Triceps brachii distal tendon reattachment with a double-row technique

[Surgical treatment of distal triceps tendon ruptures]

OBJECTIVE

Restoration of the anatomy and the original length of the muscle-tendon unit in triceps tendon ruptures.

INDICATIONS

Acute and chronic triceps tendon ruptures with persisting symptoms and significant strength deficits.

CONTRAINDICATIONS

Infections and tumors in the surgical area.

SURGICAL TECHNIQUE

Prone position. Skin incision over the distal triceps in a lateral direction around the olecranon. Mobilization of the tendon and débridement of the olecranon. Drilling of 2 × 2.9 mm suture anchor holes medial and lateral into the footprint of the olecranon. In addition, drilling through the olecranon 12 mm distal to the tip of the olecranon and transosseous introduction of 4 sutures. Then the suture anchors (all-suture or titanium anchors) are inserted into the drill holes. Refix the deep and superficial tendons with the anchor threads. Refix the upper tendon portions with the transosseous sutures. In the case of chronic lesions, a graft interposition is necessary.

POSTOPERATIVE MANAGEMENT

Dorsal 10 ° splint, then change to an orthosis fixed in 20 ° extension and passive mobility 0-30 ° flexion for 6 weeks. From the 7th week onwards, load-free, physiotherapeutically controlled increasing mobilization. Starting weight-loading from the 13th week on. Full load after 6 months.

RESULTS

In all, 34 male strength athletes with acute triceps tendon rupture underwent surgery using the hybrid technique described and were prospectively recorded. The MEPS‑G score averaged 94.7 points, there were no permanent limitations in mobility, and the postoperative strength ability averaged 94% of the original strength performance ability. The return to sport achieved 100%. The complication rate was 20.6%. Reconstruction of the distal triceps tendon using hybrid technology leads to very good functional results. Half of all patients complained of symptoms even before the rupture, which suggests previous damage to the distal triceps tendon caused by degeneration.

Surgical repair of distal triceps rupture: a systematic review of outcomes and complications

Background

Triceps tendon injury is rare and accounts for only 2% of all tendinous injuries. It typically occurs after trauma or physical strain with eccentric loading. Treatment involves surgical repair, commonly with either transosseous bone tunnels or suture anchors. Nonsurgical management is typically reserved for low-demand or high-risk patients, as this is associated with deficits in strength and functional disability. Despite several recent high-quality observational studies that have added to our understanding of outcomes after surgical repair, we are not aware of a systematic review that includes literature published after 2015. In addition, prior reviews did not compare outcomes between different surgical repair methods, particularly transosseous bone tunnel and suture anchor techniques.

Methods

This systematic review examines published literature between January 1970 and May 2021 in PubMed, Scopus, and Cochrane databases to further examine reported functional outcomes and compare those outcomes between the two surgical repair methods.

Results

Our literature search yielded 309 results, of which only 16 met inclusion criteria. At the latest follow-up, the mean Disabilities of Arm, Shoulder, and Hand score was 4, the mean Quick Disabilities of Arm, Shoulder, and Hand score was 8, the mean Mayo Elbow Performance Score was 92, the mean American Shoulder and Elbow Surgeons-Elbow score was 99, the mean modified American Shoulder and Elbow Surgeons score was 94, the mean Oxford Elbow Score was 43, and the mean isokinetic muscle strength testing was 87%. A very high percentage (95%) of patients reported being satisfied with the repair. Preinjury levels of function were achieved in 92% of patients, and 100% regained at least a score of 4 of 5 for gross muscle strength. Complications occurred in 15% of cases, of which retears accounted for 5%. Subanalysis of cases with reported repair types revealed a significantly higher overall complication rate with transosseous repairs than with suture anchor repairs (18% vs. 8%, P = .008) as well as a higher retear rate in the transosseous repair group (7% vs. 2%, P = .03).

Conclusion

Patient-reported outcome measures were favorable for both suture anchor and transosseous tunnel repair methods. Suture anchor repair showed significantly better results with regard to isokinetic strength testing, complication rates, and retear rates. Further study is needed to establish superiority of either technique and cost-efficacy. In light of the evidence supporting greater biomechanical strength and lower clinical rates of failure, surgeons may consider use of a suture anchor technique for repair of distal triceps ruptures.

The surgical management of distal triceps tendon ruptures: a systematic review

BACKGROUND

Distal triceps tendon ruptures (DTTRs) are highly uncommon injuries and can be treated with surgical repair. The purpose of this review was to compare the outcomes and complications of various surgical techniques used for primary repair of DTTRs.

METHODS

The electronic databases MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed were searched from data inception to October 15, 2020. The Methodological Index for Non-randomized Studies tool was used to assess study quality. Data are presented descriptively.

RESULTS

A total of 19 studies were identified, comprising 560 patients (565 triceps tendons), of whom 78.6% were male patients. The mean age was 46.1 ± 8.4 years, and the mean follow-up period was 31.8 ± 21.0 months. The overall complication rate across all DTTR repair procedures was 14.9%. The distribution of complications for each technique was 29.2% for the direct repair technique, 15.2% for the transosseous technique (transosseous suture), and 7.7% for the suture anchor technique. Common complications include ulnar neuropathies, infections, and pain. The overall rerupture rate for transosseous suture, suture anchor, and direct repair was 4.3% (n = 12), 2.1% (n = 3), and 0% (n = 0), respectively. Patients undergoing DTTR repair experience significant improvements postoperatively regarding pain, strength, and range of motion.

CONCLUSIONS

Patients undergoing DTTR experience improvements in postoperative outcomes; however, there is a moderate reported risk of rerupture or complication. Owing to the heterogeneity in rupture patterns, surgical procedures, and outcome measures, it is difficult to ascertain the superiority of one surgical technique over another. Future studies should use large prospective cohorts and long-term follow-up to determine more accurate complication rates and outcome scores.

Distal Triceps Tendon Injuries

Distal triceps ruptures are uncommon, usually caused by a fall on an outstretched hand or a direct blow. Factors linked to injury include eccentric loading of a contracting triceps, anabolic steroid use, weightlifting, and traumatic laceration. Risk factors include local steroid injection, hyperparathyroidism, and olecranon bursitis. Initial diagnosis can be complicated by pain and swelling, and a palpable defect is not always present. Plain radiographs can be helpful. MRI confirms the diagnosis and directs treatment. Incomplete tears can be treated nonsurgically; complete tears are best managed surgically. Good to excellent restoration of function has been shown with surgical repair.

Outcomes of Triceps Rupture in the US Military: Minimum 2-Year Follow-up

BACKGROUND

The objective of this study was to examine the subjective and objective midterm functional clinical outcomes of surgically repaired triceps injuries in a moderate- to high-demand population.

METHODS

The US Military Health System was queried to identify all surgically treated triceps tendon ruptures between 2008 and 2013. Primary endpoints included rates of rerupture, perioperative complications, or significant persistent elbow dysfunction; Disability of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow score, and ability to do push-ups were also extracted.

RESULTS

Thirty-seven patients underwent triceps tendon repair with a mean follow-up of 49.8 ± 17.3 months (range: 26.8-80.2). The most common mechanisms of injury were military duties (27%), sporting activity (24%), or fall-related (21.6%), with most injuries occurring during an eccentric movement (54%). While 45% experienced occasional elbow pain postoperatively, only 1 patient (2.7%) had a rerupture. Despite this, at 2 years, 31 patients (84%) were able to return to full military duty. While 6 patients were discharged from military service, only 1 underwent medical separation while 5 retired for reasons unrelated to their triceps tendon rupture. Patient-reported outcomes were available for 14 patients at final follow-up. The average DASH and Mayo Elbow scores were 4.7 (SD ± 4.7, range: 0-15.9) and 85.4 (SD ± 11.7, range: 60-100), respectively. The cohort could perform mean 54.2 (range: 9-90) push-ups. In additional, 12 of 14 (85.7%) were satisfied with their elbow function.

