

impossible. Viegas51 described a provocative test similar to the Thompson test that can be employed in diagnosing triceps tendon rupture. With the patient in the prone position and the forearm hanging over the side of the table, the physician squeezes the triceps muscle belly. Slight elbow extension is indicative of a partial tear, whereas no motion signals a complete rupture (FIG 8).

 

We have defined a test for triceps rupture called the fall down triceps test. This test assesses the inability of the patient to keep the forearm in maximum extension against gravity. The patient stands up with the shoulder at 90 degrees of abduction and internal rotation, the examiner stays behind and keeps the forearm in full passive extension. If the forearm falls when the examiner releases it, there is a triceps tendon rupture (FIG 9).

 

 

 

 

FIG 7 • Elbow extension can be evaluated with the patient in the prone position with the elbow flexed to 90 degrees, the upper arm supported on the table, and the forearm hanging free.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Imaging studies can help to identify the level of lesion (olecranon insertion, myotendinous junction, or intramuscular), discriminate partial from complete tear, and estimate the amount of the tendon retraction and to exclude associated osseous injuries.16,29,52

 

Lateral x-rays can demonstrate the flake sign. The bony fragment is usually small and easy to ignore, but its presence is pathognomonic of distal triceps avulsion (FIG 10). X-rays are also useful for the diagnosis of associated injuries such as radial head and capitellum fractures.

 

Ultrasonography may be used, but it provides limited anatomic details. It is useful immediately after an injury,20 when the diagnosis is in doubt.

 

MRI is the best technique for assessment of the tendon lesions13,55 because it allows for distinguishing partial versus complete lesions, the degree of tendon retraction, and any muscle atrophy as well as the location of

the tear25 (FIG 11).

 

DIFFERENTIAL DIAGNOSIS

 

 

Neurologic weakness from radial nerve problems (compression or lesion)21 C7 isolated nerve root lesions

 

Olecranon fracture

 

 

 

FIG 8 • Viegas' test. With the patient in the prone position and letting the forearm relaxed hang over the table, the physician squeezes the triceps muscle belly.

 

 

P.3921

 

 

 

FIG 9 • Fall down triceps test. The forearm falls down when the examiner leaves forearm in maximum extension. If a complete rupture is present, the elbow drops down to 90 degrees of flexion; for partial ruptures, the forearm drops down only partially.

 

 

 

FIG 10 • A,B. Lateral x-rays of the elbow are useful in confirming the diagnosis if a small extra-articular avulsion fracture (arrow) of the olecranon (flake sign) is present.

 

 

 

FIG 11 • Sagittal MRI scans demonstrating (A) partial and (B) complete rupture of the triceps tendon (arrows).

 

 

 

P.3922

NONOPERATIVE MANAGEMENT

 

Conservative management plays a role in partial triceps injuries when there is no significant loss of the extension power against gravity.

 

 

Patient age and lifestyle are important factors in deciding to treat these injuries nonoperatively. This group can include injuries to the nondominant arm injury, sedentary lifestyles, and the elderly patients who are at a higher risk for complications with surgical management.

 

Nonoperative treatment ranges from no specific treatment to elbow immobilization for 4 weeks in an extension splint.37

 

The surgeon must be careful when selecting nonoperative treatment in healthy active patients, as it may lead to permanent loss or weakness of power extension.

 

SURGICAL MANAGEMENT

 

Several surgical techniques and different approaches offer variable options for the surgical management of acute complete or chronic tears.

 

The choice depends on the tissue quality, the amount of the muscle retraction, and the chronicity of the lesion. The quality of the olecranon also has to be considered, particularly following total elbow arthroplasty.

 

For a successful direct repair, the repair has to be performed between 90 and 70 degrees of elbow extension, without tension at the tendon-bone reinsertion. Direct repair under tension increases the risk of secondary rupture and loss of elbow flexion.

