The cruciate double rip-stop technique: an all-suture distal triceps tendon repair technique combining a pulley mechanism and racking hitch knots

Clinical Outcome Measures Following Suture Anchor Repair for Traumatic Rupture of the Distal Triceps Tendon (SS-53)

Distal triceps tendon ruptures occur most commonly in middle-aged males, with possible rupture locations including the musculotendinous junction, mid-tendon, or most commonly, at the tendinous insertion. This surgical technique video demonstrates a hybrid distal triceps tendon repair construct utilizing transosseous sutures, SpeedBridge compression, and knotless suture anchor fixation. Indications for this procedure include an acute injury with complete avulsion of the distal triceps tendon from the olecranon and extension weakness. The goals of surgical repair include restoration of the tendon footprint on the olecranon and the creation of a strong fixation construct that balances tension to optimize healing and restore functional range of motion. The proximal avulsed tendon is prepared with two number 2 suture tapes placed in a locking Krackow fashion. The locking stitch exit point is determined at a distance proximal to the distal end of the tendon to optimize tension after the reduction of the tendon to the footprint. Two looped sutures are then passed through the tendon at the same exit level as the locking stitch, 1 on the medial and lateral sides of the locking stitch, respectively. Two transosseous tunnels are drilled obliquely, from proximal to distal, through the olecranon. A 4.75-mm suture anchor is then drilled and tapped in the proximal ulna, in between 2 transosseous tunnel exit points, for lateral placement. The medial and lateral locked stitches are passed through the medial and lateral transosseous tunnels, respectively. The SpeedBridge construct is formed by passing one suture from each locking stitch limb back through the tendon using the previously placed looped sutures as shuttling devices. After appropriate tensioning, the sutures are secured into the previously drilled 4.75-mm suture anchor in a specific fashion. Current literature suggests that the SpeedBridge technique for triceps tendon repair demonstrates good functional and clinical outcomes with high satisfaction rates, elbow functional scores, and rates of returning to work/activity, coupled with low complication rates. The hybrid SpeedBridge construct is an effective technique for acute distal triceps tendon repair. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Restoring footprint anatomy, minimizing gap formation, and maximizing the strength of distal triceps tendon repairs are essential factors for a successful healing process and return to sport. Hypothesis: The novel V-shaped distal triceps tendon repair technique with unicortical button fixation closely restores footprint anatomy, provides minimal gap formation and high ultimate failure load, and minimizes iatrogenic fracture risk in acute/subacute distal triceps tendon tears. Study Design: Controlled laboratory study. Methods: Twenty-four cadaveric elbows (mean ± SD age, 66 ± 5 years) were randomly assigned to 1 of 3 repair groups: the transosseous cruciate repair technique (gold standard), the knotless suture-bridge repair technique, and the V-shaped distal triceps tendon repair technique. Anatomic measurements of the central triceps tendon footprint were obtained in all specimens with a 3-dimensional digitizer before and after the repair. Cyclic loading was performed for a total of 1500 cycles at a rate of 0.25 Hz, pulling in the direction of the triceps. Displacements were measured on the medial and lateral tendon sites with 2 differential variable reluctance transducers. Load to failure and construct failure mode were recorded. Results: The mean triceps bony insertion area was 399.05 ± 81.23 mm2. The transosseous cruciate repair technique restored 36.6% ± 16.8% of the native tendon insertion area, which was significantly different when compared with the knotless suture-bridge repair technique (85.2% ± 14.8%, P = .001) and the V-shaped distal triceps tendon repair technique (88.9% ± 14.8%, P = .002). Mean displacement showed no significant difference between the V-shaped distal triceps tendon repair technique (medial side, 0.75 ± 0.56 mm; lateral side, 0.99 ± 0.59 mm) and the knotless suture-bridge repair technique (1.61 ± 0.97 mm and 1.29 ± 0.8 mm) but significance between the V-shaped distal triceps tendon repair technique and the transosseous cruciate repair technique (4.91 ± 1.12 mm and 5.78 ± 0.9 mm, P < .001). Mean peak failure load of the V-shaped distal triceps tendon repair technique (732.1 ± 156.0 N) was significantly higher than that of the knotless suture-bridge repair technique (505.4 ± 173.9 N, P = .011) and the transosseous cruciate repair technique (281.1 ± 74.8 N, P < .001). Mechanism of failure differed among the 3 repairs, with the only olecranon fracture occurring in the knotless suture-bridge repair technique at the level of the lateral row suture anchors. Conclusion: At time zero, the V-shaped distal triceps tendon repair technique and the knotless suture-bridge repair technique both provided anatomic footprint coverage. Ultimate load to failure was highest for the V-shaped distal triceps tendon repair technique, while gap formation was different only in comparison with the transosseous cruciate repair technique. Clinical Relevance: The V-shaped distal triceps tendon repair technique provides an alternative procedure to other established repairs for acute/subacute distal triceps tendon ruptures. The reduced repair site motion of the V-shaped distal triceps tendon repair technique and the knotless suture-bridge repair technique at the time of surgery may allow a more aggressive rehabilitation program in the early postoperative period.

