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DOI: 10.1055/s-0044-1795075
Proximal Ulnar Reinsertion of the Triceps Brachii Tendon with a Synthetic Implant in a Dog with Nonreconstructible Olecranon Fracture
- Abstract
- Introduction
- Case Description
- Revision Surgery #1
- Revision Surgery #2
- Discussion
- References
Abstract
Objective Reporting the reinsertion of the triceps brachii onto the proximal ulna as a salvage procedure in a dog with nonreconstructible olecranon fracture.
Case Description A Labrador Retriever was presented with a comminuted olecranon fracture. Initial fracture stabilization was unsuccessful, resulting in implant failure and a nonreconstructible comminuted fracture, thus preventing triceps tendon reattachment. Revision surgery was performed after the implants and bone fragments were removed. A synthetic implant was sutured onto the triceps tendon and fixed on the proximal ulna by an interference screw (IS) in a bone tunnel. A transarticular Jean-Alphonse Meynard external fixator was applied for 3 weeks.
Results After 3 weeks, the dog had moderate lameness with a painless elbow. At 1.5 months, it had severe lameness with a painful elbow and mild osteoarthritis (OA). Nonsteroidal anti-inflammatory drugs were prescribed, and intensive physical therapy was initiated. Lameness improved at 2.5 and 3.5 months despite mild OA. At 9 months, the dog had mild lameness and a swelling of the elbow. Radiographs showed moderate OA and lucency around the IS. Bacteriologic examination was positive. The implants and infected tissues were removed, and antibiotics were prescribed for 1 month. At 18 months, the dog had mild lameness with no pain. At 33 months, it had intermittent mild lameness with no pain, yet severe OA.
Conclusion Triceps tendon re-insertion onto the proximal ulna yielded satisfactory long-term outcome in this dog with nonreconstructible olecranon fracture.
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Introduction
Isolated olecranon fracture is a rare debilitating elbow condition in small animals.[1] [2] The olecranon is the most proximal part of the ulna, composed of the olecranon tuberosity, the anconeal process, and the proximal part of the trochlear notch.[3] It acts as a lever arm to transmit forces from the triceps brachii muscle group, allowing elbow extension and weight-bearing in quadruped animals.[3]
Olecranon fractures are often comminuted, commonly involving the articular surface of the trochlear notch, and causing lameness and pain.[1] [2] The high tensile forces exerted by the triceps brachii muscles and frequent joint movements during locomotion make olecranon reconstruction challenging.[4] [5] Fracture reduction with stable fixation of the bone fragments is required to allow primary bone healing, to limit the development of posttraumatic osteoarthritis (OA), and to maximize functional forelimb recovery.[6]
Although tension band wiring (TBW) and plate osteosynthesis (PO) are the most common techniques for olecranon fracture repair,[1] [7] they have high complication rates influenced by the type of fracture (i.e., comminuted, open) and the proximity of the joint.[1] [2] When reconstruction is impossible, elbow arthrodesis can be performed.[8] [9] An alternative is to reinsert the triceps brachii tendon into the distal aspect of the proximal ulna using a synthetic implant fixed by tendinous sutures and an interference screw (IS), which has shown satisfactory functional clinical outcome up to 8 months postoperatively in one dog.[10]
This article reports the use of this technique as salvage procedure in a dog with nonreconstructible comminuted olecranon fracture after failure of initial fracture reconstruction, supported by a 33-month follow-up.
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Case Description
Clinical History and Orthopaedic Examination
A 6.5-year-old 30-kg intact female Labrador Retriever showed weight-bearing lameness graded 3/5[11] of the left forelimb with severe pain on elbow mobilization, after a trauma of unknown origin 3 days prior.
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Clinical and Diagnostic Imaging Examinations under General Anesthesia
Orthogonal radiographs (Toshiba APR-Vet, Japan; Rayence DR panel, Korea) of the left elbow showed a complex articular comminuted displaced bevel fracture of the olecranon involving the anconeal process with two large fragments measuring up to 2.5 cm and several small fragments. Radiographs also showed a mildly displaced fracture-avulsion of the lateral humeral epicondyle, with the two largest fragments measuring 3.6 and 7.6 mm ([Fig. 1A, B]). There was no lateral instability of the elbow compared with the contralateral forelimb when using the Campbell test to evaluate the degree of rotation of the forepaw in the mediolateral plane and when manipulating the elbow in varus and valgus while maintaining it in hyperextension. Computed tomography (Canon Aquilion Lightning, 80 slices, Japan) revealed an additional short oblique fracture of the olecranon and several small bone fragments measuring up to 8.5 mm, arising from the olecranon and anconeal process, and several fragments measuring around 1 mm arising from the lateral humeral epicondyle ([Fig. 1C]). Surgical anatomical stabilization of the olecranon fracture and conservative treatment of the lateral humeral epicondyle fracture were performed.