 

The surgical options are as follows:

 

 

 

 

Direct repair to the olecranon Augmentation with autograft or allograft Anconeus rotation flap

 

Achilles tendon allograft with or without calcaneus bone

 

Preoperative Planning

 

With the patient under anesthesia, the elbow is assessed for concomitant elbow instability. Varus-valgus stability is evaluated, and the pivot shift test is used to exclude rotational instability.

 

Passive range of motion in pronosupination and flexion-extension should also be assessed.

 

 

 

FIG 12 • The patient is placed in supine position with the body rotated 30 to 40 degrees toward the contralateral side, with the arm and elbow folded over the chest.

 

 

 

FIG 13 • Alternatively, the patient is placed in the lateral position and with the affected arm over a bolster and the elbow flexed.

 

Positioning

 

The patient is placed supine with the body rotated 30 to 40 degrees toward the contralateral side with the arm and elbow folded over the chest (FIG 12).

 

Alternatively, the patient can be placed in the lateral position and with the affected arm over a bolster, the elbow flexed, and the forearm free (FIG 13).

 

A tourniquet is not always necessary because the tendon is relatively superficial and the tourniquet may limit the anatomic reinsertion of the tendon to its attachment on the proximal ulna.

 

For cases with significant tendon retraction that require an extensive release of the muscle, it is useful to use a sterile tourniquet for the surgical exposure to help identify the ulnar or the radial nerves. The tourniquet is released during tendon reinsertion to facilitate mobilization of the triceps muscle.

 

Approach

 

A posterior skin incision is made just lateral to the midline (FIG 14).

 

Skin and subcutaneous flaps are elevated off the triceps, olecranon, and ulna. The proximal insertions of the anconeus and flexor carpi ulnaris are identified.

 

 

Olecranon bursitis is removed, if it is present. The ulnar nerve is isolated and protected.

 

 

 

FIG 14 • Posterior straight skin incision is made just lateral to the midline.

 

 

P.3923

TECHNIQUES

• Direct Reattachment to the Olecranon

Partial Lesion Reattachment

The triceps tendon usually retracts no more than 3 to 5 cm. The preserved lateral continuity to anconeus triceps and aponeurotic fascia avoids significant proximal migration of the tendon.

The proximal stump of the tendon lesion is identified and débrided back to normal tendon that is directly reinserted into the olecranon (TECH FIG 1A,B).

For partial lesions without a bony fragment, the tendon is reinserted directly into the olecranon bone (TECH FIG 2A-C).

In a chronic case with bony fragments attached to the tendon, the bone is débrided and the tendon is reinserted into the olecranon bone with sutures.

 

 

 

 

TECH FIG 1 • A,B. The proximal stump of a partial or complete lesion is identified and débrided back to normal tendon which is directly reinserted into the olecranon.

 

 

 

TECH FIG 2 • A-C. A partial lesion without a bony fragment is reinserted directly into the olecranon.

 

Complete Lesion Reattachment

 

The tendon and muscle belly are mobilized, and a heavy, nonabsorbable suture is passed through the tendon using a Bunnell-or Krackow-type running locking stitch (TECH FIG 3A-D).

 

Before reattaching the tendon to the olecranon footprint, the bone is decorticated with a burr.

 

Two transverse holes are drilled (2.5-mm drill hole), starting at the triceps insertion and exiting on the dorsal side of the olecranon.

 

The sutures are passed through the drill holes using a suture pass.

 

Maintaining the elbow at 90 degrees of flexion, the tendon is advanced to the olecranon and tied with the knot placed on the radial side of the ulnar crest avoiding skin postoperative irritation (TECH FIG 4).

 

P.3924

 

 

 

TECH FIG 3 • A-D. The tendon and muscle belly are mobilized, and a running locking stitch with a heavy nonabsorbable suture is placed through the tendon. The sutures are then passed through bone tunnels in the proximal ulna.

 

 

 

TECH FIG 4 • Direct reattachment to the olecranon is possible when the tendon can be reinserted with the elbow in 90 degrees of elbow flexion.

 

 

P.3925

 

An additional fixation can be obtained by using proximal suture anchors (double-row repair) to improve the fixation of the anatomic footprint of the tendon (TECH FIG 5).

