Triceps Tendon Repair

Indications

Absolute Indications

1. Complete distal triceps rupture

   • Avulsion from olecranon insertion (80%)
   • Inability to actively extend elbow against gravity
   • Palpable defect at triceps insertion
   • Acute rupture in active or young patient (<60 years)

2. Failed conservative management

   • Partial tear >50% with persistent weakness
   • Progression from partial to complete tear
   • Functional limitation in activities of daily living

3. Iatrogenic rupture

   • Triceps detachment during posterior elbow approach
   • Post-operative extensor mechanism failure
   • Revision elbow arthroplasty complications

Relative Indications

1. Chronic rupture with weakness

   • >6 weeks old but significant functional deficit
   • Active patient desiring return to sports/work
   • Failed non-operative trial with therapy

2. Partial tear with instability

   • >50% disruption with mechanical symptoms
   • Progression despite bracing and therapy
   • Occupational requirement for elbow strength

Contraindications

Absolute:

• Active infection at surgical site
• Medical comorbidities precluding anesthesia
• Severe peripheral vascular disease with ischemic limb
• Non-compliant patient unable to follow post-operative protocol

Relative:

• Elderly low-demand patient with chronic rupture
• Severe osteoporosis compromising fixation
• Multiple previous failed repairs
• Extensive soft tissue compromise from burns or trauma
• Chronic rupture >1 year with severe retraction and muscle atrophy

Patient Selection Criteria

Ideal Candidate:

• Age 35-60 years, active lifestyle
• Acute rupture (<6 weeks)
• Good tissue quality, minimal retraction
• No significant medical comorbidities
• Motivated for rehabilitation

High-Risk Patient (requires augmentation):

• Dialysis-dependent renal failure
• Chronic tear >6 weeks
• Revision repair after previous failure
• Poor tissue quality (thin, friable, retracted >4cm)
• Steroid use or fluoroquinolone exposure

Triceps Muscle-Tendon Unit

Muscle Origins

1. Long head: Infraglenoid tubercle of scapula
2. Lateral head: Posterior humerus above radial groove
3. Medial head: Posterior humerus below radial groove

Common Tendon Insertion

• Footprint: Posterior olecranon, ~2cm wide × 1.5cm proximal-distal
• Insertion type: Fibrocartilaginous enthesis with bone integration
• Biomechanics: Primary elbow extensor (triceps generates 90% of extension force)
• Force generation: Up to 600N during eccentric loading (push-up, fall)

Vascular Supply

1. Proximal: Profunda brachii artery (branches to all three heads)
2. Middle: Radial collateral and middle collateral branches
3. Distal: Superior and inferior ulnar collateral arteries
4. Critical zone: Distal 2-3cm has relatively poor vascularity (watershed area)

Nerve Supply

• Radial nerve: All three heads (C7-C8)
• Course: Travels in spiral groove posterior to humerus, between lateral and medial heads
• Branches: Give off sequentially to medial head (proximal), lateral head, long head

Anatomical Relationships

Medial: Ulnar nerve in cubital tunnel (1-2cm from insertion) Lateral: Anconeus muscle (can be used for augmentation) Deep: Posterior joint capsule and olecranon fossa Superficial: Thin subcutaneous tissue and skin

Rupture Patterns (Frequency)

1. Avulsion from olecranon (80%): Most common, often with bone fragment
2. Musculotendinous junction (15%): Proximal to insertion, poor tissue quality
3. Intrasubstance tear (5%): Within tendon, associated with chronic degeneration

Clinical Assessment

History

• Mechanism: Eccentric loading (fall onto outstretched hand with active triceps contraction), direct trauma
• Timing: Acute (<6 weeks) vs chronic (>6 weeks) - impacts surgical approach
• Risk factors: Dialysis, steroids, fluoroquinolones, diabetes, previous surgery
• Functional deficit: Inability to extend against gravity, weakness in push-up or overhead activities

Physical Examination

Inspection:

• Ecchymosis over posterior elbow
• Swelling, palpable defect at insertion (may be subtle if chronic)
• Muscle retraction proximally with bunching

Palpation:

• Tenderness at olecranon insertion
• Gap in tendon (1-4cm depending on retraction)
• Bone fragment if avulsion injury

