1. Introduction

a. Patient Positioning

b. Mark Incision

c. Injection of Local Anesthesia

d. Limb Exsanguination with Tourniquet

2. Patient Preparation

3. Incision

4. Mobilization of Triceps Tendon

5. Running Krackow Suture

6. Preparation of Triceps Tendon Insertion Site on Proximal Ulna

7. Placement of Suture Anchors

a. Mattress Suture Placement

b. Divide Sutures and Load into PushLocks

c. Posterior Proximal Ulna Exposure

d. Suture Bridge Repair

8. Triceps Tendon Repair

9. Closure

10. Post-op Remarks

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. 

<h4>CHAPTER 1</h4>

<p>This is a case
of an acute triceps rupture occurring
from a fall onto the outstretched hand,
resulting in eccentric contracture of the triceps.
The patient presents with pain
in his posterior elbow region
and weakness with resistance to elbow extension.
Imaging is useful in these cases.
Firstly, getting a radiograph
to rule out an olecranon fracture is helpful,
as that is the primary differential.
In this case, no olecranon fracture is identified,
but an avulsion fragment off the proximal ulna
from the avulsed triceps is identified,
helping to make the diagnosis.
Furthermore, if the diagnosis is in question
or for preoperative planning purposes,
an MRI may also be helpful.
On the lateral or sagittal T2 images,
avulsion of the triceps should be readily identified.
The technique being presented here is referred to
as the suture bridge technique,
published in the Journal of Hand and Microsurgery in 2018.
This technique involves the use of multiple Arthrex anchors.
I have no conflicts or financial relationships with Arthrex.
This technique allows for maximal exposure
and repair and coverage of the footprint
of the triceps tendon insertion site.
This technique is in contradistinction
to what's known as the speed bridge technique.
Both techniques are relatively similar
and result in a knotless repair of the triceps mechanism.
As we go through the video,
I'll show the differences between the two techniques
to avoid any confusion.</p>

<h4>CHAPTER 2</h4>

<p>The surgery begins with general anesthesia.
Regional could also be used.
The patient positioned in the lateral decubitus position,
as demonstrated here.</p>

<p>The operative limb is then draped over a bolster
so that the posterior aspect of the elbow
is readily identified.
Here I'm marking out the distal insertion site
of the ruptured triceps.
I'm now marking out where the ulna is,
and then I'm gonna extend the incision proximally.
I avoid the medial aspect of the olecranon,
as that is where folks rest their arm,
so I avoid incision to that area.
So I will cheat the incision slightly lateral or radial
so that it's not centered over
where one would rest their arm.
And the incision's placed straight down the posterior elbow,
off the tip of the olecranon
and down to the level of the proximal ulna,
as demonstrated here.</p>

<p>Next, the incision is injected with a local anesthetic.
Here I'm using 0.5% bupivacaine or Marcaine
to provide analgesia in the surgical site.</p>

<p>The limb is then exsanguinated,
and the sterile tourniquet is inflated
to 250 mmHg.
Alternatively, the procedure can be performed
without tourniquet hemostasis.</p>

<h4>CHAPTER 3</h4>

<p>The incision is then placed.
Dissection through the subcutaneous tissue
is then taken down to the triceps fascia.
My preference is to do this with electrocautery
to minimize bleeding.</p>

<h4>CHAPTER 4</h4>

<p>Once down to the level of the triceps fascia,
the dissection has taken a bit slower
to help mobilize the triceps tendon
from the surrounding soft tissue.
Care is taken not to take the dissection
too aggressively medial,
as to inadvertently injure the ulnar nerve,
or too proximal along the radial border
to inadvertently injure the radial nerve.
Of note with this technique,
neither nerve needs formal exposure and dissection.
As can be seen here,
the ruptured triceps tendon is coming into view.
The soft tissue and fascia overlying the tendon continues
to be mobilized.
This will help in mobilization of the tendon
and access to the tendon for placement of its suture.
Once the distal aspect of the triceps tendon is exposed,
it can then be tagged as shown here with an Allis clamp.
This will help in mobilization of the tendon,
and blunt dissection deep to it,
and sharp dissection superficial to it
to continue to mobilize the tendon for subsequent repair.</p>

<h4>CHAPTER 5</h4>

<p>Once the tendon is fully exposed,
a running Krackow stitch is placed,
starting distally, running proximally,
and then exiting distally once more,
resulting in two tails.
In this case, we are using a number 2 FiberWire
to do this running Krackow stitch.
Once the proximal limb has been run up,
the same suture is then run distally along the other side,
as shown here in a similar Krackow fashion.
Once run proximal and then distal once more,
the two ends of the suture are brought distal.
These will be integral
to the ultimate repair of the footprint.
Good repair is confirmed
with tensioning the triceps tendon, as demonstrated here.
This will also help eliminate any slack in the suture
within the tendon.</p>

<h4>CHAPTER 6</h4>

<p>Next, attention is turned to the insertion site
of the triceps tendon in the proximal ulna.
Here you can see that the proximal ulna insertion site
is being debrided of any remaining soft tissue.
A clean bony bed is the goal.
In order to achieve that, all soft tissue has to be removed.
In addition, a burr is used to help debride the proximal ulna
down to bleeding bone.</p>

<h4>CHAPTER 7</h4>

<p>Next, attention is turned
to placement of the suture anchors.
It's important to understand the anatomy
of the proximal ulna
to avoid inadvertent placement of the suture anchors
within the articular surface
or the joint of the ulna humeral articulation.
Here, the proximal anchors are placed at an angle
underneath trochlea as shown here.
Similarly, the PushLocks are placed in a different angle
away from the articular surface once more.
Here is a schematic of the same point.
The SutureTaks in the proximal ulna will follow the path
of the yellow arrow.
Later, the PushLocks will follow the path
of the red arrow, as shown here.
In this way, the articular surface will be avoided.
As such, now two suture anchors are being placed
in the proximal ulna
at the level of the triceps insertion, or footprint.
Again, the angle with which they're being placed is
as demonstrated previously.
The anchors being used here are SutureTaks.
These are preloaded 2-0 FiberWire suture anchors.
Free needles will then subsequently be used
to provide the needle for these.
The second SutureTak in the proximal ulna is placed
in the same manner, as shown here.</p>

<h4>CHAPTER 8</h4>

<p>Next, with the aid of a free needle,
all four limbs of the suture is then brought
through the proximal tendon, as shown here,
for ultimate repair in a mattress fashion.
Once the first pair of limbs of sutures are brought
through the proximal tendon
for later repair in a mattress fashion,
the same technique is then used
to place the second pair of sutures just next to it,
as shown here.
With both suture limbs in place,
the first repair of the tendon
back to its footprint can be performed.
The arm is brought into extension
by resting it on a padded Mayo Stand.
With an assistant pulling tension on the triceps tendon
to maximize coverage of the footprint, as shown here,
the SutureTak mattress sutures are then put down
with the arm in extension
and with at least six or seven knots placed on each side.</p>

<p>Here is a closeup of the repaired tendon onto its footprint.
You'll see excellent coverage
of the footprint by the tendon.
Now this Raytec gauze is being placed
to help you see the relationship of the sutures
that will be placed with the PushLock in the proximal ulna.
One limb will be crossed to each side
so as to maximize coverage of the footprint
and tension on the footprint.
Next, each set of three suture limbs are placed
through the eyelet of each PushLock, as shown here.
The suture bridge technique requires the placement
of two PushLock anchors in the proximal ulna.
In contrast, the [speed] bridge technique consists
of a single swivel lock placed in the proximal ulna,
with all sutures running through it.</p>

<p>Next, the proximal ulna is prepared
to receive the PushLocks.
The posterior aspect of the ulna is exposed sharply,
at least 2-3 cm distal
to the proximal ulna.</p>

<p>Each PushLock is then placed
over its drill hole in a staggered fashion,
and directed away from the articular surface
through the posterior cortex of the ulna.
The PushLock is then placed
following the trajectory of the drill hole,
while tensioning all three suture limbs running
through its eyelet.
Once down, tension is relieved of the suture.
Once in position, the PushLock is malleted into place,
until flush with the cortex of the ulna.
The same steps are then repeated
for the other set of three suture tails, as shown here.
Once down and in place,
the suture tails are then cut sharply.
With that, the suture bridge repair
of the triceps tendon has been completed.</p>

<h4>CHAPTER 9</h4>

<p>The elbow is taken through gentle range of motion
to cycle the sutures and to confirm secure repair.
Once satisfied, the wound is washed
and closed in a layered fashion.
I generally do not close the fascia over the triceps.
I close only the subcutaneous tissue with a 3-0 Vicryl
and a skin with a 4-0 Monocryl in a running fashion,
and then apply a skin glue on the surface of the skin,
followed by a splint.
The splint that is applied involves placing the plaster slab
on the volar or anterior aspect of the elbow
to avoid inadvertent flexion of the elbow
during the early postoperative period.</p>

<h4>CHAPTER 10</h4>

<p>Subsequently, my postoperative protocol consists of
seeing the patient in the office a few days after surgery
and converting the patient to a hinged elbow brace.
The patient will then work
on passive range of motion of the elbow,
slowly allowing progressive more flexion
over the first 6 weeks to 90 degrees.
Once they achieve full flexion
to 90 degrees actively and passively,
at that point, the brace is discontinued
and formal therapy initiated,
focusing on TheraBand strengthening the second 6 weeks.
After 12 weeks, therapy can be discontinued
and full use of the arm, including free weights,
can be initiated on a progressive manner.
Thank you.</p>


Watch this narrated triceps tendon repair performed by Dr. Asif Ilyas at the Rothman Institute for an acute triceps tendon rupture.

DOI
Publication Date	2023/05/16
Article ID	330
Production ID	0330
Volume	2023
Issue	330
https://doi.org/10.24296/jomi/330

Triceps Repair for Acute Triceps Tendon Rupture

Procedure Outline

Table of Contents