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Reparación distal del tríceps

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Updated Sep 2026

Esta página se tradujo automáticamente y todavía no la ha revisado un médico. La versión en inglés es la versión oficial.

¿Por qué se ha recomendado esta operación?

El Dr. Kieran Hirpara, cirujano de extremidades superiores en el Mater Private Hospital Rockhampton, adapta el tratamiento a su lesión específica. El tríceps es el tendón situado en la parte posterior del codo que permite estirar el brazo. Cuando se desprende por completo del hueso, normalmente es necesaria una cirugía para restaurar ese movimiento. Esta operación, denominada reparación distal del tríceps, vuelve a unir el tendón roto.

Por lo general, los pacientes son derivados a nuestra clínica por su médico de cabecera; si un fisioterapeuta le ha sugerido que nos visite, igualmente necesitará una derivación de su médico de cabecera para poder acceder al reembolso de Medicare. Evaluamos su historial clínico, examinamos su codo y, si es necesario, solicitamos estudios de imagen para confirmar el diagnóstico.

En caso de desgarro parcial, en primer lugar se puede intentar un tratamiento no quirúrgico, como la fisioterapia. La cirugía se realiza cuando este tratamiento no produce mejoría suficiente o cuando el desgarro es completo. Con frecuencia se recomienda a personas activas, trabajadores que utilizan mucho los brazos y atletas que desean volver a competir. El objetivo de la reparación es recuperar la fuerza y la funcionalidad; la mayoría de los pacientes regresan al trabajo alrededor de los 2,2 meses, y el 89,3 % vuelve a practicar deportes.

Antes de la operación

Su cirujano confirmará la existencia del desgarro mediante estudios de imagen antes de planificar la reparación. Por lo general, esto comienza con radiografías, que indican si un pequeño fragmento óseo se ha desprendido junto con el tendón. También se puede utilizar una resonancia magnética para examinar detalladamente el propio tendón.

Antes de la cirugía, deberá abstenerse de comer y beber durante siete horas. Pedimos que sea siete horas en lugar de seis para poder adelantar su operación si el programa quirúrgico lo permite. Su cirujano le indicará qué medicamentos debe suspender y cuándo. Lleve una lista por escrito de todos los fármacos que toma. Organice que alguien lo lleve a casa después de la intervención, y el día de la operación use ropa holgada y cómoda. Si padece otras enfermedades, es posible que necesite análisis de sangre o una consulta con el anestesista.

El día de la intervención

Llegará a la unidad de admisiones quirúrgicas del hospital, donde se le registrará y preparará para la cirugía. A continuación, conocerá al anestesista, el médico encargado de sedarle y controlar su dolor durante la operación. Esta intervención se realiza bajo anestesia general. En ocasiones, se añade un bloqueo nervioso regional para aliviar el dolor postoperatorio; el anestesista hablará con usted al respecto ese mismo día. Posteriormente, será conducido al quirófano, donde se llevará a cabo la reparación.

Después, despertará en la sala de recuperación, donde las enfermeras le vigilarán atentamente mientras la anestesia va perdiendo efecto. Una vez que su estado sea estable, será trasladado a una sala de hospitalización o podrá volver a casa, según el tipo de intervención y cómo evolucione su recuperación. Si regresa a casa el mismo día, necesitará a la persona con la que haya acordado previamente para que le lleve.

Qué implica la operación

El tendón del tríceps se fija a una pequeña zona ósea en el codo. En caso de desgarro completo, el tendón se ha separado de ese hueso, de forma similar a una cuerda que se suelta de su punto de anclaje. El objetivo de la operación es volver a coser el tendón al hueso, en su posición natural.

El cirujano realiza una incisión en la parte posterior del codo para acceder al tendón desgarrado. Posteriormente, se vuelve a fijar el tendón a su punto de inserción natural mediante pequeños anclajes colocados en el hueso, utilizando puntos de sutura resistentes que mantienen el tendón bajo una tensión uniforme. Esto restaura la forma y posición normal de la inserción tendinosa, otorgando al reparo su resistencia.

