Rev. bras. ortop. vol.50 número5

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Technical

Note

Reconstruction

of

chronic

tearing

of

the

distal

triceps

using

the

double-row

configuration:

technical

note

夽

Alexandre

Firmino

Paniago

_,

_Thiago

_Medeiros

_Storti

,

Rafael

Salomon

Silva

Faria

,

Dennys

Carlos

Aragão

de

Morais

_,

_Murillo

_Pablo

_de

_Souza

a_{InstitutodoOmbrodeBrasília,Brasília,DF,Brazil}

b_{ClínicaVidere,Brasília,DF,Brazil}

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Articlehistory:

Received25August2014 Accepted6October2014 Availableonline29August2015

Keywords:

Tendoninjury Tendonsurgery Elbow

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Tearingofthedistaltricepsisuncommonandmaybedifficulttodiagnose,especiallyin situationsofpartialtearing.Imagingmethodssuchasultrasonographyandmagnetic reso-nanceimagingshouldbeusedtoconfirmthediagnosisanddefinetheextentoftheinjury. Thepreferredtreatmentforcompletetearingofthetricepsissurgical,unlikeincasesof partialtearing,inwhichthetreatmentdependsonfactorssuchaspain,functionaldeficit andthepatient’sexpectations.Here,wedescribethecaseofapatientwithpartial tear-ingofthedistaltricepsafterfallingtotheground,whichwasnotdiagnosedatthetimeof firstattendanceandevolvedwithpainandgreatfunctionalloss.Thesurgicalprocedurewas performedninemonthsaftertheinjury,withreconstructionofthetricepsbymeansof rein-forcementusingthetendonoftheipsilateralsemitendinosusandfixationintheolecranon usingthedouble-rowconfiguration.Thepatientremainedimmobilizedusingaslingforone weekandthengainsinpassiverangeofmotion(ROM)wereintroduced.Threeweekslater, thepatientwasreleasedforgainsinactiveROM.Musclestrengtheningwasstartedafter12 weeks.Sixweeksafterthesurgicalprocedure,thepatientwasfreefrompainandpresented completeROM,gradeV_{elbowextensionforceandhypertrophyofthetriceps.Thetechnique}

describedherewasshowntobeusefulfortreatingtearsofthetendonofthedistaltriceps. ©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Reconstruc¸ão

de

ruptura

crônica

do

tríceps

distal

sob

a

configurac¸ão

de

dupla

fileira:

nota

técnica

Palavras-chave:

Traumatismosdostendões

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e

s

u

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o

Rupturasdotrícepsdistalsãoincomunsepodemserdedifícildiagnóstico,especialmente asparciais.Métodosdeimagem,comoUSGeRNM,devemserusadosparaaconfirmac¸ão

夽

WorkperformedintheServic¸odeCirurgiadeOmbroeCotovelo,HospitalOrtopédicoeMedicinaEspecializada(HOME),Brasília,DF, Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](T.M.Storti).

http://dx.doi.org/10.1016/j.rboe.2015.08.010

Tendões/cirurgia Cotovelo

diagnósticaeparadefinic¸ãodaextensãodalesão.Otratamentodeescolhaparaasrupturas completasdotrícepséocirúrgico,diferentementedasparciais,quedependemdefatores comodor,déficitfuncionaleexpectativasdopaciente.Descrevemosocasodeumpaciente comrupturaparcialdotrícepsdistalapósquedaaosolo.Nãofoidiagnosticadonomomento doprimeiroatendimentoeevoluiucomdoregrandeperdafuncional.Oprocedimento cirúr-gicofoifeitoapósnovemesesdotrauma,comareconstruc¸ãodotrícepspormeiodereforc¸o comotendãodosemitendíneoipsilateralefixac¸ãonoolécranosobaconfigurac¸ãodedupla fileira.Opacientepermaneceuimobilizadocomtipoiaporumasemanaeiniciou-se,apartir daí,oganhodeamplitudedemovimento(ADM)passiva.Apóstrêssemanasfoiliberadopara oganhodeADMativa.Ofortalecimentomusculariniciou-seapós12semanas.Apósseis mesesdoprocedimentocirúrgicoopacienteapresenta-sesemdor,ADMcompleta,forc¸ade extensãodocotovelograuV_{ehipertrofiadotríceps.Atécnicadescritasemostrouútilpara}

otratamentoderupturasdotendãodotrícepsdistal.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Tearing ofthe tendon ofthe distaltriceps is arare injury thataccountsforlessthan1%ofthetendoninjuriesofthe upperlimbs.1_{Forthisreason,fewstudiesintheliteraturehave} defined any treatment patterns or made any comparisons betweenthetypesoftreatment.Thisinjurygenerallyoccurs asanavulsionattheboneinsertionofthetendon,inthe ole-cranon.Morerarely,itoccursasalesionwithinthemuscle2_or atthemuscle-tendonjunction.3_{Theinjurymechanism} con-sistsoffallingwiththehandextended,butdirecttraumato theposteriorfaceoftheelbow4_{hasalsobeendescribed.}

