triceps brachii distal tendon reattachment with a...

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n tips & techniquesSection Editor: Steven F. Harwin, MD

Triceps Brachii Distal Tendon Reattachment With a Double-row TechniqueZinon T. Kokkalis, MD; Andreas F. Mavrogenis, MD; Sarantis Spyridonos, MD; Panayiotis J. Papagelopoulos, MD, DSc; Robert W. Weiser, MPAS; Dean G. Sotereanos, MD

Triceps brachii injuries oc-cur almost exclusively at

the distal insertion of the tri-ceps brachii muscle. Triceps brachii distal tendon ruptures are rare, accounting for ap-proximately 2% of all tendon

injuries and less than 1% of all tendon ruptures of the upper extremity.1 They are more com-mon in men with a mean age of 36 years (range, 7-75 years).2-24 They occur most commonly at the tendo-osseous junction

and less commonly intramus-cularly or at the musculoten-dinous junction.2-24 The most common mechanism of rupture is indirect trauma, commonly a fall onto the outstretched hand that causes a forced ec-centric triceps brachii muscle contraction. Rarely, ruptures may occur following surgical procedures, such as total elbow arthroplasty, and in skeletally immature patients with incom-pletely fused or recently fused physes.*

Systemic risk factors for triceps brachii distal tendon ruptures include chronic renal failure with secondary hyper-parathyroidism,4-18 hypocal-cemic tetania,16 rheumatoid arthritis,17 osteogenesis im-perfecta,15 insulin-dependent diabetes mellitus,24 and ana-bolic steroid use.17-19 Local risk factors for tendon ruptures include local corticosteroid in-jections, such as those for the treatment of olecranon bursitis, and attritional changes from degenerative arthritis.4-14,20,21 In young and active patients

and those with systemic risk factors, improved fixation with augmentation of the tendon’s reattachment may be required at the surgeon’s discretion.

Most patients with triceps brachii tendon ruptures re-port sudden pain in the pos-terior aspect of the elbow. In the acute setting, pain dur-ing resisted elbow extension, swelling, ecchymosis, and tenderness to palpation over the triceps insertion are the usual clinical findings. An extension lag to active exten-sion of the elbow and a pal-pable gap are usually seen in complete ruptures, whereas diminished extension strength against resistance implies a partial rupture.27 Occasionally, a lateral radiograph of the el-bow reveals an fracture avul-sion of the olecranon (called a flake fracture).17 Chronic tendinosis and calcifications of the triceps, fractures of the olecranon and radial head, and avulsion of the medial col-lateral ligament may also be observed. If the diagnosis is uncertain, ultrasonography or magnetic resonance imaging

The authors are from the First Department of Orthopaedics (ZTK, AFM, PJP), Athens University Medical School, ATTIKON University Hospital; the Department of Hand & Upper Extremity Surgery and Microsurgery (SS), KAT Hospital, Athens, Greece; and the Department of Orthopaedics (RWW, DGS), Hand & Upper Extremity Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania.

The authors have no relevant financial relationships to disclose.The authors thank Bradley A. Palmer for drawing the schematics in this

article. Correspondence should be addressed to: Zinon T. Kokkalis, MD, First

Department of Orthopaedics, Athens University Medical School, ATTIKON University Hospital, 41 Ventouri St, 15562 Holargos, Athens, Greece ([email protected]).

doi: 10.3928/01477447-20130122-03

Abstract: Case reports and small series have reported vari-able results regarding the treatment of choice for patients with triceps brachii tendon ruptures. Early surgical repair has been recommended for acute complete ruptures of the triceps bra-chii distal tendon to prevent late functional disability. However, controversy exists regarding the optimum surgical technique of reattachment. In addition, various attachment techniques have been described, with none shown clinically to be superior. Therefore, the authors present a technique for triceps brachii distal tendon reattachment following acute complete ruptures and evaluate their results in a series of patients.

*7,12-14,18,19,22,23,25,26

FEBRUARY 2013 | Volume 36 • Number 2 111

Cover Story

Cover illustration © Clark Medical Illustration


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is useful for localization of the injury and quantification of the extent of the rupture.8

Previous case reports and small series have reported variable results regarding the treatment of choice for pa-tients with triceps brachii ten-don ruptures.† Nonoperative treatment with splint immobi-lization for 4 to 6 weeks in 30° of elbow flexion has been rec-ommended for patients with triceps brachii distal tendon partial ruptures with negligible loss of extension strength, el-derly low-demand patients, and patients in whom surgery is contraindicated because of medical comorbidities.7,14,17 Following nonoperative treat-ment, if weakness or pain per-sist, delayed repair can be per-formed.14 However, for non-operative treatment, complete ruptures must be excluded,

and delayed repair has been associated with less reliable reconstructions.7,17,22,26,28,29

Early surgical repair has been recommended for acute com-plete ruptures of the triceps bra-chii distal tendon to prevent late functional disability.7,14,17,18,20,23 However, controversy exists regarding the optimum surgi-cal technique of reattachment,‡ and various attachment tech-niques have been described, with none shown clinically to be superior.§ Therefore, the cur-rent study presents a technique for triceps brachii distal tendon reattachment following acute complete ruptures and evaluates the authors’ results in a series of patients.

Materials and MethodsThe authors retrospectively

reviewed data for 11 patients with acute distal triceps brachii tendon ruptures treated with

surgical reattachment at the authors’ institutions between January 2008 and April 2010. Patients were 9 men and 2 women with a mean age of 53 years (range, 34-64 years). Six injuries involved the dominant arm. The mechanism of injury was weight lifting in 5 patients, a backward fall in 3, and a fall onto the outstretched hand in 3. No patient reported a his-tory of anabolic steroid use, systemic endocrine disorders, metabolic bone disease, or pre-vious surgery on the involved elbow. Mean follow-up was 21 months (range, 12-40 months), and no patient was lost to follow-up. This study was ap-proved by the institutional re-view board or ethics commit-tee of the authors’ institutions.

Pain, swelling, ecchymosis, a palpable defect over the tri-ceps’ insertion, and an inability for active extension were com-mon physical finding in all pa-tients. No associated injuries existed. Radiographic findings

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 ten-don in all patients.

All patients had primary sur-gical 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 olec-ranon—2 had an avulsion of the central insertion, 2 had a rup-ture of the medial and central insertions, 2 had complete rup-ture of all insertions, and 1 had a complete rupture of the me-dial insertion and a superficial rupture of the lateral insertion with the deep layers remaining relatively intact. Three of 11 patients had complete rupture of the tendon at the musculo-tendinous junction.

surgical techniqueWith the patient under

general anesthesia, a straight posterior midline incision was performed with the patient in the lateral decubitus position and the arm over a tibial post. Dissection was performed through skin and subcutane-ous tissues, identifying the triceps tendon. The edges of the ruptured triceps ten-don were debrided, and a #5 Ethibond suture (Ethicon, Inc, Somerville, New Jersey) was inserted through the tendon using a Bunnell stitch tech-nique (Figure 1). Next, Keith Ethicon, Inc) needles were drilled through the olecranon in a crossed pattern (Figure 2). To improve fixation, 2 to

Figure 2: Illustration (A) and clinical photograph (B) showing the Keith needles (Ethicon, Inc, Somerville, New Jersey) drilled through the olecranon in a crossed pattern.

2A 2B

†2,3,7,8,14,17-24,26-35

Figure 1: Illustration showing a #5 Et-hibond (Ethicon, Inc, Somerville, New Jersey) suture inserted through the ten-don using a Bunnell stitch technique.

1

‡2,3,7,8,14,17-21,24,27,30-35§2,3,7,14,18-20,23,24,27,32-35


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3 suture anchors were drilled into the olecranon for aug-mentation of the reattach-ment; the sutures of the bone anchors were passed through the tendon in a horizontal mattress pattern (Figure 3). The Ethibond suture was in-serted into the holes of the Keith needles and advanced through the olecranon by ad-vancing the needles. With the elbow in extension, the tendon was reattached to the olecranon; the Ethibond su-tures were tied first, followed by the bone anchor sutures (Figures 4, 5). Stability of the reattachment was evaluated intraoperatively by moving the elbow through its total range of motion. The wound was irrigated and closed in layers.

Postoperatively, the arm was immobilized in a long arm posterior splint in 20° of extension for 2 weeks, fol-lowed by a supervised assisted range of motion rehabilitation program, including progres-sive elbow flexion, full passive extension, and passive/active assisted forearm rotation ex-ercises with the elbow in ex-tension for the next 4 weeks. At 6 weeks postoperatively, active extension of the elbow was initiated, followed by strengthening exercises at 10 to 12 weeks. Unrestricted ac-tivity was allowed at 5 months postoperatively.

Follow-up included clinical examination of pain at the re-attachment site, triceps brachii muscle strength, range of el-bow motion and extension lag from full active extension, pa-tients’ satisfaction, and return

to activities of daily living. Pain was determined using a 10-point visual analog scale ranging from 0 (no pain) to 10 (severe and constant pain).36 Patients’ triceps brachii mus-cle strength was graded on a 5-point muscle strength scale ranging from 0 (no movement is observed) to 5 (muscle con-tracts normally against full resistance).13 Patients’ satis-faction was graded as very satisfied, satisfied, and not satisfied. The range of elbow motion and extension lag from full active extension were measured using a goniometer. Follow-up data, complica-tions, and reruptures recorded at the last examination were used for the purpose of this study.

resultsAll patients experienced

significant pain resolution,

from a mean of 8.5 points (range, 8-9 points) preop-eratively to 2.4 points (range, 1-6 points) postoperative-ly (2-tailed paired t test, P5.0001), and significant im-provement of triceps brachii muscle strength, from a mean of 1.63 points (range, 0-3 points) preoperatively to 4.8 points (range, 4-5 points) post-operatively (Wilcoxon signed rank test, P5.001). Elbow range of motion was almost

normal in all patients (mean, 136°; range, 120°-150°); mean loss of elbow flexion was 7° (range, 0°-20°), and mean ex-tension lag was 7.3° (range, 0°-15°).

Nine of 11 patients were very satisfied with the opera-tion and returned completely to their preinjury status and activities of daily living. One patient experienced postop-erative pain over the olecra-non suture knot and moderate

Figure 3: Illustration (A) and clinical photograph (B) showing 3 suture anchors drilled into the olecranon. The sutures of the bone anchors are passed through the tendon in a horizontal mattress pattern.

3A 3B

Figure 4: Illustration showing re-attachement of the tendon to the olecranon; the Ethibond (Ethicon, Inc, Somerville, New Jersey) sutures were tied first, followed by the su-tures of the bone anchors.

4

Figure 5: Illustration (A) and clinical photograph (B) showing reattachment of the tendon to the olecranon.

5A 5B


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elbow stiffness. The patient was treated with nonsteroi-dal anti-inflammatory drugs and physical therapy. At last follow-up, he experienced moderate pain (4 points), 10° extension lag, and 4-point tri-ceps brachii muscle strength, and he stated he was satis-fied with the operation and returned completely to his previous work. Another pa-tient experienced wound in-fection and was treated with wound lavage and debride-ment with uneventful wound healing. At last follow-up, he experienced moderate pain (5 points), 15° extension lag, and 4-point triceps brachii muscle strength; he was not satisfied with the result of the operation. No patient experi-enced a rerupture of the distal triceps brachii tendon during the study period.

discussionRupture of the triceps bra-

chii distal tendon is a rare in-jury, and treatment guidelines are not well established. Case reports and small series have reported early surgical repair for acute complete ruptures of the triceps brachii distal ten-don to prevent late functional disability (Table).7,14,17,18,20,23 Magnetic resonance imaging is useful for determining the percentage of rupture in pre-operative planning; if a tear of more than 50% is shown on magnetic resonance imag-ing in addition to significant loss of triceps brachii muscle strength, surgical reattachment is also recommended.22

Surgical repair should be performed within 3 weeks of injury.23,31 Delayed repair and chronic ruptures are associ-ated with proximal retraction

of the muscle and tendon unit that makes direct reattach-ment unfeasible.17 In these cases, reattachment should be performed with autologous tendon, allograft, or synthetic ligament augmentation tech-niques or anconeus muscle ro-tation.17,23 However, any graft lengthens the native tendon and affects the triceps muscle resting length and contraction strength.26

Most acute injuries can be managed with early surgical direct reattachment of the ten-don to the olecranon using vari-ous attachment methods.18,23,37 These methods include lock-ing nonabsorbable suture tech-niques (Krakow, Kessler, or Bunnell), suture repair through olecranon drill holes, suture anchors, Kirschner wires, an-coneus muscle rotation, tri-ceps V-Y advancement, triceps

tendon rotation flap, braided Dacron sutures (Mersilene tape; Ethicon, Inc, Somerville, New Jersey) and mattress-type sutures, an olecranon perios-teal flap, and a reflected slip of fascia from the posterior fore-arm.4,7,14,18,19,23,30,33

In cases where an avulsed flake of bone from the ten-don’s insertion on the olec-ranon is of reasonable size, fixation with Kirschner wires and a tension band may be attempted.19,33 However, the use of Kirschner wires to aug-ment reattachment may lead to symptomatic hardware neces-sitating removal.19 Graft rein-forcement of the reattachment using the palmaris longus, plantaris, semitendinosus, or Achilles tendon4,7,17,21,22,23,34; anconeus muscle rotation34; a flap from the proximal tricipi-tal aponeurosis4; or forearm

Table

Summary of Published Studies on Triceps Brachii Distal Tendon Rupture and Repair

StudyNo. of Patients

(Elbows) Rupture Type Treatment TypeMean FU

(Range), mo Outcome Complications

van Riet et al23

22 (23) Complete (n58); partial (n515)

