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Abstract

The following case presentation involves treatment of a ruptured distal triceps tendon with this human ADM, DermACELL®.

Introduction

Distal triceps tendon ruptures can cause long-term disability for the patient which can be further complicated by difficulties for the surgeon in developing a diagnosis as well as determining the severity of the injury [1,2]. Distal triceps tendon ruptures are often caused from a fall onto an outstretched hand or trauma to the posterior of the arm, with pulling or tearing at the osseous tendon insertion [1,3]. Other studies report intramuscular injury or injury at the myotendinous junction as another possible cause of the rupture [1,3]. Treatment of these ruptures typically includes surgery to reattach the ruptured triceps tendon to the olecranon of the elbow [4]. This is commonly achieved with the use of sutures that are passed through tunnels in the olecranon [4]. Surgeons often augment the tendon with an allograft in patients with chronic tears or undergoing revision surgery [5].

An alternative treatment for ruptured distal triceps tendon is a matrix scaffold for new tissue generation, an acellular human dermal matrix (ADM) allograft as reviewed by Wainwright and Bury [6]. Decellularized human skin has been used for a variety of medical procedures, primarily involving wound healing, soft tissue reconstruction, and sports medicine applications [7-10].

Case study

Patient

• 42 year old, Male.

Diagnosis

• Failed repair of total full-thickness laceration of the distal tendon of the triceps. (Figure 1)
• Original failed repair had been attempted 3 months earlier.

Figure 1. Full-thickness laceration of the distal tendon of the triceps.

Treatment

• The scar tissue was resected with a resulting 6 cm gap between the tendon stumps.
• Two core sutures (Ethibond 2, Ethicon, Somerville, NJ, USA) were placed at both sides of the tendon. (Figure 2)
• One trimmed piece of 6cm x 6cm non-meshed DermACELL (LifeNet Health, Virginia Beach, VA, USA) was weaved through the tendon mid-structure for augmentation and a second custom fit piece of 6cm x 6cm non-meshed DermACELL was laid over the repair site. (Figures 3 and 4)
• A small incision was made to let the exudate drain.
• Elbow was splinted in 90° flexion for 3 weeks and progressive flexion was allowed to achieve full flexion in the following 3 weeks. (Figure 5)

Figure 2. Core sutures were placed at both sides of the tendon.

Figure 3. DermACELL was weaved through the tendon mid-structure.

Figure 4. A second custom fit piece of DermACELL was laid over the repair site.

.

Figure 5. 3 month MRI demonstrates intact distal triceps brachialis tendon.

Outcome

• Postoperative course was uneventful except for a prolonged swelling over olecranon bursa, healed spontaneously after 3 weeks
• By 6 months post-op, the patient regained 87% ROM and 70% strength

References

1. van Riet RP, Morrey BF, Ho E, O’Driscoll SW (2003) Surgical treatment of distal triceps ruptures. J Bone Joint Surg Am 85A:1961-1967. [Crossref]
2. Rajasekhar C, Kakarlapudi TK, Bhamra MS (2002) Avulsion of the triceps tendon. Emerg Med J  19: 271-272.
3. Sollender JL, Rayan GM, Barden GA (1998) Triceps tendon rupture in weight lifters. J Shoulder Elbow Surg 7: 151-153. [Crossref]
4. Bava ED, Barber FA, Lunc ER (2012) Clinical outcome after suture anchor repair for complete traumatic rupture of the distal triceps tendon. Arthroscopy 28: 1058-1063. [Crossref]
5. Vidal AR, Allen A (2004) Biceps tendon and triceps tendon injuries. Clin Sports Med 23: 707-722. [Crossref]
6. Wainwright DJ, Bury SB (2011) Acellular Dermal Matrix in the Management of the Burn Patient. Aesthet Surg J 31: 13S-23S.
7. Wong I, Burns J, Snyder S (2010) Arthroscopic GraftJacket Repair of Rotator Cuff Tears.  J Shoulder Elbow Surg 19: 104-109. [Crossref]
8. Wilkins R (2010) Acellular Dermal G2021 Copyright OAT. All rights reservn Rupture Repair. Curr Orthop Pract 21: 315-319
9. Lee, Daniel (2007) Achilles Tendon Repair with Acellular Tissue Graft Augmentation in Neglected Ruptures. J Foot Ankle Surg 46: 451-455. [Crossref]
10. Sbitany H, Sandeen S, Amalfi A, Davenport M, Langstein H (2009) Acellular Dermis-Assisted Prosthetic Breast Reconstruction versus Complete Submuscular Coverage: A Head-to-Head Comparison of Outcomes. Plast Reconstr Surg 124: 1735-1740. [Crossref]