Original Article

Clinical Outcomes of Low-Cost, Anchorless Repair of

the Triceps Tendon Using a Proximal Knot Technique
Robert R. Hall III, B.S., Alison K. Sarokhan, M.D., and Nicky L. Leung, M.D.

Purpose: To use validated outcome measures to evaluate the clinical results of surgical repair of distal triceps tendon
ruptures using transosseous tunnels and high-strength sutures with proximally based knots. Methods: A consecutive
series of traumatic distal triceps tendon ruptures at a single institution was studied. All cases were surgically repaired by 1
surgeon using high-strength suture with a bone tunnelebased repair technique. Repair knots were oriented proximally
instead of in the traditional distal position. All patients were evaluated at long-term follow-up with a physical examination
performed by the orthopaedic surgeon and the following validated outcome measures: Disabilities of the Arm, Shoulder
and Hand score; Mayo Elbow Performance Score; and visual analog scale score. Results: Seven male patients with a
mean age of 38 years (range, 19-50 years) and mean follow-up period of 4.1  1.2 years underwent distal triceps tendon
repair with bone tunnels and high-strength sutures with proximally positioned knots. Of the repairs, 4 involved the
dominant arm. At final follow-up, the mean Disabilities of the Arm, Shoulder and Hand score was 1.3  3.1; the mean
Mayo Elbow Performance Score was 99.3  1.9; and the mean visual analog scale score was 0. One additional patient who
declined participation in the study had wound dehiscence and infection with an associated partial rerupture. Con-
clusions: This case series of triceps tendon repairs using transosseous tunnels and proximally based knots showed
favorable postoperative elbow function based on validated outcome measures. Level of Evidence: Level IV, therapeutic
case series.

T he triceps brachii is a 3-headed muscle whose

tendon attaches at the olecranon process1 and
functions to enable extension of the elbow. Distal tri-
triceps tendon ruptures is recommended for all healthy
individuals.8
Traditional transosseous techniques for triceps repair
ceps ruptures are a relatively rare entity2 and usually have required tying large knots distally on the subcu-
occur in athletes, weightlifters, or anabolic steroid taneous surface of the proximal ulna, a potential source
users.3,4 Trauma, especially a laceration or fall on an of postoperative pain.9,10 Although knotless suture
outstretched hand, has been implicated in acute triceps anchor repair eliminates the necessity for such
tendon rupture.5 Although rare, such injuries are knots,11,12 it is associated with an increase in equipment
accompanied by significant impairment in upper-limb cost.
function.6,7 As such, surgical repair of complete Recent literature has described a transosseous repair
with proximal knots tied over the triceps tendon, with
the goal of minimizing the potential for symptomatic
From Tufts University School of Medicine, Boston, Massachusetts, U.S.A. prominent suture knots without the added cost of an-
(R.R.H.); Department of Orthopaedic Surgery, Tufts Medical Center, Boston,
chors.13 Although favorable results have been pub-
Massachusetts, U.S.A. (A.K.S.); and Department of Orthopaedic Surgery,
Newton-Wellesley Hospital, Newton, Massachusetts, U.S.A. (N.L.L.). lished for numerous other methods,6,14 a clinically
The authors report no conflicts of interest in the authorship and publication superior technique has yet to be proved. The purpose of
of this article. Full ICMJE author disclosure forms are available for this article our study was to use validated outcome measures to
online, as supplementary material. evaluate the clinical results of surgical repair of distal
Received August 12, 2020; accepted December 9, 2020.
triceps tendon ruptures using transosseous tunnels and
Address correspondence to Robert R. Hall III, B.S., Tufts University School
of Medicine, 145 Harrison Ave, Boston, MA 02111, U.S.A. E-mail: rrhall95@ high-strength sutures with proximally based knots. Our
[Link] hypothesis was that this technique would achieve
Ó 2021 by the Arthroscopy Association of North America. Published by adequate restoration of elbow extensor strength and
Elsevier Inc. This is an open access article under the CC BY-NC-ND license patient satisfaction while minimizing the potential for
([Link]
symptomatic prominent suture knots and without the
2666-061X/201381
[Link] additional cost of anchors.

Arthroscopy, Sports Medicine, and Rehabilitation, Vol 3, No 2 (April), 2021: pp e535-e541 e535
e536 R. R. HALL ET AL.

