Triceps Brachii Distal Tendon Reattachment with a Double-Row Technique

n tips & techniques Section Editor: Steven F. Harwin, MD Triceps Brachii Distal Tendon Reattachment With a Double-row Technique Zinon T. Kokkalis, MD; Andreas F. Mavrogenis, MD; Sarantis Spyridonos, MD; Panayiotis J. Papagelopoulos, MD, DSc; Robert W. Weiser, MPAS; Dean G. Sotereanos, MD and less commonly intramus- and those with systemic risk Abstract: Case reports and small series have reported vari- cularly or at the musculoten- factors, improved fixation with able results regarding the treatment of choice for patients with dinous junction.2-24 The most augmentation of the tendon’s triceps brachii tendon ruptures. Early surgical repair has been common mechanism of rupture reattachment may be required recommended for acute complete ruptures of the triceps bra- is indirect trauma, commonly at the surgeon’s discretion. chii distal tendon to prevent late functional disability. However, a fall onto the outstretched Most patients with triceps controversy exists regarding the optimum surgical technique hand that causes a forced ec- brachii tendon ruptures re- of reattachment. In addition, various attachment techniques centric triceps brachii muscle port sudden pain in the pos- have been described, with none shown clinically to be superior. contraction. Rarely, ruptures terior aspect of the elbow. In Therefore, the authors present a technique for triceps brachii distal tendon reattachment following acute complete ruptures may occur following surgical the acute setting, pain dur- and evaluate their results in a series of patients. procedures, such as total elbow ing resisted elbow extension, arthroplasty, and in skeletally swelling, ecchymosis, and immature patients with incom- tenderness to palpation over pletely fused or recently fused the triceps insertion are the riceps brachii injuries oc- injuries and less than 1% of all physes.* usual clinical findings. An Tcur almost exclusively at tendon ruptures of the upper Systemic risk factors for extension lag to active exten- the distal insertion of the tri- extremity.1 They are more com- triceps brachii distal tendon sion of the elbow and a pal- ceps brachii muscle. Triceps mon in men with a mean age of ruptures include chronic renal pable gap are usually seen in brachii distal tendon ruptures 36 years (range, 7-75 years).2-24 failure with secondary hyper- complete ruptures, whereas are rare, accounting for ap- They occur most commonly parathyroidism,4-18 hypocal- diminished extension strength proximately 2% of all tendon at the tendo-osseous junction cemic tetania,16 rheumatoid against resistance implies a arthritis,17 osteogenesis im- partial rupture.27 Occasionally, perfecta,15 insulin-dependent a lateral radiograph of the el- The authors are from the First Department of Orthopaedics (ZTK, AFM, diabetes mellitus,24 and ana- bow reveals an fracture avul- PJP), Athens University Medical School, ATTIKON University Hospital; the bolic steroid use.17-19 Local sion of the olecranon (called Department of Hand & Upper Extremity Surgery and Microsurgery (SS), 17 KAT Hospital, Athens, Greece; and the Department of Orthopaedics (RWW, risk factors for tendon ruptures a flake fracture). Chronic DGS), Hand & Upper Extremity Surgery, Allegheny General Hospital, include local corticosteroid in- tendinosis and calcifications Pittsburgh, Pennsylvania. jections, such as those for the of the triceps, fractures of the The authors have no relevant financial relationships to disclose. treatment of olecranon bursitis, olecranon and radial head, and The authors thank Bradley A. Palmer for drawing the schematics in this article. and attritional changes from avulsion of the medial col- Correspondence should be addressed to: Zinon T. Kokkalis, MD, First degenerative arthritis.4-14,20,21 lateral ligament may also be Department of Orthopaedics, Athens University Medical School, ATTIKON In young and active patients observed. If the diagnosis is University Hospital, 41 Ventouri St, 15562 Holargos, Athens, Greece (zinon. uncertain, ultrasonography or [email protected]). * doi: 10.3928/01477447-20130122-03 7,12-14,18,19,22,23,25,26 magnetic resonance imaging 110 ORTHOPEDICS | Healio.com/Orthopedics Cover Story Cover illustration © Clark Medical Illustration FEBRUARY 2013 | Volume 36 • Number 2 111 n tips & techniques included calcifications in the triceps brachii distal tendon in 5 patients and a flake fracture of the olecranon in 3 patients. Magnetic resonance imaging documented a complete tear of the distal triceps brachii tendon in all patients. All patients had primary surgical reattachment of the distal triceps brachii tendon between 8 days and 3 weeks after injury. At surgery, 8 of 11 patients had an avulsion fracture of the olecranon—2 had an avulsion of the 2A 2B central insertion, 2 had a rup- 1 Figure 2: Illustration (A) and clinical photograph (B) showing the Keith needles ture of the medial and central Figure 1: Illustration showing a #5 Et- (Ethicon, Inc, Somerville, New Jersey) drilled through the olecranon in a crossed hibond (Ethicon, Inc, Somerville, New