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      Surgical Repair of Distal Triceps Tendon Injuries: Short-term to Midterm Clinical Outcomes and Risk Factors for Perioperative Complications

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          Abstract

          Background:

          Few large-scale series have described functional outcomes after distal triceps tendon repair. Predictors for operative success and a comparative analysis of surgical techniques are limited in the reported literature.

          Purpose:

          To evaluate short-term to midterm functional outcomes after distal triceps tendon repair in a broad patient population and to comparatively evaluate patient-reported outcomes in patients with and without pre-existing olecranon enthesopathy while also assessing for modifiable risk factors associated with adverse patient outcomes and/or revision surgery.

          Study Design:

          Case series; Level of evidence, 4.

          Methods:

          This study was a retrospective analysis of 69 consecutive patients who underwent surgical repair of distal triceps tendon injuries at a single institution. Demographic information, time from injury to surgery, mechanism of injury, extent of the tear, pre-existing enthesopathy, perioperative complications, and validated patient-reported outcome scores were included in the analysis. Patients with a minimum of 1-year follow-up were included.

          Results:

          The most common mechanisms of injury were direct elbow trauma (44.9%), extension/lifting exercises (20.3%), overuse (17.4%), and hyperflexion or hyperextension (17.4%). Eighteen patients were identified with pre-existing symptomatic enthesopathy, and 51 tears were caused by an acute injury. A total of 36 complete and 33 partial tendon tears were identified. Bone tunnels were most commonly used (n = 30; 43.5%), while direct sutures (n = 23; 33.3%) and suture anchors (n = 13; 18.8%) were also used. Perioperative complications occurred in 21.7% of patients, but no patients experienced a rerupture at the time of final follow-up. No statistically significant relationship was found between patient age ( P = .750), degree of the tear ( P = .613), or surgical technique employed ( P = .608) and the presence of perioperative complications.

          Conclusion:

          Despite the heightened risk of perioperative complications after primary repair of distal triceps tendon injuries, the current series found favorable functional outcomes and no cases of reruptures at short-term to midterm follow-up. Furthermore, age, surgical technique, extent of the tear, and mechanism of injury were not associated with adverse patient outcomes in this investigation. Pre-existing triceps enthesopathy was shown to be associated with increased complication rates.

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          Most cited references19

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          Disruption of muscles and tendons; an analysis of 1, 014 cases.

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            Surgical treatment of distal triceps ruptures.

            Distal triceps tendon ruptures occur rarely, and the diagnosis is often missed when the injury is acute. The literature provides little guidance regarding treatment or the outcome of treatment of these injuries. The goal of this report was to present our experience with the diagnosis, timing and technique of surgical treatment, and outcome of treatment of distal triceps tendon ruptures in twenty-two patients. None of the ruptures followed joint replacement. Twenty-three procedures were performed in twenty-two patients with an average age of forty-seven years. The average duration of follow-up was ninety-three months (range, seven to 264 months). Data were obtained by a retrospective review of records and radiographs before and after surgery. Also, thirteen patients returned for follow-up and were examined clinically. Six additional patients responded to a telephone questionnaire. One patient was lost to follow-up, and two had died. Formal biomechanical evaluation of isokinetic strength and isokinetic work was performed in eight patients, at an average of eighty-eight months after surgery. Isokinetic strength data were available from the charts of two additional patients. Ten of the triceps tendon ruptures were initially misdiagnosed. At the time of diagnosis, triceps weakness with a decreased active range of motion was found in most patients, and a palpable defect in the tendon was noted after sixteen ruptures. Operative findings revealed a complete tendon rupture in eight cases and partial injuries in fifteen. Fourteen primary repairs and nine reconstructions of various types were performed. Three of the primary repairs were followed by rerupture. At the time of follow-up, the range of elbow motion averaged 10 degrees to 136 degrees. All but two elbows had a functional range of motion; however, the lack of a functional range in the two elbows was probably due to posttraumatic arthritis and not to the triceps tendon rupture. Triceps strength was noted to be 4/5 or 5/5 on manual testing in all examined subjects. Isokinetic testing of ten patients showed that peak strength was, on the average, 82% of that of the untreated extremity. Testing showed the average endurance of the involved extremity to be 99% of that of the uninvolved arm. The results after repair and reconstruction were comparable, but the patients' recovery was slower after reconstruction. The diagnosis of distal triceps tendon rupture is often missed when the injury is acute because of swelling and pain. Primary repair of the ruptured tendon is always possible when it is performed within three weeks after the injury. When the diagnosis is in doubt immediately after an injury, the patient should be followed closely and should be reexamined after the swelling and pain have diminished so that treatment can be instituted before the end of this three-week period. Reconstruction of the tendon is a much more complex, challenging procedure, and the postoperative recovery is slower. Thus, we believe that early surgical repair, within three weeks after the injury, is the treatment of choice for distal triceps tendon ruptures. of evidence.
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              The distal triceps tendon footprint and a biomechanical analysis of 3 repair techniques.

              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. An anatomic repair of distal triceps tendon ruptures more closely imitates the preinjury anatomy and may result in a more durable repair. Descriptive and controlled laboratory studies. 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. 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). 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. 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.
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                Author and article information

                Journal
                Orthop J Sports Med
                Orthop J Sports Med
                OJS
                spojs
                Orthopaedic Journal of Sports Medicine
                SAGE Publications (Sage CA: Los Angeles, CA )
                2325-9671
                30 April 2019
                April 2019
                : 7
                : 4
                : 2325967119839998
                Affiliations
                []Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
                []University of Illinois College of Medicine, Chicago, Illinois, USA.
                [§ ]Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA.
                []Rothman Orthopaedic Institute, New York City, New York, USA.
                [5-2325967119839998] Investigation performed at Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
                Author notes
                [*] [* ]Brian R. Waterman, MD, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070, USA (email: brian.r.waterman@ 123456gmail.com ).
                Article
                10.1177_2325967119839998
                10.1177/2325967119839998
                6492365
                31069242
                95b6320a-4063-47c1-a7f7-591755eab29b
                © The Author(s) 2019

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License ( http://www.creativecommons.org/licenses/by-nc-nd/4.0/) which permits non-commercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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                elbow,general sports trauma,athletic training,enthesopathy

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