Triceps Repair for Acute Triceps Tendon Rupture

CHAPTER 1

This is a caseof an acute triceps rupture occurringfrom a fall onto the outstretched hand,resulting in eccentric contracture of the triceps.The patient presents with painin his posterior elbow regionand weakness with resistance to elbow extension.Imaging is useful in these cases.Firstly, getting a radiographto 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 ulnafrom the avulsed triceps is identified,helping to make the diagnosis.Furthermore, if the diagnosis is in questionor 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 toas 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 exposureand repair and coverage of the footprintof the triceps tendon insertion site.This technique is in contradistinctionto what's known as the speed bridge technique.Both techniques are relatively similarand result in a knotless repair of the triceps mechanism.As we go through the video,I'll show the differences between the two techniquesto avoid any confusion.

CHAPTER 2

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

The operative limb is then draped over a bolsterso that the posterior aspect of the elbowis readily identified.Here I'm marking out the distal insertion siteof 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 radialso that it's not centered overwhere one would rest their arm.And the incision's placed straight down the posterior elbow,off the tip of the olecranonand down to the level of the proximal ulna,as demonstrated here.

Next, the incision is injected with a local anesthetic.Here I'm using 0.5% bupivacaine or Marcaineto provide analgesia in the surgical site.

The limb is then exsanguinated,and the sterile tourniquet is inflatedto 250 mmHg.Alternatively, the procedure can be performedwithout tourniquet hemostasis.

CHAPTER 3

The incision is then placed.Dissection through the subcutaneous tissueis then taken down to the triceps fascia.My preference is to do this with electrocauteryto minimize bleeding.

CHAPTER 4

Once down to the level of the triceps fascia,the dissection has taken a bit slowerto help mobilize the triceps tendonfrom the surrounding soft tissue.Care is taken not to take the dissectiontoo aggressively medial,as to inadvertently injure the ulnar nerve,or too proximal along the radial borderto 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 continuesto be mobilized.This will help in mobilization of the tendonand 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 itto continue to mobilize the tendon for subsequent repair.

CHAPTER 5

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 FiberWireto 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 integralto the ultimate repair of the footprint.Good repair is confirmedwith tensioning the triceps tendon, as demonstrated here.This will also help eliminate any slack in the suturewithin the tendon.

CHAPTER 6

Next, attention is turned to the insertion siteof the triceps tendon in the proximal ulna.Here you can see that the proximal ulna insertion siteis 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 ulnadown to bleeding bone.

CHAPTER 7

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

CHAPTER 8

Next, with the aid of a free needle,all four limbs of the suture is then broughtthrough the proximal tendon, as shown here,for ultimate repair in a mattress fashion.Once the first pair of limbs of sutures are broughtthrough the proximal tendonfor later repair in a mattress fashion,the same technique is then usedto place the second pair of sutures just next to it,as shown here.With both suture limbs in place,the first repair of the tendonback to its footprint can be performed.The arm is brought into extensionby resting it on a padded Mayo Stand.With an assistant pulling tension on the triceps tendonto maximize coverage of the footprint, as shown here,the SutureTak mattress sutures are then put downwith the arm in extensionand with at least six or seven knots placed on each side.

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

Next, the proximal ulna is preparedto receive the PushLocks.The posterior aspect of the ulna is exposed sharply,at least 2-3 cm distalto the proximal ulna.

Each PushLock is then placedover its drill hole in a staggered fashion,and directed away from the articular surfacethrough the posterior cortex of the ulna.The PushLock is then placedfollowing the trajectory of the drill hole,while tensioning all three suture limbs runningthrough 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 repeatedfor 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 repairof the triceps tendon has been completed.

CHAPTER 9

The elbow is taken through gentle range of motionto cycle the sutures and to confirm secure repair.Once satisfied, the wound is washedand 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 Vicryland 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 slabon the volar or anterior aspect of the elbowto avoid inadvertent flexion of the elbowduring the early postoperative period.

CHAPTER 10

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