Triceps Tendon Repair

Sterile Instruments/Equipment

• Tourniquet

• Self-retaining retractors

• Rasp

• 2-mm drill bit

• Ruler

• Rongeur

• Suture shuttling device (Hewson suture passer, Smith & Nephew, Andover, MA)

• Implants

• Two no. 2 nonabsorbable sutures (preferably different colors)

• Free needle

• Two looped nonabsorbable sutures (FiberLink, Arthrex, Naples, FL)

• Knotless suture anchor (4.75-mm BioComposite SwiveLock, Arthrex, Naples, FL)

Patient Positioning

• The patient is positioned either prone on chest rolls or in the lateral decubitus position on a beanbag, depending on surgeon preference.

• We prefer prone on chest rolls.

• All bony prominences are carefully padded.

• The elbow should be positioned such that it can be held in a flexed position of 90 degrees, with freedom to extend as needed during the surgical repair.

• With the patient prone, an arm holder is placed on the ipsilateral side of the bed at shoulder level such that the shoulder is in 90 degrees of abduction and neutral forward flexion.

• A nonsterile tourniquet is placed proximally on the upper arm at the axilla to allow an adequate surgical field.

• The upper arm is placed in the arm holder at the level of the tourniquet (Fig. 29-1).

Surgical Approach

• An 8- to 10-cm midline curvilinear incision is made over the posterior aspect of the elbow.

• The incision starts 4-5 cm proximal to the tip of the olecranon and extends 4-5 cm distal to the tip of the olecranon.

• The incision is gently curved to the radial side of the olecranon tip to prevent the healed incision from being in the area of direct contact when the elbow rests on a surface during daily activities.

Figure 29-1 | Patient positioned prone on chest rolls with tourniquet and arm holder placed.

• Medial and lateral skin flaps are created.

• The flaps should not be made too thin to avoid skin perforation and to provide adequate coverage with closure.

• The ulnar nerve is palpated medially. The nerve is not routinely exposed, but great care is taken to protect it throughout the procedure.

Triceps Tendon and Olecranon Preparation

• The site of tendon injury is identified and prepared.

• Often, the paratenon is violated. If it is intact, though, care is taken to incise it in its midline and gently elevate it off the remaining tendon for later closure.

• The ruptured tendon often is surrounded by a serous or organizing hematoma. It may be tendinotic or bulbous, requiring some debridement.

• Only the tendinotic tissue is debrided.

• There may be some delamination between the deep medial head and more superficial lateral head that should be identified so as to include both with the repair.

• The tendon is gently mobilized by freeing any surrounding adhesions.

• The tendon footprint is identified and marked to aid in later suture passage.

• The tendon footprint on the olecranon is identified and prepared.

• The proximal aspect of the tendon insertion begins ˜12 mm distal to the tip of the olecranon.

• This site is identified, and any remaining soft tissue is debrided from the bony footprint.

• The exposed surface is gently rasped to create a vascular bed, with care taken not to decorticate the bone bed (Fig. 29-2).

• The proximal olecranon periosteum is incised along the posterior ulnar border and elevated medially and laterally for later closure over the repair.

Figure 29-2 | The prepared triceps tendon and olecranon with corresponding footprint sites marked.

Repair Techniques

• Several techniques exist to repair the distal triceps tendon to the bone:

• Transosseous Cruciate Tunnels¹

▪ This technique involves securing the tendon to the footprint by passing the sutures that have been placed in the tendon through crossing bone tunnels in the olecranon.

▪ A no. 2 nonabsorbable suture is placed in a locking fashion (eg, Krackow/Bunnell) in the triceps tendon. The suture enters the previously demarcated footprint site on the medial tendon, passes along the medial edge proximally, and crosses to the lateral side and then distally along the lateral tendon edge to exit on the lateral half of the triceps footprint.

▪ A 2-mm drill bit is used to create crossing bone tunnels in the olecranon.

▪ The tunnels begin at the medial and lateral tendon footprint and extend distally to the contralateral cortical side on the dorsal ulna.

▪ Care is taken when drilling from lateral to medial to protect the ulnar nerve.

▪ A suture passer is used to retrieve each suture end through the tunnels from proximal to distal. The medial suture end is passed through the bone tunnels from medial to lateral, while the lateral suture end is passed from lateral to medial.

▪ The sutures are then tied over the bone bridge with care to maintain the knot at the entrance of the distal lateral bone tunnel. This will ensure that the suture knot is less palpable and away from the ulnar nerve (Fig. 29-3).

• Standard Suture Anchor Repair²,³,⁴

▪ This technique involves placing two single-loaded suture anchors into the anatomic footprint on the olecranon.

▪ One anchor is placed distally in the medial half of the olecranon footprint; the other anchor is placed distally in the lateral half of the olecranon footprint (Fig. 29-4A).

▪ One suture limb of the medial anchor is placed in the medial half of the tendon in a Krackow fashion from distal to proximal 3-4 cm, then proximal to distal. One suture limb of the lateral anchor is passed in the same fashion through the lateral half of the tendon.

Figure 29-3 | Completed transosseous cruciate drill tunnel technique schematic. (SAGE Publishing From Petre BM, Grutter PW, Rose DM, Belkoff SM, McFarland EG, Petersen SA. Triceps tendons: a biomechanical comparison of intact and repaired strength. J Shoulder Elbow Surg. 2011;20:213-218, Figure 2, with permission.)

Figure 29-4 | A. Plain anteroposterior (AP) radiograph showing suture anchors placed in the olecranon. B. Completed standard suture anchor repair. (From Bava ED, Barber FA, Lund ER. Clinical outcome after suture anchor repair of complete traumatic rupture of the distal triceps tendon. Arthroscopy. 2012;28:1058-1063, Figure 1, with permission; Yeh PC, Stephens KT, Solovyova O, et al. The distal triceps tendon footprint and a biomechanical analysis of 3 repair techniques. Am J Sports Med. 2010;38:1025-1033, Figure 2, with permission.)

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