Review of Repair and Reconstruction of Traumatic Deficiency of Triceps

Although triceps tendon ruptures are not common (less than 1 percent of all tendon ruptures), they must be managed through repair and reconstruction. This article reviews the historical perspective of repair and current repair techniques.

Surgical repair of triceps tendon ruptures were reported as early as 1957. In the first of two reports, the authors reviewed the procedures, the first which involved drilling holes in the olecranon (the bony tip of the elbow) and threading braided stainless steel wire. The second involved creating a periosteal (membrane) flap over the olecranon area and stitching the remaining part of the triceps with a stainless steel suture material.

Later on, in the 60s, surgeons repaired the rupture but didn't recommend using sutures through the olecranon. They did recommend using an absorbable material to do the repair and then to immobilize the arm for several weeks after. Other surgeons wanted shorter immobilization periods, so they experimented with stronger materials and techniques.

Whether surgery was indicated depends on how the injury occurred and the damage sustained. Indications for surgery include significant muscle weakness and the patients' dependence on the triceps strength, for work or use of a wheelchair, for example. Contraindications include infection and significant comorbidities that would make surgery too risky.

Where surgery is not indicated, non-operative treatments are available, but can have a failure rate of up to 40 percent if patients use their upper arms for strenuous activities.

Preoperative planning involves determining the extent of the injury and if patients have any tendon-debilitating comorbidities, such as steroid use, rheumatoid arthritis, renal failure, or diabetes.

The surgical repair used now involves advancement of triceps with placement of a locking nonabsorbable suture through the tendon and passing these through drill holes in the olecranon. If necessary, the tendon may be reconstructed using a hamstring tendon autograft (tissue from the patient) or Achilles tendon allograft (donated tissue).

Following surgery, the patient's arm is immobilized in a 90 degree angle for 24 hours. After the 24 hours, the dressing is removed and the patient's arm is placed in a sling. Full active elbow range of motion will be permitted at four to six weeks if the repair seems secure, although lifting weight is limited to five pounds during that period. No forced lifting or lifting weights over 10 pounds is permitted before the eighth or tenth week after surgery. At three months follow-up, if all seems fine, the patient is allowed to resume normal daily activities, with heavy lifting and full extension strength allowed at six months after surgery.

If there is a question as to how secure the repair is, more care is given up to the sixth week as to the amount of flexion allowed.

If a ruptured tendon results in very little tendon tissue to work with, there are two techniques of reconstruction that can be used, the choice depending on the site of the rupture, the remaining tissue and its quality. The choice is between the autogenous hamstring tendon (used if some triceps tendon is present but of poor quality) or Achilles tendon allograft if the defect in the muscle or tendon is massive and/or the there is a problem with the olecranon.

Management after these repairs include the splinting of the arm at 30 degrees for 24 hours and only gentle, passive assisted range of motion is allowed during the first four to six weeks after surgery. At six weeks, active flexion and extension can begin but not forced extension until after 12 weeks. At this point, no weight higher than 10 pounds is permitted although gradual use of the arm for daily living activities is allowed. At six months, the patients can begin gradually increasing the extension strength. It can take up to 12 months for full recovery.

Complications to the surgeries include infection, rerupture, ulnar neuropathy, extensor lag or weakness, or continued pain.

References: Rafael J. Sierra and Scott P. Steinmann. Repair and reconstruction of traumatic deficiency of the triceps. In Current Orthopedic Practice. May/June 2008. Vol. 19. No. 3. Pp. 280-288.