Methods
After receiving institutional review board approval
(Partners Healthcare protocol No. 2019P000464), we
performed a retrospective chart review to identify pa-
tients who underwent triceps tendon repair surgery
from January 2011 to January 2019 performed by a
single surgeon (N.L.L.) at 1 institution. All patients aged
between 18 and 85 years who experienced isolated,
acute, insertional triceps tears fixed with bone tunnels
and proximal knots as described by Sarokhan and
Leung13 were included. The exclusion criteria included
chronic injury, enthesophyte removal, ipsilateral biceps
injury, and myotendinous rupture. All patients expe-
rienced partial or complete triceps tears as diagnosed by
physical examination findings and magnetic resonance
imaging or radiography showing a proximally retracted
avulsion fragment. Patients underwent primary repair
surgery for discomfort and objective weakness.
The primary diagnosis, demographic characteristics,
mechanism of injury, procedure, date of surgery, and
injury-related information were obtained from the
electronic medical record. Patients were subsequently
contacted by phone to follow up with the surgeon for a
physical examination and to complete a series of
questionnaires. Participants were evaluated with vali-
dated outcome measures including the Disabilities of
the Arm, Shoulder and Hand (DASH) score; the DASH Fig 1. The suture ends with the needles should be exiting
Work and Sports/Arts optional sections; the Mayo laterally and medially, with the free limbs exiting the central
Elbow Performance Score (MEPS); and the visual tunnel. Reprinted with permission from Sarokhan and
analog scale (VAS) score. Patients were also evaluated Leung.13
with a Likert satisfaction score and a focused physical
examination that included strength and range-of-
motion assessment. native insertion of the olecranon process was facilitated
by maintaining the elbow in slight extension. Residual
Surgical Technique tissue and debris were cleared from the bony footprint
The surgical technique as described by Sarokhan and and a bleeding bed was created using a curette to pro-
Leung13 was used. The patient was placed in the supine mote healing.
position after administration of regional anesthesia. Three holes were created in the central, radial, and
Prior to sterile preparation of the surgical site, a non- ulnar aspects of the tendon footprint using a 2-mm
sterile pneumatic tourniquet was applied to the arm as drill. Three additional holes were drilled through the
far proximal as possible. dorsal cortex about 1 cm distal to the first 3 holes. The
To expose the surgical site, a 10-cm longitudinal holes were drilled proximally and then distally and
curvilinear incision was made, curving just lateral to the were connected using the large-curvature needle from
tip of the olecranon. The tendon stump was then a No. 5 Ethibond Excel suture (Ethicon, Somerville,
identified and freed from surrounding tissues. Longi- NJ), producing 3 curved bone tunnels. A nonabsorbable
tudinal incision of any intact paratenon was performed high-strength suture (No. 5 Ethibond Excel) was passed
to allow preservation for later repair. The tendon end antegrade through the central tunnel and then shuttled
was grasped with a non-penetrating clamp over a damp retrograde through the most lateral tunnel. While the
sponge, with care taken to avoid damaging the first suture was held taut, a second suture was passed
ruptured end of the tendon. To allow further mobili- antegrade through the central tunnel. To ensure that
zation of the tendon, a small extension of the longitu- the second suture needle did not transect the first su-
dinal split between the heads of the triceps was ture, the lateral suture was pulled back and forth and
performed when necessary. Longitudinal tension was then passed retrograde through the most medial tunnel.
applied to the tendon stump for several minutes to After suture passage, both suture needles exited the
lengthen the triceps muscle as much as possible. Bone- lateral and medial tunnels with the free limbs entering
to-tendon contact between the tendon stump and the the central tunnel, as shown in Figure 1. A modified
 OUTCOMES OF PROXIMAL KNOT TRICEPS REPAIR e537

range of motion at the time of cast removal. No resisted

active extension of the elbow was allowed at initial cast
removal. At 8 weeks, gentle resisted extension was
initiated. At 12 weeks, patients were allowed unre-
stricted activity.