En algunas reparaciones se emplea una técnica que cubre toda la zona de inserción con dos filas de anclajes, similar a coser un dobladillo con dos líneas paralelas. En otras, se usan anclajes fabricados íntegramente de material de sutura, que fijan el tendón con la misma firmeza que los anclajes convencionales. Su cirujano elegirá el método más adecuado para su lesión.

Una vez asegurado el tendón, el cirujano verifica que el reparo se mueva sin problemas; luego cierra la incisión con puntos de sutura y aplica un vendaje. Deberá mantener dicho vendaje durante unos 10 días, tal como se describe en la sección de recuperación.

En esencia, la operación consiste en volver a unir el tendón desgarrado al hueso y fijarlo lo suficientemente bien para que pueda cicatrizar. Lo que sucederá después, y cuán rápidamente podrá mover y utilizar el brazo, se explica en la siguiente sección de recuperación.

Después de la operación

Despertará en la sala de recuperación, donde las enfermeras lo vigilarán de cerca mientras el efecto de la anestesia desaparece. Para mayor comodidad, su brazo descansará en un cabestrillo sencillo. El codo no queda inmovilizado; se permiten movimientos suaves desde el principio. El tratamiento para el dolor se adapta a sus necesidades, y las enfermeras se asegurarán de que se sienta cómodo. Durante las primeras 24 horas después de volver a casa, debería haber alguien con usted. Su equipo le indicará si podrá irse a casa el mismo día o si deberá permanecer una noche en el hospital. Dejamos el vendaje puesto durante unos 10 días; por favor, no lo retire antes de ese plazo a menos que se lo indiquemos. Lo cambiaremos o lo retiraremos cuando venga a la consulta. La mayoría de los pacientes caminan y se mueven el mismo día de la cirugía, pero con cuidado.

Recuperación

Durante los primeros días, el codo le dolerá y se hinchará. Esto mejora gradualmente. El descanso, mantener la mano elevada al sentarse y los analgésicos recetados le serán de gran ayuda. Para mayor comodidad, el brazo se sostiene con un cabestrillo sencillo; sin embargo, el codo no se mantiene completamente inmóvil y se inician movimientos suaves desde el principio.

La terapia de la mano constituye un aspecto fundamental de su recuperación. Las sesiones las llevará a cabo Ruby Doolan en Extend Rehabilitation. Ruby es terapeuta especializada en la mano: ella le guiará en los ejercicios y confeccionará cualquier férula que necesite. Al inicio, el objetivo es proteger la zona operada mientras el codo recupera su movilidad. A medida que el tendón cicatriza, los ejercicios se intensifican para restaurar la fuerza necesaria para estirar el brazo contra resistencia.

A diario, podrá realizar tareas ligeras en casa con la otra mano mientras la zona operada se recupera. No podrá conducir mientras el brazo permanezca en el cabestrillo; además, para volver a conducir deberá ser capaz de sujetar el volante con ambas manos y reaccionar ante una frenada de emergencia, sin haber ingerido analgésicos potentes. Nuestra guía sobre conducción tras una cirugía de miembro superior explica este tema con mayor detalle.

Los hitos de la recuperación se definen por acontecimientos concretos, no por fechas específicas. Una vez que la hinchazón disminuya, doblar y estirar el codo resultará más fácil. Cuando su terapeuta autorice el entrenamiento de fuerza, podrá empezar a cargar peso sobre el brazo. La mayoría de las personas vuelven a trabajar y a practicar deportes con el mismo nivel de intensidad que antes de la lesión. Su proceso de recuperación puede ser distinto; su cirujano y Ruby le guiarán en todo momento.

Qué puede salir mal

La mayoría de los pacientes evolucionan bien, pero en ocasiones pueden surgir problemas. Su cirujano y el equipo lo vigilarán de cerca para detectar cualquier anomalía a tiempo.

El problema más grave es que la reparación se vuelva a romper. Es posible que sienta un “chasquido” repentino o una sensación de aflojamiento en la parte posterior del codo, seguida de debilidad al intentar estirar el brazo contra alguna resistencia. Algunas personas notan hinchazón y hematomas en la zona del codo, similar a lo que sintieron cuando el tendón se rompió por primera vez. Si esto ocurre, comuníquese con la clínica de inmediato. Su cirujano examinará el codo y ordenará estudios de imagen para comprobar si la reparación se mantiene intacta.