 

The medial and lateral skin flaps are mobilized, and sutures are placed between the fascia and the subcutaneous tissue of the two flaps to reduce the risk of a potential dead space.

 

 

Elbow motion is checked in particular for limitation in flexion due to overtensioning of the repair. A posterior subcutaneous drain is placed for the first 24 hours.

 

Skin and subcutaneous tissue are closed.

 

After surgery, the patient's arm is immobilized in a posterior splint, with the elbow flexed about 30 to 40 degrees.

 

 

 

TECH FIG 5 • An additional fixation can be obtained by using a proximal row of suture anchors to improve the fixation of the anatomic footprint of the tendon.

• Tendon Augmentation

 

When the direct reattachment of triceps tendon to bone in chronic lesions or following total elbow arthroplasty is only possible at 50 to 60 degrees of elbow flexion, then tendon augmentation is recommended (TECH FIG 6).

 

Small size defects can be covered using the palmaris longus, plantaris tendon autograft, flexor carpi radialis, or semitendinosus allograft. For larger defect, an Achilles tendon allograft is useful.

 

The olecranon bone footprint and the tendon defect margins are prepared similar to the direct repair.

 

The palmaris longus, the plantaris, flexor carpi radialis, or semitendinosus tendons transfer are harvested and woven through the stump of the ruptured tendon and sutured to the triceps tendon using running locking, nonabsorbable sutures (TECH FIG 7A,B).

 

 

 

TECH FIG 6 • The tendon augmentation is recommended when tendon approximation to the bone is only possible at 50 to 60 degrees of flexion (the arrow shows the traction line).

 

 

The graft is then passed through the bone tunnels into the olecranon similar to direct tendon reinsertion (TECH FIG 8).

 

Combined procedures can be performed using an autograft or allograft augmentation reinforced with a rotational proximal sleeve of forearm fascia. A flap of fascia is detached from the forearm, leaving its base attached to the olecranon8,12 (TECH FIG 9A,B).

 

The tendon graft is secured to the bone in moderate tension at about 90 degrees of elbow flexion, and the forearm fascia is turned up to cover the autograft and the triceps tendon (TECH FIG 10A-D).

 

P.3926

 

 

 

TECH FIG 7 • A,B. The tendon graft is harvested, woven through the stump of the ruptured tendon, and sutured to the triceps tendon.

 

 

 

TECH FIG 8 • The graft is then passed through the bone tunnels into the olecranon similar to direct tendon reinsertion.

 

 

 

TECH FIG 9 • A,B. Combined procedure using tendon autograft and a flap of fascia detached from the forearm leaving its base attached to the olecranon.

 

 

P.3927

 

 

 

TECH FIG 10 • A-D. The tendon graft is secured to the bone in moderate tension at about 90 degrees of elbow flexion, and the forearm fascia covers the tendon autograft and the triceps tendon.

The Anconeus Rotational Flap

 

The anconeus rotational flap described by Morrey,35,36,37 is a useful procedure when direct reattachment is impossible due to degenerative and fragile triceps tendon. It is indicated when the triceps defect is small, and the lateral triceps fascia and anconeus are preserved as well as for lateral triceps dislocation in continuity with the anconeus as complication following total elbow arthroplasty (TECH FIG 11).

 

The olecranon bone footprint and the tendon defect margins are prepared similar to the direct repair.

 

The Kocher interval between the anconeus and extensor carpi ulnaris is exposed. Care is taken to preserve its superficial fascial connection to the lateral triceps (TECH FIG 12).

 

P.3928

 

 

 

TECH FIG 11 • Lateral triceps dislocation in continuity with the anconeus muscle as a complication following total elbow arthroplasty.

 

 

The anconeus is mobilized off the ulna and the humerus without detaching the distal insertion, and the entire muscle and the lateral triceps are transferred medially to close the tendon defect.

 

 

 

TECH FIG 12 • The Kocher interval between the anconeus and extensor carpi ulnaris is exposed. Care is taken to preserve its superficial fascial connection to the lateral triceps.

