Triceps Insufficiency Following Total Elbow Arthroplasty

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. As a complication following elbow replacement, this is becoming much more appreciated, especially when the infected elbow is being treated. There is little evidence in the literature regarding this complication as most patients do not have significant pain. However, the functional limitations that result from triceps insufficiency can result in poor patient satisfaction. According to the limited literature available on this topic, the incidence of triceps insufficiency following total elbow arthroplasty ranges from 1% to 29%.

A report on the use of the Gschwend approach documents 4 of 28 elbows with triceps insufficiency after a triceps-splitting approach to insert the GSB implant (Center Pulse, Zurich). In a comprehensive review of the literature, Voloshin et al. documented an incidence of approximately 1% to 5% for triceps insufficiency associated with total elbow arthroplasty. Typically, literature reviews understate the true incidence of this problem, and triceps insufficiency may be underreported because of the failure to recognize the problem in routine follow-up after total elbow arthroplasty.

In the Mayo Clinic experience there was a 2.3% rate of reoperation (20 of 887 patients) for triceps insufficiency following total elbow arthroplasty. A significant number of these patients had associated factors, including revision surgery and infection. The number of those with this problem but who did not elect to have surgery is considerably greater. In a focused review of patients with total elbow arthroplasty complicated by infection, more than half of the patients had associated triceps insufficiency. In that series, 85% of patients with triceps insufficiency reported that the lack of triceps function significantly limited their ability to perform activities of daily living.

Numerous factors can impact the integrity of the triceps tendon following total elbow arthroplasty. Risk factors for the development of insufficiency include multiple operations, infection, poor tissue quality, and poor surgical technique. A key consideration in the development of this problem is the surgical exposure. A number of studies have examined modifications to existing exposures with the goal of improving extensor mechanism function. Olecranon osteotomy is contraindicated in joint replacement surgery. Hence some means of lessening this complication is necessary. There are several options for the exposure and repair:

• 1

  Bryan-Morrey approach: Reflection of the triceps in continuity with forearm fascia and periosteum and anconeus from medial to lateral. Reflection of the triceps with a wafer of bone is a modification that has also been described.

• 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.

• 3

  Campbell's triceps-splitting approach: The triceps is split in the midline and reflected subperiosteally both medially and laterally. This approach may be modified by release of the triceps with a wafer of bone.

• 4

  Triceps tongue: The triceps tendon is incised in an inverted-V configuration, leaving the insertion attached at the olecranon. Tendon-to-tendon repair is performed at the conclusion of the procedure.

• 5

  Triceps-sparing approaches: Multiple techniques have been described with the general principle of preserving of the triceps attachment and aggressive flexor-extensor release to “skeletonize” and deliver the distal end of the humerus.

Presentation and Symptoms

Patients will typically report loss of active extension, and about 15% to 20% will also report pain. The most common problem is the inability to reach above the head and to push through doors. Most patients will report limitations in the ability to perform activities of daily living. Many patients with triceps insufficiency will report a history of multiple operations on the affected elbow. The mean time from the 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) discernible lateral subluxation or dislocation of the extensor mechanism.

Pathology

Triceps insufficiency can be categorized as weakness with an intact extensor mechanism (type I), soft tissue deficiency (type IIA), or olecranon bone loss (type IIB). In our experience with triceps insufficiency, following the treatment of infection most patients had bone or soft tissue deficiency, with bone loss being present in more than half of patients. Careful evaluation of the cause of the triceps insufficiency is important in the treatment of this complication. At the time of surgical reconstruction of triceps insufficiency, a partial triceps rupture was identified in 6 patients, a complete rupture was identified in 10 patients, and 3 patients had bone deficiency of the olecranon process.