Background Anatomic repair of tendon ruptures is an important goal of surgical treatment. There are limited data on the triceps brachii insertion, footprint, and anatomic reconstruction of the distal triceps tendon. Hypothesis An anatomic repair of distal triceps tendon ruptures more closely imitates the preinjury anatomy and may result in a more durable repair. Study Design Descriptive and controlled laboratory studies. Methods The triceps tendon footprint was measured in 27 cadaveric elbows, and a distal tendon rupture was created. Elbows were randomly assigned to 1 of 3 repair groups: cruciate repair group, suture anchor group, and anatomic repair group. Biomechanical measurement of load at yield and peak load were measured. Cyclic loading was performed for a total of 1500 cycles and displacement measured. Results The average bony footprint of the triceps tendon was 466 mm2. Cyclic loading of tendons from the 3 repair types demonstrated that the anatomic repair produced the least amount of displacement when compared with the other repair types (P < .05). Load at yield and peak load were similar for all repair types (P > .05). Conclusion The triceps bony footprint is a large area on the olecranon that should be considered when repairing distal triceps tendon ruptures. Anatomic repair of triceps tendon ruptures demonstrated the most anatomic restoration of distal triceps ruptures and showed statistically significantly less repair-site motion when cyclically loaded. Clinical Relevance Anatomic repair better restores preinjury anatomy compared with other types of repairs and demonstrates less repair-site motion, which may play a role in early postoperative management.

Anatomical Distal Biceps and Triceps Tendon Repairs

Arthroscopic Repair of Distal Triceps Tendon Rupture Provides Excellent Functional Outcomes With Minimal Complications

Clinical Outcomes of Low-Cost, Anchorless Repair of the Triceps Tendon Using a Proximal Knot Technique

Background: Distal triceps tendon injuries are relatively rare injuries, often occurring in highly active patients with physically demanding jobs or lifestyles. Information on return to work, sport, and activity is essential for patient education and counseling after a distal triceps tendon rupture. Purpose: To determine the rates of return to work, sport, and sport-related activity after distal triceps tendon repair. Study Design: Systematic review; Level of evidence, 4. Methods: PubMed, CINAHL, MEDLINE, Web of Science, and SPORTDiscus were queried from the earliest record through January 12, 2024. Articles were included if they examined return to various activities (exercise, sport, work, or military duty) after distal triceps tendon repair. Data on return to sport/work/activity were collected as well as information on patient satisfaction, pre-existing medical history or medication use (ie, anabolic steroids or corticosteroids), and complications. Article quality was assessed via the Methodological Index for Non-Randomized Studies (MINORS) scale. Results: Of 164 articles initially retrieved, 10 retrospective studies were included. Patients (n = 318; 74.2% male, 25.8% female) who underwent distal triceps tendon repair had a mean age of 44.7 ± 5.5 years with a mean follow-up time of 52.6 ± 21.4 months. After distal triceps tendon repair, 93.3% of patients (112/120) returned to sport, 95.3% (81/85) returned to military duty, and 92.6% (100/108) returned to work. Of the studies that evaluated satisfaction, the majority of patients reported high satisfaction after surgery. The overall complication rate (ranging from persistent pain and wound complications to nerve injuries and reruptures) after distal triceps tendon repair was 18.0%, the rerupture rate (complete and partial) was 7.2%, and the reoperation rate was 3.9%, with all partial reruptures undergoing nonoperative care. Conclusion: A distal triceps tendon rupture is a rare but potentially challenging injury, traditionally occurring in an active population, and often requires surgical repair. Importantly, >90% of an active-duty military population, athletes, and the general workforce was able to return to sport or their respective activity after surgery. Furthermore, there was high patient satisfaction and low rates of complications and reoperations after distal triceps tendon repair.

BackgroundDistal triceps tendon rupture is related to high complication rates with up to 25% failures. Elbow stiffness is another severe complication, as the traditional approach considers prolonged immobilization to ensure tendon healing. Recently, a dynamic tape was designed, implementing a silicone-infused core for braid shortening and preventing repair elongation during mobilization, thus maintaining constant tissue approximation. The aim of this study was to compare biomechanically the novel dynamic tape versus conventional tape in a human cadaveric distal triceps tendon repair model.MethodsSixteen paired arms from eight donors were split to two groups. Distal triceps tendon tenotomies and repairs were performed via the crossed transosseous locking Krackow stitch technique for anatomic footprint repair. Either conventional (SutureTape) or the novel dynamic tape (DYNATape) were used. A postoperative protocol mimicking intense early rehabilitation was simulated by a 9-day, 300-cycle daily mobilization under 150 N load followed by a final destructive test.ResultsSignificant differences were identified between the groups regarding the displacement over time at the distal, intermediate, and proximal tendon aspects, p < 0.001. DYNATape demonstrated significantly less displacement compared to SutureTape (4.6 ± 1.2 mm versus 7.8 ± 2.1 mm) and higher load to failure (637 ± 113 N versus 341 ± 230 N), p ≤ 0.037. DYNATape retracted 0.95 ± 1.95 mm after each 24-hour period and withstood the whole cyclic loading sequence without failure. In contrast, SutureTape failed early in three specimens.ConclusionDYNATape demonstrated improved biomechanical competence compared to SutureTape in a distal triceps tendon repair model, with significantly lower maximal displacement and higher load to failure. These findings indicate that DYNATape may offer a more stable construct under controlled laboratory conditions. Knot slippage and bone-related complications observed in both groups underscore the technical challenges associated with this repair technique and highlight the importance of precise surgical execution.

A comparison of distal triceps tendon repair outcomes by surgical technique

IntroductionThe management of distal triceps tears must address each patient’s medical and functional status: in general, the literature has described satisfactory nonsurgical treatment in tears less than 50%. Tears greater than 50% are treated nonsurgically in a sedentary person and surgically in active patients. Complete tears are generally managed surgically: most reported repair techniques describe the use of Bunnell or Krakow whipstitch techniques, passing the sutures through transosseous drill holes in the ulna. Other described techniques include the use of suture anchors and direct tendon repair to a periosteal flap raised from the olecranon.Case presentationIn the presented report we describe the surgical technique used to treat a complete traumatic distal triceps tendon rupture associated with olecranon fracture in a 40-year-old Caucasian man with underlying poor tendon quality and postoperative assessment. To the best of our knowledge no studies describing the performed surgical technique, utilizing Krakow whipstitches, olecranon fixation with K wires and Zuggurtung tension band through transosseous drill holes have been previously described in the literature.At 30 days postoperatively the patient had regained full elbow flexion/extension and pronation/supination.ConclusionsThe described methodology, using a double ulnar tunnel to obtain fixation of the fragment, associated with a whipstitch locking-type suture for the triceps tendon, allowed proper fixation of the fracture and optimal reinsertion of the detached tendon on its footprint with sufficient strength.

Ultrasound demonstration of distal triceps tendon tears

Traumatic distal triceps tendon rupture results in substantial disability in the absence of an appropriate diagnosis and treatment. To the best of our knowledge, differences in the degree of injury according to the injury mechanisms and associated lesions are not well known. In this study, we asked: (1) What differences are seen in triceps tear patterns between indirect injuries (fall on an outstretched hand) and direct injuries? (2) What are the associated elbow and soft tissue injuries seen in indirect and direct triceps ruptures? Between 2006 and 2017, one center treated 73 elbows of 72 patients for distal triceps tendon rupture. Of those, 70% (51 of 73 elbows) was excluded from this study; 8% (6 of 73) were related to systemic diseases, 59% (43 of 73) sustained open injuries, and 3% (2 of 73) were related to local steroid injections. We retrospectively collected data on traumatic distal triceps tendon rupture in 30% (22 of 73) of elbows at a single trauma center during a 10-year period. A fall on an outstretched hand was the cause of injury in 15 patients and direct blow by object or contusion were the cause in seven. MRI and surgery were performed in all patients. Traumatic distal triceps tendon rupture was classified by the Giannicola method, which is classified according to the depth and degree of the lesion based on MRI and surgical findings. Associated fractures and bone contusions on MRI were characterized. Ligament injuries on MRI was divided into partial and complete rupture. Agreement between the MRI and intraoperative findings for the presence of a traumatic distal triceps tendon rupture was perfect, and the Giannicola classification of traumatic distal triceps tendon rupture was good (kappa = 0.713). In the indirect injury group (fall on an outstretched hand), 15 of 15 patients had injuries that involved only the tendinous portion of the distal triceps, but these injuries were not full-thickness tears, whereas in the direct injury group, three of seven patients had a full-thickness rupture (odds ratio [OR] 1.75 [95% CI 0.92 to 3.32]; p = 0.02). The direct injury group had no associated ligamentous injuries while 14 of 15 patients with indirect injuries had ligamentous injuries (OR 0.13 [95% CI 0.02 to 0.78]; p < 0.001; associated injuries in the indirect group: anterior medial collateral ligament [14 of 15], posterior medial collateral ligament [7 of 15], and lateral collateral ligament complex [2 of 15]). Similarly, one of seven patients in the direct injury group had a bone injury (capitellar contusion), whereas 15 of 15 patients with indirect ruptures had associated fractures or bone contusions (OR 16.0 [95% CI 2.4 to 106.7]; p < 0.001). A fall on an outstretched hand may result in an injury mostly to the lateral and long head of distal triceps tendon and an intact medial head tendon; however, direct injuries can involve full-thickness ruptures. Although a traumatic distal triceps tendon rupture occurs after a fall on an outstretched hand, radial neck, capitellar, and medial collateral ligament injury can occur because of valgus load and remnant extensor mechanisms. Based on our finding, the clinician encountering a distal triceps tendon rupture due to a fall on an outstretched hand should be aware of the possibility of remaining elbow extensor mechanism by intact medial head tendon portion, and associated injuries, which may induce latent complications. Level III, prognostic study.

