Treatment of an infected total elbow replacement (TER) is often successful in eradicating or suppressing the infection. However, the extensor mechanism may be compromised by both the infection and the surgery. The goal of this study was to assess triceps function in patients treated for deep infection complicating a TER. Between 1976 and 2007 a total of 217 TERs in 207 patients were treated for infection of a TER at our institution. Superficial infections and those that underwent resection arthroplasty were excluded, leaving 93 TERs. Triceps function was assessed by examination and a questionnaire. Outcome was measured using the Mayo Elbow Performance Score (MEPS). Triceps weakness was identified in 51 TERs (49 patients, 55%). At a mean follow-up of five years (0.8 to 34), the extensor mechanism was intact in 13 patients, with the remaining 38 having bone or soft-tissue loss. The mean MEPS was 70 points (5 to 100), with a mean functional score of 18 (0 to 25) of a possible 25 points. Infection following TER can often be eradicated; however, triceps weakness occurs in more than half of the patients and may represent a major functional problem. Cite this article: Bone Joint J 2014;96-B:82–7

Olecranon plates used for the internal fixation of complex olecranon fractures are applied directly over the triceps tendon on the posterior aspect of the olecranon. The aim of the study is to describe the relationship of the plates and screws to the triceps tendon at the level of the olecranon. Eight cadaveric elbows were used. Dimensions of the triceps tendon at the insertion and 1cm proximal were measured. A long or a short olecranon plate was then applied over the olecranon and the most proximal screw applied. The length of the plate impinging on the tendon and the level of the screw tract on the tendon and bone were measured. The mean olecranon height was 24.3cm (22.4-26.9cm) with a tip-to-tendon distance of 14.5cm (11.9-16.2cm). The triceps tendon footprint averaged 13.3cm (11.7-14.9cm) and 8.8cm (7.6-10.2cm) in width and length, respectively. The mean width of the central tendon 1 cm proximal to the footprint was 6.8 cm. The long olecranon plate overlay over more movable tendon length than did the short plate and consequently the superior screw pierced the triceps tendon more proximally with the long plate. Using the Mann-Whitney U test, the differences were significant. The long olecranon plates encroach on more triceps tendon than short plates. This may be an important consideration for olecranon fractures with regards implant loosening or triceps tendon injury

Introduction. Distal triceps tendon rupture is related to high complication rates with up to 25% failures. Elbow stiffness is another severe complication, as the traditional approach considers prolonged immobilization to ensure tendon healing. Recently a dynamic high-strength suture tape was designed, implementing a silicone-infused core for braid shortening and preventing repair elongation during mobilization, thus maintaining constant tissue approximation. The aim of this study was to biomechanically compare the novel dynamic tape versus a conventional high-strength suture tape in a human cadaveric distal triceps tendon rupture repair model. Method. Sixteen paired arms from eight donors were used. Distal triceps tendon rupture tenotomies and repairs were performed via the crossed transosseous locking Krackow stitch technique for anatomic footprint repair using either conventional suture tape (ST) or novel dynamic tape (DT). A postoperative protocol mimicking intense early rehabilitation was simulated, by a 9-day, 300-cycle daily mobilization under 120N pulling force followed by a final destructive test. Result. Significant differences were identified between the groups regarding the temporal progression of the displacement in the distal, intermediate, and proximal tendon aspects, p<0.001. DT demonstrated significantly less displacement compared to ST (4.6±1.2mm versus 7.8±2.1mm) and higher load to failure (637±113N versus 341±230N), p≤0.037. DT retracted 0.95±1.95mm after each 24-hour rest period and withstood the whole cyclic loading sequence without failure. In contrast, ST failed early in three specimens. Conclusion. From a biomechanical perspective, DT revealed lower tendon displacement and greater resistance in load to failure over ST during simulated daily mobilization, suggesting its potential for earlier elbow mobilization and prevention of postoperative elbow stiffness

