Functional outcomes and complications after surgical

Functional outcomes and complications after surgical repair of triceps tendon rupture Ozkan Kose, Omer Faruk Kilicaslan, Ferhat Guler, Baver Acar & Halil Yalçın Yuksel European Journal of Orthopaedic Surgery & Traumatology ISSN 1633-8065 Eur J Orthop Surg Traumatol DOI 10.1007/s00590-015-1669-3

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Author's personal copy Eur J Orthop Surg Traumatol DOI 10.1007/s00590-015-1669-3

ORIGINAL ARTICLE • UPPER LIMB - TRAUMA

Functional outcomes and complications after surgical repair of triceps tendon rupture Ozkan Kose1 • Omer Faruk Kilicaslan1 • Ferhat Guler1 • Baver Acar1 Halil Yalc¸ın Yuksel1

•

Received: 1 June 2015 / Accepted: 3 July 2015 Springer-Verlag France 2015

Abstract Objective The purpose of this study was to present the functional outcomes and complications after primary repair of triceps tendon ruptures (TTR). Patients and methods A retrospective review was performed on eight patients (six males, two females) who underwent transosseous suture repair for TTR. Mayo elbow score, range of motion, muscle strength and patient satisfaction were evaluated after at least 1-year follow-up. Results The mean age of the patients was 25.1 years (range 16–42). The mechanism of injury was a sports injury in three patients, simple fall (fall on outstretched hand) in four and motorcycle accident in one patient. Two patients had associated radial head fracture, and one had a radial head fracture and trochlear fracture, and one patient had a medial epicondyle fracture. In two patients the diagnosis was missed at the initial admission to ED (delay, 20 and 75 days). Only one patient, who was a bodybuilder, had a history of anabolic steroid use, and the rest had no underlying disease or a predisposing factor for TTR. One of the patients with radial head fracture (displaced three parts) underwent simultaneous fixation using two headless screws. Patients were followed up for a mean of 18.8 months (range 12–26). At the final follow-up, all patients were satisfied with the treatment and the Mayo elbow score was excellent in six patients and good in two

& Ozkan Kose [email protected] 1

Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Uncalı mahallesi Toroslar caddesi, Samut Comfort Palace E Blok No: 2, Konyaaltı, Antalya, Turkey

patients. There was 5 extension loss in two patients. Triceps muscle strength was 5/5 in all patients. Ulnar nerve entrapment occurred in one patient, so ulnar nerve release and anterior transposition were performed 3 months after surgery. Posterior interosseous nerve palsy occurred in one patient who underwent simultaneous radial head fracture fixation, but eventually returned back to normal 3 months postoperatively. All patients returned to their previous level of activity and occupation. Conclusion Transosseous suture technique is a safe and effective treatment method for acute TTR with a low rate of complications and excellent functional outcomes. Level of evidence Retrospective case series, Level IV. Keywords Triceps tendon rupture Surgery Mayo elbow score

Introduction Triceps tendon rupture (TTR) or avulsions are rare injuries and have been described as the least common of all tendon injuries. In a series of 1014 upper extremity tendon injuries involving 781 patients, Anzel et al. [1] reported eight cases of TTR that represented \1 % of all tendon injuries. Koplas et al. [2] retrospectively reviewed 801 consecutive elbow MRI over a 15-year period in their radiology department and identified only 28 patients with partial (n 18) and complete (n 10) triceps tendon injuries with a prevalence of 3.8 %. Mair et al. [3] reviewed the American National Football League’s injury database and identified 21 cases of TTR (10 partial, 11 complete) over a period of 6 years. TTR is more frequently seen in male patients. Koplas et al. [2] reported that 82 % of the patients in their series were male.

