TRICEPS TENDON INJURY AFTER ELBOW ARTHROPLASTY

Transcription

1 TRICEPS TENDON INJURY AFTER ELBOW ARTHROPLASTY Sławomir Dudko Damian Kusz Michał Wójcik Department of Orthopedics and Traumatology Medical University of Silesia in Katowice

2 Distal triceps tendon injury: rare injury, consists of approx. 1% of musculotendinous ruptures diagnosis of acute cases might be difficult, because of low incidence, especially after elbow arthroplasty distal avulsion more common in women > 50 yo and men < 30 yo approx. 50% initially missed 1/3 of cases total rupture scarse information about treatment

3 Mechanism fall on the abducted arm, weightlifting, snowboard injury Additional risk factors anabolic steroids use and local steroids injections Presentation loss of ability to extend elbow limited ROM palpable gap rupture most common at the distal insertion to the olecranon

4 Case report 59yo woman the injury], right-handed, currently 64yo Injury MAY 2012 Multifragmentary, intraarticular, inter- and supraepicondylar distal right humerus fracture

5 2012 MAY 1st surgery INTERNAL FIXATION

6 After 5 months: 2nd surgery: 2012 OCTOBER removal of wires modelling the skin After another 3 months; 3rd surgery: 2013 JANUARY complete wires removal

7 After year and 2 months: 4th surgery: 2014 MARCH Constricted Coonrad-Moorey total elbow arthroplasty with releasing 1/3 of the medial triceps attachment to the olecranon

8 During initial rehabilitation phase suddent onset of pain during passive redresions. Initial diagnosis periprosthetic fracture of the medial humeral epicondyle Proper diagnosis after around 6 months 5th surgery: 2014 OCTOBER; Intraoperative diagnosis: rupture of the 4/5 of the triceps, scar excision, wide release and debridement, anchoring the triceps tendon with PDS #2 suture through bone canals During rehab damage of the sutures

9 After 5 months: 6th surgery: 2015 MARCH triceps tendon reattachment (Krackow sutures + 2 anchors 3.5mm)

10 During rehab suture damage + one anchor loose

11 After 4 months 7th surgery: 2015 JULY V-Y triceps reconstruction exposure of the 1/3 distal of the triceps, adhesions release, removal of the previous sutures and anchors, reversed V incision at the musculotendinous junction

12 Elongation and muscle suturing to the decorticated olecranon (in 70 flexion), Krackow sutures + non-absorbable Etibond Poliester #4, passing sutures through perpendicular canal in the olecranon. Surgery time 55 min. Post-op: brace immobilization (70 of flexion) until wound is healed

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14 Observation time: 1 year and 8 months Final result: good Complaints: none ROM: full flexion, extension deficit 10, Muscle strength : 4/5 Lovett Patient s opinion: good; ability to use the limb freely Total treatment time: 3 years and 3 months

15 DISCUSSION Total elbow arthroplasty complications Not requiring surgery 1. Nerve paresthesias - 11% 2. Improper wound healing - 14% 3. Humerus fracture - 5% 4. Ulnar fracture - 5%

16 Usually requiring surgery 1. Nerve injury - 3% 2. Triceps injuries - 4% 3. Ankylosis - 4% Usually requiring revision 1. Loosening - 5% 2. Instability - 9% 3. Infection - 7% 4. Fracture+loosening - 5% Triceps injury after total elbow arthroplasty

17 Distal triceps injury Acute cases until 3 weeks: suturing [Keener J,Sethi P Distal tendon injuries.hand Clin.2015;31: ] Suturing techniques: 1. Bunnell / Krackow suture 2. Anchoring to the olecranon: o drilled bone canals o anchors [Yeh P i wsp. The distal, triceps tendon footprint and biomechanical analysisi of 3 repair techniques Am.J.Sports Med.2010; 2010;38: ] 3-4 anchors, 2 anchors+ endobutton Chronic cases - reconstruction

18 Variety of reconstruction techniques of chronic triceps injuries Rev Bras Ortop Sep-Ost; 50(5): Reconstruction of chronic tearing of the distal triceps using the double-row configuration: technical note, A.F.Paniago, T.M.Storti, R.F.Silva Faria, D.C Aragao de Morais, M.P de Souza Tech Hand Up Extrem Surg, 2008 Sep; 12(3): Triceps reconstruction using hamstring grafts for triceps insufficiency or recrrent rupture Wolf JM, McCarty EC, Ritchie PD

19 J Bone Joint Surg [Br] 2002;84-B: Sugical techniques for reconstruction of chronic insufficiency of the triceps-rotation flap using anconeus and tendo Achillis allograft Joaquin Sanchez Sotelo, Bernard F. Morrey Orthopedics Jan 2013-Vol 36;1: Triceps tendon Reconstruction Using Ipsilateral Palmaris Longus Autograft in Unrecognized Chronic Tears J.A. Scolaro, M.H.Blake, G.R. Huffman

20 V-Y technique - rarely described Am J Orthop (Belle Mead NJ) Jul;41(7):E96-9. Neglected triceps tendon avulsion: case report, literature review, and a new repair method. Yazdi HR, Qomashi I, Ghorban Hoseini M

21 Reconstruction results: muscle strength up to 80% of original prolonged muscle strength recovery risk of iatrogenic fracture of the proximal ulna

22 CONCLUSIONS 1. V-Y technique is the effective method for treatment chronic triceps injury after total elbow arthroplasty 2. Reliability and good outcome allow to recommend V-Y technique for treatment of aforementioned complication.

23 THANK YOU