Casesofcompletetearingrequiresurgicaltreatment,with primaryrepairorreconstruction.Ontheotherhand,casesof partialtearingareoftendifficulttodiagnoseimmediatelyafter theinjury.Theseareusuallydiagnosedafterlongperiodsof painand functionallimitation ofthe limb.5 _Imaging meth-odssuchasultrasonography(USG)andmagneticresonance imaging(MRI) are generallyused forthe diagnosis and for ascertainingtheextentoftheinjury.

Surgical treatment of partial tearing is generally done whenthepatientcontinuestopresentsymptomsdespitethe non-surgicaltreatment.Primaryrepairoftheinjuryisoften difficultincasesinwhichalongperiodoftimehaselapsed sincetheinjury.Inthesecases,tendonreconstruction tech-niquesneedtobeapplied.5

Thisarticlepresentsadescriptionofapatientwhosuffered chronictearingof thedistal tendonofthe brachial triceps muscleandthenunderwentreconstructionusingagraftfrom thetendonofthesemitendinosusmuscle,withfixationtothe olecranoninadouble-rowconfiguration.Thetechniquewas showntobereproducible,withgoodresults.

Case

report

Thepatientwas38yearsofageandhadsufferedafalltothe groundduringsportspracticeninemonthsearlier.Sincethen, hehad presentedpainanddifficulty intasksthat required elbowextensionforce,suchaspushingacardoortoopenit.

Hehadinitiallybeenattendedatanotherinstitution,where theinjuryhadnotbeendiagnosed.Instead,hehadbeen diag-nosedashavingbruisingonhiselbow.Hereceivedthecorrect diagnosiseightmonthsafterthetrauma.Hewasthenreferred toourserviceforthecorrecttreatment.Conservative treat-ment had already been administered over this period,but withoutanyimprovementinhiscondition.

Atthephysicalexamination,hepresentedbulginginthe posteriorregionofthedistalthirdoftheupperarm,acomplete rangeofflexion–extension,gradeIVelbowextensionstrength andpainwhenperformingextensionagainstresistance.MRI showedpartialtearingoftheinsertionofthetricepstendon intheolecranon(Fig.1).

Surgical

technique

Surgicaltreatmentwasindicated.Reconstructionsurgeryon theinjuredtendonwaschosenbecauseofthelengthoftime sincetheinjuryandthedegreeofretractionofthetornfibers. The techniqueoftransferring the tendonof theipsilateral semitendinosusmusclewasusedbecauseofourfamiliarity withthistechniqueandwiththecharacteristicsofthe trans-ferredtendon.

Thepatientwaspositionedondorsaldecubitusbecauseof theneedtoremovethetendonfromtheknee,andthelimb wasfixedtothepositioningdeviceofthetable(Trimano).

Fig.1–Magneticresonanceimaging(sagittalandcoronal)showingpartialtearingofthetendonofthedistaltriceps.

Twotransosseoussuturesweremademoreposteriorly,using no.2high-resistancethread,whichwaspassedthroughthe tricepsgraftcombinationwiththesuturelocked.Theexitwas atthemostdistalextremityofthetendon(Figs.3and4).The suturesweremadewiththeelbowflexedat90◦_.

Thepatient was kept immobilized by means ofa sling foroneweek.Subsequently,self-performedpassiveexercises were started.Three weekslater,gains ofactivemovement were started. Muscle strengthening exercises were started afterthethirdpostoperativemonth.Sixmonthsafterthe oper-ation,MRIwasproducedagain,andthisshowedthatcomplete tendonhealinghadbeenachieved(Fig.5).

Fig.2–Intraoperativeimagingshowingthegraftfromthe

semitendinosusinterlacedinthetricepstendon.

Thepatientevolvedinaverysatisfactorymanner.A com-plete range of motion was achieved and grade V muscle strengthwasreached,freefrompain.Thepatientisvery sat-isfiedwiththetreatmentthatwasperformed.