Function:

• Modified Thompson test: Inability to maintain elbow extension against gravity from 90° flexion
• Active extension lag: Patient cannot fully extend from flexed position
• Passive extension: Full (distinguishes from mechanical block)
• Power: Typically 1/5 or 2/5 in extension

Neurovascular:

• Ulnar nerve function (high risk area)
• Radial nerve function
• Distal pulses, sensation

Imaging

Plain Radiographs

• AP and lateral elbow: Identify bone fragment (present in 40% of avulsion injuries)
• Traction view: Apply gentle extension - may reveal gap and retraction distance
• Findings: Bone fragment at olecranon tip, soft tissue swelling, joint effusion

Ultrasound

• Dynamic assessment: Real-time visualization of gap with flexion/extension
• Measure retraction: Distance from tendon edge to footprint
• Assess tissue quality: Echogenicity changes suggest chronic degeneration
• Advantages: Fast, inexpensive, office-based

MRI

• Gold standard for surgical planning
• Sagittal T2: High signal at rupture site, measure gap and retraction
• Axial images: Assess percentage of tendon disruption (partial vs complete)
• Muscle quality: T1 signal changes indicate fatty infiltration (chronic tear)
• Planning: Gap >3cm or poor muscle quality indicates need for augmentation

Surgical Planning Checklist

1. Rupture classification:

   • Acute vs chronic (>6 weeks)
   • Complete vs partial (>50% requires repair)
   • Avulsion vs musculotendinous vs intrasubstance

2. Fixation method selection:

   • Suture anchors (preferred): 2-4 anchors for acute/chronic
   • Transosseous tunnels: If anchors unavailable
   • Bone fragment ORIF: If large fragment (>1cm³)

3. Augmentation decision:

   • Chronic tear >6 weeks
   • Retraction >3cm
   • Poor tissue quality on MRI
   • High-risk patient (dialysis, steroids)
   • Revision repair

4. Augmentation technique:

   • Anconeus turndown: Local tissue, vascularized coverage
   • Achilles allograft: Large gap (>4cm), bone plug to olecranon
   • Dermal allograft: Patch reinforcement

Equipment List

Instruments:

• Standard elbow instrument set
• Suture anchor insertion system (5.5-6.5mm anchors)
• Drill with 3-4mm bits (if transosseous tunnels)
• High-strength suture passer
• Bone awl, curettes, rongeur

Implants:

• 2-4 suture anchors (5.5mm or 6.5mm) with high-strength suture
• FiberWire #2 suture (non-absorbable, >300N strength)
• Optional: Achilles allograft with bone plug

Positioning:

• Lateral decubitus positioning setup with arm bolster OR prone setup
• Radiolucent arm table or hand table
• Tourniquet and sterile stockinette

Patient Positioning

Preferred: Lateral Decubitus

• Patient on operative side down OR non-operative side down (preference varies)
• Arm over padded bolster or arm positioner
• Advantages: Easy access to posterior elbow, allows intraoperative ROM check, easier for surgeon
• Disadvantages: Requires careful patient stabilization

Alternative: Prone

• Arm on hand table extending off bed
• Advantages: Gravity assists exposure
• Disadvantages: Harder to check ROM intraoperatively, less ergonomic

Anesthesia: General or regional (interscalene block)

Tourniquet: Upper arm, inflate to 250-300mmHg (after exsanguination with elevation)

Surgical Approach

Incision:

• Posterior midline centered over distal triceps insertion
• Length: 8-10cm (may extend proximally if chronic with retraction)
• Critical: Curve around olecranon tip medially or laterally (NOT directly over tip)
• Rationale: Avoids direct scar over bony prominence (pressure point, wound breakdown risk)

Subcutaneous Dissection:

• Create full-thickness flaps with skin, subcutaneous tissue together
• Avoid excessive undermining: Soft tissue coverage thin, prone to necrosis
• Identify ulnar nerve position on medial side (do not dissect unless symptomatic)

Step-by-Step Technique

Step 1: Exposure and Rupture Identification

1. Identify rupture pattern:

   • AVULSION from olecranon (80%): Tendon end visible, footprint exposed
   • MUSCULOTENDINOUS (15%): More proximal, muscle-tendon interface
   • INTRASUBSTANCE (5%): Within tendon, friable tissue

