Triceps Insufficiency Research Articles

Approaches for elbow arthroplasty: how to handle the triceps

The question of the best surgical approach for total elbow arthroplasty is a hot topicwith great interest at the current time. The issue has been highlighted in a recent review of complications of total elbow arthroplasty and has been studied in detail in the past. The problem of triceps insufficiency after total elbow arthroplasty has been specifically addressed by Celli et al, and potential solutions for addressing triceps insufficiency have been proposed by Sanchez-Sotelo and Morrey. As the awareness of triceps insufficiency has increased, surgeons have turned to alternative exposures. In so doing, many of the old or previously established approaches to the elbow have been rediscovered or modified. Orthopedic surgeons, especially those with an interest in elbow arthroplasty, recognized themanagement of the extensormechanism as a key element for the success of the procedure. The only relative absolute dictum in this regard is that osteotomy is not considered a viable option for joint replacement arthroplasty, except in selectedcases treatedwithhumeral hemiarthroplasty, or unexpected intraoperative conversion of fixation to arthroplasty in the treatment of distal humeral fractures.

Triceps Reconstruction Using Hamstring Graft for Triceps Insufficiency or Recurrent Rupture

Triceps ruptures are relatively rare injuries. When they occur, primary surgical repair of the tendon to the proximal ulna is recommended. However, some patients require reconstruction using tendon grafting due to shortening or insufficiency of the native triceps tendon. Triceps ruptures associated with biological abnormalities (such as renal insufficiency or metabolic disease) or recurrence of rupture represent situations where a stout augmented repair is desirable. Multiple allograft and autologous tendons have been described for augmentation, but the use of gracilis and semitendinosus tendons provides superior length and size for use in triceps reconstruction. Using an illustrative case example, the evaluation of triceps insufficiency and the need for additional graft is shown. The technique of autologous hamstring augmentation for triceps insufficiency is described in detail. The importance of graded rehabilitation is emphasized with a complete program of triceps strengthening over time.

The triceps-preserving approach for semiconstrained total elbow arthroplasty

Total elbow arthroplasty (TEA) is a useful tool to relieve pain and provide return to function for many conditions affecting the elbow. For conditions ranging from inflammatory arthropathies to comminuted intra-articular distal humeral fractures in the elderly, TEA is an excellent treatment alternative. Numerous surgical approaches for TEA have been described. Most surgeons use either a direct posterior or posterior-lateral incision. TEA is not without its complications. One such complication is insufficiency of the triceps. Many surgical approaches have been described to try to decrease the possibility of triceps insufficiency. In this article, we describe a new technique not previously described in which, using a posterior incision, the triceps is only dissected from the medial side. With this technique, the tendon insertion on the olecranon, as well as the entire lateral soft-tissue envelope of the elbow, is left undisturbed.

Triceps Insufficiency Following Total Elbow Arthroplasty

Over the past decade, the indications for total elbow arthroplasty have increased. One complication that is well recognized but is poorly described in the literature is insufficiency of the extensor mechanism involving complete or partial rupture, or avulsion, of the triceps tendon. We therefore reviewed the records of patients who had undergone surgery for the treatment of triceps insufficiency following total elbow arthroplasty to determine the management options and outcomes of intervention for this problem. The records on 887 total elbow arthroplasties performed between 1982 and 2001 were assessed to identify patients who had undergone a subsequent procedure on the triceps. Patients in whom triceps insufficiency developed after débridement for infection were excluded, leaving sixteen elbows in fourteen patients. A Mayo Elbow Performance Score was calculated and elbow extension strength against gravity was measured at the time of final follow-up. There were seven male and seven female patients. The mean age was fifty-four years. The mean duration of follow-up after the triceps reconstruction was sixty-seven months. Three basic techniques were used to repair or reconstruct the extensor mechanism; these included direct suture in seven elbows, anconeus rotation in four, and use of an Achilles tendon allograft in four. The capacity to extend against gravity was restored to fifteen of the sixteen elbows. According to the Mayo Elbow Performance Score, eleven elbows had an excellent outcome, three had a good outcome, and two were considered a clinical failure. In most patients with triceps insufficiency following total elbow arthroplasty, it is possible to reconstruct the triceps mechanism with a procedure appropriately selected on the basis of tissue quality, tendon retraction, and the status of the olecranon.

Ulnar component fracture after revision total elbow arthroplasty with proximal ulnar bone loss: A report of 2 cases

Total elbow arthroplasty (TEA) is a reliable treatment for pain in selected patients with elbow arthritis.2,3,6,11 However, associated complications are well documented.3,12 These include superficial and deep infection, dislocation, aseptic loosening, ulnar nerve palsy, triceps insufficiency, and periprosthetic fracture.12 Component fracture is a rare complication.4,7,14 Revision TEA is challenging and potentially increases complication risk. We present 2 cases of ulnar component fracture after revision semiconstrained TEA performed in elbows with proximal ulnar bone loss.

PERIPROSTHETIC HUMERAL FRACTURES AFTER TOTAL ELBOW ARTHROPLASTY

Periprosthetic fractures are among the most challenging complications of elbow arthroplasty, and published information about the outcome of treatment is limited. The purpose of the present study was to determine the results of implant revision and strut allograft augmentation for the treatment of humeral periprosthetic fractures that occur around a loose humeral component. Between 1991 and 1999, eleven periprosthetic fractures that occurred around a loose humeral component were treated with cortical strut allograft augmentation and revision arthroplasty with use of a Coonrad-Morrey semiconstrained implant. Six fractures occurred after a primary arthroplasty, and five occurred after a revision arthroplasty. Two parallel strut grafts were used for fracture fixation in most cases. Patients were followed for an average of three years (range, nine months to 7.8 years) and were evaluated clinically and radiographically. Clinical and radiographic fracture union was obtained in ten of the eleven patients. One patient required revision surgery because of aseptic loosening of the humeral component seven years and nine months after fracture union; there were no other implant failures. Complications included one additional nondisplaced humeral periprosthetic fracture after surgery that failed to heal with closed treatment, one olecranon fracture, one permanent ulnar nerve injury, and one case of triceps insufficiency. At the time of the most recent follow-up, seven of the eight patients with an intact reconstruction had a functional arc of motion and no or slight pain and one had limited motion and moderate pain. Periprosthetic humeral fractures that are associated with a loose humeral component can be effectively treated with revision elbow arthroplasty and strut allograft augmentation. The technique is associated with a high rate of fracture union, implant survival, and satisfactory clinical results. However, the complication rate is substantial.

Complications of Total Elbow Arthroplasty

The need for revision surgery for loosening exceeds 25% with tightly constrained prostheses but is much less with the semiconstrained designs. Resurfacing prostheses may be unstable if not adequately balanced by static and dynamic soft-tissue constraints. Infection is excessive (4%-9%), but resection arthroplasty is a reasonably good salvage procedure. Implant failure is rare. The ulnar nerve is subject to transient (10%) or, occasionally, partial dysfunction. Routine anterior translocation has been beneficial, but there is considerable variation in technique in this regard. Triceps insufficiency can be virtually eliminated with the Kocher lateral-to-medial or the Bryan lateral-to-medial triceps-sparing approach. Fractures of the ulna usually can be treated by cast application, but humeral fractures may require revision surgery because of component loosening. Some complications are decreasing in frequency, whereas others are becoming more widely appreciated. The procedure remains a challenging one, and is one that should be performed by those who are experienced in elbow surgery and who have a detailed knowledge of the numerous potential pitfalls.