Results
During the study period, 17 triceps repair cases were
performed by the senior surgeon. Each case was
screened and evaluated for inclusion in this study. We
excluded 1 patient who was aged younger than 18
years, 3 patients who underwent surgery for chronic
tendinitis with enthesophyte excision to remove the
calcified tendon area and then reattach the tendon, 1
patient who underwent a myotendinous repair tech-
nique with suture only, and 1 patient who had a non-
Fig 2. All sutures exit the dorsal surface of the tendon. concomitant ipsilateral distal biceps injury. A total of 11
Reprinted with permission from Sarokhan and Leung.13 insertional ruptures were identified to be included in
the analysis of patients who underwent repair with
bone tunnels and proximal knots. These 11 patients
Krackow locking-loop stitch was used to weave the were contacted by phone to participate in the study,
lateral suture through the lateral half of the tendon. which involved a physical examination by the surgeon
Next, the free end of the same suture was passed from and a series of subjective questionnaires. Of the 11
deep to superficial within the tendon using a free remaining patients, 3 were lost to follow-up and 1
needle. Both the post limb and the limb that was run declined to participate. The latter patient had experi-
proximally and distally in the tendon exited the tendon enced a postoperative infection and subsequent partial
on the dorsal surface. The procedure was then repeated rerupture. This left a total of 7 patients for inclusion in
on the medial half of the tendon, which was also the final analyses.
shuttled through the tendon using a modified Krackow Patient demographic characteristics are presented in
locking-loop stitch, as depicted in Figure 2. Table 1. All patients were men, with a mean age of 38
After all of the sutures were passed, 2 half-hitches years (range, 19-50 years; standard deviation [SD], 13.3
were tied to allow the suture to bring the tendon to years). Of the injuries, 5 occurred after falls during
bone; then, 5 more reversed alternating half-hitches participation in athletics, 1 occurred during a fall from a
were tied over the post limb with the elbow main- height, and 1 occurred after a patient struck his arm on
tained in extension. The knots, tied in this manner, a door frame. Participants were largely free of comor-
wound up on the dorsal surface of the triceps tendon bidities because none had a history of anabolic steroid
about 1 cm proximal to the olecranon tip, where they use or kidney disease. One patient was an occasional
were covered by a layer of fat at the time of skin smoker. Of the surgical repairs in these patients, 4 were
closure. The sutures were then cut, and the elbow was performed on the dominant arm. Three repairs were
flexed to 90 to ensure that there was no gapping be- performed for complete tears, whereas 4 repairs were
tween the tendon and bone. If gapping occurred prior performed for high-grade partial tears significant
to reaching 90 of flexion, the elbow was cast at the enough to cause notable weakness and ongoing pain.
position of flexion that did not produce gapping. The time from injury to surgery, time to follow-up,
A nonabsorbable suture was used to repair the lon- and range of motion and strength at follow-up are
gitudinal split between the heads of the triceps if pre- presented in Table 2. After acute tears, operative repair
sent. Any intact overlying paratenon was repaired using was performed in all patients with a mean time to
a fine absorbable suture. The skin was closed in a surgery of 54.4 days (range, 10-105 days; SD, 39.5
layered manner, and a long arm cast was applied to days). The mean time to follow-up was 4.1 years
immobilize the elbow at the aforementioned position of (range, 2.4-5.3 years; SD, 1.2 years). Range of motion
flexion that prevented repair gapping. showed an arc from 0 to 140 of flexion with full su-
The postoperative protocol was similar for all patients. pination and pronation after physical examination in all
The elbow remained in a cast until 2 weeks post- 7 patients. Grade 5 strength of elbow extension on
operatively, at which time the sutures were removed physical examination was regained in each respondent.
and the elbow was recast at 90 of flexion. At 4 weeks, No complications or areas of irritation related to
the cast was removed. Patients were given a sling and prominent knot stacks were found. These knot stacks
started physical therapy allowing full active and passive could be identified on physical examination, but no
e538 R. R. HALL ET AL.

Table 1. Demographic Data

Dominant vs Mechanism of Partial vs

Patient No. Age, yr Sex Nondominant Arm Injury Medical History Smoker Complete in OR
1 46 M Dominant Fall from height Healthy No Complete
2 19 M Dominant Fall during Healthy No Partial (90%)
collegiate bike
race
3 42 M Dominant Fall off alpine slide Kidney stones and psoriasis No Partial (80%)
4 50 M Nondominant Fall during hockey Asthma No Partial (60%)
5 50 M Dominant Fall during lacrosse Arthritis No Complete
6 40 M Nondominant Arm struck against Depression No Partial (60%)
door frame
7 20 M Nondominant Fall during rugby Healthy Some days Complete
M, male; OR, operating room.

