Vascular anatomy relevant to distal biceps tendon repair

Ultrasonographic Evaluation of the Optimal Needle Position in the Supinator Muscle

BACKGROUND AND PURPOSE

Investigating the supinator muscle (SUP) is important for diagnosing radial neuropathy or cervical radiculopathy in needle electromyography (EMG). However, different authors have proposed several locations for needle EMG placement in the SUP. This study aimed to determine the optimal needle insertion position for examining the SUP via needle EMG under ultrasonographic guidance.

METHODS

This study included 16 male (32 upper limbs) and 15 females (30 upper limbs). In the supine position, the line connecting the midpoint of the dorsal wrist to the upper margin of the radial head (RH) (RH_WRIST line) was measured while the forearm was pronated. Under ultrasonographic guidance, the thickness of the SUP was measured at 1-cm intervals from the RH to 4 cm along the RH_WRIST line. Moreover, the horizontal distance (HD) from the RH_WRIST line to the posterior interosseous nerve (PIN) and the distance from the RH to the point where the RH_WRIST line and the PIN intersected (VD_PIN_CROSS) were measured.

RESULTS

VD_PIN_CROSS was 51.25±7.0 mm (mean±SD). The muscle was the thickest at 3 cm (5.6±0.8 mm) and 4 cm (5.4±1.0 mm) from the RH. The distances from the PIN to these points were 14.1±3.9 mm and 9.0±4.3 mm, respectively.

CONCLUSIONS

Our findings suggest that the optimal needle placement is at 3 cm from the RH.

Single Incision Modified Tension Slide Technique in Distal Biceps Repair: Improved Load to Failure While Reducing Surgical Pitfalls

Historically, distal biceps tendon repair through the tension slide technique (TST) using a cortical button has yielded the strongest published repair measured by observed gap formation in both cyclic and maximal load to failure. The modified tension slide technique (MTST) was developed in order to provide the surgeon with a technically simpler and biomechanically more effective way to reduce gap formation and consistently seat/bottom-out the tendon within the bone tunnel through a more direct line of pull. In order to compare the biomechanics of the MTST to the TST, we used 24 matched bovine extensor tendons, and conducted maximal load to failure and cyclical load to failure testing using an Instron 5566 machine. The mean maximal load to failure for the MTST was 444 N versus 229 N for the TST ( P <0.004) while no gap formation was observed in either group after cyclic load testing. These findings indicate that the MTST has a statistically significant increased load to gap formation of ∼2-fold in comparison to TST. In the MTST both limbs of suture are passed back through the tendon, before button implantation, eliminating the "operating in a hole" effect required in the TST, and making for a simpler surgical procedure.

Optimal placement for needle electromyography of the supinator muscle: Cadaveric studies

INTRODUCTION/AIMS

The existing methods for needle electromyography are confusing as to which is the safest and most effective. Our aim was to identify the optimal and safest needle electromyographic insertion site in the supinator muscle.

METHODS

We performed a two-step cadaveric dissection of the supinator muscle and related neurovascular structures. The study was performed using 18 upper limbs of 9 fresh adult cadavers (step 1) and 14 upper limbs of 7 fresh adult cadavers (step 2). In step 1, an imaginary line connecting the radial head (RH) and midpoint of the dorsal wrist (RW line) was drawn, and the distance from the RH to the point where the RW line and posterior interosseous nerve (PIN) intersect (L_CROSS) was measured on the RW line. In step 2, the needle was inserted 30 mm distal to the RH according to the results of step 1. After injection with India ink, dissection was performed to measure the distance between the needle insertion site and PIN (L_CROSS_Inj) on the RW line.

RESULTS

The median L_CROSS was 51.4 (35.5-65.6) mm. Needle insertion spared the PIN in all cases during step 2, and the needle was inserted into the supinator muscle in all cases. The median L_CROSS_Inj was 27.4 (13.2-39.8) mm.

DISCUSSION

A safe and accurate needle insertion site for the supinator muscle is approximately 30 to 40 mm distal to the RH along the RW line.

"All-Endoscopic" Management of Refractory Elbow Bicipitoradial Bursitis and Partial Distal Biceps Tendon Tears

Elbow bicipitoradial bursitis and partial distal biceps tendon (DBT) tears are a result of chronic overuse or other infective/inflammatory pathology and may be refractory to conservative treatment. The all-endoscopic approach provides minimally invasive access to the bursal space and DBT, and diagnostic and therapeutic procedures can be performed under direct endoscopic vision. The technique uses 2 portals, the proximal parabiceps portal and distal anterior portal, and the bursa is insufflated to create a working space. Tissue biopsies are obtained under direct endoscopic visualization, and debridement along 6 bursal zones can be effectively performed. An endoscopic probe test is demonstrated for assessment of partial DBT tears, and low-grade tears are debrided to stable tissue. The all-endoscopic technique is safe and reproducible, and it is a stepping-stone in the learning curve of all-endoscopic repair and reconstruction of distal biceps ruptures.

Acute complete and partial distal biceps tendon ruptures: what have we learned? A review

Acute distal biceps tendon (DBT) pathology includes bicipitoradial bursitis, tendinosis, partial and complete tears.

Diagnosis of complete DBT tears is mainly clinical, whereas in partial tears medical imaging is a valuable addition to the clinical diagnosis.

New insights in clinical and medical imaging of partial tears may reduce time to diagnosis and may guide the treatment plan.

Most complete tears are best treated with primary repair using either a single-incision or double-incision approach with good clinical outcome.

The double-incision technique has a higher risk of heterotopic ossification, whereas a single-incision technique carries a higher risk of nerve-related complications.

Intramedullary fixation may be a viable solution to negate the risk of posterior interosseus nerve lesions in single-incision repairs.

DBT endoscopy can be used to treat low-grade partial tears and tendinosis.

Cite this article: EFORT Open Rev 2021;6:956-965. DOI: 10.1302/2058-5241.6.200145

[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.

Dynamic Brachial Artery Entrapment After Distal Biceps Repair: A Case Report

CASE

A 57-year-old man presented with paleness and coolness of the hand with elbow flexion 4 months after primary distal biceps repair. Diagnosis of dynamic brachial artery entrapment was confirmed with ultrasound and Magnetic Resonance Angiography. During revision surgery, the brachial artery was identified traveling underneath the repaired distal biceps tendon. After revision surgery, the patient made a full recovery with no residual symptoms.

CONCLUSION

Adverse vascular events have been rarely reported in distal biceps repairs. Before and immediately after repair, the path of the tendon should be critically evaluated to ensure neurovascular structures were not placed under the repaired tendon.

Partial rupture of the distal biceps brachii tendon: a magnetic resonance imaging analysis

BACKGROUND

This study is the largest cohort of partial distal biceps brachii tendon ruptures in the literature that was analyzed according to rupture morphology of the long and short tendon heads.

METHODS

Patients with partial distal biceps tendon ruptures were identified using an institutional enterprise data warehouse query at a single institution. A retrospective chart review was performed to record patient demographics, past medical history, and injury mechanism for each patient. Each patient's magnetic resonance images were reviewed to determine injury patterns, specifically the extent of long head (LH) and short head (SH) tendon involvement, and associated injuries. Rupture morphologies were correlated with mechanism of injury, diabetes status, and smoking history.

RESULTS

Seventy-seven patients were included in the study. The average age was 52 years (±11.9, range: 23-90 years); 67% were male, with an average body mass index of 28.3 (±4.3). A smoking history was reported in 31.2% of patients and 5.2% were diabetic. The partial ruptures were caused by a traumatic mechanism in 57.1% of cases, 23.4% were atraumatic, and 19.5% had an unknown mechanism. The most common injury morphology was a partial LH rupture with an intact SH tendon (33.8%). Isolated complete ruptures of the LH represented the least common injury morphology. Injury morphology was significantly related to mechanism (P < .01). Traumatic ruptures had a higher percentage of SH involvement compared with the atraumatic group (77.3% vs. 37.7%, respectively). In contrast, atraumatic ruptures involved the LH tendon in 89% of cases, with only 37.7% of cases involving the SH tendon. Patients with a history of smoking were more likely to have an atraumatic mechanism (P = .01). A history of diabetes was unrelated to mechanism (P = .20).

CONCLUSION

Partial ruptures of the distal biceps brachii tendon represent a spectrum of patterns with varying involvement of the LH and SH tendons. Injury morphology was significantly related to mechanism (P < .01). LH tendon involvement was seen in 88.9% of atraumatic cases, whereas SH tendon involvement was seen in 77.3% of traumatic cases. A more comprehensive understanding of partial rupture patterns is critical to further understand the risk factors that may preclude to worse clinical outcomes, and aid in deciding which patients would benefit from operative vs. nonoperative management.

Acute distal biceps tendon ruptures: anatomy, pathology and management - state of the art

All patients with acute complete distal biceps tendon ruptures who are not low demand or medically unfit to proceed with surgery are offered operative repair. This restores arm shape, supination strength and function, and decreases their cramping symptoms. Surgical repair technique varies significantly depending on location and training centre. Nuances in technique and appropriate implant selection need to be noted in order to achieve a strong repair allowing early active range of motion. Intimate knowledge of distal biceps tendon anatomy is key to avoid complications associated with the different approaches. The cumulative body of evidence on complications, coupled with knowledge of the different biomechanical construct strengths of the alternative methods of fixation, points to the use of the cortical button technique without the addition of an interference screw. Subtle variations in drill hole positioning on the bicipital tuberosity secures either an anatomic or non-anatomic repair. Anatomic repair results in greater supination peak torque and fatigue strength, and in greater flexion fatigue strength. It is advisable to perform an anatomic repair in elite athletes or those patients who significantly rely on supination strength and endurance for their livelihood. A universal postoperative protocol is suggested for all repairs.

High Bifurcation of the Brachial Artery: An Embryological Overview

The brachial artery is the main artery of the arm and constitutes the continuation of the axillary artery. It gives off two terminal branches, the radial and ulnar arteries. According to the literature, the brachial artery might present a deviation from the normal pattern in 20% of the cases. High bifurcation of the artery seems to be the most common variation and may result in a series of complications during surgery and interventional radiology. An embryological overview is necessary for a better understanding of this variant. The brachial artery is being developed during embryonic life by the main trunk of the axis artery. The superficial brachial artery is also an important stable fetal vessel for normal arterial morphogenesis of the upper limb.

Analysis of technical feasibility and neurovascular safety of endoscopic distal biceps repair: a cadaveric study

BACKGROUND

This cadaveric study was designed to analyze the safety of endoscopic repair of distal biceps tendon (DBT) tears using 2 reattachment techniques. We evaluated the proximity of neurovascular structures to endoscopy portals; iatrogenic injury to neurovascular, musculotendinous, and osseous structures; and changes in compartment pressures. We hypothesized that an all-endoscopic repair of the ruptured DBT would be technically safe and the risk of iatrogenic injury would be low.

METHODS

A 2-portal endoscopic tendon repair was performed in 28 fresh-frozen cadaveric elbows with button devices (with or without interference screws) (n = 17) and suture anchors (n = 11). Dissection was performed, and neurovascular, musculotendinous, and osseous structures were assessed for iatrogenic injury. The repair construct (tendon-tuberosity contact area and implant placement site) was evaluated, and compartment pressures were measured. Statistical analysis was performed to determine significant differences in iatrogenic injury, compartment pressure changes, and tendon-bone contact area between different devices.

RESULTS

The lateral cutaneous nerve, cephalic vein, and radial artery were in close proximity to the portals. The button group showed a significantly higher number of iatrogenic injuries than the anchor group (P = .036). All-suture anchor repair showed a significantly higher contact area (mean, 85 mm²) than repairs with all other devices (P < .001). Compartment pressures increased by 2-4 mm in each of the 3 compartments tested (P < .001).

CONCLUSION

Endoscopic DBT repair was technically feasible with both fixation techniques. Button devices were associated with a significantly higher number of iatrogenic injuries. Endoscopic repair with dual suture anchors was safe in cadavers; however, further clinical results are necessary to establish the clinical safety of this technique.

Distal Biceps Tendon Anatomic Repair

Distal biceps injuries, which usually occur in active middle-aged men, can result in chronic pain and loss of supination and flexion strength³,⁴. Surgical repair of a ruptured distal biceps tendon can reliably decrease pain and improve strength compared with nonoperative management³,⁴. However, even following successful healing and rehabilitation of a surgically repaired biceps tendon, full supination strength is rarely restored⁵-⁷. The expected outcome following distal biceps repair using a traditional anterior approach is a measurable loss of rotational strength, especially from neutral to supinated positions⁵,⁷. This deficit can lead to difficulty with occupational and recreational activities⁵,⁸. The center of an uninjured biceps tendon inserts into the radial tuberosity 6.7 mm anterior to its apex⁹,¹⁰. This posterior location forces the biceps tendon to wrap around the radial protuberance during pronation, thus utilizing the protuberance as a mechanical cam during forceful forearm supination¹⁰,¹¹. The distal biceps tendon comprises a medial short head and lateral long head; the 2 heads are continuations of the proximal muscles²,²⁰,²¹. The short head inserts distal to the long head on their radial attachment site²,²⁰,²¹. Performing a distal biceps repair via an anterior approach typically places the center of the reattachment site 12.9 mm anterior to its apex or approximately 6 mm anterior to an uninjured control tendon⁹. This shifts the repair site from its anatomic location (posterior to the radial protuberance) to a new nonanatomic location (on top of the protuberance). This anterior reattachment location decreases the cam effect of the radial protuberance, resulting in an average supination loss of 10% in neutral rotation and 33% in 60° of supination⁷,¹⁰. A posterior approach to the radial tuberosity using 2 separate intramedullary buttons for the short and long heads reliably positions the distal biceps insertion at its anatomic footprint, which is posterior to the radial protuberance⁹,¹⁰,¹¹. This technique has been named the distal biceps tendon anatomic repair. Not only does it restore the normal supination cam effect of the radial protuberance, but it also provides superior initial fixation strength, with load to failure strength similar to the native tendon¹. The distal biceps anatomic repair can be divided into the following 9 key steps: Step 1: Preoperative planning; Step 2: Positioning; Step 3: Identifying and retrieving the tendon; Step 4: Preparing the 2 heads of the tendon; Step 5: Posterior exposure of tendon footprint; Step 6: Drilling the short and long-head drill holes; Step 7: Passage of the tendon; Step 8: Unicortical button fixation; Step 9: Alternative fixation: cortical trough; and Step 10: Postoperative management.

Endoscopic Repair of Acute and Chronic Retracted Distal Biceps Ruptures

Distal biceps tendon (DBT) ruptures are infrequent injuries that result in pain, weakness, and cosmetic deformity. Severe retraction of the ruptured DBT can occur at the time of injury, or in chronic neglected ruptures, and surgical exposure is performed using a single incision or a 2-incision technique. The technique presented here describes an endoscopic approach using 3 portals that provide access to the retracted DBT, biceps sheath, and radial tuberosity. Preoperative sonographic localization of the retracted DBT and neurovascular structures is used to guide portal placement. The parabiceps portal is used for visualization of the biceps sheath remnant, and the midbiceps portal is used to visualize and retrieve the retracted tendon in the arm. The retracted DBT is shuttled through the biceps sheath into the upper forearm, and 2 suture anchors are passed into the radial tuberosity under direct endoscopic vision. The DBT is whipstitched via the distal anterior portal, and nonsliding knots are tied to securely reattach the DBT to the prepared radial tuberosity.

Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting-2015

Understanding of the distal biceps anatomy, mechanics, and biology during the last 75 years has greatly improved the physician's ability to advise and to treat patients with ruptured distal tendons. The goal of this paper is to review the past and current advances on complete distal biceps ruptures as well as controversies and future directions that were discussed and debated during the closed American Shoulder and Elbow Surgeons meeting in 2015.