Triceps Repair for Acute Triceps Tendon Rupture

Abstract

The function of the triceps tendon is elbow extension. Triceps tendon ruptures are uncommon tendon injuries of the upper extremity and generally result from either direct injury and/or forced eccentric contracture during a fall on an outstretched hand. The treatment goal is re-approximating the distal triceps tendon to the olecranon in order to restore elbow extension strength and upper extremity function. The surgical technique demonstrated in this video is the suture bridge technique. 

Case Overview

Background

Triceps tendon ruptures are rare injuries, with Anzel et al. finding a total prevalence of 8 in 1014 patients with tendon ruptures of any type.¹ In a more recent study of the military population, triceps tendon ruptures were found to occur at only 1.1 per 100,000 person years.² These injuries most often occur in young, physically active men such as weightlifters, in older adults with systemic diseases such as chronic renal failure or hyperparathyroidism, and in relation to pharmacologic treatments such as chronic corticosteroids, statins, or fluoroquinolones.^2, 3 The general mechanism of the injury is during eccentric contraction of the triceps, with overloading force on the tendon’s insertion at the olecranon, such as during a fall onto an outstretched hand or during an extension movement while weightlifting.² Alternatively, penetrating trauma can also result in a triceps rupture. Anatomically, the injury can occur in three specific places: from intramuscular separation of the tendon, rupture of the myotendinous junction or avulsion of the tendinous insertion off of the olecranon, which occurs most commonly.³ There is no formal grading system for triceps tendon tears but they can be broadly considered as full or partial tears, with partial representing a less than 50% tear.

Focused History of Patient

The male patient in this video suffered a fall on an outstretched hand, leading to a forceful eccentric contracture of the triceps. He complained of pain in the posterior elbow region, and his physical exam demonstrated weakness with resistance to elbow extension. A plain film of the arm ruled out an olecranon fracture but did reveal an avulsion of the triceps tendon off of the ulna. An MRI for preoperative planning further demonstrated the avulsion of the tendon on T2 imaging. 

Physical Exam 

Patients with an acute triceps tendon rupture will often present with tenderness, ecchymosis, and edema in the posterior elbow. A bulge in the upper arm may be present with a palpable gap proximal to the elbow joint, representing the unattached distal end of the triceps muscle. On strength testing, patients will likely show weakness to extension of the elbow against resistance.⁴

Imaging 

We recommend to begin with a plain film radiograph of the joint to determine if there is an olecranon fracture as this represents the major differential diagnosis, although other elbow joint fractures, olecranon bursitis, and elbow sprain are additional diagnoses to consider.⁵ A positive “flake sign”, or an extra-articular avulsion fracture of the olecranon, on lateral view is consistent with a triceps tendon rupture.⁶ Magnetic resonance imaging is most useful in making the diagnosis, determining if there is a complete or partial tear, and for preoperative planning.

Natural History 

Unrepaired triceps tendon ruptures will result in persistent weakness of elbow extension strength, and therefore surgery is typically recommended. A patient with a complete rupture of the triceps tendon may opt for conservative management if they have minimal physical demands, minimal restriction of motion from the injury, or if they are not a surgical candidate secondary to medical comorbidities.⁶ Partial ruptures can be treated surgically or non-surgically based on patient symptoms and the extent of weakness or dysfunction.

Options for Treatment 

Surgical repair falls into three categories: transosseous tunnels, suture anchor, and anatomic.^{2, 4, 8, 9} In this patient, the anatomic suture bridge technique was utilized, using a running locked (Krackow) suture that allows for maximal exposure, repair, and coverage of the triceps tendon insertion site.^8, 9

Surgical Technique 

The patient was taken to the operating room and underwent general anesthesia, although regional anesthesia can be used. They were placed in the lateral decubitus position with the operative limb sterilely draped over a bolster. An incision was made over the posterior aspect of the arm at the level of the proximal ulna and extended proximally, with care taken to avoid the medial olecranon as that is where many patients rest their arms. At that point, local anesthesia with 0.5% bupivicaine was injected into the incision. The operative limb was then exsanguinated with a tourniquet to 250 mmHg. Dissection was carried through the subcutaneous tissue down to triceps fascia. Next, a dissection to mobilize the triceps tendon from surrounding tissue was performed with care taken to avoid radial or ulnar nerves, although these structures do not need to be dissected out and isolated.

At this point, with a mobilized triceps tendon, a running Krackow stitch starting distally, going proximally, and then returning distally is performed followed by an additional parallel running Krackow stitch, creating two ends which are brought distally. 

Next, attention is turned to the triceps insertion site at the proximal ulna, which is debrided of soft tissue down to bleeding bone. After this, suture anchors are then placed, with care taken to avoid placement into the articular surface at the ulnar-humeral joint space. Two preloaded 2-0 FiberWire suture anchors are drilled into this space. With a free needle, all four suture limbs are brought through the proximal tendon for ultimate repair in a mattress fashion, consisting of two pairs of two sutures.

The arm is then brought into extension, resting on a padded Mayo stand with traction pulled on the triceps tendon to increase the anatomic footprint. The suture tack mattress sutures are then placed bilaterally using the suture bridge technique. First, the posterior ulna is sharply exposed at least 2–3 cm distal to the proximal ulna. Two PushLocks are placed into the drill holes through the posterior cortex in the proximal ulna, directed away from the articular surface. Three suture limbs are placed per islet. The position of the push locks is then finalized using a mallet to make them flush with the cortex of the ulna. The suture tails are cut sharply. The suture bridge repair of the triceps tendon has now been completed.

The operative limb is then brought through gentle range of motion to test the integrity and stability of the repair; once satisfactory, the operative site is irrigated and closed in layered fashion, beginning with subcutaneous interrupted 3-0 Vicryl sutures. Skin is closed with a running 4-0 Monocryl suture. Dermabond and Steri-Strips are applied over the incision followed by a splint applied on the volar aspect to avoid inadvertent flexion of the elbow in the early postoperative period.

Discussion 

The patient in this case suffered an acute triceps tendon rupture and opted for surgical repair to restore function. His physical exam findings of tenderness at the olecranon and weakness against resistance during elbow extension, combined with plain film imaging revealing a positive fleck sign representing an avulsion the triceps tendon off of the olecranon, gave us the diagnosis of acute triceps tendon rupture. The patient underwent surgical repair under general anesthesia, was placed in lateral decubitus position, and a sterile tourniquet was used for hemostasis.

Following surgery, the patient will be placed in a splint with the elbow at 0 degrees of flexion and then be transitioned to a removable brace in clinic within 1 week after the operation. The brace will remain on for 6 weeks as the patient gradually trials active elbow flexion up to 90 degrees. At 6 weeks, patients generally begin physical therapy and can return to full use or participation in sports 6 weeks later. Avinesh et al. found that these patients averaged a return to work within 10 weeks from their surgeries.¹⁰

Triceps tendon ruptures represent an uncommon injury and can be easily missed by an unsuspecting clinician. The time from injury to operation may be an important factor in determining whether the patient returns to preinjury levels of strength and function. In a study by van Riet et al., they found that outcomes in patients undergoing surgery within 3 weeks of injury had more robust return to function timelines as well as fewer intraoperative difficulties compared to surgical repair of chronic ruptures.¹¹ Patients did undergo operations up to 20 months out from the initial injury but surgical findings included retraction of the triceps tendon and significant scar tissue formation.¹¹

Key aspects of the surgical repair for triceps tendon ruptures include triceps tendon mobilization, identification of the ulnar nerve, removal of adhesions from the tendon and the olecranon insertion site, creation of the suture, and fixation into the olecranon.⁸ In this video, the suture bridge technique was utilized for operative repair as it has been shown to increase the anatomic exposure, repair, and coverage of the triceps tendon.⁹ Other considerations would be the speed bridge anatomic repair, which also avoids drilling tunnels into the olecranon and is a knotless technique, but is associated with a type 2 failure pattern.⁸ Overall, the anatomic repair has been shown to most closely approximate preinjury function.^8, 12 Specific risks of this surgery include rerupture, postoperative stiffness, and neurapraxia of the ulnar nerve given its proximity. At this time, the best surgical technique remains unclear; however, knotless suture technique has shown increased load and cycle to failure when compared to transosseous tunnel repair.^9, 13 Positive results have also been shown when utilizing suture anchors. The infrequent nature of the injury makes prospective surgical technique comparison studies challenging as well as management guidelines for partial tears.^5, 14

Equipment 

Arthrex suture anchors.

Disclosures 

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.