The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 9

Scientific Articles | September 01, 2005

Triceps Insufficiency Following Total Elbow Arthroplasty

Andrea Celli, MD¹; Araghi Arash, DO²; Robert A. Adams, MA, RPA³; Bernard F. Morrey, MD³

¹ Via 4, Pilastri 3, Carpi (Modena) 41012, Italy
² 15440 North 71st Street, Apartment #218, Scottsdale, AZ 85254
³ Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905

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A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, . The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: .

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. B.F. Morrey received royalties with the Coonrad-Morrey total elbow arthroplasty. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Mayo Clinic, Rochester, Minnesota

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Sep 01;87(9):1957-1964. doi: 10.2106/JBJS.D.02423

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Abstract

Background: Over the past decade, the indications for total elbow arthroplasty have increased. One complication that is well recognized but is poorly described in the literature is insufficiency of the extensor mechanism involving complete or partial rupture, or avulsion, of the triceps tendon. We therefore reviewed the records of patients who had undergone surgery for the treatment of triceps insufficiency following total elbow arthroplasty to determine the management options and outcomes of intervention for this problem.

Methods: The records on 887 total elbow arthroplasties performed between 1982 and 2001 were assessed to identify patients who had undergone a subsequent procedure on the triceps. Patients in whom triceps insufficiency developed after débridement for infection were excluded, leaving sixteen elbows in fourteen patients. A Mayo Elbow Performance Score was calculated and elbow extension strength against gravity was measured at the time of final follow-up.

Results: There were seven male and seven female patients. The mean age was fifty-four years. The mean duration of follow-up after the triceps reconstruction was sixty-seven months. Three basic techniques were used to repair or reconstruct the extensor mechanism; these included direct suture in seven elbows, anconeus rotation in four, and use of an Achilles tendon allograft in four. The capacity to extend against gravity was restored to fifteen of the sixteen elbows. According to the Mayo Elbow Performance Score, eleven elbows had an excellent outcome, three had a good outcome, and two were considered a clinical failure.

Conclusions: In most patients with triceps insufficiency following total elbow arthroplasty, it is possible to reconstruct the triceps mechanism with a procedure appropriately selected on the basis of tissue quality, tendon retraction, and the status of the olecranon.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Over the past decade, the indications for total elbow arthroplasty performed for the treatment of posttraumatic, degenerative, and inflammatory arthritis, as well as for selected intra-articular fractures of the distal part of the humerus in elderly patients, have increased markedly. We can therefore expect an increase in the number of complications in the future. One of us (B.F.M.) and Bryan^1,2 classified the complications following total elbow arthroplasty into three groups according to their management: complications requiring revision surgery, those requiring additional surgery but not replacement of the components, and those that increase morbidity but do not require additional surgery. One of the complications that requires additional surgery but not replacement of the prosthesis is triceps insufficiency.

Triceps insufficiency can occur as a result of a traumatic rupture of the tendon or, most commonly, following a failed surgical reattachment, particularly when tendon quality is poor^3-5. The objective of this retrospective study was to evaluate our experience with surgical treatment of triceps insufficiency that occurred after total elbow replacement; our purpose was to determine the rate of reoperations in a large consecutive series of patients, the characteristics of the lesion, and the clinical and functional results of operative intervention.

Materials and Methods

Materials and Methods | Results | Discussion | References

We retrospectively reviewed the medical records of all patients treated with total elbow arthroplasty at our institution between 1982 and 2001. Eight hundred and eighty-seven total elbow arthroplasties were performed at our institution and, of these, twenty in eighteen patients were followed by surgical treatment because of triceps insufficiency. Four of the twenty elbows were excluded from the present study because the deficiency followed aggressive débridement for the treatment of infection, leaving sixteen elbows in the study group (Table I). There were seven male and seven female patients, and the dominant elbow had been replaced in nine of them. The mean age was fifty-four years (range, twenty-nine to seventy-five years). The underlying diagnoses for which the primary total elbow arthroplasty had been performed were rheumatoid arthritis in nine elbows and posttraumatic conditions in seven. At the time of the total elbow arthroplasty, the triceps-sparing approach described by Bryan and one of us (B.F.M.)⁶ was used in fifteen elbows and the triceps-splitting approach described by Campbell⁷ was used in one. The Coonrad-Morrey total elbow prosthesis (Zimmer, Warsaw, Indiana) was used in nine patients; the Coonrad-I prosthesis (Zimmer), in four; the Questor prosthesis (Wright Medical Technology, Arlington, Tennessee), in one; and the Pritchard prosthesis (DePuy, Warsaw, Indiana), in two. Four patients had had previous revisions because of component loosening.