Purpose: We have sometimes observed paralysis of the long portion of the triceps in patients operated after traumatic damage to the axillary nerve. In anatomy textbooks, the motor branch of the long portion of the triceps arises from the radial nerve within the triceps. We studied the position of the motor branch of the long portion of the triceps in order to better detail its origin. Material and methods: Group I: this group included nine patients with trauma-induced lesions of the axillary nerve associated with clinical involvement of the long portion of the triceps. Group II: this group was composed of 20 cadaver specimens of the secondary posterior trunks. Group III: fif-teen approaches to the subclavian plexus with dissection of the secondary posterior trunk. Lesions to the axillary nerve were retrieved from the operation reports in group I. The origin of the motor branch of the long portion of the triceps was identified in group II. The same origin was identified by neurostimulation in group III. Results: In group I there were six lesions of the axillary nerve situated a mean 10 mm from the division of the secondary posterior trunk and three lesions of the secondary posterior trunk. There were four type IV lesions and five type V lesions. In group II, the motor branch of the long portion of the triceps arose a mean 6 mm from the division of the secondary posterior trunk in 13 cases, at the division in five cases, and 10 mm downstream in two cases, but never from the radial nerve. In group III, the branch of long portion of the triceps arose a men 4.5 mm from the division of the secondary posterior trunk in 11 cases, and at the division in four cases, but never from the radial nerve. Discussion: In patients with trauma to the axillary nerve with paralysis of the long portion of the triceps, lesions to the axillary nerve occur proximally and are severe. In our study, the motor branch of the long portion of the triceps always arose from the axillary nerve or the secondary posterior branch. This shows that paralysis of the long portion of the triceps is a sign of poor prognosis in patients with traumatic lesions to the axillary nerve. This association is for us an element in favour of a proximal and serious lesion to the axillary nerve. Conclusion: Involvement of the long portion of the triceps must be searched for in patients with traumatic lesions to the axillary nerve. Paralysis of the long portion of the triceps is a sign of a serious lesion requiring early surgical repair before two months

Total elbow arthroplasty is usually performed through a posterior approach. The management of the triceps tendon insertion include; Triceps division (V-Y Triceps turn down), Detachment of the Triceps insertion either by triceps splitting (Gschwind approach) or triceps reflecting (Bryan-Morrey approach), or by leaving the Triceps insertion intact (Triceps On approach). The ideal approach needs to meet three broad criteria; firstly it should be quick and easy, secondly it should offer excellent exposure and thirdly it should have low morbidity to the Triceps tendon. An approach that is also versatile provides an additional advantage. The purpose of this study was to present and discuss the surgical technique of a “new” posterior approach to the elbow. To biomechanically evaluate and compare the strength of the Triceps tendon repair with the Bryan-Morrey approach (recently demonstrated in a cadaveric study to be the strongest of three methods of management of the Triceps tendon). The Bryan-Morrey and Oxford approach were each performed on fourteen pairs of cadaveric elbows with the two Triceps tendon repairs carried out. The contra-lateral elbow served as the control. The specimens were then mounted on a material testing system and a constant velocity elongation was applied. This new approach demonstrated a significant reduction in operative time as well as providing excellent exposure suitable for multiple indications. Final analysis of the data using % ultimate strength loss (%USL) compared to the control specimens as the ultimate end point showed this new approach is as strong as the Bryan-Morrey approach with %USL of −40% for both approaches

Abstract. Objective. Radial to axillary nerve and spinal accessory (XI) to suprascapular nerve (SSN) transfers are standard procedures to restore function after C5 brachial plexus dysfunction. The anterior approach to the SSN may miss concomitant pathology at the suprascapular notch and sacrifices lateral trapezius function, resulting in poor restoration of shoulder external rotation. A posterior approach allows decompression and visualisation of the SSN at the notch and distal coaptation of the medial XI branch. The medial triceps has a double fascicle structure that may be coapted to both the anterior and posterior division of the axillary nerve, whilst preserving the stabilising effect of the long head of triceps at the glenohumeral joint. Reinnervation of two shoulder abductors and two external rotators may confer advantages over previous approaches with improved external rotation range of motion and strength. Methods. Review of the clinical outcomes of 22 patients who underwent a double nerve transfer from XI and radial nerves. Motor strength was evaluated using the MRC scale and grade 4 was defined as the threshold for success. Results. 18/22 patients had adequate follow-up (Mean: 29.5 months). Of these, 72.2% achieved ≥grade 4 power of shoulder abduction and a mean range of motion of 103°. 64.7% achieved ≥grade 4 external rotation with a mean range of motion of 99.6°. Conclusions. The results suggest the use of the combined nerve transfer for restoration of shoulder function via a posterior approach, involving the medial head branch of triceps to the axillary nerve and the XI to SSN

