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  • 1. Introduction
  • 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
  • 8. Triceps Tendon Repair
  • 9. Closure
  • 10. Post-op Remarks
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Triceps Repair for Acute Triceps Tendon Rupture

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Gregory Schneider, BS1; Asif M. Ilyas, MD, MBA, FACS1,2
1 Sidney Kimmel Medical College at Thomas Jefferson University
2 Rothman Institute at Thomas Jefferson University

Transcription

CHAPTER 1

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.

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 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.

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.

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

CHAPTER 3

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.

CHAPTER 4

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.

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 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.

CHAPTER 6

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.

CHAPTER 7

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.

CHAPTER 8

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.

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.

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.

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.

CHAPTER 9

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.

CHAPTER 10

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.