CONCLUSIONS

The active duty cohort experienced excellent postoperative results with a high rate of return to military duty, despite nearly half of the patients recognizing some degree of activity-related, elbow pain.

Distal triceps transosseous cruciate versus suture anchor repair using equal constructs: a biomechanical comparison

BACKGROUND/HYPOTHESIS

Suture anchor-based repair has been advocated for repair of distal triceps avulsion, but previous models have used an unequal number of sutures across the repair site. We hypothesized that there would be no difference in triceps tendon displacement between gold standard repair with transosseous cruciate bone tunnels and suture anchor repair with an equal number of sutures in the constructs.

METHODS

The triceps tendon footprint was measured in 20 cadaveric elbows (10 matched pairs), and a distal triceps tendon rupture was created. The specimens in each pair were randomly assigned to transosseous cruciate repair or knotless, double-row, anatomic footprint, suture anchor repair. Specimens underwent cyclic loading to 1500 cycles and then load to failure. Footprint uncoverage was measured at 1500 cycles. Data for medial and lateral triceps tendon displacement, footprint uncoverage, and failure load were obtained.

RESULTS

Triceps displacement did not differ significantly between the transosseous cruciate and the suture anchor repair group at 1500 cycles on the medial (3.6 ±  0.9 mm vs. 4.3 ± 1.6 mm [mean ± standard deviation], respectively; P = .27) and lateral side (3.1 ± 1.2 mm vs. 2.0 ± 1.2 mm, respectively; P = .06). No other differences were found between the constructs.

DISCUSSION/CONCLUSION

Transosseous cruciate distal triceps repair and knotless double-row suture anchor repair using constructs with an equal number of sutures showed no significant difference in tendon displacement at 1500 loading cycles. These findings suggest that the biomechanical strength of an all-suture construct is not different from that of suture anchors for repair of distal triceps avulsions.

Operative Management of Acute Triceps Tendon Ruptures: Review of 184 Cases

BACKGROUND

Distal triceps tendon ruptures are rare. The authors present a series of 184 surgically treated, acute, traumatic triceps tendon avulsions and compare the complications between those treated with anchors (A) versus transosseous (TO) suture repair.

HYPOTHESIS

No difference exists in the retear rate between TO and A repairs. Study Designed: Cohort study; Level of evidence, 3.

METHODS

All patients who underwent an open primary repair of a traumatic triceps tendon avulsion within 90 days of injury, between 2007 and 2015, were retrospectively reviewed. Surgeries were performed within a multisurgeon (75 surgeons), multicenter (14 centers), community-based integrated health care system. Patient demographic information, type of repair, complications, and time from surgery to release from medical care were recorded.

RESULTS

184 triceps tears in 181 patients met the inclusion criteria. The mean age was 49 years (range, 15-83 years). There were 169 males. The most common mechanisms of injury were fall (56.5%) and weight lifting (19%). Mean time from injury to surgery was 19 days (range, 1-90 days); in 74.5% of cases, surgery was performed in 3 weeks or less. There were 105 TO and 73 A repairs. No significant difference was found between the two groups in the mean age ( P = .18), sex ( P = .51), completeness of tears ( P = .74), tourniquet time ( P = .455), and prevalence of smokers ( P = .64). Significant differences were noted between TO and A repairs in terms of reruptures (6.7% vs 0%, respectively; P = .0244), overall reoperation rate (9.5% vs 1.4%; P = .026), and release from medical care (4.3 vs 3.4 months; P = .0014), but no difference was seen in infection rate (3.8% vs 0%; P = .092). No difference was noted in release from medical care in patients who underwent surgery 3 weeks or less after injury compared with those undergoing surgery more than 3 weeks after injury (3.90 vs 4.09 months, respectively; P = .911).