Aim. To assess clinical outcome of massive rotator cuff tear repair using triceps myotendinous flap. Method. This is a prospective cohort of 43 patients (24 male, 19 female) with average age of 62 years. The primary indication of surgery was pain. Patients with massive rotator cuff tear involving supraspinatus and infraspinatus, showing retraction and fatty infiltration in MRI were selected. Few (8/43) were with failed surgical treatment and rest had conservative treatment failed. They underwent rotator cuff repair during Feb 1999 to Jan 2004. The long head of the triceps was detached from the olecranon, rotated 180 degrees from its pivot point with its major vascular pedicle under the deltoid and acromion through the posterior capsule and attached to the greater tuberosity and any remnant of remaining cuff. All patients were assessed pre-operatively, at 3, 6 and 12 months post-operatively clinically and also using UCLA pain and functional score for shoulder. Shoulder range of motion was assessed before and after the surgery. 24 patients had minimum of 1 year and 19 had 2 year minimum follow-up. Results. The mean total UCLA score of 9.7 pre-operatively improved to 27.8 (p<0.0001) following the operation. The mean pre-operative UCLA pain score 2.2 improved to 7.8 post-operatively (p<0.001). The UCLA functional score improved from a pre-operative average of 3.4 to 8.2 (p<0.0001) following the operation. There was significant improvement in forward elevation, external and internal rotation but not abduction. There was no weakness in elbow extension. Complications: 3 superficial infections, 1 ulnar neuritis (resolved in 6 weeks), 1 olecranon bursitis (resolved in 3 months). Conclusion. Long head triceps tendon transfer is an effective technique to alleviate pain and improve functions in patients with massive rotator cuff tear, specially in difficult group of patients with limited options

Purpose: Most displaced olecranon fractures can be treated with ORIF. However with severe comminution or bone loss, excision of the fragments and repair of the triceps to the ulna is recommended. The triceps can be reattached to either the anterior or posterior aspect of the ulna. The purpose of this in-vitro study was to determine the effect of triceps repair technique on elbow laxity and extension strength in the setting of olecranon deficiency. Method: Eight unpreserved cadaveric arms were used (age 75 ± 11 years). Surface models were generated from CT images and sequential olecranon resections in 25% increments were performed using real-time navigation. Muscle tendons (biceps, brachialis, brachioradialis and triceps) were sutured to actuators of an elbow motion simulator, which produced active extension. A tracking system recorded kinematics in the varus and valgus positions. A triceps advancement was performed using either an anterior or posterior repair to the remaining olecranon in random order. Triceps extension strength was measured in the dependent position with the elbow flexed 90° using a force transducer located at the distal ulnar styloid, while triceps tension was increased from 25–200 N. Outcome variables included maximum varus-valgus elbow laxity and triceps extension strength. Two-way repeated measures ANOVAs were performed for laxity comparing resection level and repair method. Three-way repeated measures ANOVAs were performed for triceps extension strength comparing triceps tension, resection level and repair method. Significance was set at p < 0.05. Results: Progressive olecranon resection increased elbow laxity (p < 0.001). Although the posterior repair produced slightly greater laxity for all but the 50% resection, this difference was not significant (p = 0.2). The posterior repair provided greater extension strength than the anterior repair at all applied triceps tensions and for all olecranon resections (p = 0.01). The initial 0% resection reduced extension strength for both repairs (p < 0.01), however, there was no effect of progressive olecranon resections (p = 0.09). Conclusion: There was no significant difference in laxity between the anterior and posterior repairs. Thus even for large olecranon resections, the technique of triceps repair does not have significant influence on joint stability. Extension strength was not reduced by progressive olecranon resections, perhaps due to wrapping of the triceps tendon around the trochlea putting it in-line with the ulna and giving it a constant moment arm. Triceps extension strength was higher for the posterior repair. This is likely due to the greater distance and hence moment arm of the posterior repair to the joint rotation center. Conversely, the anterior repair brings the triceps insertion closer to the joint center, reducing the moment arm. Since there was no significant difference in laxity between the repairs, the authors favour the posterior repair due to its significantly higher triceps extension strength