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Premedication Protocol
For all surgeries, analgesia consisted in morphine chlorhydrate (Lavoisier; 0.3 mg/kg) and diazepam (Diazedor, Axience; 0.2 mg/kg) administered intravenously (IV). Antibiotic prophylaxis (Cefazoline, Panpharma, 22 mg/kg IV) was administered 30 minutes before skin incision and every 2 hours thereafter until surgery was completed.
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Initial Surgery
Under general anesthesia, the dog was positioned in right lateral recumbency with the left forelimb suspended by adhesive tape to a stirrup and an infusion stand. A 10-cm caudolateral approach to the elbow was performed. The fracture was reduced and stabilized with two 2.7 × 18 mm compression screws (AdVetis, France) at the level of the main fracture, associated with two bicortical 1.8-mm-diameter oblique K-wires (Génia, France) and a 1-mm-diameter cerclage K-wire (Génia, France). The two oblique K-wires were inserted into the proximal bone fragment and perpendicular to the bevel fracture, then through the distal fragment, and exited at the level of the lateral part of the proximal ulna. The caudal and caudolateral parts of the joint were explored, allowing the removal of non-refixable part of the anconeal process and small intra-articular bone fragments. The joint was rinsed abundantly. A partial 1-cm tricipital tendon tear located 2 cm proximally to the olecranon was sutured with two locking-loop suture patterns using 2–0 polydioxanone (PDS, Ethicon). The brachial and antebrachial fascia, subcutaneous tissue, and skin were sutured using 2–0 polysorb (Polysorb, Covidien) and 3–0 polyamide 6 (Ethilon, Ethicon) respectively, using a simple continuous suture pattern. Immediate postoperative examination showed normal elbow range of motion in flexion, extension, pronation, and supination without crepitus. The tricipital tendon had a good tension and showed continuity with the olecranon when the elbow was flexed. Radiographs confirmed fracture reduction, with good implant positioning and bone alignment ([Fig. 2]).
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Postoperative Management
The dog received morphine chlorhydrate (Lavoisier; 0.1–0.3 mg/kg) every 6 hours for 1 day. It was discharged the next day with 10 days of cefalexin (Cefaseptin, Vétoquinol; 15 mg/kg b.i.d.), as a precaution to anticipate the consequences of a suspected preoperative asepsis lack, and 1 week of nonsteroidal anti-inflammatory drugs (NSAIDs; cimicoxib, Cimalgex, Vétoquinol; 2 mg/kg s.i.d.). Discharge instruction consisted in restricted activity for two months. A custom lateral Spica splint made with aluminum bars and cotton dressing was applied for eight weeks to maintain the elbow in extension with bandage change every 15 days.
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Follow-up
The dog returned 15 days later with a broken splint after having run away. Radiographs showed loose implants and new comminuted olecranon fractures, including fractures of the previously repaired fragments. The presence of numerous small bone fragments prevented reconstruction without high risk of complication ([Fig. 3]). The lateral humeral epicondyle bone fragments were stable. Revision surgery was scheduled four days later to reinsert the triceps tendon onto the distal aspect of the proximal ulna.