También pueden aparecer problemas relacionados directamente con la herida. Esté atento a un dolor que empeore en lugar de mejorar, a enrojecimiento que se extienda desde la zona de la incisión o a líquido que se filtre a través del vendaje. La fiebre o una sensación general de malestar junto con estos signos también son relevantes. Si observa cualquiera de estos síntomas, llame a la clínica ese mismo día en lugar de esperar a su próxima cita.

En algunos casos, la reparación requiere una intervención quirúrgica adicional. Esto puede deberse a que el tendón se haya vuelto a romper o a que algún otro aspecto de la reparación no evolucione como debería. Normalmente, esto se percibe mediante dolor persistente, debilidad o la sensación de que el codo no está recuperándose según lo esperado. Comente esto en su cita de seguimiento, o contáctenos antes si nota que algo no va bien.

La recuperación tras estos problemas puede tardar más de lo previsto inicialmente; algunas personas necesitan más tiempo alejadas del trabajo o de sus actividades habituales de lo que pensaban. Su cirujano le explicará lo ocurrido y cuáles serán los siguientes pasos si esto le afecta a usted.

En la tabla de complicaciones de esta página se detallan las tasas típicas, por si desea conocer los datos específicos.

¿Cuándo deben contactarnos?

La mayoría de las recuperaciones transcurren sin problemas, pero existen ciertos signos que requieren atención inmediata. Llámenos si presenta fiebre, o si el enrojecimiento o la secreción alrededor de la herida siguen aumentando. Acuda a urgencias si experimenta un dolor intenso y repentino en el codo, o un “chasquido” acompañado de debilidad al intentar estirar el brazo. Acuda a urgencias también si la pantorrilla se hincha o le duele, o si le cuesta respirar. Llámenos de inmediato si pierde la sensibilidad en el brazo o la mano, o si no puede mover la extremidad.

Reviewed by AI synthesis (v2) — pending human review · 21 August 2026.

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Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology

Bony Anatomy

  • The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [3].
  • The trochlea articulates with the ulna within the greater sigmoid notch to form the ulnohumeral, hinged, or trochoid portion of the elbow joint [3].
  • The ulnohumeral articulation provides highly congruent anatomy through almost 180° of articular contact [3].
  • The greater sigmoid notch of the ulna contains a bare area devoid of cartilage [3].
  • The coronoid process has medial and lateral facets that buttress the trochlea anteriorly [3].
  • The sublime tubercle is located just distal and medial to the coronoid and serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [3].
  • The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle [3].
  • The capitellum and radial head form the radiocapitellar joint [3].
  • The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [3].
  • The lesser sigmoid notch is the area of the ulna that articulates with the margin of the radial head at the proximal radioulnar joint [3].
  • The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [3].
  • The lateral epicondyle is the origin of the lateral extensor musculature [3].
  • The origin of the lateral ulnar collateral ligament complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [3].
  • The distal humeral articulation is angled 30° from the longitudinal axis [3].
  • The anterior humeral line should pass through the center of the axis of rotation [3].
  • The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [3].
  • The olecranon provides a broad attachment site for the triceps [3].
  • The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [3].
  • The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [3].

