Name:
Chronic Triceps Tear Reconstruction with Semitendinosus Graft+ Anconeus Muscle Medial Transposition
Description:
Chronic Triceps Tear Reconstruction with Semitendinosus Graft+ Anconeus Muscle Medial Transposition
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/9465984d-b723-4e6a-aea6-bbf96af00a53/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H12M32S
Embed URL:
https://stream.cadmore.media/player/9465984d-b723-4e6a-aea6-bbf96af00a53
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/9465984d-b723-4e6a-aea6-bbf96af00a53/CHRONIC TRICEPS TEAR RECONSTRUCTION WITH SEMITENDINOSUS GRAF.mp4?sv=2019-02-02&sr=c&sig=twINByqTtr%2BiDaobIvky7%2B2GIKU7TFK2dPddg%2FMJlG8%3D&st=2024-12-04T09%3A04%3A52Z&se=2024-12-04T11%3A09%3A52Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, from SHOULDERPLANET here from the city of São Paolo, Brazil. In this video, I'm presenting to you a very, very different and interesting case, about the surgical reconstruction of a chronic tear of the triceps tendon of the elbow, in a competitive athlete of the famous Brazilian jiu jitsu sport.
So this surgery was done in 2009, 11 years ago, in which we had to reconstruct the triceps tendon of that athlete, in a super chronic tear, in a degenerated tendon, with the semitendinosus graft, from the knee. I counted in this surgery with the tremendous help of this guy here, Dr. Jose Carlos Garcia, here from the city of São Paulo, very, very good shoulder and elbow surgeon,
who really did an outstanding job, helping me in this surgery, 11 years ago. He basically did the whole job. So I hope you like this video, I hope you understand the tips to do this unusual and very beautiful and quite complex procedure. And don't forget, subscribe. Don't forget to leave your thumbs up, leave your comment and let us see this beautiful video.
Triceps tendon rupture is quite uncommon problem, even in a shoulder & elbow surgeon's office, and this lesion is usually, if not always, related to the use of anabolic steroids. When these lesions become chronic, the surgical solution becomes much more difficult, and this is what this case is about. So this case is about a 29-year-old patient, very healthy one, who came to my office in March, 2009.
The patient was a chronic user of anabolic steroids in the last 10 years, and he used to go 5 times a week to the gym, to work out, as a bodybuilder. Also, he used it to play jiu jitsu as a competitive athlete. In the beginning of 2008 he started to feel pain in his left triceps tendon, when he was at the gym. And that pain started to grow progressively so that each week it was getting worse. In spite of that,
he didn't go to the doctor, to see what was happening with his elbow, and the patient continued to work out, five times a week. In September 2008, when he was working out, he heard, as he says, a big noise in the posterior aspect of his left elbow, Followed immediately by intense pain and strong edema. At that moment, his left tendon triceps had a rupture.
He went to an orthopedic doctor, the day after, at his hometown, with intense pain and swelling, in the posterior aspect of his elbow and, unfortunately, the doctor that was seeing him not only did not recognize that his left tendon was ruptured, but also performed an injection in his left triceps tendon. So with that injection, his pain got really better, very quickly,
and one week after the patient was back to the gym, with loss of strength in his left arm, but without pain in his left elbow. After two week, the pain came back again, and he went to the same doctor who, unfortunately, again gave him another injection in the left tendon of the triceps. He tried to come back to the gym at that moment, in the end of 2008, but he wasn't able to do that, do due to intense loss of strength, and four months after the initial injury,
so this patient came to my office. In his first appointment, I gave him the diagnosis of a chronic rupture of the left triceps tendon, and I advised him about immediate surgery. So this is a sagittal view of his left elbow MRI, done four months after the rupture, revealing a chronic tear of the left triceps tendon. In this photo, we can see the posterior aspect of his right elbow and arm, the normal one, revealing a quite strong patient.
And in this photo, we can see the posterior aspect of his left arm and elbow, the affected one, for months after the tendon rupture. Here we see the lateral clinical view of the right arm, showing, again, a quite strong man. And here we see the lateral view of the left arm, in which we can see a strong difference when compared to the unaffected arm. In this video, we can see his right arm and elbow, with obviously a normal active range of motion, since it was an affected arm, and we see his active motion in the affected arm,
four months after the tendon rupture. So, even being so strong, he couldn't extend his left elbow against gravity, due to the tendon rupture. In April 2009 the patient was operated by me, in supine position, since we would have to harvest graft from his left knee. So we harvested his Gracilis and semitendinosus tendon, and we created a very strong graft,
as we are seeing here, that would be used in the triceps tendon reconstruction. When when we opened his arm, we realized that his left tendon was absolutely gone, and that the muscular unit was importantly retracted, too. At that moment, the triceps muscular retraction seemed to have more than 10 centimeters. So, very gently, we isolated the triceps muscular unit, and we isolated the ulnar nerve,
also. We did not remove the nerve pulley, once we didn't want to anteriorize it. As a next step, we isolated the anconeus muscle, since we would perform an anconeus muscle transposition, becaus,e once transposed medially, anconeus can work as an elbow extensor. In this video, we can see that the triceps muscle unit, and that the anconeus muscle were very well isolated, and it was also the ulnar nerve.
Here we can see that the anconeus muscle could be easily medialized, with that muscle transposition. Then, using a 2.0 k-wire, we performed three holes in the olecranon, to very gently pass our graft, and here we can see the three holes. Also, in this photo, we can see that the anconeus muscle was absolutely ready for transposition.
We created, then, a new tendon, suturing the graft that was passed through the olecranon with the triceps muscle unit. At that moment, we realized that the construction was with more attention than we wanted, so we performed, also, and augmentation of the triceps using a V-Y advancement flap. In this photo, we can clearly see that we can clearly see how the muscle VY was performed.
It's important to say that this muscular dissection must be performed very gently, to avoid much muscular damage. Here we see the final construction, with the V-Y flap sutured, and with the anconeus already medially transposed. We used very strong number five Ethibond sutures, to create a very good and strong musculo-tendinous unit. And here, in this video, we can see how the final new muscle tendon unit was gently sliding over the distal humerus, in the very end of the surgery.
The V-Y flaps were sutured, and the construction was tension free, allowing good elbow flexion. The anconeus was medializing, using also one of the olecranon holes. So the patient used a sling for four weeks, after the surgery, and after that, he started his physical therapy very slowly, under medical supervision. In this photo, we can see the scar one month after the surgery, and, at that moment, the patient still had a reasonable amount of edema in the operated area.
Here in this video, we can see the patient four months after surgery, with a quite full active extension of his left elbow, against gravity. The patient was authorized, at that moment, to go back to the gym, and I strongly advised him not to use any more anabolic steroids. This is the clinical aspect of the patient one year after surgery. He was back at the gym, saying that his left arm was, in spite of the clinical deformity, as strong as the other one.
Here we see the lateral view of the right arm, the unaffected one, 01 year after the surgery, when he was going normally to the gym, and this is the lateral clinical aspect of the left arm, the operated one, also one year after the surgery. Here we see the posterior clinical view of the right arm, one year after the surgery, and here we see the lateral clinical view of the left arm, the operated one, 01 year after the surgery, too.
In spite of the residual clinical deformity, the patient was very satisfied with his surgery and went back to his sports activities. Thank you. So, my friends, I hope you liked this nice demonstration about how to do a reconstruction of a triceps tear, in such a difficult case. It's very important for us to understand that, in this case, the doctor that firstly see saw that patient,
he did a very big misconception in his mind, when, in spite of trying to analyze with an ultrasound or an MRI, that triceps had a rupture, as he had, he did an injection, and he repeated the same, I would say, not correct attitude, three weeks after, and this is one of the biggest reasons why this tendon was so degenerated. So I hope you like the video.
Please don't forget. Subscribe, leave your comment again, I thank this doctor, Dr. Jose Carlos Garcia, for the tremendous help he did in this case, and, as Dr. Sergio always says, never stop flying. See you folks in the next video. Bye
