Biceps and Triceps Ruptures in Athletes

Surgically treated acute distal biceps tendon injuries: What results do they have in comparison with the contralateral healthy arm? A systematic review and meta-analysis

BACKGROUND

Surgical repair of distal biceps tendon injury restores flexion and supination strength, resulting in good functional outcome. There are few studies that consider clinical results of the operated arm compared to the healthy contralateral arm, whereas there are many articles examining the results of different surgical techniques. We carried out a systematic review with meta-analysis of the studies that consider this comparison. The aim was to evaluate if there are significative differences in terms of functional results between the operated arm and the non-injured contralateral arm. In fact, we believe that this comparison is useful for assessing patient true satisfaction.

PATIENTS AND METHODS

In accordance with the PRISMA and QUORUM statements, a comprehensive search on PubMed, Scopus, Embase, Cochrane, Google Scholar and Web of Science databases was conducted to identify studies reporting comparative functional results of the operated arm with healthy contralateral arm from January 1985 until November 2022. Criteria for inclusion were acute complete injury of the distal biceps' tendon operated within 30days; range of motion (ROM), isokinetic and isometric strength measurements; minimum patients follow-up of 24months; studies written in English language. Then a DerSimonian and Laird meta-analysis was conducted to compare the functional outcomes of the operated arm to the non-injured arm.

RESULTS

Of the 588 initial studies, 18 studies met the inclusion criteria; methodological quality was assessed using the Newcastle-Ottawa scale. A total of 272 surgically treated distal biceps ruptures were included in the study. The mean follow-up time was of 39.6months (24 to 72months). ROM flexion, pronation, and supination of the operated elbows were significantly decreased, with mean differences of -1.24̊ (p=0.004), -7.95̊ (p=0.003), and -9.27̊ (p=0.004) respectively, compared to the non-injured healthy elbows. The difference of ROM extension was not-statistically significant (+0.21̊; p=0.66). The Isokinetic data showed a statistically significant reduction in the flexion strength (-4.56Nm; p=0.0004) and a statistical significative reduction in the supination strength (-1.18 Nm; p=0.02) of the injured operated arm compared with the healthy one. The forest-plot table of the isometric data was not elaborated due to the small number of studies eligible for the meta-analysis.

DISCUSSION

This study represents the first systematic review and meta-analysis to compare functional and clinical outcomes following operative treatment of distal biceps tendon ruptures with the contralateral healthy arm. Significant differences in ROM flexion, supination, and pronation and in isokinetic and isometric data were found between the operated and non-operated unaffected arm, demonstrating that, as expected, the unaffected arm performed better than the operated one. However, the functional differences between the data of the operated and healthy arm were slight and lead us to overall consider surgery as good functional result.

LEVELS OF EVIDENCE

III.

Augmentation of triceps tendon repair with a bio-inductive collagen scaffold

Two active, adult male patients, one with prior triceps rupture and direct repair, presented with traumatic rupture of the distal triceps tendon. MRI confirmed not only complete rupture with retraction in both, but also signal changes within the tendon, raising concern for healing potential and re-rupture. Surgical repair was performed using heavy, non-absorbable suture and suture anchors in the standard fashion, followed by augmentation with a bovine, bio-inductive collagen scaffold in order to increase tendon thickness and aid with healing capability. This technique is well described for rotator cuff repair augmentation but is a novel technique to the literature in the setting of triceps tendons repair. Both patients returned to full, preinjury activity without complication with sustained results at 3 and 3.5 years postoperatively.

Progressive Loading in a Strongman Following Distal Biceps Repair: Re-Thinking Load Progression - A Case Report

Background

Rupture of the distal biceps is relatively rare and post-operative protocols are typically vague and are used on many patients, regardless of pre-morbid status. The primary objective is to share the progressive loading strategy used in the rehabilitation of a strongman athlete following a surgical repair of the distal biceps. An additional objective is to highlight the need for individualized protocols and progressions with respect to patient goals and sport demands, as well as the need for shared decision making (SDM) between the medical doctor, patient, and rehabilitation provider.

Case Presentation

The subject is a 39-year-old strong man competitor who suffered a distal biceps rupture while doing a tire flip during training. After having it repaired, the post-operative recovery was unremarkable. The focus of the described intervention was establishing load during rehabilitation exercises that were unique to this individual based on his pre-morbid level of strength and training history as well as the unique demands of his sport.

Outcomes

The patient achieved symmetrical isokinetic strength of the elbow flexors at 60°/second in supine at six months post-operative.