Discussion

Tearingofthedistaltendonofthetricepsisarareinjurythat accountsforlessthan1%ofalltendontears.1_{Thereislittle} informationintheliteraturetoguidesurgicaltreatment.The

Fig.3–Intraoperativeimagingshowingthepositioningof

thetwoanchorsinananteriorpositionintheolecranon

Fig.4–Intraoperativeimagingshowingthefinalfixationof

thetendontotheolecranon.

meanageatwhichitoccursis36years(range:7–75),andit occursmorecommonlyinmales(3:1).6

This injury is generally caused by a fall to the ground withthewristextended,whichgeneratesaneccentric con-tractionofthetriceps.7_{Substantialforceisusuallyrequired} forthetricepstendontotear;However,whenthestructural integrityofthetendonisaltered,tearingmayoccurasa conse-quenceofminimaltomoderateforce.7_{Hyperparathyroidism} secondarytochronickidneydisease,hypocalcemia, rheuma-toidarthritis,imperfectosteogenesis,useofanabolicsteroids andinsulin-dependentdiabetesaresystemicfactorsthathave been reported asrelated totearing ofthe tricepstendon.7 Amongthelocalfactorsthathavebeencited,localinjectionof corticoids,degenerativearthritisandbursitisoftheolecranon havebeenthemostfrequent.7

Thediagnosis of acute tearingofthe triceps can easily gounnoticed.Whentearingoccurs,elbowextensionagainst gravitybecomesdifficultorimpossible.Apalpabledefect prox-imaltotheolecranonmaybedetected,butthelocalswelling inacutecasesmaylimitinitialidentification.7

Theradiographicfindings associatedwithtearingofthe distaltricepsareminimal.Avulsionofabonefragmentfrom thetipoftheolecranonhasbeendescribedintheliterature, andthis findingmay beveryuseful inmakingthe diagno-sis. MRIenables accurate demarcation of the location and extentoftheinjuryanditiscommonlythepreferred exami-nationformakingthediagnosis.5_{Finally,ultrasonographyhas} beendescribedasanimportantdiagnosticmethodforthese injuries,giventhatitprovidesdynamicimagesandisamuch cheapermethodthanMRI,althoughthequalityoftheimages dependsonthetechniqueused.7

In most cases, complete tearing of the distal triceps is immediately treated surgically, comprising repair or reconstruction.7_{Ontheotherhand,incasesofpartialtearing,}

Fig.5–Postoperativemagneticresonanceimaging

showingtendonhealedintheolecranon.

theinitialtreatmentisusuallynon-surgical.Whenpartorall ofthetendonhasbecomedetachedfromtheproximalulna andpersistentpain,weaknessorfunctionaldeficitispresent, primarysurgicaltreatmentshouldbeconsidered.8

Severalsurgicaltechniqueshavebeendescribedfor treat-ingpartialorcompletetearingofthetricepstendon.Primary repairofacute complete tearsusing non-absorbable sutur-ing with locking stitches across the tendon and passing through perforations in the olecranon has been proposed when possible.8 _{Anauto or allograftshould beused when} primaryrepairisimpossible.8

InaseriespresentedbyvanRietetal.,7_{casesoftearingof} thedistaltendonofthetricepswereidentified.Reconstruction wasnecessaryinninecasesandtransferofautogenoustissue wasnecessaryinsixpatients.Thetendonstransferredwere theAchilles, plantar, semitendinosus,latissimus,anconeus andpalmartendons.Ineachcase,thetendontransferredwas interlacedwiththedistalstumpofthetricepsandthesuturing waspassedthroughperforationsintheolecranon.7

Inthe case ofour patient, an autograftfrom the semi-tendinosushad tobeused,eventhoughthiswasacaseof partialtearing, becauseofthechronicnatureoftheinjury. Thetendon-graftcombinationwasfixedtotheolecranonby meansoftransosseoussuturingandsutureanchors,which reinforcedthefixationandmadeitmoresecure.

The technique described here is easy to carry out and enablesearlygainsofrangeofmotion,thusmaking active extensionofthe elbowpossiblesix weeksafterthe opera-tion, with good long-term functional results. We observed thatbecausethisisarareinjury, thereisgreatdifficulty in undertakinglargeprospectivestudiestocomparethe surgi-caltreatmentmethodsforthisinjury.However,thetechnique describedaboveseemstobeagoodoptionforcasesofchronic tearingofthedistaltriceps.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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