patient noticed their presence or requested knot-stack Discussion

removal. Our study used standardized outcome measures and
Outcome measures, occupation, and sports are pre- physical examination findings to show favorable out-
sented in Table 3. Further evaluation comprised the comes in patients who underwent a previously
DASH score, DASH Work score, DASH Sports/Arts score, described transosseous triceps repair technique. This
MEPS, VAS score, and postoperative patient satisfaction method aimed to simplify the repair, minimize cost, and
reporting (1-5). The average DASH score was 1.3 (range, use proximal knots, potentially reducing painful knot
0-8.3; SD, 3.1), indicating excellent outcomes in all par- prominence on the dorsal forearm. Distal triceps in-
ticipants. The mean MEPS was 99.3 (range, 95-100; SD, juries are a relatively uncommon entity and usually
1.89). Regarding the MEPS, only 1 patient reported a occur in male individuals during athletics15 or after falls
score of 95, with all other respondents reporting a score on outstretched arms,4 as was indicated in our series.
of 100. The same patient also reported a satisfaction score Traditional techniques for distal triceps repair use either
of 4 of 5 because he experienced occasional ulnar nerve heavy nonabsorbable sutures9 passed through bone
symptoms during elbow flexion. All other patients re- tunnels or suture anchors16 to reattach the tendon to
ported a satisfaction score of 5 of 5. The mean satisfaction the olecranon process.
score was 4.86 (range, 4-5; SD, 0.38). All patients re- On the basis of this case review, we believe the
ported a VAS pain score of 0. Each of the 7 respondents described repair technique shows favorable long-term
was able to return to work without restriction. Each re- outcomes. No patients experienced complications or
ported a DASH Work score of 0. Five patients indicated reoperation related to prominent knot stacks, and none
participation in sports, with 1 participating in golf alone, 1 requested knot-stack removal. One patient experienced
participating in competitive road cycling, 1 participating an infection-related partial rerupture. This patient was a
in lacrosse and soccer, and 2 participating in multiple cigarette smoker, which has been shown to contribute
sports, as detailed in Table 3. Two patients indicated no to delayed wound healing17 and higher rates of post-
participation in sports. Of note, the only suboptimal operative surgical-site infection.18 Another complica-
DASH Sports/Arts score was 75, which was reported in tion was intermittent ulnar neuropathy, occurring in
the high-level cyclist. the competitive cyclist, limiting his ability to participate

Table 2. Time From Injury to Surgery, Time to Follow-up, and Range of Motion and Strength at Follow-up

Range of Motion,
Patient No. Time from Injury to Surgery, d Time to Follow-up, yr Flexion/Extension Pronation/Supination Strength (0-5)
1 30 5.4 5-135/0-135 90/90 5
2 50 4.8 0-140/0-140 90/90 5
3 10 4.6 5-135/5-130 90/90 5
4 90 4.1 0-135/0-135 90/90 5
5 10 2.6 5-135/<5 to 135 90/90 5
6 86 2.4 0-140/0-140 90/90 5
7 105 5.1 0-135/0-135 90/90 5
 OUTCOMES OF PROXIMAL KNOT TRICEPS REPAIR e539

Table 3. Outcome Measures

DASH Sports and/or Arts DASH Sports/ VAS Satisfaction

Patient No. DASH Score Current Occupation Work Score Participation Arts Score MEPS Score (0-10) Score (1-5)
1 0 Firefighter 0 Golf 0 100 0 5
2 8.3 Software project 0 Competitive road 75 95 0 4
manager cycling
3 0 Assistant project 0 NA NA 100 0 5
manager
4 0 HVAC technician 0 Golf, hockey, 0 100 0 5
boxing, and
fishing
5 0.8 Physical therapist, 0 Lacrosse and soccer 6.3 100 0 5
personal trainer,
and strength and
conditioning
coach
6 0 Union ironworker 0 NA NA 100 0 5
(heavy
construction)
7 0 Financial advisor 0 Soccer, biking, and 0 100 0 5
lifting weights
DASH, Disabilities of the Arm, Shoulder and Hand; HVAC, heating, ventilation, and air conditioning; MEPS, Mayo Elbow Performance Score;
NA, not applicable; VAS, visual analog scale.

in this activity postoperatively. However, he declined patients to return to play. Of note, our case series
further intervention for treatment of ulnar neuropathy. included 5 cases of triceps repair in patients who
We believe that this is the first triceps repair series participated in athletics, and all but 1 returned to play
that includes DASH sports-specific information. The without complication, suggesting the efficacy of this
inclusion of this evaluation tool may allow identifica- technique in athletes.
tion of more hardships than the general DASH instru- Similarly, evaluations of military personnel have
ment, especially in higher-level athletes. Detection of shown a return to high activity levels after triceps
such limitations is especially critical in patients with repair. A 2016 study of triceps repairs in 48 active-duty
triceps injuries because the demographic that experi- American military personnel showed that strength and
ences such injuries often participates in competitive or function are adequately restored after surgery even in
high-level athletics or activities.19 high-demand individuals.8 At a mean 26-month
Mair et al.20 examined triceps injuries in National follow-up, 45 patients (94%) had returned to active
Football League (NFL) players during a 6-year span duty, 6 (12.5%) experienced traumatic rerupture, and
from 1991-1996. They included 10 partial and 11 4 (8.3%) continued to experience chronic pain or
complete triceps ruptures. Of the partial ruptures, 4 weakness. Similar results were reported in a 2019 study
were surgically repaired, and all 10 patients continued of 37 repairs, in which 84% of participants returned to
playing in the NFL for at least 1 season after injury. full military duty at 2 years.22 In this report, 1 partici-
Among the 11 complete ruptures that were surgically pant experienced rerupture. A large group continued to
repaired, there was 1 rerupture; 1 player retired, experience discomfort, with 45% of patients reporting
whereas 10 played at least 1 season after injury. This occasional elbow pain. Follow-up phone interviews
finding shows the ability of athletes to return to a high with 14 members of the original cohort were conducted
level of performance after both complete and partial at an average of 52.4 months (range, 7-84.9 months).
triceps tendon repairs. However, the article did not state Participants reported an average DASH score of 4.7
which repair technique was used in its participants, (range, 0-15.9; SD, 4.7) and average MEPS of 85.4
limiting comparison or determination of an optimal (range, 60-100; SD, 11.7). Of these 14 patients, 12
technique in the competitive athlete. (85.7%) were satisfied. Our cases showed comparable
In a subsequent case series, Finstein et al.21 exam- outcomes to these studies of military personnel, spe-
ined 37 triceps repairs in NFL players from 2000- cifically a lower average DASH score, a higher average
2009. Although all players returned to NFL play MEPS, and high satisfaction rates. Although technique
postoperatively, significant recovery times were re- superiority cannot be concluded based on these com-
ported, with players missing an average of 165 days parisons, these data suggest that the outcomes found in
(range, 49-318 days). Again, no information was our cases were similar to those in other series exam-
provided on which type of repair was used in these ining outcomes that included individuals who partici-
patients, but it was shown that surgical repair allows pated in high levels of activity.
e540 R. R. HALL ET AL.

Further studies have shown good outcomes in gen- enthesopathy was determined to be associated with
eral populations for both the transosseous technique increased complications, including pain, numbness,
and the suture anchor technique. Because our series tendon calcification, subcutaneous adhesions, cyst for-
includes patients treated with anchorless repair, the mation, and wound dehiscence. Although Waterman
efficacy of the anchorless transosseous technique is of et al. provided an adequate comparative analysis of
relevance. Various examinations of the transosseous patient-reported outcomes in patients with and without
technique with distal knots have reported good out- pre-existing olecranon enthesopathy, their case series is
comes. Van Riet et al.9 reported that 3 of 14 patients limited. The lack of a power analysis and the inclusion
experienced rerupture, with 1 experiencing a stitch of cases with various operative indications and surgical
abscess. An additional study reported that in a series of techniques suggest that further analyses are required to
10 patients, 1 patient experienced rerupture.2 Finally, a determine additional risk factors for postoperative
2015 examination of 8 repairs found no reruptures but complications and to describe clinical outcomes after
reported that 1 patient required ulnar nerve release.23 distal triceps repair.
A single-row suture anchor technique has also shown
good outcomes, with a 2012 case series of 5 repairs Limitations
showing no rerupture and reporting an average DASH The limitations of our study include the small sample
score of 1.4 (range, 0-7; SD, 3) and average MEPS of size and lack of a comparison group; moreover, no
95.8 (range, 79-100; SD, 9).24 Subsequent studies have biomechanical evaluation of our repair was performed.
aimed to compare distal triceps repair techniques. Strengths include long-term follow-up with validated
Horneff et al.25 retrospectively reviewed 56 cases, outcomes, technical simplicity, potential for decreased
comparing a transosseous repair with suture anchor knot discomfort, and low cost of surgery. Further
constructs, and examined rerupture rates and patient comparison studies examining clinical outcomes and
satisfaction, as well as the VAS score, MEPS, and DASH cost are necessary to determine the ideal repair tech-
score. They contacted patients by telephone, with an nique that maximizes clinical outcomes and minimizes
average follow-up period of 4.3 years. They found no cost.
statistically significant difference in patient satisfaction,
rerupture rate, MEPS, or VAS score based on construct Conclusions
type. They did, however, find a statistically significant This case series of triceps tendon repairs using trans-
difference in the DASH score, with the transosseous osseous tunnels and proximally based knots showed
group averaging 3 points lower. Although statistically favorable postoperative elbow function based on vali-
significant, this difference is not believed to be clinically dated outcome measures.
relevant because it has been shown that the minimal
clinically important difference for the DASH score is
between 10 and 12 points.26 References
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