Ligaments and Soft Tissue

  • The medial ulnar collateral ligament is comprised of the anterior bundle, posterior bundle, and transverse ligament [2].
  • The anterior bundle of the medial ulnar collateral ligament is the strongest component and the primary restraint to valgus stress [2].
  • The anterior bundle of the medial ulnar collateral ligament is subdivided into anterior and posterior bands that provide reciprocal function, with the anterior band tight in extension and the posterior band tight in flexion [2].
  • The lateral ulnar collateral ligament origin center is 10.7 mm from the lateral epicondyle [2].
  • The lateral ulnar collateral ligament insertion is 3.3 mm from the apex of the supinator crest [2].
  • The triceps muscle insertions have three distinct insertional areas to the olecranon: posterior capsular insertion, deep muscular portion, and superficial tendinous portion [2].
  • The deep muscular head of the triceps corresponds to the medial head of the triceps [2].
  • The superficial tendinous portion of the triceps corresponds to the long and lateral heads [2].
  • The width of the triceps insertion is 2.6 cm [2].
  • The triceps insertion is located 1.1 cm from the tip of the olecranon [2].
  • The primary elbow extensor, the triceps, inserts on the olecranon process [4].
  • The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [4].
  • The biceps brachii inserts at the ulnar margin of the radial tuberosity, with the long head inserting proximally and the short head distally [4].
  • The biceps brachii is a powerful supinator of the forearm [4].
  • The mobile wad consists of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis [4].
  • The flexor-pronator mass consists of the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [4].
  • Tensile forces are present at the medial elbow while compressive forces are present at the lateral elbow [4].
  • The elbow capsule allows maximum distension at approximately 70 to 80 degrees of flexion [4].
  • The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [4].
  • The coronoid tip is an intraarticular structure visualized during elbow arthroscopy [4].
  • The medial or ulnar collateral ligament is the primary valgus stabilizer [4].
  • The anterior bundle of the medial ulnar collateral ligament is the most important component for stability [4].
  • The posterior bundle of the medial ulnar collateral ligament has the greatest change in length and becomes taut at flexion beyond 120 degrees [4].
  • The lateral ulnar collateral ligament is the posterolateral stabilizer [4].
  • Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [4].
  • The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [4].

Biomechanics and Motion

  • The normal elbow has a range of motion from 0° to 140° from extension to flexion [1].
  • The normal elbow has a range of motion of 75° in pronation and 85° in supination [1].
  • A functional arc for flexion and extension is 100° [1].
  • A functional arc for forearm rotation is 100° [1].
  • Elbow stability is determined by primary and secondary stabilizers [1].
  • The three primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament, and the lateral ulnar collateral ligament complex [1].
  • Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [1].

Investigations

Physical Examination

  • The physical examination of the elbow is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect [1].
  • Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [9].
  • The contralateral elbow should be examined for comparison during range of motion assessment [9].
  • If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament is contracted and must be released to restore flexion [9].
  • Pain during the mid-arc of motion is more common with intrinsic disease and may not improve with contracture release alone [9].
  • The ulnar nerve is of utmost importance in the physical examination due to its anatomic proximity to the elbow [9].
  • The posterior bundle of the medial collateral ligament forms the floor of the cubital tunnel along the course of the ulnar nerve [9].
  • Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [9].
  • An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [9].
  • The soft tissue surrounding the elbow should be examined for previous skin incisions, grafts, eschar, or infection [9].

Imaging

  • Plain radiographs remain the hallmark and the best screening test for elbow evaluation [1].
  • Standard radiographic views include AP, lateral, and oblique views [9].
  • Serial radiography is used as follow-up when heterotopic ossification is present [9].
  • Primary bony landmarks assessed on radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [9].
  • CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [9].
  • Three-dimensional CT is used to check for heterotopic ossification [9].
  • CT is not necessary when the stiffness is entirely soft-tissue related [9].
  • CT is beneficial if any joint incongruity or abnormal bony anatomy is present [9].
  • MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [9].
  • AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [11].
  • CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [11].
  • MRI may be most helpful in evaluating associated injuries including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [11].
  • Radiographic evaluations are essential when diagnosing an osteochondritis dissecans lesion of the elbow [12].
  • Important aspects of osteochondritis dissecans lesions may be better seen with MRI [12].

References

[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Summary and Conclusions.

[2] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Annotated References.

[3] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Anatomy > Bony Anatomy.

[4] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > TABLE 2.3 Shoulder Spaces.

[9] Aaos Comprehensive Orthopaedic Review 3. Elbow Stiffness* > IV. Evaluation.

[11] Aaos Comprehensive Orthopaedic Review 3. Elbow Injuries in the Athlete* > III. Valgus Extension Overload Syndrome and Posterior Impingement.

[12] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.

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3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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