Skip to main content

V-shaped double-row distal triceps tendon repair: a novel technique using unicortical button fixation



This report was designed to present a novel technique combining suture anchor and unicortical button fixation for distal triceps tendon repair.

Technical description

For anatomical reinsertion of an acute distal triceps tendon rupture, two suture anchors and one unicortical button forming a V-shaped configuration were used. The operative approach is described in detail.


Excellent clinical and functional results were achieved in the early postoperative phase. The patient reached full elbow range of motion and extension muscle strength (5/5) compared to the uninjured arm 12 weeks after surgery. Complications did not occur.


This is the first report using unicortical button fixation in distal triceps tendon repair with promising preliminary results.

Level of evidence

Technical description, case report, Level V


The distal triceps tendon rupture is a rare entity [13]. Anzel et al. published a series of 1014 cases of tendon and muscle disruption. Only 1% of them involved the distal triceps tendon [4]. The mechanism of injury is mainly a fall on the outstretched forearm or contraction against resistance (weightlifting) [5, 6]. Triceps tendon ruptures are furthermore associated with systemic diseases (e.g. hyperparathyroidism), corticosteroid use and anabolic steroid abuse [7, 8]. Especially men and professional American football players are at increased risk to suffer distal triceps tendon tears [6]. Anatomic studies have shown that total and/or partial tendon tears mostly occur at the bone–tendon interface on the olecranon insertion site, and also musculotendinous and intramuscular tears have been described [912].

For anatomic reconstruction of distal triceps tendon ruptures, a standard surgical technique has not yet been established. In the transosseous cruciate repair technique, Krakow-type sutures placed in the tendon are passed through two crossing bone tunnels and tied over a bone bridge. However, this procedure has shown a high re-rupture rate of up to 21% [13].

The purpose of currently published techniques is the anatomic reinsertion at the bony footprint of the olecranon with restored tendon–surface contact [14]. Learning from the progress of arthroscopic tendon repair at the shoulder joint, Yeh et al. reported of a suture anchor repair for distal triceps ruptures [15]. The authors compared this single- and double-row suture anchor repair technique with the transosseous cruciate repair technique. They could demonstrate that the anatomic repair with a suture bridge consisting of four anchors provides superior footprint contact characteristics and lowest displacement during increased cyclic loading compared to single-row repair and transosseous cruciate repair [15]. In 2014, Clark et al. reported on a new knotless anatomic repair technique to minimise the risk of intra-articular joint breach, knot failure, as well as bursal and subcutaneous irritation. Two bone tunnels and one knotless anchor were used. This technique showed significantly higher load and cycle to failure compared to the traditional transosseous cruciate repair [16, 17].

In the present article, we describe a novel technique for anatomic footprint repair in case of distal triceps tendon ruptures using two suture anchors and one intramedullary placed button in a V-shaped double-row configuration.

Case presentation and technical description

We report on the case of a 30-year-old male patient with an acute distal triceps tendon rupture after a snowboarding accident. The patient described a fall onto the extended forearm followed by immediate pain and weakness upon extension of the elbow. Clinical evaluation showed an inability to extend the elbow against resistance. Radiographs of the elbow (ap- and lateral-view) excluded osseous lesion. Subsequent magnetic resonance imaging (MRI) confirmed the diagnosis of a total rupture of the triceps tendon with 15 mm of retraction.

For surgery (14 days after injury), the patient was positioned in the prone position. A standard posterior approach was used for exposure of the distal triceps tendon rupture. The tendon was mobilised and debrided at the rupture site. Then, the footprint at the olecranon was identified and the bone bed debrided. Two 5.5-mm double-loaded titanium suture anchors (5.5 Corkscrew FT, Arthrex Inc., Naples, FL, USA) were placed at the proximal area of the footprint, one medial and one lateral. A Krakow whipstitch was performed at the distal triceps tendon with both ends of each Fiberwire®. In the following, the sutures were tied. Subsequently, one end of each suture was cut.

In the next step, the V-shaped double-row fixation was performed using the unicortical button fixation technique analogous to the previously described distal biceps tendon repair [18]. Four centimetre distal to the distal footprint line, a 3.2-mm drill-hole was centrally drilled into the posterior cortex of the ulna at an angle of 45° (with proximal direction) related to the ulnar shaft. The cancellous bone within the intramedullary canal was then compressed using a small clamp to create space for the BicepsButton™ (Bicepsbutton, Arthrex Inc., Naples, FL, USA) implantation. Next, the button was loaded with all four FibreWire sutures (in reversed fashion), passed through the posterior cortex and flipped intramedullary (Fig. 1). Due to this V-shaped suture configuration, the distal tendon stump was planar pressed to its insertion. Each suture was strongly tightened after flipping the button to compress cancellous bone at the intramedullary canal. Like a pulley system principle, the tension onto the reconstructed distal triceps tendon footprint could then be modified for optimal tendon–bone pressure before knotting. The elbow was finally moved with full range of motion (ROM) conditioning the construct. If necessary, the V-shaped pulley system could have been retightened. Skin closure was performed in a standard manner. The detailed operative approach is demonstrated in Fig. 2.

