CHAPTER 63 Triceps Insufficiency Following Total Elbow Arthroplasty

INTRODUCTION

Triceps insufficiency can occur as a result of traumatic rupture of the tendon or, most commonly, following a failed surgical reattachment, particularly when there is poor tendon quality.^5,^12,^15,^17,¹⁸ As a complication following elbow replacement, this is becoming much more appreciated.⁴

According to the limited literature available on this topic, the incidence of triceps insufficiency following total elbow arthroplasty ranges from 1% to 29%.^7,^9,^10,^14,^16,¹⁷ A recent report using the Gschwend approach documents four of 28 elbows with triceps insufficiency after a triceps-splitting approach to insert the GSB implant (Center Pulse, Zurich).¹¹ In a recent comprehensive review of the literature, Voloshin et al²² documented an incidence of approximately 1% to 5% of triceps insufficiency associated with total elbow arthroplasty. Typically, literature reviews understate the true incidence of this problem.

The key factor in avoiding the development of this problem is the nature and execution of the surgical exposure. In this regard, a number of recent studies ²³ have examined modifications to existing exposures (see Chapter 7).^6,¹⁹ Olecranon osteotomy is contraindicated in joint replacement surgery. Hence, some means of dealing with the triceps attachment is necessary. There are several options:

1. Reflection of the triceps in continuity with forearm fascia and periosteum and anconeus from medial to lateral.² Reflection of the triceps with a wafer of bone is a modification that has also been recommended.²⁴

2. Extensile Mayo Modified Kocher approach: following a posterior lateral exposure reflection of the anconeus and approximately one third of the lateral triceps attachment from the tip of the olecranon (see Chapter 7).

3. Campbell’s triceps-splitting approach. This approach may be modified by releasing the triceps with wafer of bone.⁸

4. Preservation of the triceps attachment and aggressive flexor-extensor release to “skeletonize” and deliver the distal humerus. This approach is modified by excision of humeral condyles.¹

PRESENTATION AND SYMPTOMS

All patients will report loss of active extension and about 15% to 20% will also report pain.⁴ The most common problem is the inability to reach above the head and to push through doors. The mean time from initial procedure to revision for triceps insufficiency is about 3 years. In our experience the clinical findings at the time of surgical revision were (1) a change in the posterior contour of the elbow with visual and palpable prominence of the implant and atrophy of the subcutaneous tissue; (2) the presence of an olecranon bursitis; (3) atrophy of the triceps muscle; and (4) discernable lateral subluxation or dislocation of the extensor mechanism.

MANAGEMENT

Our recommendations are based on the Mayo Clinic experience with triceps insufficiency for any cause ²¹ and particularly after joint replacement.⁴ From 887 total elbow arthroplasty operations, we identified 16 elbows that underwent subsequent surgical treatment for triceps insufficiency at our institution. The underyling diagnoses for which the primary total elbow arthroplasty was performed were rheumatoid arthritis in nine cases and post-traumatic conditions in seven cases. Initially, the triceps-sparing approach as described by Bryan and Morrey² was used in 15; in one patient, the triceps-splitting approach as described by Campbell³ was used.