Injuries to the distal triceps brachii tendon are rare, but they can be challenging to diagnose accurately. While imaging radiographs are commonly used to confirm physical examination findings and guide treatment, magnetic resonance imaging (MRI) is considered the gold standard for diagnostic imaging. However, the accuracy of MRI in distinguishing between partial and full-thickness tears of the distal triceps tendon is not very reliable. A recent study conducted from 2011 to 2015 involving eight patients with nine triceps tendon tears aimed to assess MRI's accuracy in this differentiation. The study revealed that MRI correctly identified all three surgically confirmed complete tears, but its accuracy in detecting partial tears was less reliable, correctly identifying only four out of six cases. Notably, two cases were mistakenly identified as complete tears by MRI but were found to be partial tears during surgery. The characteristics of the distal triceps brachii insertion on the olecranon are fascinating and provide valuable insights into the diagnostic challenges faced by clinicians. Therefore, a recent study included fourteen fresh-frozen elbows were dissected, and a histologic examination was conducted on the distal triceps brachii insertion. Concurrently, T1-weighted elbow MR images of 102 patients without triceps pathology were analyzed. The study found that there are three distinct insertional areas of the distal triceps brachii tendon on the olecranon: capsular, deep muscular, and superficial tendinous. The superficial tendinous insertion exhibited a thickened portion known as the "central cord." MR analysis revealed a cleft between the superficial tendinous and deep muscular insertions, designated as the "lacuna," in some cases. Understanding this anatomy can help surgeons identify partial triceps injuries and avoid iatrogenic injury during surgery. While MRI is valuable in diagnosis, it is not always accurate, and false-positive results are not uncommon. Therefore, it is crucial to combine clinical examination with imaging for accurate diagnosis and treatment planning. These findings highlight the importance of a comprehensive approach that includes clinical assessment, with MRI serving as a valuable adjunctive tool in the diagnostic process and treatment planning for distal triceps tendon injuries.

Injury to the distal triceps brachii tendon is rare. Imaging radiographs are used to confirm the findings of physical examination, classify the extent of injury, and guide treatment. Magnetic resonance imaging (MRI) is considered the gold standard of diagnostic imaging. However, no previous study has reported on the accuracy of differentiation between partial- and full-thickness triceps tendon tears. Our study's aim was to define the accuracy of MRI in differentiating partial- from full-thickness tear of the distal triceps tendon. We hypothesized that MRI has low accuracy in differentiating partial- from full-thickness tears. A total of eight patients with nine triceps tendon tears underwent surgical repair from 2011 to 2015. MRI of the elbows were retrospectively reviewed for the presence and type of tear, tendon involvement, and location of the tear, and later correlated with surgical findings. Of the three surgically confirmed complete tears, MRI correctly reported a complete tear in all patients. Of the six partial tears confirmed at surgery, MRI correctly identified four tears. In two cases, MRI described a complete tear, but only a partial tear was noted at surgery. False-positive MRI assessment of distal triceps injury is not rare. Surgeons should rely on clinical examination in assessing distal triceps tendon injury, with imaging studies providing an adjunctive role in the diagnosis and decision-making.