Acute failure of distal biceps reconstruction: a case report

Diagnosis, Etiology and Outcomes of Revision Distal Biceps Tendon Reattachment

PURPOSE

To evaluate the incidence, etiology, and clinical outcomes after revision distal biceps tendon repair. We hypothesized that re-ruptures are rare and can be reattached with satisfactory results.

METHODS

Cases were identified from the case log of the senior author. Demographic information, details regarding the primary repair and subsequent injury, time between reinjury and reattachment, and operative findings were recorded. Clinical outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) and American Shoulder and Elbow Surgeons-Elbow (ASES-E) functional outcome scoring systems. Range of motion, strength, and ability to return to work were recorded.

RESULTS

We identified 10 patients with re-rupture, all of whom were men. Average age was 46 years (range, 35-57 years). Four ruptures occurred in the dominant arm. Three patients had a history of bilateral ruptures. Incidence of primary failure was 1.1%. In 6 patients, re-rupture occurred 6 days to 11 months after the primary surgery. Three patients described a sense of ripping or tearing after a specific traumatic event. Four others had persistent pain after the primary reattachment. Re-rupture resulted from the loss of fixation owing to technical error, the suture pulling out from the tendon, or suture breakage. Two patients required an allograft. The hook test was abnormal in 3 patients. Magnetic resonance imaging results did not affect the operative plan. Nine patients returned to their former occupation. Five returned for follow-up evaluation and completion of the DASH and ASES-E self-assessment examinations. Average DASH score was 4.4 (range, 0-19) and average ASES-E was 93.2 (range, 74-100). Postoperative average elbow flexion was 141° (range, 135° to 145°), elbow extension was -12° (range, -5° to -30°), pronation was 70°, and supination was 80°. Postoperative average supination strength was 87.8% of the nonsurgical arm (range, 79% to 106%); average pronation strength was 79.2% of the nonsurgical arm (range, 50% to 110%).

CONCLUSIONS

Revision reattachment resulted in acceptable functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Reconstruction of distal biceps tendon ruptures with a cortical button

PURPOSE

Reconstruction of the ruptured distal biceps tendon is best done with a cortical button technique according to recent biomechanical studies. However, clinical outcome studies that evaluate the cortical button reconstruction technique are scarce. The purpose of this study was to evaluate the results of a cortical button reconstruction technique in patients with a traumatic distal biceps tendon rupture.

METHODS

Twenty-two patients with 24 traumatic distal biceps tendon ruptures underwent surgical treatment. Reconstructions were done using the Endobutton or Toggle Loc. Postoperative evaluation consisted of ROM, strength, stability, neurological status and standard radiographs in AP view and lateral direction. The Mayo Elbow Performance Index (MEPI) and quick Disabilities of Arm, Shoulder and Hand (qDASH) questionnaires were also obtained.

RESULTS

At a median follow-up of 22 months, the mean strength for flexion was 100 % (SD 21.3) and for supination 97 % (SD 7.8), compared to the contralateral side. There were complications in 8 patients (36 %), and heterotopic ossifications were seen on radiographs in 23 % of patients. Heterotopic ossifications were symptomatic in one patient.

CONCLUSIONS

The results after distal biceps tendon refixation with a cortical button were good according to ROM, MEPI and qDASH scores and strength. However, this procedure was accompanied with complications; in particular, the formation of heterotopic ossifications was frequently seen, though clinically relevant in only one patient.

Re-rupture rate of primarily repaired distal biceps tendon injuries

BACKGROUND

Distal biceps tendon rupture is a common injury, and primary repair results in excellent return of function and strength. Complications resulting from distal biceps tendon repairs are well reported, but the incidence of re-ruptures has never been investigated.

METHODS

A search of the Mayo Clinic's Medical/Surgical Index was performed, and all distal biceps tendon repairs from January 1981 through May 2009 were identified. All patients who completed 12 months or more of follow-up were included. All charts were reviewed and patients contacted as necessary to identify a re-rupture. We also investigated the situation causing the re-rupture.

RESULTS

We identified a total of 190 distal biceps tendon ruptures that underwent repair and met our inclusion and exclusion criteria. Of the 190 repairs, 172 (90.5%) were performed by the Mayo modification of the Boyd-Anderson 2-incision technique. Bilateral ruptures occurred in 13 patients (7.3%). Six primary ruptures (3.2%) occurred in women, 4 of the 6 being partial ruptures. Partial ruptures were found to be statistically more common than complete ruptures in women (P = .05). We identified 3 re-ruptures (1.5%), all occurring within 3 weeks of the index surgery.

CONCLUSION

The re-rupture rate after primary repair of the distal biceps tendon is low at 1.5% and occurs within 3 weeks of index repair. This appears to be due to patient compliance and excessive force placed on repairs. We also found the incidence of women who sustain a distal biceps tendon tear to be 3.2%, with partial tears being statistically more common than complete ruptures.

LEVEL OF EVIDENCE

Level IV, case series, treatment study

Primary repair of retracted distal biceps tendon ruptures in extreme flexion

BACKGROUND

Distal biceps tendon ruptures may have tendinous retraction, making primary repair difficult and calling into question the need for graft reconstruction. The decision for when to primarily fix or augment high-flexion repairs has not been addressed. We hypothesized high-flexion repairs would have good outcomes without graft augmentation. The purpose of this study was to examine allograft use and outcomes of distal biceps tendon ruptures requiring repair in greater than 60° of flexion.

METHODS

This was a retrospective case-control study 188 distal biceps tendon repairs; of these, 19 chronic and 4 acute cases were identified with repairs of >60° of flexion using a 2-incision technique. Graft need, complications, and Mayo Elbow Performance Score to assess function, were examined with a record review. Patients were surveyed regarding return to work and subjective satisfaction. A control group matched for surgeon, chronicity, and age, but without a high-flexion repair, was compared with cases by using the Student paired t test.

RESULTS

Graft augmentation was used in 1 patient with poor tendon quality. The Mayo Elbow Performance Score was 100 for all 23 patients, with extension/flexion range of motion from 3° to 138°. All were subjectively "very satisfied/satisfied," with full work return, yet 3 reported mild fatigability. There were 4 complications: 3 transient lateral antebrachial cutaneous neurapraxias and 1 rerupture at the myotendinous junction after retrauma. Differences between cases and controls were not statistically significant.

CONCLUSION

Contracted distal biceps tendons may be reliably reattached to their anatomic insertion with up to 90° of elbow flexion. This lessens the need for reconstruction in such circumstances.

Biomechanical comparison of interference screw and cortical button with screw hybrid technique for distal biceps brachii tendon repair

Various fixation techniques have been described for ruptured distal biceps tendons. The authors hypothesized that no significant differences would be found between the mean failure strength, maximum strength, and stiffness of the interference screw and hybrid technique. Fourteen fresh-frozen human cadaveric elbows were prepared. Specimens were randomized to either interference screw or hybrid cortical button with screw fixation. The tendon was pulled at a rate of 4 mm/s until failure. Failure strength, maximum strength, and stiffness were measured and compared. Failure strength, maximum strength, and stiffness were 294±81.9 N, 294±82.1 N, and 64.4±40.5 N/mm, respectively, for the interference screw technique and 333±129 N, 383±121 N, and 56.2±40.5 N/mm, respectively, for the hybrid technique. No statistically significant difference existed between the screw and hybrid technique in failure strength, maximum strength, or stiffness (P>.05). The interference screws primarily failed by pullout of the screw and tendon, whereas in the hybrid technique, failure occurred with screw pullout followed by tearing of the biceps tendon. The results suggest that this hybrid technique is nearly as strong and stiff as the interference screw alone. Although the hybrid technique facilitates tensioning of the reconstructed tendon, the addition of the cortical button did not significantly improve the failure strength of the interference screw alone.

Distal biceps tendon rupture: an in vitro study

BACKGROUND

Options for repair of distal biceps tendon ruptures are well-described. However, scant data exist in the literature regarding failure strength of the native tendon. We hypothesize that a) the distal biceps tendon failure strength is sensitive to loading angle, and b) the failure strength is greater than what has been previously reported in the literature.

METHODS

15 radii were potted in a simulated supine position, and the native tendon was pulled from the tuberosity at angles of 90, 60, and 30° of flexion (5 per group) relative to the long axis of the radius. The failure load and stiffness were recorded and compared.

FINDINGS

The native tendon's mean failure load tended to increase as flexion angle decreased. Due to the large variability in strength, mean failure loads of the 90° (mean 358 (SE 117N)), 60° (mean 617 (SE 141N)), and 30° (mean 762 (SE 130N)) groups were not statistically different from each other (P=0.12). The mean stiffness results for each group (mean 501 (SE 176N/mm), mean 763 (SE 226N/mm), and mean 756N (SE 179N/mm), respectively) were not significantly different from each other (P>0.6).

INTERPRETATION

The load to failure of the distal biceps tendon may be higher than what has previously been reported, and may be dependent on the elbow flexion angle. Though this difference may be attributed to the difference in methodology it should be taken into account during consideration of repair and rehabilitation.

Failed distal biceps tendon repair using a single-incision EndoButton technique and its successful treatment: case report

Surgical repair has become a mainstay in the treatment of ruptures of the distal biceps tendon and multiple surgical techniques have been described advocating anatomic or near-anatomic repair. Fixation with an EndoButton technique has been shown to have superior fixation strength and durable clinical outcomes. Here, we describe a case of failed EndoButton fixation of the distal biceps tendon, and its successful treatment.

Complications of distal biceps tendon repairs

Surgical repair is the most reliable method of restoring flexion and supination strength of the elbow and forearm after acute rupture of the distal biceps tendon. Although there may be small measurable deficits in power, endurance, and terminal forearm rotation when carefully evaluated, most of the patients regain near normal upper extremity motion and function and can return to preinjury activities. There are currently 2 basic surgical approaches for distal biceps tendon repair, using 1 anterior incision or using 1 anterior and 1 lateral incision. Anterior repair alone has the advantage of a minimal risk of heterotopic bone formation, but carries a greater chance of injury to the posterior interosseous nerve. In turn, the 2-incision technique markedly diminishes the risk of radial nerve palsy, but is associated with a greater likelihood of heterotopic bone formation limiting forearm rotation. Rerupture of the distal biceps tendon after repair is uncommon with either technique, and the risk of all complications seems to increase with a delay in surgical intervention after rupture. When motion limiting heterotopic ossification does occur, surgical resection can proceed when the process becomes mature as defined by plain radiographs. Fortunately, functional forearm motion can be commonly restored in these cases with careful attention to surgical details and postoperative rehabilitation.