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Revision Surgery #1
The implants and bone fragments were removed. The end of the triceps tendon was separated from bone fragments. An oblique bone tunnel was drilled through the remnant of the proximal part of the olecranon with a caudodistal exit. Tunnel positioning was secured with a 2-mm K-wire. It was then drilled using a 3.6-mm cannulated drill bit (Arthrex, France). Sufficient cranial and caudal bone margins were preserved to avoid fractures. A transverse bone tunnel was drilled orthogonally 7.5 mm distally from the first one, from the lateral to the medial side of the olecranon with a 3.6-mm cannulated drill bit (Arthrex, France) mounted on a 2-mm K-wire that secured its positioning. The tunnels were flushed to remove bone debris. The transverse tunnel was tapped. The half caudal thickness of the triceps tendon was longitudinally incised up to the musculotendinous junction. An ultra-high molecular weight polyethylene (UHMWPE) implant (Novalig 8000, Novetech Surgery, France) was sandwiched inside the tendon incision with eight simple interrupted sutures of 2–0 polyamide 6 (Ethilon, Ethicon), spaced 5 mm apart. The implant was inserted proximally to distally into the first tunnel and laterally to medially into the second one, using a passing tube (Novetech Surgery, France). The elbow was placed in extension with a stretched tendon in contact with the bone. Tension was applied by pulling the implant with a Kocher clamp placed 2 cm from the tunnel exit to avoid implant damage. Tension was adjusted and maintained with the Kocher clamp to avoid bending overload. Fixation was achieved by inserting a 5 × 15-mm titanium IS (Novetech Surgery, France) in the transverse tunnel from lateral to medial. Abundant rinsing was performed. Soft tissues and skin were routinely closed. A transarticular Jean-Alphonse Meynard external fixator (Génia, France), composed of four 3-mm transfixing end-threaded pins (two placed in the humerus and two in the radius on the lateral aspect) connected by two curved 4-mm bars and clamps, was placed to maintain mild elbow hyperextension and prevent excessive tensions exerted on the implant and sutures. Only two curved bars, one on each side of the joint, were used to limit excessive stiffness of the support. Radiographs confirmed the good positioning of the bone tunnels, IS and external fixator ([Fig. 4]).
Postoperative Management
The dog was discharged with amoxicillin–clavulanic acid antibiotics (Clavaseptin, Vétoquinol; 12.5 mg/kg twice daily [b.i.d.]) for 10 days and NSAIDs (cimicoxib, Cimalgex, Vétoquinol; 2 mg/kg once daily [s.i.d.]) for 5 days. A bumper bandage was applied. Cleaning of the fixation element/skin interface with povidone-iodine solution and application of an antiseptic gel (Betadine 10% gel, Mylan) were performed once to twice a week. The flanges of the external fixator were loosened every week to slightly and progressively mobilize the elbow. Discharge instructions included restricted activity for 2 months and maintaining the external fixator for 3 weeks.
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Long-Term Follow-Up
Upon removal of the external fixator at 3 weeks postoperative, the dog showed 2/5 lameness and a painless elbow with reduced range of motion when compared with the contralateral limb. Physical therapy was initiated just after fixator removal. It included land-based exercise therapy (weight-bearing transfer proprioceptive exercises) and hydrotherapy in a specialized rehabilitation center.
After 1.5 months, the dog had 3/5 lameness. Elbow manipulation caused moderate pain, especially in hyperextension. The triceps was attached to the proximal ulna. Radiographs showed stable implant positioning and development of mild OA ([Fig. 5A, F]). A synovial tap yielded hemorrhagic, low-viscosity fluid. NSAIDs (cimicoxib, Cimalgex, Vétoquinol; 2 mg/kg s.i.d.) were prescribed for 4 weeks. An infection was suspected. Microbial cultures with enrichment under aerobic conditions were performed and amoxicillin–clavulanic acid antibiotics (Clavaseptin, Vétoquinol; 12.5 mg/kg b.i.d.) were prescribed for 1 week as precaution. Antibiotics were stopped after having received negative results from 48-hour cultures, indicating absence of aerobic germs. Intensive physical therapy was initiated, including myofunctional therapy massages, home physical therapy exercises (weight-bearing transfer proprioceptive exercises) twice a day and underwater treadmill hydrotherapy twice a week. At 2.5 months, lameness had improved to 2/5 and was stable at 3.5 months. Radiographs at 2.5 and 3.5 months showed no significant changes, except a mild increase in OA ([Fig. 5B, C, G, H]). Three bedinvetmab injections (Librela 15 mg, Zoetis) were administered 1 month apart and resulted in improved lameness (1/5) and comfort.
At 9 months, the dog showed 2/5 lameness and a swollen elbow with a subcutaneous fistula. Radiography revealed moderate progression of OA and a wide lucent halo surrounding the IS, consistent with osteomyelitis ([Fig. 5D, I]). Revision surgery was scheduled 3 days later to remove the implants.
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Revision Surgery #2
The IS and UHMWPE implant were removed and infected tissues were resected. The joint capsule was not open. Microbiological samples were taken from both implant and tissues and processed for bacteriological examination. The triceps tendon was sutured with 3–0 PDS II (Ethicon) using a simple continuous suture pattern. The surgical site was rinsed abundantly. Soft tissues and skin were closed routinely.
Postoperative Management
A passive drain (Latex Penrose Tubing, Fioniavet) was applied at the surgical site and outside of the joint capsule to limit risk of infection before obtaining bacteriological results. Daily bandage replacement and disinfection of the exit sites with povidone-iodine solution were performed. The drain was removed 4 days later, upon reception of the bacteriological results and in the absence of flow. Microbial aerobic cultures with enrichment were positive after 24 hours. Staphylococcus intermedius sensitive to amoxicillin-clavulanic acid was isolated. As the infection seemed associated with the presence of implants, amoxicillin–clavulanic acid antibiotics (Clavaseptin, Vétoquinol; 12.5 mg/kg b.i.d.) were administered for 1 month. NSAIDs (cimicoxib, Cimalgex, Vétoquinol; 2 mg/kg s.i.d.) were prescribed for 5 days. Activity restriction was advised for 3 weeks.
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Long-Term Follow-Up
Eighteen months after tricipital reinsertion, the dog showed 1/5 lameness with painless elbow manipulation. At 33 postoperative months, the dog had an intermittent 1/5 lameness with no pain. The elbow range of motion was mildly reduced compared with the contralateral limb. Radiographs showed severe OA ([Fig. 5E, J]). Bedinvetmab injections (Librela 15 mg, Zoetis) were administered once to twice a year depending on the dog's lameness and discomfort.
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Discussion
The distal reinsertion of the triceps brachii tendon using a UHMWPE implant in a case of nonreconstructible comminuted olecranon fracture resulted in a satisfactory long-term functional clinical outcome, in light of the severity of the impairment: mild lameness, mild reduction of elbow range of motion, absence of pain, yet severe OA.
Reconstruction of comminuted articular fractures is challenging. Anatomical reduction and internal fixation with TBW or PO are commonly used to treat olecranon fractures.[1] PO showed fewer postoperative complications, including failure, than TBW (21 and 48%, respectively).[1] However, the large lateroproximal-mediodistal bevel fracture with a small and thin medial fragment, and the comminuted nature and very proximal location of the fracture prevented the use of a plate or orthogonal plating and increased the risks of complications. Placing a screw or a lateral plate with a single screw in the proximal fragment would have made nonfeasible to place another orthogonal caudal plate due to the presence of the first screw in the very thin medial olecranon fragment. A combination of screws, pins, and a TBW method with a Spica splint was used as comminution did not affect the area where the screws and pins were placed. However, the reconstruction failed 15 days later, after the dog ran away.
Conventional pin positioning to treat olecranon fracture with a proximocranial-distocaudal bevel consists in longer pins inserted caudally at the level of the olecranon tuberosity toward the cranial part of the proximal ulna.[1] Due to the atypical bevel of the fracture in this case, positioning the pins in this axis would not have allowed the fracture site to be compressed. Compression of the fracture site with two screws inserted from lateral to medial was preferred. The presence of these screws did not allow conventional pin positioning.
The two compression screws may have provided better rigidity to the reconstruction if placed from medial to lateral due to the largest thickness of the lateral fragment which would have allowed a more important screw anchoring. However, the risk of fracturing the medial fragment would have been increased because of its small size and thickness, especially when making 2.7-mm diameter sliding holes. The choice of performing a lateromedial insertion was reinforced by the limited accessibility due to the caudolateral approach used and the presence of forceps to maintain fracture reduction. The lateromedial insertion performed may have contributed to failure of the reconstruction.
The cerclage wire aiming to support the reconstruction was not strongly tightened since it could not be placed in the axis of compression of the fracture site due to the significant bevel. In the absence of significant compression of the fracture site by the cerclage wire, an eight shape[1] was not performed, as this might have not increased the rigidity of the assembly. Regarding postoperative immobilization, an external fixator would have provided better immobilization than a Spica splint.
Fracture reconstruction was prevented by the appearance of new small bone fragments. This led to the absence of the proximal part of the olecranon as well as most of the anconeal process. The latter acts as primary and secondary stabilizers when the elbow is in pronation and supination, respectively.[12] Its absence was expected to worsen OA, owing to persistent joint incongruity and elbow instability.[13] The reinsertion of the triceps tendon onto the distal aspect of the proximal ulna was decided despite this expected outcome. It was considered preferable to elbow arthrodesis, as it made it possible to preserve joint mobility and limited complications.[8] [9] Other possible causes may explain the severe OA observed. As no elbow instability was observed preoperatively, the mildly displaced lateral humeral epicondylar fracture was treated using conservative treatment. This choice was made since the fracture was composed of several small bone fragments and two very thin larger fragments, which made fixation of bone fragments uncertain. Perhaps, the absence of surgical repair may have participated in worsening OA.
Infection may also have contributed to worsen OA. An infection was detected at 9 months post-tricipital reinsertion. At this time, OA had moderately progressed since the previous control at 3.5 months when OA progression was mild. After implant removal and antibiotic therapy, no signs of infection, either general or local, nor elbow effusion were observed until the end of the follow-up at 33 months postoperatively. Discomfort caused by severe OA was managed using medication. A joint tap between 9 and 33 months postoperatively would have allowed to confirm the absence of infection or local immune reaction.
Various techniques have been described to reinsert the triceps tendon onto an intact olecranon. They include modified three-loop pulley nylon sutures in the tendon fixed onto the olecranon through a bone tunnel,[14] [15] [16] two horizontal mattress polyester sutures in the tendon with two bone tunnels,[17] Krackow suture technique through bone tunnels,[18] the use of synthetic mesh graft[19] or autograft augmentation,[20] and the use of FiberLoop implants.[21] A combination of modified three-loop pulley sutures, locking loop sutures, and synthetic mesh augmentation with Krakow sutures has been described to reinsert the triceps tendon onto an olecranon after comminuted fracture resulting from failure of initial reconstruction of olecranon avulsion.[22] Surgeries were completed with either a splint, a cast, a Robert Jones bandage, or an external fixator.[14] [15] [16] [18] [20] [22]
Although 3-loop and 4-loop pulley patterns provide the highest tensile strength for tendon reapposition,[23] [24] [25] sutures do not mechanically resist gap formation,[23] [24] [25] even when augmented by synthetic meshes.[26] The use of a UHMWPE implant fixed by tendinous sutures and an IS placed in a bone tunnel on the calcaneum provided superior stiffness and strength than suture techniques when tested ex vivo.[27] Fixation with an IS avoided the use of knots[21] that may slip with UHMWPE.[28] The transverse tunnel created a counter-support that facilitated implant tensioning and IS implantation.[10] [27] This method was chosen for its stiffness[27] and previous successful clinical re-apposition of triceps tendon after an avulsion fracture.[10] In the present case, it resulted in a stable triceps brachii tendon re-apposition over the whole follow-up.
Immobilization with a splint was successful in limiting the mechanical constraints and promoting healing after surgical triceps tendon reinsertion with this implant.[10] However, owing to the failure of the Spica splint immobilization after the initial reconstruction, the use of an external fixator was decided.
Implants in UHMWPE have excellent biocompatibility.[29] The implant was well supported with no signs of reaction from the dog. The braiding provides superior mechanical[30] and biological properties compared with free fibers.[31] However, as the open pores facilitate cell migration,[31] braided implants may be associated with increased postoperative infectious risks in the event of contact with the biofilm.[32] Careful asepsis and precautions, like not placing the implant in an infected area or in an open wound, must be ensured during surgery. The use of an antimicrobial incisional drape would help to reduce the infectious risk further.
A long-term infection was detected at 9 months postoperatively. It is always difficult to determine the cause of an infection that manifests clinically several months after surgery (i.e., subclinical preoperative infection that becomes clinical or distant postoperative infection which contaminates an inflammatory site). No distant infection has been reported in the dog. The infection was resolved after implant removal and antibiotic treatment. The implant had allowed sufficient tendon healing, which remained functional after implant removal.
Used as salvage procedure, this technique allowed the robust distal reinsertion of the triceps brachii tendon onto the distal aspect of the proximal ulna, leading to the satisfactory long-term recovery of limb function. This technique could be considered to treat complex tendon re-apposition and avoid elbow arthrodesis.
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Conflict of Interest
B.G. and A.C. are employed by Novetech Surgery. The authors declare no additional conflicts of interest.
Acknowledgments
The authors thank Florence Thierry, DVM, ECVDI for the analysis of medical imaging. The authors also thank Emilie Cooke-Martageix for copyediting.
Author Contributions
N.E., DVM, and D.J., DVM, ECVS, examined the patient, diagnosed the pathology, performed surgeries, performed follow-up visits, analyzed data, and wrote and revised the manuscript. E.E., DVM, ECVDI resident, analyzed medical images and wrote and revised the manuscript. B.G., PhD, and A.C., PhD, analyzed data and wrote and revised the manuscript.
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References
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Address for correspondence
Publication History
Received: 13 June 2024
Accepted: 16 September 2024
Article published online:
19 November 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
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