CONCLUSION

Primary repair of triceps ruptures with TO fixation has a significantly higher rerupture rate, higher reoperation rate, and longer release from medical care than does repair with A fixation. Implementation of suture anchors in triceps repairs offers a lower complication rate and earlier release from medical care.

Triceps Tendon Anatomic Repair Utilizing the "Suture Bridge" Technique

Triceps tendon ruptures are uncommon injuries, but they typically require surgical repair. Multiple primary repair techniques are available, including transosseous, suture anchor, and anatomic repairs. The technique described here, the "suture bridge" repair, provides an anatomic repair of the distal triceps tendon to its footprint. It has the potential advantages of increased load to failure, better footprint coverage, higher load resistance, and allows for early motion.

Distal Biceps and Triceps Injuries

Background:

Rupture of the distal biceps and triceps tendons are relatively uncommon injuries typically occurring in middle-aged males as a result of eccentric loading of the tendon.

Methods:

A literature search was performed and the authors’ personal experiences reported.

Results:

This review discusses the diagnosis, indications and guidelines for management of these injuries and provides a description of the authors’ preferred operative techniques.

Conclusion:

Whilst non-operative treatment may be appropriate for patients with low functional demands, surgical management is the preferred option for the majority of patients. We have described a cortical button technique and osseous tunnel technique utilised at our institution for distal biceps and triceps tendon fixation respectively. For biceps or triceps tendon injuries, those receiving an early diagnosis and undergoing surgical intervention, an excellent functional outcome can be expected.

Triceps Tendon Ruptures: A Systematic Review

BACKGROUND

Triceps tendon ruptures (TTR) are an uncommon injury. The aim of this systematic review was to classify diagnostic signs, report outcomes and rerupture rates, and identify potential predisposing risk factors in all reported cases of surgical treated TTR.

METHODS

A literature search collecting surgical treated cases of TTR was performed, identifying 175 articles, 40 of which met inclusion criteria, accounting for 262 patients. Data were pooled and analyzed focusing on medical comorbidities, presence of a fleck fracture on the preoperative lateral elbow x-ray film (Dunn-Kusnezov Sign [DKS]), outcomes, and rerupture rates.

RESULTS

The average age of injury was 45.6 years. The average time from injury to day of surgery was 24 days while 10 patients had a delay in diagnosis of more than 1 month. Renal disease (10%) and anabolic steroid use (7%) were the 2 most common medical comorbidities. The DKS was present in 61% to 88% of cases on the lateral x-ray film. Postoperatively, 89% of patients returned to preinjury level of activity, and there was a 6% rerupture rate at an average follow-up of 34.6 months. The vast majority (81%) of the patients in this review underwent repair via suture fixation.

CONCLUSIONS

TTR is an uncommon injury. Risks factors for rupture include renal disease and anabolic steroid use. Lateral elbow radiographs should be scrutinized for the DKS in patients with extension weakness. Outcomes are excellent following repair, and rates of rerupture are low.

Distal triceps injuries (including snapping triceps): A systematic review of the literature

AIM

To review current literature on types of distal triceps injury and determine diagnosis and appropriate management.

METHODS

We performed a systematic review in PubMed, Cochrane and EMBASE using the terms distal triceps tears and snapping triceps on the 10^th January 2017. We excluded all animal, review, foreign language and repeat papers. We reviewed all papers for relevance and of the papers left we were able to establish the types of distal triceps injury, how these injuries are diagnosed and investigated and the types of management of these injuries including surgical. The results are then presented in a review paper format.