Purpose of the study: Equinus in patients with cerebral palsy results from at least two factors: excessive contracture of the triceps surae and muscle retraction. Tendon surgery and progressive lengthening techniques using plaster walking boots can provide variable improvement in retraction. We compared the effect of this technique when applied with or without prior 40°C warming in the same patients. We also assessed the efficacy of this treatment method in terms or degree of retraction, patient age, puberty maturity, and sex. Materials and methods: This series included 70 muscles in 52 patients with cerebral palsy aged 2 years 11 months to 21 years (mean 8 years 3 months). Common features in these patients were: equinus mainly explained by triceps retraction, no history of prior surgery on the triceps tendon, knee flexion less than 15° in the upright position, easily reduced lateral deformation of the foot, absence of mediotarsal dislocation, triceps stretching could be achieved without triggering unacceptably intense contracture. The retraction of the triceps surae was measured from the maximal passive dorsal flexion angle of the foot, before and after applying each stretching boot. The difference between these measurements gave the gain obtained with the plaster boot. Protocol R− (stretching with plaster boot) consisted in a series of slow stretchings for 10 minutes before making the boot which was worn 7 days. Recurrent retraction in these same patients warranted another treatment within a delay of 3 to 17 months (mean delay 8.7 months). The same treatment then followed protocol R+ where the stretching was preceded by immersion of the segment in a 40°C water bath for 10 minutes. Results: Mean gain obtained with protocol R+ (warming) was 6.8° knee extended and 7.1° knee flexed. These differences were highly significant in both cases (p < 0.0001). We had no failures with protocol R+ while with protocol R− (stretching without warming) the gain was nil or less than 5° for 29 muscles knee extended and for 32 muscles, knee flexed. The gain was not related to age, sex or puberty maturity. It was not related to the angle of dorsal flexion of the foot prior to stretching. Discussion: Our findings demonstrate that when the conditions allowing prolonged stretching of the triceps surae are present, prior warming at 40°C for 10 minutes leads to an improvement in muscle lengthening in all patients, even in those for whom prior treatment had been unsuccessful without warming. This observation would indicate that the mechanisms allowing greater lengthening are present in all patients with cerebral palsy but that they cannot be triggered due to abnormal muscle viscosity related to distal vasomotor disorders frequently observed in this condition. Further research is needed to detail this point

1 . A case is described in which complete transposition of the latissimus dorsi muscle with its neurovascular pedicle was performed to compensate for complete paralysis of the triceps and partial paralysis of the posterior part of the deltoid muscle. 2. Muscle necrosis did not occur to any significant degree. 3. Strong substitute triceps function was achieved

We have reviewed seven patients who had triceps transfer after an old brachial plexus injury. All patients had a useful functional improvement with a good range of powerful elbow flexion; five patients could manage to bring their hand to their mouth. The basis of patient selection and the relative advantages of triceps transfer are discussed

Eleven cases are reported of contracture of the triceps muscle following intramuscular injections. This occurred in one arm of each of 11 children aged from 6 to 13 years, all of whom had a definite history of repeated injections. In seven of the cases the injections were of oxytetracycline. On presentation only 30 degrees to 35 degrees of flexion was possible. Physiotherapy for 4 to 12 weeks produced improvement, but in four cases early operation for excision of fibrous tissue and lengthening of the triceps was necessary to restore adequate flexion. Four other cases required operation after late relapse. The condition is rare, and is compared with similar and more commonly reported contractures in the quadriceps and the deltoid muscles