pattern. insertions, 2 had complete rup- Jersey) suture inserted through the ten- ture of all insertions, and 1 had don using a Bunnell stitch technique. a complete rupture of the me- and delayed repair has been surgical reattachment at the dial insertion and a superficial associated with less reliable authors’ institutions between rupture of the lateral insertion is useful for localization of the reconstructions.7,17,22,26,28,29 January 2008 and April 2010. with the deep layers remaining injury and quantification of the Early surgical repair has been Patients were 9 men and 2 relatively intact. Three of 11 extent of the rupture.8 recommended for acute com- women with a mean age of 53 patients had complete rupture Previous case reports and plete ruptures of the triceps bra- years (range, 34-64 years). Six of the tendon at the musculo- small series have reported chii distal tendon to prevent late injuries involved the dominant tendinous junction. variable results regarding the functional disability.7,14,17,18,20,23 arm. The mechanism of injury treatment of choice for pa- However, controversy exists was weight lifting in 5 patients, SURGICAL TECHNIQUE tients with triceps brachii ten- regarding the optimum surgi- a backward fall in 3, and a fall With the patient under don ruptures.† Nonoperative cal technique of reattachment,‡ onto the outstretched hand in general anesthesia, a straight treatment with splint immobi- and various attachment tech- 3. No patient reported a his- posterior midline incision was lization for 4 to 6 weeks in 30° niques have been described, tory of anabolic steroid use, performed with the patient in of elbow flexion has been rec- with none shown clinically to systemic endocrine disorders, the lateral decubitus position ommended for patients with be superior.§ Therefore, the cur- metabolic bone disease, or pre- and the arm over a tibial post. triceps brachii distal tendon rent study presents a technique vious surgery on the involved Dissection was performed partial ruptures with negligible for triceps brachii distal tendon elbow. Mean follow-up was 21 through skin and subcutane- loss of extension strength, el- reattachment following acute months (range, 12-40 months), ous tissues, identifying the derly low-demand patients, complete ruptures and evaluates and no patient was lost to triceps tendon. The edges and patients in whom surgery the authors’ results in a series of follow-up. This study was ap- of the ruptured triceps ten- is contraindicated because of patients. proved by the institutional re- don were debrided, and a #5 medical comorbidities.7,14,17 view board or ethics commit- Ethibond suture (Ethicon, Inc, Following nonoperative treat- MATERIALS AND METHODS tee of the authors’ institutions. Somerville, New Jersey) was ment, if weakness or pain per- The authors retrospectively Pain, swelling, ecchymosis, inserted through the tendon sist, delayed repair can be per- reviewed data for 11 patients a palpable defect over the tri- using a Bunnell stitch tech- formed.14 However, for non- with acute distal triceps brachii ceps’ insertion, and an inability nique (Figure 1). Next, Keith operative treatment, complete tendon ruptures treated with for active extension were com- Ethicon, Inc) needles were ruptures must be excluded, mon physical finding in all pa- drilled through the olecranon ‡2,3,7,8,14,17-21,24,27,30-35 tients. No associated injuries in a crossed pattern (Figure †2,3,7,8,14,17-24,26-35 §2,3,7,14,18-20,23,24,27,32-35 existed. Radiographic findings 2). To improve fixation, 2 to 112 ORTHOPEDICS | Healio.com/Orthopedics n tips & techniques 3 suture anchors were drilled to activities of daily living. from a mean of 8.5 points normal in all patients (mean, into the olecranon for aug- Pain was determined using a (range, 8-9 points) preop- 136°; range, 120°-150°); mean mentation of the reattach- 10-point visual analog scale eratively to 2.4 points (range, loss of elbow flexion was 7° ment; the sutures of the bone ranging from 0 (no pain) to 10 1-6 points) postoperative- (range, 0°-20°), and mean ex- anchors were passed through (severe and constant pain).36 ly (2-tailed paired t test, tension lag was 7.3° (range, the tendon in a horizontal Patients’ triceps brachii mus- P5.0001), and significant im- 0°-15°). mattress pattern (Figure 3). cle strength was graded on a provement of triceps brachii Nine of 11 patients were The Ethibond suture was in- 5-point muscle strength scale muscle strength, from a mean very satisfied with the opera- serted into the holes of the ranging from 0 (no movement of 1.63 points (range, 0-3 tion and returned completely Keith needles and advanced is observed) to 5 (muscle con- points) preoperatively to 4.8 to their preinjury status and through the olecranon by ad- tracts normally against full points (range, 4-5 points) post- activities of daily living. One vancing the needles. With resistance).13 Patients’ satis- operatively (Wilcoxon signed patient experienced postop- the elbow in extension, the faction was graded as very rank test, P5.001).

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