 

 

 

TECH FIG 13 • A,B. The anconeus flap is mobilized and then oriented over the tip of the olecranon and sutured on it through drill holes.

 

 

The anconeus flap is mobilized and then oriented over the tip of the olecranon and sutured on it through drill holes (TECH FIG 13A,B).

 

 

The anconeus is stabilized to the olecranon, and the medial fascia of the anconeus is sutured to the tendinous portion of the triceps ruptured stump.

 

• Achilles Tendon Allograft

P.3929

 

When a chronic rupture has a significant muscle retraction and there is tendon tissue deficiency, the Achilles allograft reconstruction is indicated (TECH FIG 14).

 

The Achilles tendon allograft with a small piece of calcaneus can be used to reconstruct the continuity of the triceps tendon and also as an osseous graft to olecranon if it is deficient.35,36,37

 

The standard posterior approach is used, and tendon and olecranon preparation are identical for primary repair.

 

The triceps muscle and tendon are elevated from the posterior humerus, removing any scarring tissue deep in the muscle belly as well as in the subcutaneous tissue.

 

Care must be taken with this maneuver because the radial nerve is vulnerable to injury in the spiral

 

groove between the middle and distal thirds of the humerus. Two reconstructive techniques may be used:

 

Attach the allograft tendon directly to the olecranon through drill holes. The distal Achilles tendon is secured to the proximal ulna using drill holes as described for the direct repair.

 

Fix the calcaneal portion of the allograft to the remaining olecranon with a screw or a tension band wire. The allograft with calcaneal bone provides an ideal reconstructive unit, especially if the olecranon is deficient as is common in triceps insufficiency following total elbow arthroplasty10,11 (TECH FIG

15A-C).

 

With either technique, locking nonabsorbable sutures are placed through the distal stump of the triceps tendon and tied to the allograft (TECH FIG 16).

 

 

 

TECH FIG 14 • Achilles allograft reconstruction is indicated in cases of chronic rupture with significant muscle retraction and tendon tissue deficiency.

 

 

 

TECH FIG 15 • A-C. The allograft with calcaneal bone provides an ideal reconstructive unit especially with the olecranon deficiency, commonly it occurs in triceps insufficiency following total elbow arthroplasty.

 

 

The proximal expansion of the allograft is used to wrap the remaining triceps contractile muscle as well as the remaining tendon and secured with heavy nonabsorbable sutures (TECH FIG 17A-D).

 

The procedure is performed in at about 90 degrees of elbow flexion.

 

Motion is delayed with the osteotendinous allograft technique to allow adequate bone graft revascularization.

 

P.3930

 

 

 

TECH FIG 16 • The distal stump of the triceps tendon is tied to the allograft.

 

 

 

TECH FIG 17 • A-D. The proximal expansion of the allograft is used to wrap the remaining triceps muscle as well as the remaining tendon using nonabsorbable sutures.

 

 

 

P.3931

PEARLS AND PITFALLS
	Acute versus ▪ Acute chronic lesions ▪ In acute lesions, swelling and body habitus may not allow the examiner to palpate the tendon rupture. It is palpable when the swelling subsides.

 

• Chronic

   

  • In the chronic lesions, the olecranon bursa is often associated with the torn tendon.

  • The anconeus rotational flap is a useful procedure to reinforce the tendon reinsertion when the triceps defect is small and the lateral triceps fascia and anconeus are preserved. Surgeons must ensure that the fascia release laterally is complete and that the muscle and fascia transfer laterally and not slip back with flexion of the elbow. The anconeus has to be well incorporated in the torn triceps while the elbow is extended.

  • With Achilles tendon allograft reconstruction, the surgeon has to consider:

     

    • Excess bulk of allograft tendon might compromise wound closure.