Discussion

The case highlights a successful outcome in a strongman competitor with a distal biceps rupture repair. Typically, protocols are vague and lack specific standards for establishment of load for exercises. Often starting points and progressions are arbitrary and lack rationale tailored to individual needs and/or pre-morbid status. The case offers a framework for establishing and progressing load while also discussing how a shared decision-making model can lead to positive outcomes.

Brachial artery trauma as a complication of bicep muscle injury

We describe a rare case of injury to a branch of the brachial artery in a 48-year-old man with a bicep musculotendinous injury. His presenting symptoms included severe pain, swelling, and paresthesias in the right upper extremity. Examination revealed significant soft tissue swelling with ecchymoses in the right upper arm with diminished palpable pulses. Imaging revealed a biceps muscle injury along with active arterial extravasation of a branch of the deep brachial artery. Interventional radiology successfully performed coil embolization. Bicep musculotendinous injury is typically characterized by pain, swelling, and decreased strength. Rarely, complications such as compartment syndrome have been reported. Brachial arterial injury has not been implicated in the setting of this entity, especially in the absence of blunt or penetrating trauma, until our current patient's presentation.

Systematic review of distal biceps tendon rupture in athletes: treatment and rehabilitation

BACKGROUND

Distal biceps tendon rupture is a rare injury associated with decreased elbow flexion and forearm supination strength. This impairment is not tolerated by high-demand patients like athletes.

PURPOSE

To review treatment and rehabilitation applied to injured athletes and study their impact in return to sports.

METHODS

MEDLINE, Cochrane, Web of Science, and Scopus online databases were searched. A systematic review was conducted using the PRISMA guidelines; studies published on distal biceps tendon rupture treatment and rehabilitation of athletes until June 30, 2021, were identified. A quantitative synthesis of factor related to return to preinjury sport activity was made.

RESULTS

Ten articles were identified, including 157 athletes. Mean age was 40.5 years, and the dominant arm was injured in 103 cases (66%). Rupture was acute in 121 athletes (77%), and the mean follow-up was 25.7 months. A hundred and fifty-three athletes (97.5%) successfully returned to sport within a mean time of 6.2 months. Surgical treatment was followed in all cases. One-incision technique was chosen in 115 (73%) and suture anchor fixation in 52 (33%) cases. No postsurgical immobilization was reported in 38 (24%) and immobilization for 2 weeks in 124 (79%) athletes. Decreased supination-pronation and flexion-extension arc was found in 63 (40%) and 27 (17%) cases, respectively. Earlier return to sport was associated with nondominant-side (P = .007) and acute (P < .001) injuries, participation in weightlifting (P = .001), double-incision approach (P = .005), cortical button fixation (P < .001), and absence of supination-pronation restriction (P = .032). Time of return to sport activity was independent of rehabilitation, including immobilization (P = .539) and strengthening (P = .155), and decreased flexion-extension arc (P = .059).

CONCLUSION

Athletes sustaining distal biceps tendon rupture have a high postoperative return to sport rate, independently of selected surgical technique or rehabilitation program. However, a relation between the surgical technique and time of return to sport was found. Rehabilitation did not influence time of return to sport.

Characterization of novel stress degradation products of Bempedoic acid and Ezetimibe using UPLC–MS/MS: development and validation of stability-indicating UPLC method

Background

A receptive and easily comprehended technique was evolved for simultaneous assessment of Bempedoic acid and Ezetimibe and its impurities characterized by UPLC–MS/MS.

Results

This technique involves chromatographic separation with a C18 column of water symmetry (150 mm × 4.6 mm, 3.5 µm). A mobile phase of 0.1% OPA (orthophosphoric acid) and acetonitrile in 50:50 v/v with 1 mL/min flow rate and ambient temperature was used. UV observation was taken at 230 nm. The recoveries, linearity, and quantification limits were found to be within the acceptable limit.

Conclusions

This technique was successfully tested with UPLC–MS to confirm the chemical structures of newly formed degradation products of Bempedoic acid and Ezetimibe and stress studies as per ICH Q2 (R1) guidelines.