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TABLE I Results According to Type of Procedure

Surgical Technique	No. of Procedures	No. with Restoration of Triceps Function	No. with Satisfactory Mayo Elbow Performance Score
Direct repair with bone suture	11	8	7
Achilles tendon allograft	5	4	4
Anconeus rotational flap	4	4	3
Fascia lata	1
LAD	2

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TABLE I Results According to Type of Procedure

Surgical Technique	No. of Procedures	No. with Restoration of Triceps Function	No. with Satisfactory Mayo Elbow Performance Score
Direct repair with bone suture	11	8	7
Achilles tendon allograft	5	4	4
Anconeus rotational flap	4	4	3
Fascia lata	1
LAD	2

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Figs. 1-A and 1-B: Direct suture to bone. Fig. 1-A When the triceps tendon has not retracted and is of good quality, drill holes for crisscrossed sutures are placed in the proximal part of the ulna along with a transverse tunnel. (By permission of the Mayo Foundation.)

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A number-5 nonabsorbable locking suture is placed on either side of the triceps tendon. The suture is then brought into the second osseous tunnel and is secured to itself. (By permission of the Mayo Foundation.)

A traumatic episode was described for two elbows, whereas the extensor mechanism function in the other fourteen elbows was lost without apparent injury. All patients reported loss of active elbow extension, and all but two reported pain. The most commonly lost functions were the ability to reach above the head and to push open doors. The triceps operations were performed at a mean of thirty-nine months after the total elbow arthroplasties. At the time of the triceps surgery, the clinical findings included a change in the posterior aspect of the elbow with visual and palpable prominence of the implant in the subcutaneous tissue (four elbows), olecranon bursitis (three), atrophy of the triceps muscle (eight), lateral dislocation or rupture of the triceps tendon (ten), and insufficiency of the triceps tendon (all). The tendon was found to be completely ruptured in four elbows, partially ruptured in five, completely avulsed from the olecranon in six, and partially avulsed from the olecranon in one. The patients who had had more than one prior operation on the triceps tendon had the poorest-quality tissue. Three had resorption of the olecranon process that was observed radiographically and confirmed at surgery.

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An Achilles tendon allograft may be employed in patients with deficient triceps tissue. When the olecranon is deficient, the calcaneal portion of the graft is first attached to the residual olecranon with a cancellous screw. The elbow is placed in 45° of flexion, and a continuous number-1 absorbable suture is used to envelop the triceps muscle with the fascial portion of the allograft. (By permission of the Mayo Foundation.)

Twenty-three procedures were performed to repair or reconstruct the triceps mechanism in the sixteen elbows. Fourteen patients had one operation to repair or reconstruct the triceps, one (Case 13) had three operations, and one (Case 2) underwent six operations. Direct suture to bone with a number-5 nonabsorbable suture crisscrossed through a tunnel in the olecranon was used in seven elbows (Figs. 1-A and 1-B). An Achilles tendon allograft (Musculoskeletal Trans-plant Foundation [MTF], Edison, New Jersey) was used in four elbows, and in two of those elbows the calcaneal fragment was used as a graft to augment an absent olecranon (Fig. 2). A ligament augmentation device (LAD; 3M, St. Paul, Minnesota)⁸ was used in one elbow, and a rotation myoplasty with use of the anconeus was performed in four (Figs. 3-A and 3-B)³.