Fig. 1
figure 1

Intraoperative situs of the V-shaped technique: the unicortical fixation using a BicepsButton™ provides a planar contact pressure of the triceps tendon

Fig. 2
figure 2

Cadavaric demonstration of the double-row V-shaped triceps repair. a Following debridement, pilot holes for two 5.5-mm suture anchors are created at the proximal border of the footprint. b Krakow whipstich sutures placed along the medial, lateral and central part of the triceps tendon. c 4 cm distal to the footprint line, a monocortical 3.2-mm drill-hole is placed in an angle of 45° in proximal direction to the ulnar shaft. d Result following knot tying creating a proximal row repair, subsequently one end of each suture is cut. e Loaded BicepsButton™. Before it is passed through the posterior cortex, the cancellous bone within the intramedullary canal should be compressed using a small clamp

For postoperative management, the elbow was immobilised in a posterior splint (90° of elbow flexion) for 5 days. Subsequently, a mobile, hinged brace (Epico ROM, medi, Bayreuth, Germany) was applied for 6 weeks, limiting elbow flexion to 90°. Passive and active (gravity-assisted) motion was started at day 1 after surgery with restriction of active extension for 6 weeks. Sports activities were allowed after 12 weeks.

The patient was very satisfied and would undergo the same surgical procedure again. Follow-up examinations after 12 weeks showed full elbow range of motion (flexion/extension 130°–0°–0°) (Fig. 3). Comparable strength of elbow extension (muscle strength 5/5 according to Janda scale [19]) was measured in relation to the contralateral site at 12-week follow-up. Postoperative radiographs showed no implant displacement (Fig. 4).

Fig. 3
figure 3

Full active ROM 12 weeks postoperatively

Fig. 4
figure 4

Postoperative radiograph showing the intramedullary cortical button

Discussion and conclusions

The novel technique of double-row distal triceps tendon repair performing a V-configuration by unicortical button fixation showed an excellent functional outcome in the present case. To the best of our knowledge, this is the first report dealing with unicortical button fixation in triceps tendon repair.

The biomechanical benefits of complete anatomical footprint coverage with double-row repair technique have already been demonstrated in multiple studies for rotator cuff repair [2026].

Kim et al. showed superior results in strength, stiffness and gap formation using the double-row technique. Mazzocca et al. found equivalent results for load-to-failure, cyclic loading and gap formation for the single-row technique compared to the double-row repair. However, a larger area of the footprint was restored using the double-row technique [27, 28]. These biomechanical findings were now transferred to distal triceps tendon repair [15].

The V-shaped double-row repair technique combines the outclassing properties of an anatomical footprint coverage and technical advantage of using a single fixation distal to the joint. The unicortical button fixation enables a modification in tendon contact pressure by tightening or loosening the sutures, once the fixation system has been installed. This represents a technical key benefit compared to the suture bridge repair or the knotless anatomic repair. Similar to already-described techniques, an accelerated rehabilitation program is practicable due to double-row repair. Titanium suture anchors were used in the present case; however, bio-absorbable suture anchors would be a potential alternative for proximal row fixation.

Siebenlist et al. established “the intramedullary cortical button fixation technique” for distal biceps tendon repair [18, 29]. They have shown that biomechanical characteristics for this repair technique are comparable or superior to suture anchor repair and bicortical button fixation, respectively [18, 30]. Buchholz et al. also found no major differences between monocortical button fixation versus interference screw for subpectoral proximal biceps tenodesis [31]. However, it has to be clearly stated that no biomechanical studies exist for unicortical button fixation in distal triceps tendon repair.

The main advantages of the present fixation technique are the reduced risk of iatrogenic fractures at the proximal ulna due to monocortical drilling, a simple implantation and lower implant costs compared to double-row anchor systems (two anchors and one button instead of four anchors) [16, 17]. However, transosseous techniques have the favourable costs. Additionally, this technique facilitates a complete footprint coverage with a flat contact pressure to possibly favour tendon-to-bone healing. The preliminary excellent functional results in the present case are encouraging to continue using the V-shaped double-row repair technique for triceps tendon ruptures. Nevertheless, the present report has a limited clinical follow-up of 3 months what is too short to compare this technique to others. Therefore, further follow-up evaluation including objective strength measurements and MRI controls is mandatory.