Introduction: It may not be possible to obtain anatomical reduction of displaced supracondylar fractures in children by closed manipulation. We have found difficulties performing open reduction using the described surgical approaches. We report an approach based on studies of the vascular anatomy of triceps, which provides a wide exposure facilitating surgery. Material And Methods: Between 2002 and 2004 we performed open reduction and internal fixation on 12 children (8 girls, 4 boys: mean age 6). Our vascular injection studies indicate that the blood supply to triceps brachii is proximally based. We used a posterior approach identifying the ulnar nerve. We mobilised lateral triceps and anconeus in continuity preserving the vascularity and separated the components of distal triceps through an intermuscular septum. The fractures were reduced and fixed using K wires. Results: The fractures healed in the anatomical position in each child and all 12 demonstrated a full range of elbow movements within 6–8 weeks of K wire removal. We observed no complications. Discussion: Although closed reduction and percutaneous K wire fixation remains the treatment of choice for displaced supracondylar humeral fractures, anatomical reduction must be achieved ideally and residual rotation of the fracture fragments avoided. We have found that this surgical approach has reduced our reluctance to proceed to surgical treatment of these difficult fractures and consequently a tendency to accept sub optimal reduction. Conclusion: A surgical approach based on the vascular anatomy of triceps can be used to provide a wide, symmetrical and safe exposure facilitating open reduction and internal fixation of supracondylar fractures of the humerus in children whilst avoiding complications including residual elbow stiffness

Intraarticular fractures of the distal humerus comprise 1% of all fractures in adults. Triceps reflecting and olecranon osteotomy approach provide adequate exposure in intraarticular fracture with its own advantage and disadvantages. Forty consecutive patients with fractures of the distal humerus were treated over a 36-month period. The patients were randomly allotted into two groups; group A consists of twenty patients with olecranon osteotomy and group B consists of twenty patients with triceps reflecting approach. In both the groups fracture was fixed using orthogonal or parallel plating techniques. Clinical outcome was assessed using the DASH SCORE, radiological union and complications was noted in both the group and compared. In group A the mean DASH score was 15.9 points. Three patients underwent a second procedure for hardware removal, 2 patients had non-union at osteotomy site, one patient had transient ulna nerve neuropraxia and one patient had superficial infection. In group B the mean DASH score was 14 points. There was no statistical significance between both groups regarding final outcome except complications were more in osteotomy approach. We conclude both approach is an effective procedure with an excellent or good functional outcome but osteotomy approach has more complications

Two cases of unusual snapping at the elbow are described. In both, the medial head of the triceps was found to be separated from the main muscle belly. During flexion of the elbow, the medial head dislocated over the medial epicondyle, producing a characteristic snapping phenomenon. Both cases were of long standing and had been asymptomatic for years. The first clinical symptoms were those of an ulnar neuropathy. In order to restore the normal position of the medial head of the triceps, its tendon was detached from the olecranon, passed under the central tendon and interlaced to it. The ulnar nerve was left in the epicondylar groove in one case and transposed anteriorly in the other. At the end of the procedure flexion of the elbow was unobstructed and the snapping phenomenon had disappeared

Seven patients with chronic insufficiency of the triceps were treated by either a rotation flap using anconeus (4) or an allograft of tendo Achillis (3). The latter procedure was selected for patients with a large defect in whom the anconeus muscle had been devitalised. Five disruptions were in patients who had previously undergone an elbow replacement. The patients were assessed for subjective satisfaction, pain, range of movement and strength, and the results were graded using the Mayo Elbow Performance Score (MEPS). The mean follow-up was for 33 months (9 to 63). One rotation flap failed six months after operation. At the most recent follow-up, the remaining six patients had no or slight pain, restoration of a functional arc of movement and normal or slightly decreased power of extension. All six were satisfied with the outcome and were able to resume their daily activities with no limitations other than those imposed by the previous elbow replacement. The final MEPS was 100 points in five patients and 75 in one

We compared the results in two groups of patients with late reduction of posterior elbow dislocations, one of which had lengthening of the triceps (group A, n = 36) and the other did not (group B, n = 34). The elbows had all been dislocated for more than one month and less than three months. The patients in group B had better clinical results and significantly less postoperative flexion contracture (p < 0.05)

Two children with radial club hand and absence of the biceps muscle were treated by centralisation of the ulna into the carpus and triceps transfer. The two operations were performed only a short time apart so that the period between the procedures could be used to stretch the triceps and to enable the children to adapt to an altered position of the wrist and to mobility of the elbow at one step and following a single period of plaster immobilisation. It is very likely that function is better than it would have been had the condition remained untreated. Before operation the children had only a crude hook function of the hand against the forearm and could not bring the hand to the mouth. Even if function is not much improved, the improvement in appearance is considerable and is by itself sufficient to justify the procedures

Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications

Introduction. Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. Material & Methods. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. Results. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Conclusion. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications