Rafael J. Sierra MD, Nicholas G. Weiss MD, Michael W. Shrader MD and Scott P. Steinmann MD
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA Rupture of the triceps tendon is rare.1 and 29 Even less common is the occurrence of bilateral triceps tendon ruptures.11 and 15 A case of simultaneous bilateral triceps tendon ruptures with unilateral patellar tendon rupture occurring in a healthy patient prompted this review of the institutional files. This case turned out to be the only acute bilateral triceps tendon rupture in the Mayo Clinic (Rochester, MN) files over the past 25 years. To our knowledge, this is the first such report in the English-language literature of bilateral triceps and patellar tendon ruptures occurring simultaneously. In addition, currently, there is very little reported on the treatment and outcome of the surgical repair of this acute injury in a cohort of patients. We report the results of treatment of 16 closed acute triceps tendon ruptures.
A 36-year-old man presented to the emergency department with complaints of severe pain in his knee and the inability to support his weight. He stated that he had rounded first base in a recreational softball game when he felt the sudden onset of pain in his right knee. This resulted in his falling forward onto his forearms with the elbows in a semiflexed position.
Upon presentation, the patient complained of significant knee pain and minimal bilateral elbow discomfort. His medical history was significant for a history of asthma, for which he was taking Azmacort (KOS Pharmaceuticals, Inc., Miami, FL, USA). He had not required oral or parenteral steroids in the past. He reported that he was an avid weightlifter. He acknowledged a history of anabolic steroid use in the past but reported no use in the last 8 years. Physical examination revealed an inability to extend the knee with any appreciable force. A diagnosis of complete patellar tendon rupture was made based on examination. Several days later, the patient underwent repair of his torn patellar tendon.
Postoperatively, the patient complained of bilateral elbow pain. A palpable defect of the triceps tendon just proximal to the olecranon was noted bilaterally. Strength testing of the triceps at that time revealed 3/5 to 4/5 on the right and 2/5 on the left. These findings prompted bilateral magnetic resonance imaging, which confirmed the diagnosis of rupture of both triceps tendons The patient then underwent sequential bilateral triceps tendon repair under the same anesthesia. Intraoperatively, both triceps tendons were found to be completely detached from the olecranon. Large No. 5 nonabsorbable sutures were used to run a Krakow-type stitch through the detached triceps tendon, leaving 4 Ethibond (Ethicon, Sommerville, NJ) tails extending from the torn triceps tendon. We then drilled 3 holes from proximal to distal through the olecranon, angling dorsally. By use of a Hewson suture passer, the No. 5 Ethibond sutures were brought through the drill holes. The 2 middle limbs were brought through the middle hole, and 1 limb each was brought through the medial and lateral hole. The arm was held in approximately 35° to 40° of flexion for tensioning. The sutures were tied. This resulted in a very stable repair that was able to extend fully and flex to 90°. The same surgical intervention was performed on both sides. An example of this repair on another patient by use of No. 2 Fiberwire (Arthrex, Naples, FL, USA)
The patient immediately began active flexion as well as passive/gravity-assisted extension exercises without immobilization or a brace for his reconstructed triceps tendons. Given his inability to use his upper extremities to assist in ambulation, his arm was placed in a long cast for 2 weeks after his triceps repair to allow weight bearing as tolerated on the right lower extremity and ambulation without a cane or crutches. At 6 weeks postoperatively, he began gentle active extension of both elbows.
At the most recent follow-up (26 months postoperatively), the patient had 3° to 140° of extension and flexion of both elbows. Supination and pronation were full bilaterally. Palpation upon gentle resistance of elbow extension revealed an intact triceps tendon bilaterally. Manual and biomechanical triceps strength testing was performed, demonstrating excellent strength bilaterally. Specifically elbow extension strength was 55.3 Nm and 47.1 Nm on the right and left sides, respectively. These results are 134% and 118% from normal, respectively, as reported by Askew et al2 in 104 patients with no elbow pathology who underwent biomechanical testing at our institution. Despite good biomechanical strength testing, the patient did feel that he had not returned to his preoperative strength baseline, and we believe that he may, in fact, have some residual deficit despite his good strength.
Retrospective chart review At our institution, 15 patients with 16 acute closed ruptures of the triceps tendon were treated from 1976 to 2001. Triceps tendon ruptures occurring in patients with previous total elbow arthroplasties were excluded. The final cohort consisted of 12 male patients and 3 female patients with a mean age of 50 years (range, 16-71 years). None of the patients had a history of chronic renal failure, dialysis, hyperparathyroidism, or long-term steroid use. Only 1 patient (case report) had a history of past anabolic steroid use. The patients occupations varied significantly, and the injury occurred during work in 2 patients (Table I). The injury occurred on the right side in 10 and on the left in 6. The mechanism of injury was associated with trauma in 12 patients and without trauma in 3. Two of the atraumatic ruptures occurred after septic olecranon bursitis. The most common pattern was an avulsion of the triceps insertion into the olecranon, occurring in 13 elbows, 3 of which were partial avulsions at the time of injury and were treated nonoperatively. An intratendinous rupture occurred in 2 elbows, and an intramuscular rupture occurred in 1. Preoperative triceps strength testing was available in 13 of 16 elbows. All elbows except 1 had a deficit on examination, ranging from 2/5 to 4/5 on manual muscle strength testing. Eleven elbows underwent surgical intervention for repair of the triceps; the remaining five were treated nonoperatively. The mean time from injury to surgery was 12 days (range, 1-45 days). Intraoperatively, incomplete tendon avulsions were more common than avulsions of the whole insertion. When incomplete ruptures occurred, the central portion was involved occasionally leaving medial and/or lateral peripheral attachments intact. For the 10 avulsions of the triceps mechanism treated surgically, this consisted of advancement of triceps with placement of a locking (Krakow, Kessler, or Bunnell) nonabsorbable stitch through tendon and passing of these through drill holes into the olecranon as described in the case report. Wire was used to augment the repair in 1 patient who had avulsion of a piece of bone with the tendon. The anconeus was rotated to reinforce the triceps reconstruction in 2 cases. This was done to reinforce the triceps reconstruction in a 33-year-old female musician in whom surgery was done 44 days after the injury and who was found to have a deficit in the retinaculum and contraction of the tendon. The other patient was a 79-year-old retired man whose repair was done 14 days after the injury. He had a large olecranon spur that had avulsed with the tendon. After excision of the spur, it was noticed that there was contracture of the tendon, which involved the mid and medial portions primarily, with some continuity still present laterally. It was believed that a solid repair would require mobilization of the anconeus. The 1 triceps intramuscular rupture involved both the medial and lateral bellies and was also treated operatively with reapproximation of the muscle bellies with the use of Mersilene tape (Ethicon) and mattress-type stitches into the muscle bellies (at 8 months after injury).
In 3 of 11 elbows treated surgically, a postoperative complication that required reoperation developed. Two elbows operated on for triceps avulsions required subsequent reoperations, one for rerupture after repeat trauma and the other for removal of wire that was used to augment the fixation to bone (in which a transient ulnar neuropathy also developed). The 1 patient with an intramuscular rupture was operated on late (8 months) and had a rerupture of the muscle on 2 occasions, necessitating 2 subsequent reoperations, and also had a transient radial neuropathy developed after one of the surgical interventions. He recovered uneventfully from the transient neuropathy and, at final examination, had a triceps strength of 5/5.
Postoperatively, patients were followed up for a mean of 1.4 years (range, 7 months to 14 years). Of those elbows treated operatively, strength testing was good (4/5) in 2 and excellent (5/5) in the other 9. At follow-up, all but 1 patient had returned to their preinjury occupation.
Discussion Triceps tendon ruptures are rare and have been described as the least common of all tendon injuries.29 Anzel et al1 reviewed a series of 1014 tendon injury cases. Only 8 of these cases were triceps tendon ruptures. Up to 1987, 50 cases of triceps tendon ruptures had been reported (primarily in case report form), and all were unilateral except in 2 patients.3 Bilateral triceps tendon ruptures occur primarily in patients with chronic renal failure undergoing long-term hemodialysis.11 and 15 To our knowledge, however, bilaterality of triceps tendon ruptures occurring simultaneously with a patellar tendon rupture in a relatively healthy athletic individual has never been reported. In addition, we have reported on 14 additional cases of acute triceps tendon ruptures seen at the Mayo Clinic from 1976 to 2001.
Most patients with triceps tendon ruptures present to the clinician with an acute injury complaining of sudden pain in the posterior aspect of the elbow after trauma. On initial presentation, severe swelling, ecchymosis, and pain are the hallmarks of the examination. Once swelling subsides, most patients demonstrate a palpable gap and weakness of the elbow extensor mechanism on muscle testing. This finding was consistent in all of our patients except 1, who had normal strength testing but tenderness to palpation over the triceps insertion and was thought to have a partial tendon avulsion. In addition, a thorough neurologic examination is recommended because compartment syndrome and cubital tunnel syndrome have complicated triceps tendon ruptures.10 and 13
Triceps tendon ruptures most commonly occur acutely, but chronic lesions have also been reported.14 and 28 These ruptures can be complete or incomplete3 and have been reported to occur through different anatomic regions.1, 3, 5, 10, 12, 21 and 28 These include ruptures occurring proximally at the origin of the lateral head of the triceps; those occurring through the triceps muscle belly, musculotendinous junction, or tendon per se; or those occurring as an avulsion of the olecranon. The most common type is an avulsion of the olecranon, and this was seen in 13 of 16 cases in our series.
A forced contraction of the muscle with the elbow in extension, as when a patient falls on an outstretched hand, has been reported previously as the most common mechanism, but this was not the case in our series.12 The most common mechanism of rupture seen in our series was direct trauma to the flexed elbow, occurring in 6 patients.26 This was followed by the mechanism of forced elbow extension, occurring in 5 elbows. In the case of the bilateral tendon rupture, the patient reported falling forward on his forearms with his elbows in a semiflexed position. In 2 additional elbows, the mechanism was a spontaneous rupture when transferring from a chair to a bed. Rupture can also occur spontaneously and has been reported during exercise and competition in bodybuilders and power lifters3, 13 and 24and in patients with underlying medical comorbidities known to weaken tendons.9, 11 and 28 Specifically to the triceps tendon, ruptures have been reported to occur after olecranon bursitis, and this may have precipitated the event in 2 elbows in our series.
Tendon ruptures occur most commonly through abnormal tendon. Kannus and Jozsa16 analyzed 891 ruptured tendons histologically. Healthy tendon structures were not seen in any spontaneously ruptured tendons. Ninety-five percent of the pathologic changes were degenerative. Multiple conditions have been associated with tendon ruptures. Rheumatoid arthritis, systemic lupus erythematosus, hyperparathyroidism, xanthoma, chronic renal failure and hemodialysis, hemangioendothelioma, Marfan syndrome, osteogenesis imperfecta tarda, and olecranon bursitis are some entities that can lead to weak tendons and have been associated with triceps tendon ruptures.3 and 8 In addition, treatment with quinolones,6 and 23 systemic steroids and local steroid injections,7, 10 and 25 and injected anabolic steroids18 and 27 has also been implicated in tendon ruptures. To our surprise, none of the patients in our series had underlying medical conditions other than olecranon bursitis in 2 that could predispose to tendon ruptures.
Weightlifters and power lifters, especially if taking anabolic steroids, have been demonstrated to have tendon ruptures in uncommon locations. Such locations include the extensor pollicis longus, biceps, pectoralis major, distal rectus femoris, and as in the patient presented here, both triceps and a patellar tendon. Although a relationship between anabolic steroid use and tendon ruptures has been proposed, there has been a lack of well-controlled experiments establishing a cause-and-effect relationship. There is, however, good experimental evidence demonstrating that the use of anabolic steroids combined with intense exercise can cause changes in tendons. Michna19 has shown damage to the ultrastructure of tendons in anabolic steroidtreated mice. At 5 weeks of treatment, there was a reduction in the number of collagen fibrils per volume and in cross-sectional areas of flexor digitorum tendons when compared with controls. There was also a significant change in the distribution of collagen fibril diameters, and the alignment of collagen fibril was highly disorganized in those treated with anabolic steroids. Wood et al30 and Miles et al20 have also demonstrated changes in the normal biomechanics of the muscle tendon unit in Achilles tendons in rats treated with anabolic steroids. Similarly, recent studies have shown a decrease in elastin, fibronectin, and B1 integrin in Achilles tendons of dogs treated with ciprofloxacin.23 These changes may be due to the magnesium-antagonistic effects of these antibacterial agents.
Surgical treatment has been the mainstay of treatment for most acute triceps tendon ruptures.17 The treatment of acute triceps tendon avulsions during the past 25 years at our institution demonstrates that acute surgical repair of these ruptures by use of a locking suture through the tendon edges passed through 3 drill holes in the olecranon yields a good outcome in most patients. Unless a large piece of bone avulses with the tendon, the use of wire to augment fixation, as used in 1 case, is not recommended, as it may lead to symptomatic hardware necessitating removal. Tendon graft augmentation (palmaris longus, plantaris tendon, Achilles tendon, or anconeus muscle) may be necessary in some instances, especially in patients with specific tendon-weakening comorbidities (diabetes, chronic renal failure)28 or in patients with chronic ruptures.22 The anconeus muscle flap is useful in patients who present with triceps tendon contractures leading to deficits, most likely over the medial aspect of the tendon. Elevation and rotation of the anconeus muscle allow medialization of the triceps mechanism with coverage of this area, as was done in 2 cases in our review. A transient ulnar nerve injury occurred in only 1 case in this series. No ulnar nerve transpositions were performed before repair of the triceps tendon in any case. We believe that care must be taken when handling the ulnar nerve because it is very close to the surgical field and may be prone to injury, but we do not recommend prophylactic ulnar nerve transposition.
A weakness of this study was the fact that objective preoperative and postoperative muscle testing results were not available for patients in the case series.
In conclusion, triceps ruptures are rare, with a previously reported prevalence of less than 1% of all tendon ruptures. The most common injury is an avulsion of the olecranon insertion. Early surgical management with repair of the tendon to bone can provide a satisfactory outcome in most patients.4, 22 and 25.
Journal of Shoulder and Elbow Surgery Volume 15, Issue 1 , January-February 2006, Pages 130-134.