Prophylaxis for Heterotopic Ossification Following Distal Biceps Tendon Repair

Heterotopic ossification (HO) is a possible complication of distal biceps tendon repair (DBTR). Several agents can prevent HO formation, although relatively few studies have investigated prophylaxis specifically after DBTR. The purposes of this study were to survey members of the American Shoulder and Elbow Surgeons (ASES) to determine (1) what percentage use HO prophylaxis after DBTR; (2) type, dosage, and duration of prophylaxis used; and (3) use of single-incision or double-incision surgical technique. An anonymous electronic survey was distributed to ASES members to determine the use of HO prophylaxis and DBTR technique. The survey included questions regarding the number of DBTRs performed annually; preferred surgical technique and implants; and type, dosage, and duration of HO prophylaxis used before, during, and after surgery. Descriptive statistics were used to analyze the results. Of 173 respondents, 98 (56.6%) performed 1 to 10 DBTRs per year, 65 (37.6%) performed 11 to 25 DBTRs per year, and 10 (5.8%) performed 26 to 50 DBTRs per year. A total of 131 (75.7%) preferred the single-incision technique, whereas 42 (24.3%) preferred the double-incision technique. A total of 94 (54.3%) performed DBTR using a metal button and interference screw, 35 (20.2%) through drill holes, 25 (14.5%) with suture anchors, and 19 (11.0%) with a metal button alone. A total of 132 (76.3%) respondents did not use HO prophylaxis, and 41 (23.7%) used nonsteroidal anti-inflammatory drugs following surgery. A total of 35 (85.4%) used indomethacin, 18 (51.4%) of whom preferred 75 mg/d for 3 to 4 weeks. Heterotopic ossification is a commonly reported complication following DBTR, especially with the double-incision technique. Prophylaxis with anti-inflammatory medications and suppressive modalities (radiation therapy) appear to reduce the incidence of HO. Despite these data, most surgeons (76.3%) do not use HO prophylaxis. Low annual volume of cases, lack of large-volume studies with outcome data, and the dominant use of the single-incision repair technique may explain this. [Orthopedics. 2021;44(4):e588-e592.].

Simultaneous, Ipsilateral Distal Biceps and Distal Triceps Rupture in Healthy Weight Lifter: A Case Report

CASE

A 38-year-old weight lifter presented with a complete distal biceps rupture with retraction and a near complete ipsilateral distal triceps tear sustained during the bench press exercise. The tendons were fixed operatively using a simultaneous posterior and anterolateral approach to the elbow.

CONCLUSION

Simultaneous, ipsilateral distal biceps and distal triceps tendon injury is a rare occurrence that leads to significant functional loss. Repair of distal biceps rupture using a single-incision technique with a cortical button and distal triceps using a double-row suture anchor repair was successful in restoring functional anatomy to our patient.

[Rehabilitation of patients after surgical treatment of avulsion rupture of the distal biceps brachial tendon]

Avulsion subcutaneous rupture of the distal tendon of the biceps brachial is a relatively rare occurrence. In the context of postoperative treatment, there are isolated references to rehabilitation therapists and sports physicians in the literature. However, the popularization of sports among the general population forces specialists to face this problem in clinical practice. The objective of the presented study was to review our own concept of rehabilitation in the early and late postoperative periods using the example of a specific clinical case of surgical treatment using fixation with a cortical button and an interference screw in trauma in a professional athlete. A group of surgeons and rehabilitation therapists focused their efforts on returning the patient to normal amplitudes of movements in the joints of the injured limb the ability to endure previous loads without pain in the shortest possible time without fear of relapse. The results obtained during the treatment of a sports-organized patient with an avulsion rupture of the distal tendon of the biceps brachial made it possible to question the success of the previous «immobilization» concepts broadened the professional understanding of the possibilities of modern rehabilitation allowed surgeons and rehabilitation therapists to come close to developing a universal rehabilitation protocol form.

A unique case of bilateral triceps avulsion fracture in a patient with pseudohypoparathyroidism

Triceps tendon ruptures and avulsions are rare injuries and are often associated with systemic diseases. This paper illustrates the unique case of a 20-year-old female patient with pseudohypoparathyroidism, who sustained bilateral triceps avulsion fractures after a fall. She underwent suture anchor fixation, augmented with tension band suture as double row repair with excellent post-operative results. We describe the pathophysiology of this injury and the unique method of fixation, which can be an alternative effective method to repair these injuries.

The Role of Deadlifts in Distal Biceps Brachii Tendon Ruptures: An Alternative Mechanism Described With YouTube Videos

BACKGROUND

The classic injury mechanism of a distal biceps brachii tendon rupture (DBBTR) is eccentric loading to the flexed elbow when the forearm is supinated.

PURPOSE

To determine alternative mechanisms of a DBBTR in powerlifting sports, particularly in deadlift competitions, with the use of YouTube videos.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

A search on YouTube was performed using the search terms "distal biceps tendon rupture" and "distal biceps tendon injury" combined with "competition," "deadlift," and "powerlifting." The videos underwent an evaluation for accuracy by 3 surgeons according to predetermined criteria. Type of sports activity, participant sex, side of the injury, and arm positions at the time of the injury were recorded.