As noted above, two patients underwent a total of nine procedures before good triceps function was restored. The unsuccessful techniques performed in these two patients consisted of an initial attempt at direct suture, direct repair to bone on three additional occasions, use of a fascia lata autograft in one patient, and use of a ligament augmentation device in one patient. The common feature of these failures was the lack of an olecranon process. The final, successful procedures were a direct suture of the triceps to a rib allograft for augmentation of the olecranon in one patient and use of an Achilles tendon allograft with the calcaneal portion employed as a bone graft in the other.

Typically, the repair or reconstruction was protected in a splint for three weeks postoperatively, after which gentle passive mobilization was started. Active flexion and extension was begun at three to eight weeks, and extension against gravity was allowed at eight to twelve weeks. If all was well at three months, daily activity with a 1 to 2-kg extension limit (i.e., the patient was advised not to extend the arm while holding a weight of more than 1 to 2 kg) was allowed. Normal daily activities as tolerated were allowed at six months.

All patients were evaluated at least one year after the injury to assess their satisfaction, pain, range of motion, daily activities, and elbow extension strength overhead against gravity. The clinical evaluations of two patients were performed by a family doctor, ten patients were examined at our institution, and two patients were assessed on the basis of a telephone interview. The mean time of the last follow-up evaluation in the entire group was sixty-seven months (range, five to 230 months). The outcomes were evaluated with use of the Mayo Elbow Performance Score, which includes a subjective assessment of pain and objective documentation of motion, stability, and function. The score is calculated on the basis of data obtained through an examination or interview of the patient. Strength against gravity is defined as the ability to extend the elbow with the humerus in the fully elevated position. We attempted to further assess the outcome on the basis of the described pathological changes in the triceps and the treatment strategy employed. A chi-square test for significance was performed on the data, with differences of <0.05 considered significant.

Results

Materials and Methods | Results | Discussion | References

Strength Against Gravity

At the time of the final follow-up, the capacity to extend against gravity had been recovered in fifteen of the sixteen elbows and had not been recovered in one (Case 16). In the patient who did not regain the capacity to extend the elbow against gravity, triceps insufficiency had developed at nine months after a total elbow arthroplasty that had been performed following nonunion of a comminuted intra-articular fracture of the elbow. The triceps reconstruction was carried out with a ligament augmentation device, and the patient did not recover useful triceps function. He declined to have an additional operation.

Mayo Elbow Performance Score

An overall satisfactory outcome according to the Mayo Elbow Performance Score was obtained in fourteen of the sixteen elbows. An excellent result (=95 points) was recorded for eleven elbows in ten patients. All had no pain, a good arc of motion with the capacity to extend the elbow against gravity, and no limitation of daily activities. Eighteen procedures had been performed to recover triceps function in these eleven elbows, as two (Cases 2 and 13) had undergone multiple operations, as noted above. Of the elbows with an excellent Mayo Elbow Performance Score, three had been treated with an anconeus flap; three, an Achilles tendon allograft (with two treated with a calcaneal bone graft as well); and five, with direct repair to bone. In one patient (Case 2), a rib allograft had been used to recover the mechanical advantage of the olecranon.

Three elbows (Cases 1, 5, and 14) had a second revision of the total elbow prosthesis after the triceps reconstruction reported here. At the time of the implant revision, the triceps was found to be completely restored and well attached to the olecranon in all three elbows. The function of the extensor mechanism had been restored with an Achilles tendon allograft with a calcaneal bone graft in one of these elbows and with direct bone suture in the other two.

Prognostic Features

We found no association between the outcome and the underlying diagnoses or the pathological state of the tissue. We did, however, design the surgical procedure to address the variations in the pathological findings that were encountered (Fig. 4).

The Mayo Elbow Performance Score was associated with the procedure type. When the failed attempts at repair were considered along with the successful efforts, patients treated with an Achilles tendon allograft or an anconeus rotational flap were found to have obtained better results and higher Mayo Elbow Performance Scores than did those treated with direct suture (Tables I and II). Patients treated with the Achilles tendon allograft and the anconeus rotational flap also obtained a better capacity to extend the elbow against gravity. Direct repair to the bone with use of the crisscross technique was used eleven times, but it restored good strength against gravity and a satisfactory Mayo Elbow Performance Score only seven times.

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TABLE II Characteristics of Study Group

					Time Between Total Elbow Arthroplasty and Triceps Repair or Reconstruction (mo)					Postoperative Results
Case	Age (yr)	Gender	Diagnosis	No. of Ops. Before Total Elbow Arthroplasty		Triceps Status	Type of Triceps Repair or Reconstruction	Previous Triceps Repair	Durat. of Follow-up (mo)	Strength	Pain	Ext.-Flex. (deg)	Mayo Elbow Performance Score (points)
1	68	F	Rheum. arth.		2	Complete avulsion	Bone suture	No	73	Good	None	23-135	100
2	72	F	Posttraum. osteoarth.		12	Complete avulsion	Bone suture with bone graft augment.	Yes	57	Good	None	0-140	100
3	57	M	Rheum. arth.		1	Partial rupture	Bone suture	No	68	Slight	None	0-140	100
4	45	F	Rheum. arth.		1	Complete avulsion	Bone suture	No	230	Slight	Mild	0-145	80
5	45	F	Rheum. arth.		1	Complete avulsion	Bone suture	No	218	Good	Mild	20-145	85
6	42	F	Rheum. arth.	1	72	Partial rupture	Bone suture	No	38	Good	None	40-120	100
7	70	F	Posttraum. osteoarth.	1	3	Partial avulsion	Bone suture	No	27	Good	None	40-145	100
8	60	M	Rheum. arth.		96	Complete rupture	Anconeus flap	No	63	Good	None	15-135	100
9	44	F	Rheum. arth.	2	72	Complete avulsion	Anconeus flap	No	14	Good	None	40-135	100
10	75	M	Rheum. arth.		4	Complete avulsion	Anconeus flap	No	51	Good	None	25-135	100
11	58	M	Rheum. arth.	1	9	Partial rupture	Anconeus flap	No	12	Good	Mild	30-135	75
12	31	M	Posttraum. osteoarth.	1	2	Complete rupture	Achilles tendon graft with bone graft augment.	No	5	Good	None	10-135	95
13	54	F	Posttraum. osteoarth.	3	16	Partial rupture	Achilles tendon graft with bone graft augment.	Yes	15	Good	None	10-120	100
14	60	F	Posttraum. osteoarth.		84	Partial rupture	Achilles tendon graft with bone graft augment.	No	62	Good	None	0-125	100
15	55	M	Posttraum. osteoarth.	1	223	Complete rupture	Achilles tendon graft	No	27	Good	Mod.	0-130	70
16	29	M	Posttraum. osteoarth.	1	9	Complete rupture	LAD/fascia lata	No	118	No active extension	Mild	90-120	55

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TABLE II Characteristics of Study Group

					Time Between Total Elbow Arthroplasty and Triceps Repair or Reconstruction (mo)					Postoperative Results
Case	Age (yr)	Gender	Diagnosis	No. of Ops. Before Total Elbow Arthroplasty		Triceps Status	Type of Triceps Repair or Reconstruction	Previous Triceps Repair	Durat. of Follow-up (mo)	Strength	Pain	Ext.-Flex. (deg)	Mayo Elbow Performance Score (points)
1	68	F	Rheum. arth.		2	Complete avulsion	Bone suture	No	73	Good	None	23-135	100
2	72	F	Posttraum. osteoarth.		12	Complete avulsion	Bone suture with bone graft augment.	Yes	57	Good	None	0-140	100
3	57	M	Rheum. arth.		1	Partial rupture	Bone suture	No	68	Slight	None	0-140	100
4	45	F	Rheum. arth.		1	Complete avulsion	Bone suture	No	230	Slight	Mild	0-145	80
5	45	F	Rheum. arth.		1	Complete avulsion	Bone suture	No	218	Good	Mild	20-145	85
6	42	F	Rheum. arth.	1	72	Partial rupture	Bone suture	No	38	Good	None	40-120	100
7	70	F	Posttraum. osteoarth.	1	3	Partial avulsion	Bone suture	No	27	Good	None	40-145	100
8	60	M	Rheum. arth.		96	Complete rupture	Anconeus flap	No	63	Good	None	15-135	100
9	44	F	Rheum. arth.	2	72	Complete avulsion	Anconeus flap	No	14	Good	None	40-135	100
10	75	M	Rheum. arth.		4	Complete avulsion	Anconeus flap	No	51	Good	None	25-135	100
11	58	M	Rheum. arth.	1	9	Partial rupture	Anconeus flap	No	12	Good	Mild	30-135	75
12	31	M	Posttraum. osteoarth.	1	2	Complete rupture	Achilles tendon graft with bone graft augment.	No	5	Good	None	10-135	95
13	54	F	Posttraum. osteoarth.	3	16	Partial rupture	Achilles tendon graft with bone graft augment.	Yes	15	Good	None	10-120	100
14	60	F	Posttraum. osteoarth.		84	Partial rupture	Achilles tendon graft with bone graft augment.	No	62	Good	None	0-125	100
15	55	M	Posttraum. osteoarth.	1	223	Complete rupture	Achilles tendon graft	No	27	Good	Mod.	0-130	70
16	29	M	Posttraum. osteoarth.	1	9	Complete rupture	LAD/fascia lata	No	118	No active extension	Mild	90-120	55

Discussion

Materials and Methods | Results | Discussion | References

According to the limited literature available on this topic, the prevalence of triceps insufficiency following total elbow arthroplasty ranges from 1% to 29%^4,9-13. A recent report documented triceps insufficiency in four of twenty-eight elbows that had been treated with a triceps-splitting approach to insert the GSB (Gschwend-Scheier-Bahler) implant (Centerpulse, Zurich, Switzerland)¹⁴. This approach is significantly different from the Bryan-Morrey approach in that the triceps is split and the olecranon attachment is released with a thin wafer of bone. At our institution, sixteen (2%) of 887 elbows that had been treated with a total elbow arthroplasty subsequently had weakness, pain, and functional impairment that was severe enough to justify a reoperation. Triceps insufficiency following total elbow arthroplasty may have several causes. Although the pathological state of the tissue dictated the treatment strategy, it did not, of itself, correlate with the outcome. Although patients with rheumatoid arthritis would seem to have a high risk for the development of this complication because of the nature of the disease¹⁵, we found no greater prevalence in these patients compared with that in the patients with traumatic arthritis. Furthermore, because the tendon is clearly damaged by débridement for the treatment of deep infection, we excluded from this study four patients in whom multiple débridements for infection had caused the extensor mechanism deficiency. Finally, patients who have had multiple operations on the elbow before or after the total elbow arthroplasty have an increased risk of triceps insufficiency. Two of our patients had three or more operations on the elbow, including the total elbow arthroplasty.

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Triceps reconstruction with an anconeus rotational flap begins by the surgeon identifying and entering the interval between the anconeus and the extensor carpi ulnaris. The anconeus is elevated from the ulna and is rotated medially. (By permission of the Mayo Foundation.)

We used several surgical techniques to restore the extensor mechanism, with the specific method selected on the basis of the quality of the triceps and the status of the olecranon¹⁶. Direct repair to bone was performed eleven times in seven patients, and four of the procedures failed. We believe that all four failures were due to resorption of the olecranon. A LAD was used once and failed. An anconeus rotational flap was employed four times, and it failed once. An Achilles tendon allograft was used on five occasions, with calcaneal bone grafted to the ulna in three procedures; the only failure was in a patient in whom a calcaneal bone graft was not used.

Of particular importance is the recognition of resorption of the olecranon as an important factor to be considered in the choice of the appropriate technique. This finding was present in four of our patients and was the cause of two initial treatment failures because it resulted in loss of the lever arm of the triceps attachment. Fixation of the calcaneal fragment of the Achilles tendon allograft² to the olecranon with a cancellous screw was effective for reconstructing a deficient olecranon in three elbows.

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The anconeus is in continuity with the triceps. The construct is mobilized and repositioned over the olecranon and is secured to the olecranon with a number-5 nonabsorbable suture placed through drill holes. (By permission of the Mayo Foundation.)

