import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Ulnar nerve**. Location: Passes posterior to medial epicondyle in cubital tunnel, 1-2cm medial to olecranon tip. Protection: Avoid dissection or anchor placement on medial aspect, palpate to confirm not entrapped by hardware or sutures **Posterior interosseous nerve**. Location: Emerges between two heads of supinator 6-8cm distal to lateral epicondyle. Protection: Limit lateral dissection beyond radial head level, stay posterior **Elbow joint**. Location: Anterior to olecranon footprint, separated by thin cortex. Protection: Angle anchors/tunnels distal and posterior, avoid anterior trajectory, confirm extra-articular on fluoroscopy **Olecranon skin envelope**. Location: Thin soft tissue coverage over posterior olecranon prominence. Protection: Curve incision around tip (not over), avoid excessive undermining, careful closure without tension **Anconeus muscle pedicle**. Location: Vascular supply enters from lateral epicondyle traveling medially. Protection: If using anconeus turndown, preserve lateral base and vascular pedicle during mobilization ## 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 **Technical Tip**: "Most ruptures are avulsions from the olecranon (80%). I assess three key factors: rupture pattern, tendon quality, and retraction distance. Retraction >3cm or poor tissue quality means I'll plan augmentation with anconeus turndown or Achilles allograft." ### 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) Elbow joint is anterior to footprint, separated by thin cortex. Plan anchor trajectory distal and posterior (away from joint). Consider fluoroscopic confirmation if anatomy unclear. ### 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 **Technical Tip**: "I place Krackow locking sutures with FiberWire into the tendon stump before anchor placement. This allows me to test tendon excursion and confirms it reaches the footprint. If significant tension, I consider V-Y lengthening or augmentation rather than over-tensioning the repair." ### 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 Over-tensioning causes flexion contracture (most common complication, 20-40%). Under-tensioning causes gap and re-rupture. Tension at 30-40° flexion. Verify: full extension (0°) possible, flexion >120° possible, no palpable gap at insertion. ### 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 **Technical Tip**: "For chronic tears with poor tissue, I augment with anconeus turndown if local tissue adequate, or Achilles allograft if large gap (>4cm). Anconeus provides vascularized coverage and reduces re-rupture risk from 5-10% to <5%. I preserve the lateral vascular pedicle when harvesting the anconeus flap." ### 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) Fracture through tunnels if too large (>4mm), too close together (<8mm), or too many (>4). Intra-articular sutures can cause irritation. Knot prominence if tied anteriorly. Consider bone quality before choosing this method. ### 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 **Technical Tip**: "Intraoperative ROM check is critical. I verify full extension (0°) - stiffness is the most common complication. I confirm flexion >120° and active extension against gravity. The repair should feel solid without palpable gap. Ulnar nerve must be free, not compressed by medial hardware or sutures." ## 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 | Timeframe | Goals | Restrictions | |-----------|-------|--------------| | 0-2 weeks | Wound healing, edema control | No ROM, splint at 30-40° flexion | | 3-6 weeks | Passive ROM 0-90°, pain control | No active extension, no resistance | | 6-8 weeks | Full passive ROM, active extension (no resistance) | No resisted extension | | 8-12 weeks | Active ROM, begin light strengthening (1-2 lbs) | No heavy lifting | | 3-4 months | Progressive resistance, functional activities | Gradual return to sports | | 4-6 months | Full unrestricted activity, sports clearance | None if strength >80% contralateral | ## 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 ## References 1. Sollender JL, Rayan GM, Barden GA. Triceps tendon rupture in weight lifters. J Shoulder Elbow Surg. 1998;7(2):151-153. doi:10.1016/S1058-2746(98)90225-1. PMID: 9593093. **Classic paper describing triceps ruptures in athletes with anabolic steroid use - mechanism and risk factors.** 2. Yeh PC, Dodds SD, Smart LR, Mazzocca AD, Sethi PM. Distal triceps rupture. J Am Acad Orthop Surg. 2010;18(1):31-40. doi:10.5435/00124635-201001000-00005. PMID: 20047937. **Comprehensive JAAOS review of triceps tendon ruptures - anatomy, diagnosis, treatment options.** 3. Pantazopoulos T, Exarchou E, Stavrou Z, Hartofilakidis-Garofalidis G. Avulsion of the triceps tendon. J Trauma. 1975;15(9):827-829. doi:10.1097/00005373-197509000-00013. PMID: 1159860. **Early case series describing avulsion pattern as most common - established classification system.** 4. Levy M, Goldberg I, Meir I. Fracture of the head of the radius with a tear or avulsion of the triceps tendon. J Bone Joint Surg Br. 1982;64(1):70-72. doi:10.1302/0301-620X.64B1.7068724. PMID: 7068724. **Described association between radial head fracture and triceps injury - complex elbow trauma.** 5. Sanchez-Sotelo J, Morrey BF. Surgical techniques for reconstruction of chronic insufficiency of the triceps. Rotation flap using anconeus and tendo achillis allograft. J Bone Joint Surg Br. 2002;84(8):1116-1120. doi:10.1302/0301-620x.84b8.13436. PMID: 12463655. **Key paper by Morrey describing augmentation techniques - anconeus turndown and Achilles allograft for chronic tears.** 6. Strauch RJ. Biceps and triceps tendon injuries of the elbow. Orthop Clin North Am. 1999;30(1):95-107. doi:10.1016/s0030-5898(05)70063-1. PMID: 9882727. **Detailed surgical technique review covering acute and chronic repairs - fixation methods comparison.** 7. van Riet RP, Morrey BF, Ho E, O'Driscoll SW. Surgical treatment of distal triceps ruptures. J Bone Joint Surg Am. 2003;85(10):1961-1967. doi:10.2106/00004623-200310000-00015. PMID: 14563805. **Large series from Mayo Clinic - outcomes of surgical repair, complication rates, functional results.** 8. Sharma SC, Singh R, Sharma AK, Kohli HS. Triceps tendon rupture in chronic renal failure patients. Int Orthop. 2004;28(3):143-145. doi:10.1007/s00264-004-0541-3. PMID: 15138640. **Described high risk of triceps rupture in dialysis patients - uremic tendinopathy and hyperparathyroidism mechanism.** 9. Dunn JC, Kusnezov N, Orr JD, Pallis M, Bailowitz Z. The Achilles tendon allograft in triceps reconstruction. Orthopedics. 2017;40(1):e200-e204. doi:10.3928/01477447-20160902-01. PMID: 27598832. **Modern series using Achilles allograft for chronic triceps ruptures - technique and outcomes.** 10. Keener JD, Chafik D, Kim HM, Galatz LM, Yamaguchi K. Insertional anatomy of the triceps brachii tendon. J Shoulder Elbow Surg. 2010;19(3):399-405. doi:10.1016/j.jse.2009.07.006. PMID: 19884021. **Detailed anatomic study of triceps footprint - guides anchor placement and repair techniques.**

Triceps Tendon Repair

Triceps Tendon Repair