Triceps Insufficiency Following Total Elbow Arthroplasty

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CHAPTER 63 Triceps Insufficiency Following Total Elbow Arthroplasty

Andrea Celli, Bernard F. Morrey

INTRODUCTION

Triceps insufficiency can occur as a result of traumatic rupture of the tendon or, most commonly, following a failed surgical reattachment, particularly when there is poor tendon quality.^5,^12,^15,^17,¹⁸ As a complication following elbow replacement, this is becoming much more appreciated.⁴

According to the limited literature available on this topic, the incidence of triceps insufficiency following total elbow arthroplasty ranges from 1% to 29%.^7,^9,^10,^14,^16,¹⁷ A recent report using the Gschwend approach documents four of 28 elbows with triceps insufficiency after a triceps-splitting approach to insert the GSB implant (Center Pulse, Zurich).¹¹ In a recent comprehensive review of the literature, Voloshin et al²² documented an incidence of approximately 1% to 5% of triceps insufficiency associated with total elbow arthroplasty. Typically, literature reviews understate the true incidence of this problem.

The key factor in avoiding the development of this problem is the nature and execution of the surgical exposure. In this regard, a number of recent studies ²³ have examined modifications to existing exposures (see Chapter 7).^6,¹⁹ Olecranon osteotomy is contraindicated in joint replacement surgery. Hence, some means of dealing with the triceps attachment is necessary. There are several options:

1. Reflection of the triceps in continuity with forearm fascia and periosteum and anconeus from medial to lateral.² Reflection of the triceps with a wafer of bone is a modification that has also been recommended.²⁴

2. Extensile Mayo Modified Kocher approach: following a posterior lateral exposure reflection of the anconeus and approximately one third of the lateral triceps attachment from the tip of the olecranon (see Chapter 7).

3. Campbell’s triceps-splitting approach. This approach may be modified by releasing the triceps with wafer of bone.⁸

4. Preservation of the triceps attachment and aggressive flexor-extensor release to “skeletonize” and deliver the distal humerus. This approach is modified by excision of humeral condyles.¹

PRESENTATION AND SYMPTOMS

All patients will report loss of active extension and about 15% to 20% will also report pain.⁴ The most common problem is the inability to reach above the head and to push through doors. The mean time from initial procedure to revision for triceps insufficiency is about 3 years. In our experience the clinical findings at the time of surgical revision were (1) a change in the posterior contour of the elbow with visual and palpable prominence of the implant and atrophy of the subcutaneous tissue; (2) the presence of an olecranon bursitis; (3) atrophy of the triceps muscle; and (4) discernable lateral subluxation or dislocation of the extensor mechanism.

MANAGEMENT

Our recommendations are based on the Mayo Clinic experience with triceps insufficiency for any cause ²¹ and particularly after joint replacement.⁴ From 887 total elbow arthroplasty operations, we identified 16 elbows that underwent subsequent surgical treatment for triceps insufficiency at our institution. The underyling diagnoses for which the primary total elbow arthroplasty was performed were rheumatoid arthritis in nine cases and post-traumatic conditions in seven cases. Initially, the triceps-sparing approach as described by Bryan and Morrey² was used in 15; in one patient, the triceps-splitting approach as described by Campbell³ was used.

PATHOLOGY

At exploration, a complete rupture was observed in 10 and a partial rupture in six of our patients. Of particular importance is the fact that three patients had resorption of the olecranon process. This is a key factor in determining the strategy for successful reconstruction.

REPAIR OR RECONSTRUCTION

The logic we currently employ to determine how these problems should be managed is similar to the algorithm developed for management of triceps insufficiency for any cause ^13,²¹ (Fig. 63-1). If the tissue quality is good and the olecranon is preserved, we repeat the direct attachment to bone if the tissue is of adequate quality for this. If the tissue is not of good quality but the anconeus and the olecranon are preserved, then we perform an anconeus rotational flap. Finally, if the tissue is not of good quality and the anconeus is not perserved, then an Achilles tendon allograft is carried out. The calcaneus is used to supplement the olecranon if it is resorbed; otherwise, the tendinous tissue is sewn to the intact olecranon and the calcaneus is removed from the allograft.

FIGURE 63-1 The treatment algorithm for managing patients with triceps insufficiency following total elbow arthroplasty.

(Redrawn with permission of the Mayo Foundation.)