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The most commonly encountered mechanism of injury for acute traumatic distal TTR is a sudden eccentric load applied to a contracting triceps muscle which usually occurs during a fall onto an outstretched hand [4]. TTR can occur in previously healthy patients, although several predisposing factors or underlying diseases that impair the tensile strength of the tendons have been shown in the etiology, such as hyperparathyroidism, use of local or systemic corticosteroids or anabolic drugs, chronic renal failure and hemodialysis [3, 5–7]. Other than distal avulsions, rupture from the musculotendinous junction and detachment from the proximal tendon attachment have also been reported [8–11]. Treatment of complete TTR is usually performed through primary tendon repair. As TTR is a rare injury, available knowledge comes from the published case reports. There are very few studies in current literature that have reported the functional outcomes and complications after surgical repair of TTR. The purpose of this study was to present eight patients with TTR who underwent transosseous suture (TOS) repair in our clinic. All previously published case series of TTR were reviewed, and the demographic and clinical characteristics, imaging findings, treatment options, complications and prognosis were discussed.

Patients and methods A retrospective chart review was performed in our institution’s clinical database (Level 1 trauma center) and eight patients were identified with triceps tendon distal avulsion who underwent TOS repair between January 2009 and January 2013. All the radiological imaging files including plain radiographs, computerized tomography and magnetic resonance imaging which were stored in the picture archiving and communication system (PACS), patients’ charts, medical records, operation notes and notes taken during the follow-up visits were obtained from the institutional patient database and were used to extract the demographic information, clinical findings and imaging findings. This study was carried out in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All patients gave informed consent prior to their inclusion in the study. Surgical technique The surgical repair was performed according to the description of the TOS technique published by van Riet et al. [4]. All patients were operated on by the senior author (OK) using the TOS repair technique. With the patient in a supine position and under tourniquet control, a longitudinal

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Fig. 1 Surgical appearance of Krakow locking-type sutures

posterior midline incision sparing the olecranon tip was made. Dissection was made through the subcutaneous tissue and triceps fascia, and the olecranon was exposed by producing medial and lateral skin flaps. The tendon rupture was identified, hematoma was evacuated, and the wound was rinsed with saline. The ulnar nerve was identified and protected but not dissected down to the ulnar tunnel. Once the tendon was exposed, Krakow stitches were placed from distal to proximal and then brought from proximal to distal on both sides of the tendon using No. 5 non-absorbable suture (Ethibond, Ethicon) (Fig. 1). Two drill holes were made parallel to each other over the triceps footprint on the olecranon tip toward the dorsal aspect of the proximal ulna using a 2-mm drill bit. The suture ends were passed through the drill holes with a suture passer and tied with the elbow in 45 flexion. An additional 3–5 augmentation sutures were placed around the periosteal soft tissue and triceps tendon with No.1 absorbable sutures (Vicryl, Ethicon). The subcutaneous tissues and skin were closed properly, and the patient was placed in an above-the-elbow plaster cast at 90–100 of elbow flexion. Postoperative rehabilitation and follow-up All patients were immobilized until the sutures were removed at postoperative 12–15 days. The plaster cast was removed, and passive elbow range of motion exercises was started. Active triceps loading was not allowed until the end of 8 weeks. Returning to active sport was delayed until the sixth month. All patients were followed up for at least 1 year. At the final follow-up, all patients were invited to the hospital and underwent clinical and radiological


assessments. Elbow radiographs were taken to asses any abnormality in the joint. Range of motion was evaluated and compared to the contralateral side. Triceps muscle strength was graded on a 5-point muscle strength scale ranging from 0 (no movement is observed) to 5 (muscle contracts normally against full resistance of the physician). Functional outcomes were assessed with the Mayo elbow score. Any complication and secondary interventions during the follow-up were recorded.

Results There were eight patients (two females and six males) with a mean age of 25.1 years (range 16–42). The mechanism of injury was a sports injury in three patients, a simple fall (fall on outstretched hand) in four and a motorcycle accident in one patient. Two patients had an associated radial head fracture, one had a radial head fracture and trochlear fracture, and one patient had a medial epicondyle fracture. Only one patient, who was a bodybuilder, had a history of anabolic steroid use, and the rest had no underlying disease or predisposing factor for TTR. The demographic characteristics of the patients are presented in Table 1. Imaging work-up Avulsion of a small cortical bone from the tip of the olecranon was visible in all cases (Fig. 2). In spite of this radiographic evidence of TTR, the diagnosis was missed at the initial admission to ED in two patients (delay, 20 and 75 days). In one case (case#3), the ED physician was doubtful about the diagnosis and ordered ultrasonography for confirmation (Fig. 3). In one case (case#5), which was a chronic rupture, MRI was used to confirm the diagnosis (Fig. 4). In 3 cases (case #2,#6 and #7), computed tomography (CT) was used to delineate the accompanying fractures (Fig. 5).

Fig. 2 Lateral elbow radiograph of a patient with TTR. White indicates a small avulsion fracture (Fleck sign)

One of the patients with a radial head fracture (displaced three parts) underwent simultaneous fixation using two headless screws. Patients were followed up for a mean of 18.8 months (range 12–26). At the final follow-up, all patients were satisfied with the treatment and the Mayo elbow score was excellent in six patients and good in two patients. There was 5 extension loss in two patients. Triceps muscle strength was 5/5 in all patients. Ulnar nerve entrapment, confirmed with EMG, occurred in one patient, so ulnar nerve release and anterior transposition were applied 3 months after surgery. Posterior interosseous nerve palsy occurred in one patient who underwent simultaneous radial head fracture fixation, but eventually returned back to normal 3 months postoperatively. All patients returned to their previous level of activity and occupation. The clinical results are summarized in Table 2.

Table 1 Demographic and clinical characteristics of patients Case#

Age

Sex

Mechanism of injury

Diagnosis at ED

Associated injuries

Predisposing factor

1

17

M

Sport injury (football)

Yes

None

None

2

16

M

Sport injury (wrestling)

Missed (20 days)

Radial head fracture

None

Trochlear osteochondral fracture 3

27

F

Simple fall on outstretched hand

Yes

None

None

4

26

M


Yes

None

None

5

26

M

Body building (bench press)

Missed (75 days)

None

Anabolic steroid use

6

17

M

Motorcycle accident

Yes

Radial head fracture

None

7

30

F


Yes

Medial epicondylar avulsion fracture

None

8

42

M


Yes

None

None

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Fig. 3 Ultrasound image in transverse orientation in the distal humerus showing distal triceps tendon, with an anechoic area (fluid) demonstrating lack of tendon continuity and olecranon

Fig. 4 T2-weighted sagittal MR image showing complete triceps tendon rupture from the tip of the olecranon

Discussion The purpose of this study was to present the clinical results of patients who underwent surgical treatment of TTR with TOS technique. The results of this study showed that TOS technique is a safe and effective treatment method without major complications. All the patients in this series had good and excellent results. In two patients, there was 5 extension loss which did not interfere with daily activities. In one patient, late ulnar nerve entrapment occurred, which required nerve release and transposition. It is probable that excessive fibrosis secondary to ulnar nerve dissection

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caused this complication. Duchow et al. [12] reported a case of acute ulnar nerve compression in a patient with TTR. However, this compression was explained by the presence of a large hematoma at the site of the injury. Similarly, in a series reported by Sierra, a case of transient ulnar nerve compression symptoms occurred after the surgery [8]. Although the ulnar nerve is close to the field of surgery, ulnar nerve dissection is not necessarily done. However, care should be taken in respect of possible iatrogenic injury. Patients with TTR usually present with a history of sudden sharp pain at the back of the elbow with subsequent inability to extend the elbow. Swelling, ecchymosis around the elbow and tenderness over the olecranon are common findings in these patients. A gap between the ruptured tendon stump and the tip of the olecranon can be palpated. This is also called the gap sign. An inability to extend the elbow against resistance or gravity is a more specific physical examination finding, although some patients with a complete TTR can achieve active extension because of intact lateral expansion or a compensating anconeus muscle [8, 13]. This clinical finding may cause confusion and misdiagnosis; thus, diagnosis should not be solely based on ability to extend the elbow. Another physical examination test is the lack of extension upon squeezing the triceps muscle belly with the patient lying prone with the upper arm supported, elbow flexed to 90 and the forearm hanging free. This test is similar to the Thompson squeeze test used in Achilles tendon ruptures [14, 15]. After a careful physical examination, imaging studies can be utilized to support the diagnosis. Direct elbow radiography is the first imaging modality used in the emergency department for a patient who has sustained an elbow traumatic injury. Avulsion of a small cortical bone from the tip of the olecranon, also called the flake sign, can be detected on direct lateral elbow radiograph. The flake sign is pathognomonic for TTR if the above-mentioned physical examination findings are suggestive [16]. Patella cubiti is an accessory sesamoid bone found within the triceps tendon at the tip of the olecranon. Its exact etiology is unknown but congenital, developmental and traumatic theories have been postulated. In the context of trauma, this normal anatomic variant may be misdiagnosed as fleck sign; thus, patella cubiti should be considered in the differential diagnosis of TTR although it is extremely rare [17, 18]. Further imaging studies can be performed for definitive diagnosis in case of suspicion. Ultrasonography (USG) is a noninvasive and simple technique that clearly shows the rupture. It is particularly helpful for partial ruptures when clinical findings are doubtful [19, 20]. MRI provides detailed anatomy of the triceps tendon and easily differentiates partial and complete ruptures [2]. CT is usually not indicated unless there are

Author's personal copy Eur J Orthop Surg Traumatol Fig. 5 A patient with simultaneous TT rupture and radial head fracture. a 3D CT image and b sagittal reconstruction clearly demonstrate the avulsion fracture and degree of radial displacement

Table 2 Clinical results of patients Case#

Treatment

Secondary interventions

Followup (months)

1

TOS

None

26

2

TOS, fragment removal

None

21

3

TOS

19

4

TOS

Ulnar nerve release (postoperative third month) None

5

TOS

None

6

TOS, Radial head fixation with 2 screws

7 8

Complications

Mayo elbow score

Loss of motion

Muscle strength (elbow extension)

None

100

None

5/5

None

85 (mild pain)

None

5/5

None

100

5/5

14

None

100

5 extension loss None

16

None

100

None

5/5

None

23

PIN neuropraxy (healed at second month)

85 (mild pain)

None

5/5

TOS

None

20

None

100

None

5/5

TOS

None

12

None

100

5 extension loss

5/5

5/5

TOS transosseous suture, PIN posterior interosseous nerve

other associated bony injuries. In current literature there are several case reports of TTR missed at initial ED admission [21]. The most important reason for under diagnosis is the lack of suspicion, lack of proper diagnostic studies and inability to recognize the pathology, as TTR is a rare injury. TTR can occur as an isolated lesion. However, as the mechanism of injury (fall onto an outstretched hand) is a common mechanism of injury for several other elbow and upper extremity injuries, additional injuries may occur simultaneously with TTR. Levy et al. [22] presented 16 cases of TTR associated with radial head fracture and proposed that this combination of injury is a new syndrome. Similarly in the current series, there were two patients with associated radial head fracture, and one also had a trochlear fracture. Another patient had a medial

epicondylar avulsion fracture. Apart from radial head fracture, numerous other associated injuries have been reported such as elbow fracture-dislocation, capitellum fracture and collateral ligament injuries [23–27]. Therefore, all patients with TTR should be evaluated carefully and the occurrence of other injuries should be kept in mind. The treatment of TT injuries depends on the extent and location of the rupture. An incomplete or partial rupture may be managed conservatively with immobilization in the form of splint protection at 30 flexion for a period of approximately 6 weeks [3, 28, 29]. Harris et al. [29] reported a sportsman (weightlifter) with partial TT rupture who returned to his previous level of activity and career after conservative treatment. Close follow-up with repeated imaging using USG was recommended for early identification of progression to complete rupture. However, there

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is a risk of re-rupture or residual weakness in these patients, particularly those who are involved in sports activities. In a case series reported by Mair et al. [3] one patient had rerupture after conservative treatment, and three patients with initial partial tears required surgical treatment due to weakness in elbow extension. Khiami et al. [30] advocated surgical repair of partial TT rupture in manual laborers or sportsmen and in young people due to high activity demands. Due to insufficient and controversial findings in literature, it cannot be presently suggested that a partial TT tear is a definitive indication for surgery, but the activity demands of the patients should be taken into consideration during decision making. In case of complete rupture, surgical treatment is the gold standard for functional recovery. To date, several surgical techniques have been described for the surgical repair of TT rupture. The main goal of the surgery is reattachment of the tendon stump to its anatomic footprint on the tip of the olecranon. Furthermore, the strength of fixation should permit elbow motion and rehabilitation as early as possible to provide faster functional recovery and prevent elbow stiffness. The most commonly utilized technique in current literature is the TOS technique. In this technique, the tendon stump is held by a locking-type stitch (Krakow or Bunnell) with non-absorbable sutures passed through transosseous drill holes in the olecranon and tied over a bone bridge. Mair et al. [3] used this technique in 15 cases of TTR and reported re-rupture in one case that required repeated surgery due to re-rupture. All patients had an excellent result at the final follow-up. Sierra et al. [8] treated ten patients using the TOS technique and again reported one case of re-rupture, but the other patients had good and excellent results. Similarly in the current study, excellent results were obtained in the patients. None of the patients had re-rupture within the follow-up period. One patient had 5 extension loss, and two other patients experienced transient neurological complications. Repair of TTR can also be achieved using suture anchors. Bava et al. [31] used two suture anchors in five patients and reported excellent results in all patients without any rerupture or any other complication. Evans et al. [32] treated 10 patients with double-row suture anchors and stated that this technique provides better reattachment of the tendon to its anatomic foot print. Kokkalis et al. [33] augmented the TOS technique with suture anchors and achieved excellent results. Authors who have used suture anchors have reported that this technique provides better fixation strength, with a small incision and better cosmetic results and an early return to physical rehabilitation. Yeh et al. [34] described a new anatomic repair technique similar to rotator cuff repair techniques and compared that technique with TOS and suture anchor repair on a cadaver model of TTR. Better strength and minimal displacement on cyclic

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loading was reported with their anatomic repair. In parallel with advances in arthroscopic techniques and instruments, arthroscopic treatment of TTR has been described. Athwal et al. [35] treated two patients with partial TTR using arthroscopic guidance and reported no complications and full functional recovery. Heikenfeld et al. [36] reported the results of 14 patients with partial TTR who were treated with arthroscopic technique. Excellent clinical results were reported with full strength and range of motion after a 1-year follow-up period. The arthroscopic technique was recommended due to its shorter hospitalization, less morbidity and favorable clinical outcomes. However, all patients in both of these studies had partial tears. Currently, there have been no reports of the use of arthroscopy in complete ruptures. In case of delayed diagnosis, in other words chronic TT insufficiency, standard techniques that are used in acute ruptures may not be sufficient or effective for reattachment due to retraction of the tendon. Augmentation techniques and use of allograft may be inevitable, particularly in patients with low tissue quality. Graft reinforcement of the reattachment using the palmaris longus, plantaris, semitendinosus or Achilles tendon, anconeus muscle rotation, a flap from the proximal tricipital aponeurosis or forearm fascia has been reported with favorable results in relevant literature [4, 14, 28, 37–39]. In the current series, there was a patient with delayed diagnosis (75 days), but primary repair was achieved with proper debridement of the fibrotic tissues and release. The necessity of tendon grafting should be kept in mind in delayed cases, although primary repair should be attempted first. In general, surgical treatment of TTR regardless of the technique can achieve good and excellent results, although re-rupture, infection, loss of elbow motion, ulnar and radial neuropathy, extensor lag or weakness and pain at the surgical site may been seen after surgery. To the best of our knowledge, there are 10 previous case series in English literature that have reported the clinical results of patients who underwent surgical repair of TTR (Table 3) [3, 4, 8, 11, 22, 31–33, 36, 40]. There are some strengths and limitations to this study. The most important limitation of this study is its retrospective nature and inclusion of a small number of patients. However, TT is an uncommon injury and the largest series in literature retrospectively reports the results of 22 patients [4]. Secondly, acute and chronic cases and cases with other accompanying fractures were included and analyzed together. However, all patients underwent the same surgical procedure. Although the same author examined all the patients at the final follow-up, muscle strength testing is still a subjective test method. Patients with clinically undetectable residual weakness may have been missed with manual muscle strength testing in this series.

Not reported

6M/2F

10

14

5

8

Lempainen et al.

Heikenfeld et al.

Evans et al.

Current study

12M/2F

All M

5M/2F

7

9M/7F

19M/3F

Tarsney et al.

22 (23)

Van Riet et al.

12M/3F

16

15 (16)

Sierra et al.

All M

9M/2F

All M

Sex

Levy et al.

19 (21)

11

Kokkalis et al.

Mair et al.

5

#Patients (elbows)

Bava et al.

Authors

25.1 (16–42)

Not reported

58.4 (39–71)

35 (25–49)

31.8 (13–60)

30 (7–59)

47 (21–69)

50 (16–71)

29 (22–36)

53 (34–64)

46.8 (35–54)

Age (years)

All complete

All complete

Complete 13 Partial 3 Complete 8 Partial 15 Complete 13 Partial 3 Complete 6 Partial 1 6 Musculotendinous junction 3 Complete distal avulsion 1 Avulsion from the scapula All partial

Complete 11 Partial 10

8 Distal avulsion 3 Musculotendinous rupture

Complete distal avulsion

Type of tear

Suture anchor Double-row suture anchor TOS

Mayo Elbow Performance Index Quick DASH Isokinetic strength measurement Elbow MRI Mayo elbow score Oxford elbow score Mayo elbow score

18.8 months (12–26)

6 months

12 months

Excellent in six patients, good in two patients Ulnar nerve entrapment (n 1) PIN neuropraxy (n 1)

4 excellent 1 good

All excellent

5 excellent, 4 good and 1 fair

5 years (2–9) Authors’ own fourcategory (excellent, good, fair, poor) rating system

Primary suture for musculotendinous ruptures, suture anchor for avulsions

Arthroscopic suture anchor

1 elbow stiffness

9 excellent, 2 good Re-rupture: 2 3 re-rupture 1 infection Not reported

10 of 11 patients returned to preinjury activities and were satisfied with the operation 1 infection 1 elbow stiffness Re-rupture (n 1); pain and weakness (n 1)

Excellent in four patients, good in 1

Results and complications

Not reported

Not reported

93 (7–24)

16.8 (7–168)

34 months

21 months (12–40)

32 months (18–49)

Follow-up duration

Not reported

Not reported

Isokinetic muscle strength

ROM Pain Muscle strength Muscle strength

DASH ASES elbow assessment form Mayo elbow performance Index Oxford elbow score VAS ROM Muscle strength

Outcome measure

TOS

TOS (n 11) Conservative 5 TOS (n 13) Reconstruction (n 9) TOS

TOS (n 15) Conservative (n 6)

Double-row technique with a crossed suture and suture anchors

Suture anchor

Treatment

Table 3 Previously published studies (case series) that reported results of surgical treatment of TTR in English literature

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Eur J Orthop Surg Traumatol

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In conclusion, surgical treatment of complete distal TTR using TOS technique is a safe and effective method with minor complications and excellent functional outcomes. Physicians should be alert for a possible injury of triceps tendon in all patients who present in ED after a fall onto the outstretched hand. The gap sign and the inability to extend the elbow are strong physical examination signs which suggest TT rupture, and a simple elbow radiograph showing the fleck sign is pathognomonic for TT rupture. In case of suspicious clinical findings, USG and MRI can be performed to confirm the diagnosis. Partial TTR may be managed conservatively, but total ruptures should be managed surgically for functional recovery. Due to its rarity, there are few studies that have reported clinical results in a large number of patients. Further well-designed randomized clinical trials are necessary to obtain evidencebased knowledge on the treatment of TTR. Compliance with Ethical Standards Conflict of interest Fundind

All authors have no conflict of interest.

No funds have been received for this study.

Ethical standard All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent

Informed consent was obtained for all patients.

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