Should the triceps be released during total elbow arthroplasty?
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Triceps tongue approach is ideal
A posterior approach is indicated for both open reduction and internal fixation and total elbow arthroplasty, with multiple approaches described for navigating around the extensor mechanism.
For total elbow arthroplasty, triceps options include the reflect, para-tricipital, split or tongue approach. The ideal approach provides adequate exposure enabling optimal placement of implants while minimizing soft-tissue disruption, additional injuries and complications. While dividing the triceps is seemingly risky, it is the ideal approach for total elbow arthroplasty.
The least invasive approach is the para-tricipital approach, in which medial and lateral windows are developed with triceps retraction in either direction and the triceps insertion on the olecranon is left intact. Maintaining the triceps insertion is ideal as it may reduce the risk of triceps avulsion or insufficiency. This is adequate in distal humeral fracture conversion to a total elbow arthroplasty, but for elective cases, coupling of the implant and soft tissue balancing are challenging. The triceps-reflecting anconeus pedicle approach was popularized at the Mayo Clinic and gave excellent exposure but is plagued by triceps insertional complications causing weakness.
The triceps fascial tongue approach was originally described in 1940 by George W. Van Gorder, MD, for T-type distal humeral fractures. While mostly forgotten, the technique was reintroduced in 2015 and confirmed in 2018 as an approach for total elbow arthroplasty, and, more recently. In 2019 and 2022, the technique was used for intra-articular ulnar distal humeral fractures. In this approach, a distally based triceps fascial tongue flap is elevated off the muscle while leaving a distally intact cuff of tendon attached to the olecranon for later repair. The triceps tongue approach provides excellent visualization of the articular surface and metadiaphyseal region of the distal humerus and the proximal ulna. Importantly, this approach is extensile and continued triceps split proximally exposes most of the shaft and, distally, the ulna can be fully exposed.
Despite concern for extensor mechanism weakness or insufficiency with the triceps fascial tongue approach, this has not been realized in multiple studies. When directly assessed in a series of total elbow arthroplasties performed for arthritis, triceps strength was significantly improved compared with preoperative measures, and no cases of postoperative triceps weakness were encountered.
- References:
- Celli A, et al. J Bone Joint Surg Am. 2005;doi:10.2106/JBJS.D.02423.
- Fei TT, et al. JSES Int. 2019;doi:10.1016/j.jses.2019.10.107.
- Marinello PG, et al. Tech Hand Up Extrem Surg. 2015;doi:10.1097/BTH.0000000000000079.
- Na KT, et al. J Shoulder Elbow Surg. 2018;doi:10.1016/j.jse.2018.01.005.
- Van Gorder GW, et al. J Bone Joint Surg Am. 1940; 22 (2): 278.
- Voloshin I, et al. J Shoulder Elbow Surg. 2011;doi:10.1016/j.jse.2010.08.026.
- Weber MB, et al. J Shoulder Elbow Surg. 2022;doi:10.1016/j.jse.2022.01.128.
Peter J. Evans, MD, PhD, FRCSC, FAAOS, is the division chair of orthopedic surgery, rehabilitation and sports therapy at Cleveland Clinic Florida.
Preserve the triceps
Treatment of the triceps is a critical part of prosthetic or interpositional elbow arthroplasty. Triceps failure has been reported in more than 30% of cases performed with “triceps-off” techniques.
Prosthetic total elbow arthroplasty is a technically challenging surgery. The outcome is related to, in part, correct placement of the components to maximize the fidelity to the normal elbow mechanics. The challenge is that the surgical exposure is technically difficult. Adequate exposure to implant the prosthesis, particularly the ulnar component, is difficult.
The evolution of the best surgical approach continues to this day, without a totally satisfactory solution. Early exposures involved releasing, and subsequently repairing, the triceps, but have a failure rate of more than 30% even in the hands of experienced elbow surgeons. Triceps-preserving (triceps-on) approaches are more challenging and, even when correctly performed, proper component placement is difficult.
Furthermore, triceps failure is associated with poorer outcomes and inadequate soft tissue coverage that can increase the incidence of infection, a devastating complication. Also, outcomes of triceps repair are discouraging and may require the use of allograft materials and heavy, non-absorbable sutures that predispose to healing and infectious complications. In short, work continues on the optimal approach, but it will almost certainly involve protection and preservation of the triceps.
- References:
- Baik JS, et al. Clin Shoulder Elb. 2020;doi:10.5397/cise.2020.00052.
- Barco R, et al. J Bone Joint Surg Am. 2017;doi:10.2106/JBJS.16.01222.
- Borton H, et al. J Shoulder Elbow Surg. 2021;doi:10.1016/j.jse.2020.12.007.
- Celli A, et al. J Bone Joint Surg Am. 2005;doi:10.2106/JBJS.D.02423.
- Duquin TR, et al. Bone Joint J. 2014;doi:10.1302/0301-620X.96B1.31127.
- Morrey BF, et al. Clin Orthop Relat Res. 1982; Oct:(170):204-12.
- Morrey BF, et al. J Bone Joint Surg Am. 1981; Sep;63(7):1050-63.
- Pierce TD, et al. Clin Orthop Relat Res. 1998;doi:10.1097/00003086-199809000-00017.
- Prki A, et al. J Shoulder Elb. 2019;doi:10.1016/j.jse.2019.02.029.
Michael R. Hausman, MD, is the Lippman Professor of orthopedic surgery and chief of upper extremity surgery at Mount Sinai Health System.
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