RESULTS

Among the videos reviewed, 35 injuries were found appropriate for an evaluation. All participants were male. The majority of the injuries (n = 25) were observed during the deadlift. Only in 1 deadlift injury were both forearms in supination. In the remaining deadlift injuries (n = 24), all elbows were in extension, with 1 forearm in supination and the other in pronation. Among the deadlift injuries in the mixed-grip position, all ruptures occurred in a supinated extremity: 25% (n = 6) of ruptures occurred on the right side, and 75% (n = 18) of ruptures occurred on the left side; this was a significant difference (P = .014).

CONCLUSION

We described an alternative mechanism for a DBBTR, namely, eccentric loading to an extended elbow when the forearm is supinated during the deadlift. As all the ruptures occurred in a supinated extremity, holding the bar with both forearms in pronation may prevent or decrease the risk of ruptures during the deadlift.

A comprehensive review of the normal, abnormal, and post-operative MRI appearance of the distal biceps brachii

The biceps brachii myotendinous unit is a common source of shoulder, arm, and elbow pain. Its complex anatomy can present a challenge when interpreting MR images. We discuss the clinical and imaging presentations of injury related to the proximal biceps brachii separately in another manuscript. The purpose of this manuscript is to review the distal biceps anatomy along with pathology and post-operative appearance as seen on MRI.

Rupture of the Short Head of the Biceps Brachii Muscle Belly Caused by a Rock-Climbing Accident

The case of a 42-y-old rock climber who sustained a complete, isolated rupture of the short head of the biceps brachii muscle after falling onto his upper arm while bouldering is presented. This is the first description of this rare injury after a climbing accident. Moreover, there is no definitive consensus on whether and when surgical intervention is necessary in such a case. We performed a direct end-to-end suture of the muscle belly through an open surgical approach. Postoperatively, we performed a detailed follow-up, including clinical examinations and sonography and magnetic resonance imaging to check the integrity of the suture. After 6 mo, our patient had regained a full range of motion without functional complaints or pain. Concerning the sports-specific outcome, we only found a slight decrease in rock-climbing abilities (Union Internationale des Associations d'Alpinisme Scale of Difficulty grade VII+ postsurgery compared to VIII preinjury). In conclusion, we suggest that early surgical reapproximation of the muscle belly might be the best treatment option for this severe but rare injury in athletes.

Distal insertional anatomy of the triceps brachii muscle: MRI assessment in cadaveric specimens employing histologic correlation and Play-doh® models of the anatomic findings

OBJECTIVES

Assess the insertional anatomy of the distal aspect of the triceps brachii muscle using magnetic resonance imaging (MRI) in cadavers with histologic correlation and Play-doh^® models of the anatomic findings.

MATERIALS

Elbows were obtained from twelve cadaveric arm specimens by transverse sectioning through the proximal portion of the humerus and the midportion of the radius and ulna. MRI was performed in all elbows. Two of the elbow specimens were then dissected while ten were studied histologically. Subsequently, Play-doh^® models of the anatomic findings of the distal attachment sites of the triceps brachii muscle were prepared.

RESULTS

MRI showed a dual partitioned appearance of the distal attachment sites into the olecranon in all specimens. In the deeper tissue planes, the medial head muscle insertion was clearly identified while superficially, the terminal portion of the long and lateral heads appeared as a conjoined tendon. Histologic analysis, however, showed continuous tissue rather than separate structures attaching to the olecranon.

CONCLUSION

Although MRI appeared to reveal separate and distinct attachments of the triceps brachii muscle into the olecranon, histologic analysis delineated complex but continuous tissue related to the attachments of the three heads of this muscle. The Play-doh^® models were helpful for the comprehension of this complex anatomy and might serve as a valuable educational tool when applied to the analysis of other musculoskeletal regions.

Surgical treatment of distal biceps tendon rupture: a case report

Objectives. Distal biceps tendon rupture affects the functional upper-extremity movement, impairing supination and flexion strength. According to age, profession and additional risks treatment might be nonoperative or surgical. Methods. We describe the case of a 43 years old male patient who sustained an injury to his right distal biceps and was diagnosed with acute right distal biceps rupture. Surgical treatment was decided and biceps tendon was reinserted to the radius tuberosity using a combination of a cortical button fixation associated with an interference screw. Results. Postoperative functional result was favorable with no complications and with no movement limitation after one month. Conclusions. When possible, distal biceps tendon repair should be realized surgically because this permits restoring of the muscle strength to near normal levels with no loss of motion. Nerve complications are common; therefore the surgery should be realized by experienced upper extremity surgeons.