Primary suture repair (n514); late reconstruction (n59)

93 (7-264) ROM, 10°-136°; MTS, 4/5 or 5/5; ITT, 82% (10 patients)

Rerupture (n53); ulnar neuropathy (n51); painful snapping (n51)

Mair et al14

21 Complete (n511); partial (n510)

Primary suture repair (n515); nonoperative (n56)

34 ROM, n/a; MTS, N/A; 20 of 21 returned to professional football

Rerupture (n51); pain and weakness (n51)

Sierra et al19



17 (7-168) ROM, n/a; MTS, 4/5 (n52) and 5/5 (n59); 10 of 11 patients returned to preinjury activities

Rerupture (n51); radial nerve palsy (n51); ulnar neuropathy (n51)

Farrar & Lippert7



10 (9-12) ROM, normal; MTS, 4/5 (n53) and 5/5 (n51)

None

Current study

11 Complete Primary repair (double-row technique with a crossed suture and suture anchors)

21 (12-40) ROM, 120°-150°; MTS, 4.8; 10 of 11 patients returned to preinjury activities and were satisfied with the operation

Pain over the olecranon suture knot and moderate elbow stiffness (n51); infection (n51)

Abbreviations: deg, degrees; FU, follow-up; ITT, Isokinetic triceps testing; MTS, manual triceps strength; n/a: not available; ROM, range of motion.


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fascia7 may be necessary in patients with local or systemic risk factors for tendon rupture, those with chronic retracted tears, and when tissue quality is in question.

However, no detailed infor-mation is available regarding the outcome and the quality of the tissue used for augmenta-tion in these procedures. The anconeus muscle rotational flap is suitable for the recon-struction of moderately sized defects; for larger defects, Achilles tendon autografts or allografts are recommended. The use of tricipital fascia may further compromise the exten-sor mechanism.34

The current authors concur that early surgical repair is the appropriate treatment for acute complete ruptures of the tri-ceps brachii distal tendon and present a technique of direct reattachment of the tendon us-ing sutures advanced through the olecranon with Keith needles and augmentation of the reattachment with suture bone anchors. The current re-sults showed significant pain relief, improvement of muscle strength, and almost normal elbow range of motion, with a mean postoperative exten-sion lag of 7.3°. Ten of the 11 patients were satisfied with the operative results, although 2 developed complications.

One may argue that using the suture anchors adds com-plexity and increases opera-tive time. However, the current authors recommend the use of suture anchors as described in the current technique for aug-mentation and secure fixation of the reattachment, especially

in young and active patients and patients with systemic risk factors for tendon ruptures. In most cases, it may not be nec-essary to perform the larger procedure (ie, suture anchors), and it should only be used to improve on fixation if it is in question.

Limitations of this study were the small number of cases of an unusual injury, the fact that the results were not compared between repairs performed at different time periods after the rupture, the lack of a group of patients in whom a different reattachment technique was performed, and the unavailable Cybex strength data due to the study’s retro-spective design.

The surgical results of tri-ceps brachii distal tendon reat-tachment are generally good. Patients usually regain almost complete range of motion and good triceps strength after ade-quate rehabilitation.3,7,17,22,29 In the early postoperative phase, rehabilitation includes protec-tion of the repaired tendon and prevention of elbow stiffness.38 Postoperatively, the arm is im-mobilized in mid-flexion (30° to 45°) for 4 to 6 weeks, fol-lowed by progressive range of motion and strengthening exer-cises. Therapy begins after this period of immobilization with passive range of motion. At 6 weeks, active range of motion is begun.1,3,4,7,17,21,24,39 Lifting weights should be avoided for at least 4 to 6 months.1,3,4,17,21,24,39

The results after surgi-cal repair of acute ruptures and reconstruction of chronic ruptures are comparable, but patients’ recovery is slower af-

ter reconstruction.23 Potential complications include rerupture (range, 6.25%19-13%19,23) ulnar or radial neuropathy (range, 4.4%23-12.5%19) prominent hardware,23 stitch abscess,23 and elbow contracture.19,22,23

Reruptured tendons can be re-paired primarily without further sequelae,23 although reruptures, delayed repairs, and poor tissue quality may complicate recon-structions.17 Prominent hard-ware can be removed after the triceps repair has healed.26

In the current series, 2 of the 11 patients experienced com-plications, including elbow pain and stiffness and infection. Elbow pain was considered a minor complication that re-solved completely with nonste-roidal anti-inflammatory drugs and physical therapy. Wound infection was a major surgical complication that should not be attributed to the described tech-nique of reattachment, but rath-er to a generally encountered surgical complication.

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