    • Appropriate length of the transfer to avoid insufficiency or retraction of the extensor mechanism

    • Long postsurgical time for allograft healing

 

Imaging studies

• MRI is useful for identifying the level of the lesion, discriminating partial from complete tear, and defining the amount of the tendon retraction and muscular atrophy, especially in the case of chronic ruptures. The x-ray and computed tomography (CT) excluded associated osseous injuries.

 

Management ▪ Be careful to advise nonoperative treatment for partial rupture in healthy active patients.

 

POSTOPERATIVE CARE

 

The postoperative protocol consists of immobilization in 30 to 40 degrees of elbow flexion for 2 weeks (it will be increasing in chronic lesion if augmentation is used to recovered the extensor mechanism).

 

Following the first period, a dynamic brace is used for an additional 4 weeks.

 

Passive range of motion is permitted after primary repair, and active range of motion begins at 6 weeks following surgical repair. Complete return to previous activities is expected after 3 months from surgery. In cases of tendon augmentation or Achilles allograft, postoperative immobilization is used for 4 weeks and a dynamic brace is used for the following month.

 

OUTCOMES6,15,26,41,42,49,54

 

Little information has been described in the literature regarding the outcomes of triceps repairs. All studies reporting triceps repair or reconstruction are small and retrospective. Triceps rupture is the least common of all major tendon injuries.45,53 It accounts for less than 1% of all tendon ruptures within the upper extremity.1,34

 

Most investigators described their results as very good to excellent in terms of range of motion, pain relief, and restoration of extensor mechanism function.5,31,33,47,51

 

The results of immediate or delayed repair are reported to be similar with good results in both series.37 Outcomes following reconstruction have been shown to be comparable to direct repair,28,37 although the

technique is more challenging and the recovery is slower.37

Good results have been reported with nonoperative management for partial triceps rupture.3,9 Mair et al33 reported on 10 professional football players with partial tears, 6 of whom had tears that healed, allowing them to return to competitive football.

Sierra et al45 reported the results of treatment of 16 acute triceps tendon ruptures (15 patients) treated from 1976 to 2001.The mean age was 50 years (range, 16 to 71 years). The most common pattern was the triceps avulsion of the insertion from the olecranon (13 elbows). An intratendinous rupture occurred in 2 elbows, and an intramuscular rupture occurred in 1. Eleven elbows underwent surgical repair of the extensor mechanism; the remaining 5 were treated nonoperatively. The surgical repair consisted of advancement of triceps with placement of locking nonabsorbable sutures through tendon and passing through drill holes into the olecranon. Wire was used to augment the repair in one patient who had avulsion of a piece of bone with the tendon. The anconeus muscle was rotated to reinforce the triceps reconstruction in two cases. Three of the 11 surgically treated elbows developed postoperative complications that required reoperation. Postoperatively, patients were followed up for a mean of 1.4 years (range, 7 months to 14 years). Of those elbows treated operatively, strength testing was good and excellent in all.

Sanchez-Sotelo and Morrey43 reported the results on seven patients treated for chronic insufficiency of the triceps using the anconeus rotation flaps and the Achilles tendon allograft. At mean follow-up of 33 months (range from 9 to 93 months), one patient underwent a revision surgery for failed anconeus rotation flap 6 months after surgery. The remaining six had slight or no pain with restoration of functional arc of motion and normal or minimal decrease of the power in extension. All of them were satisfied from the results and the final Mayo elbow performance index was 100 points in five and 75 points in one. On the basis of their experience, the authors consider these procedures of choice in case of chronic ruptures with a moderate or large defects.

 

COMPLICATIONS

Complications include rerupture, variable loss of extension strength, and transient ulnar nerve palsy.

Poor tissue quality of the tendon and extensile proximal retraction of the muscle are related to high risk of secondary rerupture, if a direct repair is performed without any augmentation.

 

 

 

REFERENCES

P.3932

 

1. Anzel SH, Convey KW, Weiner AD, et al. Disruption of muscles and tendons: an analysis of 1014 cases. Surgery 1959;45:406-414.

    

2. Apple DV, O'Toole J, Annis C. Professional basketball injuries. Physician Sports Med 1982;10:81-86.

    

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