The V-shaped double-row fixation represents a novel, alternative technique for treatment of distal triceps tendon ruptures with promising preliminary clinical results. Compared to previous published reconstruction methods, the advantage of this technique is the possible modification in tendon footprint coverage once the fixation system has been installed. Furthermore, the iatrogenic fracture risk can be reduced by monocortical drilling. However, additional studies are needed to evaluate the long-term efficacy of this surgical procedure.





magnetic resonance imaging


range of motion


  1. Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. J Hand Surg Am. 2009;34:566–76.

    Article  PubMed  Google Scholar 

  2. Holleb PD, Bach BR Jr. Triceps brachii injuries. Sports Med. 1990;10:273–6.

    Article  CAS  PubMed  Google Scholar 

  3. Yeh PC, Dodds SD, Smart LR, Mazzocca AD, Sethi PM. Distal triceps rupture. J Am Acad Orthop Surg. 2010;18:31–40.

    Article  PubMed  Google Scholar 

  4. Anzel SH, Covey KW, Weiner AD, Lipscomb PR. Disruption of muscles and tendons; an analysis of 1014 cases. Surgery. 1959;45:406–14.

    CAS  PubMed  Google Scholar 

  5. Sollender JL, Rayan GM, Barden GA. Triceps tendon rupture in weight lifters. J Shoulder Elb Surg. 1998;7:151–3.

    Article  CAS  Google Scholar 

  6. Mair SD, Isbell WM, Gill TJ, Schlegel TF, Hawkins RJ. Triceps tendon ruptures in professional football players. Am J Sports Med. 2004;32:431–4.

    Article  PubMed  Google Scholar 

  7. Lambert MI, Lambert MI, Lambert MI, Gibson SCR, Noakes TD. Rupture of the triceps tendon associated with steroid injections. Am J Sports Med. 1995;23:778.

    Article  CAS  PubMed  Google Scholar 

  8. Tsourvakas S, Gouvalas K, Gimtsas C, Tsianas N, Founta P, Ameridis N. Bilateral and simultaneous rupture of the triceps tendons in chronic renal failure and secondary hyperparathyroidism. Arch Orthop Trauma Surg. 2004;124:278–80.

    Article  PubMed  Google Scholar 

  9. Madsen M, Marx RG, Millett PJ, Rodeo SA, Sperling JW, Warren RF. Surgical anatomy of the triceps brachii tendon: anatomical study and clinical correlation. Am J Sports Med. 2006;34:1839–43.

    Article  PubMed  Google Scholar 

  10. Keener JD, Chafik D, Kim HM, Galatz LM, Yamaguchi K. Insertional anatomy of the triceps brachii tendon. J Shoulder Elbow Surg. 2010;19:399–405.

    Article  PubMed  Google Scholar 

  11. Wagner JR, Cooney WP. Rupture of the triceps muscle at the musculotendinous junction: a case report. J Hand Surg Am. 1997;22:341–3.

    Article  CAS  PubMed  Google Scholar 

  12. O’Driscoll SW. Intramuscular triceps rupture. Can J Surg. 1992;35:203–7.

    PubMed  Google Scholar 

  13. van Riet RP, Morrey BF, Ho E, O’Driscoll SW. Surgical treatment of distal triceps ruptures. J Bone Joint Surg Am. 2003;85-A:1961–7.

    Article  PubMed  Google Scholar 

  14. Keener JD, Sethi PM. Distal triceps tendon injuries. Hand Clin. 2015;31:641–50.

    Article  PubMed  Google Scholar 

  15. Yeh PC, Stephens KT, Solovyova O, Obopilwe E, Smart LR, Mazzocca AD, Sethi PM. The distal triceps tendon footprint and a biomechanical analysis of 3 repair techniques. Am J Sports Med. 2010;38:1025–33.

    Article  PubMed  Google Scholar 

  16. Clark J, Obopilwe E, Rizzi A, Komatsu DE, Singh H, Mazzocca AD, Paci JM. Distal triceps knotless anatomic footprint repair is superior to transosseous cruciate repair: a biomechanical comparison. Arthroscopy. 2014;30:1254–60.

    Article  PubMed  Google Scholar 

  17. Paci JM, Clark J, Rizzi A. Distal triceps knotless anatomic footprint repair: a new technique. Arthrosc Tech. 2014;3:e621–6.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Siebenlist S, Buchholz A, Zapf J, Sandmann GH, Braun KF, Martetschlager F, Hapfelmeier A, Kraus TM, Lenich A, Biberthaler P, Elser F. Double intramedullary cortical button versus suture anchors for distal biceps tendon repair: a biomechanical comparison. Knee Surg Sports Traumatol Arthrosc. 2015;23:926–33.