RESULTS

Three hundred and seventy-nine papers were identified of which 65 were relevant to distal triceps injuries. After exclusion we had 47 appropriate papers. The papers highlighted 2 main distal triceps injuries: Distal triceps tears and snapping triceps. Triceps tear are more common in males than females occurring in the 4^th-5^th decade of life and often due to a direct trauma but are also strongly associated with weightlifting and American football. The tears are diagnosed by history and clinically with a palpable gap. Diagnosis can be confirmed with the use of ultrasound (US) and magnetic resonance imaging. Treatment depends on type of tear. Partial tears can be treated conservatively with bracing and physio whereas acute tears need repair either open or arthroscopic using suture anchor or bone tunnel techniques with similar success. Chronic tears often need augmenting with tendon allograft or autograft. Snapping triceps are also seen more in men than women but at a mean age of 32 years. They are characterized by a snapping sensation mostly medially and can be associated with ulna nerve subluxation and ulna nerve symptoms. US is the diagnostic modality of choice due to its dynamic nature and to differentiate between snapping triceps tendon or ulna nerve. Treatment is conservative initially with activity avoidance and if that fails surgical management includes resection of triceps edge or transposition of the tendon plus or minus ulna nerve transposition.

CONCLUSION

Distal triceps injuries are uncommon. This systematic review examines the evidence base behind diagnosis, imaging and treatment options of distal triceps injuries including tears and snapping triceps.

A Comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs

BACKGROUND

Triceps tendon ruptures are rare orthopaedic injuries that almost always require surgical repair. This study tests the biomechanical properties of an original anchorless double-row triceps repair against a previously reported knotless double-row repair.

HYPOTHESIS

The anchorless double-row triceps repair technique will yield similar biomechanical properties when compared with the knotless double-row repair technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen cadaver arms were randomized into 2 groups. One group received the anchorless repair and the other received the knotless anchor repair. A materials testing system (MTS) machine was used to cycle the repaired arms from 0° to 90° with a 2.5-pound weight for 1500 cycles at 0.25 Hz. Real-time displacement of the tendon was measured during cycling using a probe. Load to failure was performed after completion of cyclic loading.

RESULTS

The mean displacement with the anchorless technique was 0.77 mm (SD, 0.25 mm) at 0° (full elbow extension) and 0.76 mm (SD, 0.38 mm) at 90° (elbow flexion). The mean displacement with the anchored technique was 0.83 mm (SD, 0.57 mm) at 0° and 1.01 mm (SD, 0.62 mm) at 90°. There was no statistically significant difference for tendon displacement at 0º (P = .75) or 90º (P = .31). The mean load to failure with the anchorless technique was 618.9 N (SD, 185.6 N), while it was 560.5 N (SD, 154.1 N) with the anchored technique, again with no statistically significant difference (P = .28).

CONCLUSION

Our anchorless double-row triceps repair technique yields comparable biomechanical properties to previously described double-row triceps tendon repair techniques, with the added benefit of avoiding the cost of suture anchors.

CLINICAL RELEVANCE

This anchorless double-row triceps tendon repair can be considered as an acceptable alternative to a knotless anchor repair for triceps tendon ruptures.

Treatment of a Complex Distal Triceps Tendon Rupture With a New Technique: A Case Report

Introduction:

The distal triceps tendon rupture is an uncommon injury. The acute treatment is well-defined, but when a delayed diagnosis is made or when a tendon retraction is present the alternatives or reconstruction are limited and sometimes complex.

Case Presentation:

In this case, we report on a 28-year-old man who presented with a chronic disruption of the distal triceps tendon with a gap of approximately 15 cm. The patient was diagnosed in another center with an inveterate breakage of the distal triceps tendon and was initially treated with an Achilles allograft that was complicated by a wound infection and required more than ten surgeries. Nearly 22 months after the initial trauma, and 12 months after the first surgery, we performed a reconstruction with an Achilles tendon allograft using the new technique of distal attachment. At the 12-month follow-up the patient presented a joint balance from -5º to 110º and presented with no pain.

Conclusions:

The use of an Achilles tendon allograft provides excellent results in complex distal triceps tendon ruptures. We report the use of a new technique to anchor a distal Achilles allograft.

Distal Triceps Tendon Injuries

Acute triceps ruptures are an uncommon entity, occurring mainly in athletes, weight lifters (especially those taking anabolic steroids), and following elbow trauma. Accurate diagnosis is made clinically, although MRI may aid in confirmation and surgical planning. Acute ruptures are classified on an anatomic basis based on tear location and the degree of tendon involvement. Most complete tears are treated surgically in medically fit patients. Partial-thickness tears are managed according to the tear severity, functional demands, and response to conservative treatment. We favor an anatomic footprint repair of the triceps to provide optimal tendon to bone healing and, ultimately, functional outcome.

Functional outcomes and complications after surgical repair of triceps tendon rupture

OBJECTIVE

The purpose of this study was to present the functional outcomes and complications after primary repair of triceps tendon ruptures (TTR).

PATIENTS AND METHODS

A retrospective review was performed on eight patients (six males, two females) who underwent transosseous suture repair for TTR. Mayo elbow score, range of motion, muscle strength and patient satisfaction were evaluated after at least 1-year follow-up.

RESULTS

The mean age of the patients was 25.1 years (range 16-42). The mechanism of injury was a sports injury in three patients, simple fall (fall on outstretched hand) in four and motorcycle accident in one patient. Two patients had associated radial head fracture, and one had a radial head fracture and trochlear fracture, and one patient had a medial epicondyle fracture. In two patients the diagnosis was missed at the initial admission to ED (delay, 20 and 75 days). Only one patient, who was a bodybuilder, had a history of anabolic steroid use, and the rest had no underlying disease or a predisposing factor for TTR. One of the patients with radial head fracture (displaced three parts) underwent simultaneous fixation using two headless screws. Patients were followed up for a mean of 18.8 months (range 12-26). At the final follow-up, all patients were satisfied with the treatment and the Mayo elbow score was excellent in six patients and good in two patients. There was 5° extension loss in two patients. Triceps muscle strength was 5/5 in all patients. Ulnar nerve entrapment occurred in one patient, so ulnar nerve release and anterior transposition were performed 3 months after surgery. Posterior interosseous nerve palsy occurred in one patient who underwent simultaneous radial head fracture fixation, but eventually returned back to normal 3 months postoperatively. All patients returned to their previous level of activity and occupation.

CONCLUSION

Transosseous suture technique is a safe and effective treatment method for acute TTR with a low rate of complications and excellent functional outcomes.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Triceps tendon rupture: an uncommon orthopaedic condition

Triceps tendon disruption is a rare orthopaedic injury that can lead to poor outcomes if misdiagnosed or managed inappropriately. This case report illustrates the importance of early, precise diagnosis of triceps rupture by clinical and radiological examination with appropriate management. A weightlifter who had fallen while riding his bike presented with pain, swelling around the posterior aspect of the left arm just above the elbow. Physical examination revealed ecchymosis and weakness in elbow extension. A radiograph of the elbow showed a small fleck of bone proximal to the tip of the olecranon. The patient was initially stabilised. Early intervention in the form of primary tendon repair was performed within 3 days and rehabilitation was started. The patient improved significantly to his best possible functional status with Mayo elbow score of 85. Early intervention was the key to better prognosis.

Distal biceps and triceps ruptures

Biceps and triceps tendon ruptures are rather uncommon injuries and are most commonly diagnosed clinically. Magnetic resonance imaging can help the clinician to differentiate an incomplete tear and define any degeneration of the tendon. Surgical anatomical repair is typically performed in acute complete ruptures whereas nonoperative treatment can be used for partial ruptures, as well as for patients unfit for surgery. Single incision techniques are associated with a higher rate of nerve injuries, while double incision repairs have a higher prevalence of heterotopic ossification. Although various fixation methods have been applied including bone tunnels, interference screws, suture anchors, cortical button fixation, the current evidence does not support the superiority of one method over the other. A well-planned postoperative rehabilitation programme is essential for a good final outcome. As better fixation devices are being used, more aggressive rehabilitation programmes have been applied. Epidemiology, clinical evaluation, diagnosis, surgical and conservative management of these injuries are presented in this review along with the authors' preferred technique for the anatomical repair of acute complete ruptures.