Anatomic reinsertion of the distal biceps tendon rupture through a single anterior approach: extensile or mini-invasive approach? A retrospective study at mean 45-month follow-up

Operative Versus Nonoperative Management for Distal Biceps Brachii Tendon Lesions: A Systematic Review and Meta-analysis

BACKGROUND

Both nonoperative and operative treatments have been proposed to manage distal biceps brachii tendon avulsions. However, the advantages and disadvantages of these approaches have not been properly quantified.

PURPOSE

To summarize the current literature on both nonoperative and operative approaches for distal biceps brachii tendon ruptures and to quantify results and limitations. The advantages and disadvantages of the different surgical strategies were investigated as well.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic literature search was performed in March 2020 using PubMed Central, Web of Science, Cochrane Library, MEDLINE, Iscrctn.com, clinicaltrials.gov, greylit.org, opengrey.eu, and Scopus literature databases. All human studies evaluating the clinical outcome of nonoperative treatment as well as different surgical techniques were included. The influence of the treatment approach was assessed in terms of the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Mayo Elbow Performance Index; extension, flexion, supination, and pronation range of motion (ROM); and flexion and supination strength ratio between the injured and uninjured arms. Risk of bias and quality of evidence were assessed using the Cochrane guidelines.

RESULTS

Of 1275 studies, 53 studies (N = 1380 patients) matched the inclusion criteria. The results of the meta-analysis comparing operative versus nonoperative approaches for distal biceps tendon avulsion showed significant differences in favor of surgery in terms of DASH score (P = .02), Mayo Elbow Performance Index (P < .001), flexion strength (94.7% vs 83.0%, respectively; P < .001), and supination strength (89.2% vs 62.6%, respectively; P < .001). The surgical approach presented 10% heterotopic ossifications, 10% transient sensory nerve injuries, 1.6% transient motor nerve injuries, and a 0.1% rate of persistent motorial disorders. Comparison of the different surgical techniques showed similar results for the fixation methods, whereas the single-incision technique led to a better pronation ROM versus the double-incision approach (81.5° vs 76.1°, respectively; P = .01).

CONCLUSION

The results of this meta-analysis showed the superiority of surgical management over the nonoperative approach for distal biceps tendon detachment, with superior flexion and supination strength and better patient-reported outcomes. The single-incision surgical approach demonstrated a slightly better pronation ROM compared with the double-incision approach, whereas all fixation methods led to similar outcomes.

Return to work following a distal biceps repair: a systematic review of the literature

BACKGROUND

Among an active aging population, distal biceps tendon ruptures are becoming increasingly common. Typically, they are the result of an acute heavy eccentric load being placed on an already contracted muscle, and surgery is the gold standard treatment for optimal clinical and functional outcomes. Although improved strength has been shown after operative repair, there is little evidence available regarding a timeframe for return to work-related activity. The purpose of this study was to conduct a systematic review of the literature to provide guidance for return to work after a distal biceps repair.

METHODS

The authors searched online databases (EMBASE, MEDLINE) from inception until October 11, 2018, for literature pertaining to functional outcomes after distal biceps repair. Study inclusion and exclusion criteria were established a priori and applied in duplicate independently by 2 reviewers.

RESULTS

Of the 480 initial studies, 40 papers satisfied full text inclusion criteria (19 case control studies, 12 retrospective reviews, 9 prospective reviews). A total of 1270 patients with 1280 distal bicep ruptures were included in the study. The mean age of patients was 45.38 years, and 97% (n = 1067) of reported patients were male. The mean follow-up time was 30 months (range, 6-84 months). After distal biceps repair, 1128 (89%) of patients were able to fully return to work without any modification of duties. Time to return to work was reported in 17 of the included studies with a mean of 14.37 ± 0.52 weeks.

DISCUSSION

The average time to return to work after distal biceps repair in the literature was just beyond 14 weeks. Patients and employers may be given a range between 3 and 4 months, with variation dependent on job demands. Further studies are needed to establish whether the surgical approach or repair technique has any impact on time to return to work.

Treatment of primary total distal biceps tendon rupture using cortical button, transosseus fixation and suture anchor: A single center experience

INTRODUCTION

There remains as of yet no consensus on the optimal treatment for total or partial distal biceps tendon repairs. As such, the purpose of this study was to assess functional outcome, the impact of complications and cost effectiveness, in patients undergoing primary distal biceps tendon repair by either cortical button (CB), transosseous suture (TO) or suture anchor (SA).

HYPOTHESIS

There is no difference in functional outcome and cost effectiveness, in patients undergoing distal biceps tendon repair.

MATERIAL & METHODS

A retrospective analysis was performed on prospectively collected data from 47 consecutive patients treated for total or partial distal biceps tendon rupture. Functional outcome was assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Strength measurements (e.g., flexion, supination and pronation) in the operated and non-operated extremities were recorded with the use of a dynamometer. Furthermore, all complications, as well as their impact on functional outcome and costs for surgical intervention were evaluated.

RESULTS

Minimum follow-up time was 35 weeks, average 46.3±13.8 weeks. The overall DASH score was 7.9±4.7. There were no differences in functional outcome (i.e., DASH score) between CB, TO, SA (p=0.32), nor were there differences in regards to strength (supination, flexion and pronation) (p=0.60) and ability to return to work & sports activity. The total complication rate was 21.6%. Complications had a significant impact on functional outcome (p=0.003). Re-rupture occurred 2 times in the SA group. In 5 patients, revisional surgery had to be performed. The shortest operation times and the lowest material costs were observed in the TO group (p=0.004).

DISCUSSION

All reported fixation methods for total or partial distal biceps tendon rupture yielded good functional results. However, transosseous suture fixation for total distal biceps tendon rupture, performed through a double incision approach by an experienced surgeon, seems to be a simple, inexpensive and successful method, offering satisfying clinical results.

LEVEL OF EVIDENCE

IV, a retrospective, comparative study.