REATTACHMENT

This is not commonly indicated if the tendon was properly reattached initially. The key is to avoid the intervention of synovium between the attachment of the triceps tissue and the olecranon. The way to ensure this is to add a circumferential “cinch” suture to apply or compress the triceps tendon closely to its attachment site (Fig. 63-2).

FIGURE 63-2 Direct suture to bone. When the triceps tendon has not retracted and is of good quality, cruciate criss-cross drill holes are placed in the proximal ulna along with a transverse tunnel (A). A #5 nonabsorbable locking suture (B)

is placed through the tendon starting from distal medially. After passing through the tendon portion, it is then brought into the second osseous tunnel and secured to itself (C). A specific transverse tunnel is made (D). A No. 5 nonabsorbable suture passes through this tunnel (E), which serves to firmly secure the tendon to its original attachment site on the olecranon (arrow) (F).

ANCONEUS ROTATIONAL FLAP

We prefer this technique when the continuity has been lost between the triceps tendon and the periosteal and forearm fascia.

Technique

With the patient supine and the arm brought across the chest, the previous skin incision is entered. The triceps mechanism is carefully explored, and the ulnar nerve is protected. The Kocher interval between the anconeus and extensor carpi ulnaris is identified. The anconeus is elevated from the olecranon insertion, leaving intact the distal 20% (Fig. 63-3A). The humeral attachment is detached, allowing the entire extensor mechanism to be rotated from lateral to medial. The fascial attachment of the anconeus is oriented over the posterior aspect of the olecranon and secured with a criss-cross and transverse suture, as described previously (see Fig. 63-3B). The original triceps attachment is now medially displaced. It is incorporated back into the extensor mechanism in order to enhance extension strength.

FIGURE 63-3 A, The anconeus rotational triceps reconstruction begins by identifying and entering the interval between the anconeus and the extensor carpi ulnaris. The anconeus is elevated from the ulna and rotated medially. B, The anconeus is in continuity with the triceps. The construct is mobilized and repositioned over the olecranon and secured to the olecranon with a No. 5 nonabsorbable suture placed through bone holes.

Note: This is an attractive technique to employ during the primary procedure if the triceps attachment is compromised due to inadequacy of the periosteum and forearm fascia.

ACHILLES TENDON RECONSTRUCTION

In instances when the anconeus is no longer functional and there is significant tissue loss, an Achilles tendon allograft procedure is performed.

Technique

The patient is supine on the table, and the arm is brought across the chest. The olecranon and triceps are widely exposed. The ulnar nerve is identified and protected or translocated, if appropriate. If the olecranon is intact, the triceps muscle is mobilized and the radial nerve is identified and protected as necessary. The fascial expansion of the allograft tendon is brought around the triceps, and the aponeurosis of the allograft securely fastened to the triceps muscle (Fig. 63-4A). The tendinous portion of the achilles allograft is then attached to the olecranon by creating a groove in the posterior aspect of the olecranon with a high-speed burr (Fig. 63-4A, arrow). The graft is placed in the groove and folds over the tip of the olecranon. It is secured with a No. 5 nonabsorbable suture through drill holes in the proximal ulna.

FIGURE 63-4 The Achilles tendon allograft is secured to the remnants of the triceps muscle; a groove is prepared in the proximal ulna (yellow arrow) (A). With the elbow at 45 degrees of flexion, the tendon is securely attached to the ulna with No. 5 nonabsorbable sutures placed through bone (B).

Note: Take care to avoid going too deep and notching the ulnar component. The knots are placed off the subcutaneous border to avoid problems of skin irritation.

The arm is placed in 45 degrees of extension, and a No. 5 nonabsorbable suture is used to securely attach the distal aspect of the triceps and its tendinous attachment to the allograft. A No. 1 Ethibond running locked suture is then employed circumferentially to attach the fascia of the allograft to the muscle and fascia of the triceps mechanism (see Fig. 63-4B).

Note: If the olecranon is deficient, the calcaneus is left on the Achilles tendon and is fashioned in such a way as to be applied to the proximal ulna (Fig. 63-5). The allograft is secured with two Kirschner wires and a circumferential wire according to the AO method. Once the allograft has been secured, once again the elbow is brought into 40 to 45 degrees of extension and the fascial expansion of the tendon is secured to the triceps mechanism as described above.