2. Assess tendon quality:

   • Acute: Good quality, healthy appearance
   • Chronic: Thin, friable, retracted with scarring

3. Measure retraction:

   • Apply gentle traction - tendon should reach footprint without tension
   • If >3cm retraction: Plan augmentation or V-Y lengthening

4. Identify bone fragment:

   • Present in 40% of avulsion injuries
   • If large (>1cm³): Consider ORIF with screws/tension band
   • If small: Excise and advance tendon to footprint

Step 2: Footprint Preparation

1. Expose olecranon footprint:

   • Remove scar tissue and fibrous debris
   • Identify anatomic footprint (~2cm wide × 1.5cm proximal-distal)

2. Prepare surface:

   • Debride to bleeding bone (promotes healing)
   • Preserve cortical integrity (need solid purchase for anchors)
   • Create slight decortication without weakening bone

3. Plan anchor placement:

   • Standard pattern: 2-4 anchors in double-row configuration
   • Medial row: 2 anchors, 1cm apart
   • Lateral row: 2 anchors, 1cm apart (if space allows)

Step 3: Tendon Preparation

1. Mobilize tendon proximally:

   • Release adhesions gently (preserve vascularity)
   • Extend dissection proximally if needed (chronic cases)
   • May need to release intermuscular septum

2. Debride tendon edge:

   • Minimal debridement (preserve length)
   • Remove only non-viable, friable tissue
   • Create stable edge for suture placement

3. Place locking sutures:

   • Use FiberWire #2 (high strength, non-absorbable)
   • Krackow or whipstitch configuration
   • Extend 3-4cm proximally into tendon
   • Lock with multiple throws (prevents pullout)

4. Test excursion:

   • Apply traction - tendon should reach footprint without excessive tension
   • If cannot reach: Consider V-Y lengthening, flexor carpi ulnaris transfer, or allograft bridging

Step 4: Suture Anchor Fixation (Preferred Method)

1. Anchor selection:

   • Size: 5.5mm or 6.5mm (based on bone quality)
   • Type: Modern all-suture anchors or screw-in anchors
   • Sutures: High-strength braided (FiberWire, FiberTape)

2. Anchor insertion:

   • Start with medial row
   • Create pilot hole with awl or drill
   • Trajectory: Aim distal and posterior (30-45° angle from vertical)
   • Insert anchor with driver, ensuring solid purchase
   • Repeat for lateral row

3. Double-row configuration (if footprint allows):

   • Medial row: 2 anchors medially
   • Lateral row: 2 anchors laterally
   • Increases contact area and biomechanical strength by 30-40%

Step 5: Tendon-to-Bone Repair

1. Suture passage:

   • Pass anchor sutures through tendon in mattress or Krackow fashion
   • Incorporate pre-placed locking sutures if used
   • Create strong suture-tendon interface

2. Positioning for tensioning:

   • Position elbow at 30-40° flexion
   • Assistant maintains this position during tensioning

3. Sequential tensioning:

   • Tie medial sutures first (medial row)
   • Then lateral sutures (lateral row)
   • Apply tension to eliminate gap completely
   • Each knot with 6-8 throws, alternating post

4. Final tension check:

   • Should allow full extension (0°) without gapping
   • Should allow flexion to >120° without excessive tension
   • Balance: Adequate to prevent gap, not over-tensioned to cause stiffness

Step 6: Augmentation (If Indicated)

Indications for augmentation:

• Chronic tear >6 weeks
• Poor tissue quality (thin, friable)
• Retraction >3cm with tension after mobilization
• High-risk patient (dialysis, steroids)
• Revision repair

Option 1: Anconeus Turndown Flap

1. Identify anconeus muscle lateral to triceps
2. Create muscle flap: Incise along medial border, maintain lateral base (vascular pedicle)
3. Rotate flap medially over repair site
4. Suture to triceps and surrounding tissue
5. Advantages: Local tissue, vascularized, no donor site
6. Disadvantages: Limited size, potential for denervation

Option 2: Achilles Allograft

1. Use Achilles tendon allograft with calcaneal bone plug
2. Prepare trough in olecranon for bone plug
3. Fix bone plug with interference screw or suture anchors
4. Weave tendon portion through native triceps
5. Suture to tendon edges and surrounding tissue
6. Advantages: Bridges large gaps (>4cm), strong construct
7. Disadvantages: Allograft risk (disease transmission low, integration slower)

Option 3: Dermal Allograft Patch

1. Place dermal allograft patch over repair
2. Suture circumferentially to tendon edges
3. Reinforces repair without bridging gap
4. Advantages: Off-the-shelf, low profile
5. Disadvantages: Less mechanical strength than other options

Step 7: Alternative - Transosseous Tunnel Technique

Indications: No suture anchors available, poor bone quality for anchors

1. Tunnel creation:

   • Drill 3-4 transosseous tunnels (3mm diameter)
   • Start at posterior footprint
   • Exit anteriorly or intra-articularly (controversial)
   • Space 8-10mm apart

2. Suture passage:

   • Pass FiberWire #2 through pre-placed Krackow sutures in tendon
   • Thread sutures through tunnels posterior to anterior
   • Use suture passer or wire loop

3. Fixation:

   • Tie over anterior cortex OR
   • Tie over bone bridge posteriorly (preserves anterior cortex)

4. Tensioning: Same principles as anchor technique (30-40° flexion)

Biomechanics: 400-450N load to failure (slightly less than anchors but clinically equivalent if well-executed)

Step 8: Closure

1. Release tourniquet: Check hemostasis, cauterize bleeders

2. ROM and stability check:

   • Passive: Full extension (0°), flexion to 130-140°
   • Active: Patient extends elbow against gravity (if awake under block)
   • Palpate repair: Should feel solid, no gap

3. Ulnar nerve check:

   • Palpate in cubital tunnel
   • Ensure not compressed by hardware, sutures, or hematoma

4. Layer closure:

   • Triceps fascia: Close with running absorbable suture (provides additional layer over repair)
   • Subcutaneous: Minimize dead space, absorbable suture
   • Skin: Interrupted nylon or subcuticular absorbable

5. Dressing: Soft dressing, compressive wrap

6. Splint: Posterior splint or hinged elbow brace locked at 30-40° flexion

Immobilization Protocol

Weeks 0-2: Posterior splint or hinged brace locked at 30-40° flexion

• Rationale: Protects repair during early healing
• Avoid full extension (tension on repair)

Weeks 3-6: Hinged brace unlocked, protected ROM

• Allowed: 0-90° passive and active-assisted ROM
• Forbidden: Active extension against resistance
• Therapy: Focus on maintaining extension, gradual flexion progression

Weeks 6-8: Progress ROM, begin gentle active extension

• Allowed: Full passive ROM (0-140° flexion)
• Active extension without resistance (gravity only)
• Progress flexion >120° as tolerated

Weeks 8-12: Strengthen

• Light resistance for extension (1-2 lbs)
• Gradual progression based on pain and function
• Avoid heavy lifting or push-ups

Months 3-6: Return to full activity

• Progressive strengthening program
• Sport-specific training if athlete
• Unrestricted activities by 4-6 months

Rehabilitation Milestones

Physical Therapy Emphasis

Extension ROM priority: Stiffness with flexion contracture is MOST COMMON complication

• Daily extension stretching from week 3
• Serial extension splinting if contracture develops
• Avoid aggressive flexion that sacrifices extension

Strengthening progression:

• Isometric extension (weeks 6-8)
• Light resistance extension (weeks 8-12)
• Progressive resistance (months 3-4)
• Functional/sport-specific (months 4-6)

Follow-up Schedule

• 2 weeks: Wound check, suture removal, begin protected ROM in brace
• 6 weeks: Clinical exam (ROM, strength), radiographs if bone fragment
• 12 weeks: Assess ROM and strength, progress to unrestricted activities if appropriate
• 6 months: Final outcome assessment, discharge if doing well

Red Flags for Complication

• Wound drainage or erythema: Infection concern
• Increasing pain with fever: Deep infection or abscess
• Palpable gap: Re-rupture or repair failure
• Inability to extend actively: Extensor mechanism failure
• Progressive flexion contracture: Over-aggressive therapy or over-tensioned repair
• Ulnar nerve symptoms: Compression from hardware or scarring