Our results support an expectation of success when the appropriate technique, as determined on the basis of tissue quality, the degree of tendon retraction, and the status of the olecranon, is selected. On the basis of these variables, we currently follow the treatment algorithm shown in Figure 4. If the quality of the tendon is good and the muscle is not retracted, we use a number-5 nonabsorbable bone suture crisscrossed through a bone tunnel in the olecranon. An anconeus flap is used in patients when retraction or poor quality of the tendon makes reattachment of the extensor mechanism difficult and the anconeus muscle is well preserved. An Achilles tendon allograft is used when the anconeus muscle is devitalized or there is a large soft-tissue defect. The spontaneous resorption of the olecranon process must be addressed if reconstruction of the extensor mechanism is to be reliable. The calcaneal bone fragment should be used to augment the olecranon when the olecranon is deficient. ?

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The treatment algorithm for managing patients with triceps insufficiency following total elbow arthroplasty. (By permission of the Mayo Foundation.)

References

Materials and Methods | Results | Discussion | References

Morrey BF. Complications of elbow replacement surgery. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia: WB Saunders; 2000. p 667-76.667 2000

Morrey BF, Bryan RS. Complications of total elbow arthroplasty. Clin Orthop Relat Res.1982;170: 204-12.170204 1982 [PubMed]

Sanchez-Sotelo J, Morrey BF. Surgical techniques for reconstruction of chronic insufficiency of the triceps. Rotation flap using anconeus and tendo achillis allograft. J Bone Joint Surg Br.2002;84: 1116-20.841116 2002 [CrossRef]

Pierce TD, Herndon JH. The triceps preserving approach to total elbow arthroplasty. Clin Orthop Relat Res.1998;354: 144-52.354144 1998 [CrossRef]

Clayton ML, Thirupathi RG. Rupture of the triceps tendon with olecranon bursitis. A case report with a new method of repair. Clin Orthop Relat Res.1984;184: 183-5.184183 1984 [PubMed]

Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res.1982;166: 188-92.166188 1982

Campbell WC. Surgical approaches. In: Crenshaw AH, editor. Campbell's operative orthopaedics. Volume 1. 5th ed. St. Louis: C.V. Mosby; 1971. p 119.1119 1971

Morrey BF. Rupture of the triceps tendon. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia: WB Saunders; 2000. p 479-84.479 2000

Inglis AE, Pellicci PM. Total elbow replacement. J Bone Joint Surg Am.1980;62: 1252-8.621252 1980 [PubMed]

Morrey BF, Bryan RS, Dobyns JH, Linscheid RL. Total elbow arthroplasty. A five-year experience at the Mayo Clinic. J Bone Joint Surg Am.1981;63: 1050-63.631050 1981 [PubMed]

Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ. Functional outcome of semiconstrained total elbow arthroplasty. J Bone Joint Surg Am.2000;82: 1379-86.821379 2000 [PubMed]

Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J Bone Joint Surg Am.1998;80: 1327-35.801327 1998 [PubMed]

Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am.1992;74: 479-90.74479 1992

Kelly EW, Coghlan J, Bell S. Five- to thirteen-year follow-up of the GSB III total elbow arthroplasty. J Shoulder Elbow Surg.2004;13: 434-40.13434 2004 [CrossRef]

Wolfe SW, Figgie MP, Inglis AE, Bohn WW, Ranawat CS. Management of infection about total elbow prostheses. J Bone Joint Surg Am.1990;72: 198-212.72198 1990

van Riet RP, Morrey BF, Ho E, O'Driscoll SW. Surgical treatment of distal triceps ruptures. J Bone Joint Surg Am.2003;85: 1961-7.851961 2003

Topics

achilles tendon ; elbow region ; reconstructive surgical procedures ; sutures ; olecranon ; elbow replacement arthroplasty ; triceps brachii ; allografting ; force of gravity ; anconeus muscle

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Andrea Celli, Araghi Arash, Robert A. Adams, Bernard F. Morrey; Triceps Insufficiency Following Total Elbow Arthroplasty. The Journal of Bone & Joint Surgery. 2005 Sep;87(9):1957-1964.

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