    Article  PubMed  Google Scholar 

  19. Janda V. Muscle function testing. London: Butterworths; 1983.

    Google Scholar 

  20. Ahmad CS, Kleweno C, Jacir AM, Bell JE, Gardner TR, Levine WN, Bigliani LU. Biomechanical performance of rotator cuff repairs with humeral rotation: a new rotator cuff repair failure model. Am J Sports Med. 2008;36:888–92.

    Article  PubMed  Google Scholar 

  21. Apreleva M, Ozbaydar M, Fitzgibbons PG, Warner JJ. Rotator cuff tears: the effect of the reconstruction method on three-dimensional repair site area. Arthroscopy. 2002;18:519–26.

    Article  PubMed  Google Scholar 

  22. Barber FA, Drew OR. A biomechanical comparison of tendon-bone interface motion and cyclic loading between single-row, triple-loaded cuff repairs and double-row, suture-tape cuff repairs using biocomposite anchors. Arthroscopy. 2012;28:1197–205.

    Article  PubMed  Google Scholar 

  23. Baums MH, Buchhorn GH, Spahn G, Poppendieck B, Schultz W, Klinger HM. Biomechanical characteristics of single-row repair in comparison to double-row repair with consideration of the suture configuration and suture material. Knee Surg Sports Traumatol Arthrosc. 2008;16:1052–60.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Charousset C, Grimberg J, Duranthon LD, Bellaiche L, Petrover D. Can a double-row anchorage technique improve tendon healing in arthroscopic rotator cuff repair? A prospective, nonrandomized, comparative study of double-row and single-row anchorage techniques with computed tomographic arthrography tendon healing assessment. Am J Sports Med. 2007;35:1247–53.

    Article  PubMed  Google Scholar 

  25. Meier SW, Meier JD. Rotator cuff repair: the effect of double-row fixation on three-dimensional repair site. J Shoulder Elbow Surg. 2006;15:691–6.

    Article  PubMed  Google Scholar 

  26. Meier SW, Meier JD. The effect of double-row fixation on initial repair strength in rotator cuff repair: a biomechanical study. Arthroscopy. 2006;22:1168–73.

    Article  PubMed  Google Scholar 

  27. Kim DH, Elattrache NS, Tibone JE, Jun BJ, DeLaMora SN, Kvitne RS, Lee TQ. Biomechanical comparison of a single-row versus double-row suture anchor technique for rotator cuff repair. Am J Sports Med. 2006;34:407–14.

    Article  CAS  PubMed  Google Scholar 

  28. Mazzocca AD, Millett PJ, Guanche CA, Santangelo SA, Arciero RA. Arthroscopic single-row versus double-row suture anchor rotator cuff repair. Am J Sports Med. 2005;33:1861–8.

    Article  PubMed  Google Scholar 

  29. Siebenlist S, Elser F, Sandmann GH, Buchholz A, Martetschlager F, Stockle U, Lenich A. The double intramedullary cortical button fixation for distal biceps tendon repair. Knee Surg Sports Traumatol Arthrosc. 2011;19:1925–9.

    Article  PubMed  Google Scholar 

  30. Siebenlist S, Lenich A, Buchholz A, Martetschlager F, Eichhorn S, Heinrich P, Fingerle A, Doebele S, Sandmann GH, Millett PJ, et al. Biomechanical in vitro validation of intramedullary cortical button fixation for distal biceps tendon repair: a new technique. Am J Sports Med. 2011;39:1762–8.

    Article  PubMed  Google Scholar 

  31. Buchholz A, Martetschlager F, Siebenlist S, Sandmann GH, Hapfelmeier A, Lenich A, Millett PJ, Stockle U, Elser F. Biomechanical comparison of intramedullary cortical button fixation and interference screw technique for subpectoral biceps tenodesis. Arthroscopy. 2013;29:845–53.

    Article  PubMed  Google Scholar 

Download references

Authors’ contributions

All authors contributed in a significant way in the steps of processing the patient history as well as writing and editing the manuscript. BS and SS conceived of the idea for the study/publication. LL additional was engaged in writing the first draft and provided research support. AI advice throughout the project and reviewed the manuscript. All authors read and approved the final manuscript.



Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author.

Ethical approval and consent to participate

All procedures performed in this study involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standard. An approval of the institutional ethic committee was not applicable for this study. Written informed consent was obtained a priori by all participants and the department of anatomy for cadaveric demonstration.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Sebastian Siebenlist.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Scheiderer, B., Lacheta, L., Imhoff, A.B. et al. V-shaped double-row distal triceps tendon repair: a novel technique using unicortical button fixation. Eur J Med Res 22, 9 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: