Complete rupture of the distal biceps brachii tendon in female patients: a report of 2 cases

Female patient with bilateral distal biceps tendon reconstruction: A case report

This is a case of a 57-year-old healthy woman with traumatic bilateral distal biceps tendon rupture with tendon retraction requiring reconstruction. The functional outcomes were recorded pre-operatively and at 3 months, 6 months, 1 year and 2 years postoperatively. Conclusion: Distal biceps tendon rupture usually occurs in male patients; however, this injury may occur in females. Delay in treatment may result in tendon degeneration precluding repair. Distal biceps tendon reconstruction with Achilles allograft yielded favorable outcome in a middle-aged female patient who sustained bilateral distal biceps tendon rupture.

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.

Distal Biceps Repairs in Females: A Large Single-Center Case Series

BACKGROUND

Distal biceps repair is a commonly reported procedure in male patients, with reliable outcomes and minimal long-term complications. Information on female patients, however, is limited, and variation in presentation and clinical outcomes is unknown.

QUESTIONS/PURPOSE

We sought to report on the presentation, treatment algorithm, and outcomes of a case series of female patients with distal biceps pathology.

METHODS

A retrospective evaluation was performed from a large, single specialty orthopedic group from 2005 to 2017. Inclusion criteria were surgical treatment of the distal biceps in female patients, with minimum 3 months of follow-up. The primary outcome variable was the Mayo Elbow Performance Score (MEPS).

RESULTS

Of 26 patients who met inclusion criteria, 18 (70%) were available for follow-up with patient-reported outcomes. Median age at time of injury was 56.1 years; 46.2% of patients presented with a complete tear of the distal biceps, and the remaining 53.8% presented with a partial tear that failed nonoperative treatment. Six patients had lateral antebrachial cutaneous neuritis in early follow-up, which ultimately resolved. Median MEPS score was 100 (interquartile range: 20).

CONCLUSION

This study represents the largest case series to date describing the presentation, treatment, and outcomes of female patients with distal biceps repair. Women tend to be older than men, have more insidious onset of pain, present with partial tearing, and may benefit from nonoperative treatment. Ultimately, based on this case series we believe distal biceps repair in female patients is a successful operation with minimal complications and high patient satisfaction.

Injuries in Muscle-Tendon-Bone Units: A Systematic Review Considering the Role of Passive Tissue Fatigue

Background:

Low-cycle fatigue damage accumulating to the point of structural failure has been recently reported at the origin of the human anterior cruciate ligament under strenuous repetitive loading. If this can occur in a ligament, low-cycle fatigue damage may also occur in the connective tissue of muscle-tendon units. To this end, we reviewed what is known about how, when, and where injuries of muscle-tendon units occur throughout the body.

Purpose:

To systematically review injuries in the muscle-tendon-bone complex; assess the site of injury (muscle belly, musculotendinous junction [MTJ], tendon/aponeurosis, tendon/aponeurosis–bone junction, and tendon/aponeurosis avulsion), incidence, muscles and tendons involved, mechanism of injury, and main symptoms; and consider the hypothesis that injury may often be consistent with the accumulation of multiscale material fatigue damage during repetitive submaximal loading regimens.

Methods:

PubMed, Web of Science, Scopus, and ProQuest were searched on July 24, 2019. Quality assessment was undertaken using ARRIVE, STROBE, and CARE (Animal Research: Reporting In Vivo Experiments, Strengthening the Reporting of Observational Studies in Epidemiology, and the Case Report Statement and Checklist, respectively).

Results:

Overall, 131 studies met the inclusion criteria, including 799 specimens and 2,823 patients who sustained 3,246 injuries. Laboratory studies showed a preponderance of failures at the MTJ, a viscoelastic behavior of muscle-tendon units, and damage accumulation at the MTJ with repetitive loading. Observational studies showed that 35% of injuries occurred in the tendon midsubstance; 28%, at the MTJ; 18%, at the tendon-bone junction; 13%, within the muscle belly and that 6% were tendon avulsions including a bone fragment. The biceps femoris was the most injured muscle (25%), followed by the supraspinatus (12%) and the Achilles tendon (9%). The most common symptoms were hematoma and/or swelling, tenderness, edema and muscle/tendon retraction. The onset of injury was consistent with tissue fatigue at all injury sites except for tendon avulsions, where 63% of the injuries were caused by an evident trauma.

Conclusion:

Excluding traumatic tendon avulsions, most injuries were consistent with the hypothesis that material fatigue damage accumulated during repetitive submaximal loading regimens. If supported by data from better imaging modalities, this has implications for improving injury detection, prevention, and training regimens.

Shoulder and elbow pathology in the female athlete: sex-specific considerations

Unique biologic and biomechanical aspects of the female body make women more prone to certain orthopedic injuries. Sex differences are well understood with regard to certain orthopedic pathologies such as anterior cruciate ligament injury, hallux valgus, carpal tunnel, and carpometacarpal joint arthritis; however, sex differences are less commonly discussed with regard to shoulder and elbow pathology. The purpose of this review is to elucidate sex differences specific to sports-related shoulder and elbow injuries in the female athlete population.

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 and triceps ruptures

Biceps and triceps tendon ruptures are rather uncommon injuries and are most commonly diagnosed clinically. Magnetic resonance imaging can help the clinician to differentiate an incomplete tear and define any degeneration of the tendon. Surgical anatomical repair is typically performed in acute complete ruptures whereas nonoperative treatment can be used for partial ruptures, as well as for patients unfit for surgery. Single incision techniques are associated with a higher rate of nerve injuries, while double incision repairs have a higher prevalence of heterotopic ossification. Although various fixation methods have been applied including bone tunnels, interference screws, suture anchors, cortical button fixation, the current evidence does not support the superiority of one method over the other. A well-planned postoperative rehabilitation programme is essential for a good final outcome. As better fixation devices are being used, more aggressive rehabilitation programmes have been applied. Epidemiology, clinical evaluation, diagnosis, surgical and conservative management of these injuries are presented in this review along with the authors' preferred technique for the anatomical repair of acute complete ruptures.

The role of tenodesis in surgery of the upper limb

This paper describes the presence of tenodesis effects in normal physiology and explores the uses of operative tenodesis in surgery of the upper limb.

[Results of transosseous reattachment for distal rupture of the biceps tendon. Evaluation of results]

Avulsion of the distal biceps brachii tendon is an uncommon injury. This is a retrospective review of cases operated in our department by transosseous suture fixation on the radial tuberosity, using the single anterior incision. Between 2000 and 2007, a total of 10 patients with distal biceps tendon injury were included. All were men, with an average age of 39 years. The most common mechanism was passive extension against active flexion. The dominant limb was affected in all patients. Clinical diagnosis was the rule. Surgical reattachment to the radial tuberosity through the anterior approach to the elbow was performed. The preoperative period was one week in three cases, between one and three weeks in five cases, and superior to three weeks in two cases. Clinical and instrumental evaluation of the results was done. Average follow-up was 48 months. Subjective results were good in seven cases, acceptable in two cases and poor in one case. Nine patients return to their previous level activity with no limitations. The average range of motion was 0° of extension to 135° of flexion. Strength testing of the injured limbs, compared to the contralateral, using the criteria described by Baker and Bierwagen, revealed a loss of 22% of supination strength and 32% of supination endurance. There was a loss of 14% of flexion strength and 27% of flexion endurance. There were two cases of superficial surgical site infection. There were no cases of nerve damage or heterotopic bone formation. Two main factors were found to explain the poor outcomes: experience of the surgeon and a long preoperative delay. Despite the limitations of this study, we found that transosseous reattachment of the biceps' distal tendon to the radial tuberosity can restore supination. Strength and endurance for supination can be better restored by early intervention. Complications are easily avoided if surgery is performed early and by experts.

Distal biceps tendon tears in women

HYPOTHESIS

Is the presentation and outcome of surgical treatment of distal biceps tendon tears different in women than men?

MATERIALS AND METHODS

From 1999 to 2008, 15 cases of distal biceps tendon tears in 13 female patients were treated surgically at a single institution. Mean age was 63 years (range, 48-79 years). A retrospective review evaluated patient presentation, diagnosis, and treatment. Postoperative outcomes were assessed by physical examination, a patient satisfaction survey, the American Shoulder and Elbow Surgeons (ASES) elbow assessment form, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

RESULTS

Two-thirds of the tears were in the dominant arm, of which 7 resulted from a single injury, and 8 reported insidious onset of symptoms. All patients presented with pain in the antecubital fossa. A distinct cystic mass was palpable in 6. Of the 15 cases, 13 were partially detached, 1 was completely detached, and 1 was weakly attached. Fourteen regained full strength, and all had nearly complete range of motion. Mean follow-up was 46 months (range, 2-117 months). Eleven completed a postoperative patient satisfaction survey, ASES elbow, and DASH questionnaire. Mean scores were 95 (range, 58-100) for ASES and 7 (range, 0-43) for DASH. The only complication was a transient lateral antebrachial cutaneous nerve sensory palsy.

DISCUSSION

Distal biceps tendon tears in women present at an advanced age with no history of an acute injury. They are frequently associated with a cystic mass and have a predominance of partial tears.

CONCLUSIONS

Distal biceps tendon tears in women present differently than in men. The tears are rarely complete and they respond well to surgical repair.

Biceps tendon injuries in athletes

Although rare, athletes involved in competitive strength training and contact sports may sustain distal tendon biceps injuries. Treatment of complete distal biceps tendon ruptures in athletes is primarily surgical. Early repair, through either one-incision or two-incision techniques with anatomic reinsertion of the ruptured tendon to the bicipital tuberosity, is highly recommended. In this article the etiology and pathophysiology of distal biceps tendon ruptures, current diagnostic modalities, and surgical indications are discussed. Also, treatment options, surgical techniques, outcomes, and potential complications are reviewed.

Bilateral ruptures of the distal biceps brachii tendon

BACKGROUND

The purpose of this study was to identify characteristics associated with bilateral ruptures of the distal biceps tendons.

METHODS

We present a retrospective case series of 25 patients who sustained non-simultaneous bilateral distal biceps brachii tendon ruptures that were repaired surgically, with follow-up available on 10 patients. The average age of the patients was 50 years (range 28-76). All patients were male. The mean time from the first tendon rupture to the contralateral tendon rupture was 2.7 years (range 0.5 - 6.3). Follow-up averaged 45 months (range 24-85).

RESULTS

Patients with bilateral ruptures tended to be middle-aged men, who commonly participated in weight lifting, manual labor, or sports, and who had higher rates of nicotine (50%) and anabolic steroid use (20%) than the general population. After surgical repair of 9 of 10 patients, patients with bilateral distal biceps tendon ruptures had good to excellent outcomes. With the numbers available, outcomes were not statistically associated with manual labor, past medical history, prescription medications, prior tendon injury, body mass index, current activity in sports, use of nutritional supplements, or anabolic steroid use, although worker's compensation claims approached statistical significance (p = 0.059).

CONCLUSIONS

Patients who sustained bilateral distal biceps tendon ruptures tended to be middle-aged men with higher rates of nicotine and anabolic steroid use than the general population.

Anatomical refixation for acute ruptures of the distal biceps tendon using a novel transcortical refixation system

INTRODUCTION

In this study, minimally invasive CurvTek refixation is introduced as a novel approach for repair of distal biceps tendon ruptures. Exploration at the radial tuberosity is minimized using CurvTek, thereby reducing operative trauma. Treatment outcomes were compared for this technique against the conventional technique. In addition, we introduce position-dependent isometric myometry to allow quantitative measures of post-operative strength at specific elbow joint positions, for improved comparative analyses.

MATERIALS AND METHODS

Eighteen patients were included in this study and the mean follow-up was 17.6 months (range 6-35, SD +/- 6.9). Nine patients underwent conventional anatomical refixation, while the remaining nine patients underwent anatomical refixation using CurvTek-sutures. Clinical results and position-dependent strength were compared.

RESULTS

Mean age was 49.8 years (range 38-61; SD +/- 5.8). The average EFA-score was 82.2 (range 61-97; SD +/- 9.8). The CurvTek group scored a mean 87.0 (range 77-97; SD +/- 7.0) and the conventional anatomical refixation group a mean 77.4 (range 61-93; SD +/- 10.2) (P = 0.091). Position-dependent dynamic myometry revealed a loss of strength at end stage flexion and supination in the injured arm. Comparison of the two groups, revealed a statistically significant improvement in relative supination strength in the maximally supinated position for patients of the CurvTek group over those undergoing conventional refixation (P = 0.009).

CONCLUSION

Our results show that the CurvTek system leads to good post-operative strength and ROM without increasing the complication rate.

Distal biceps rupture

Recognition and treatment of distal biceps tendon ruptures is increasing, likely because of greater clinical awareness and the greater activity and demands of the middle-aged population. This article focuses on the proper evaluation and treatment of distal biceps tendon ruptures with special attention focused on recently developed techniques. A review of the recent clinical literature will accompany an overview of pertinent biomechanical studies and an explanation of the risks and benefits of the most popular surgical techniques for distal biceps repair.

Distal biceps tendon insertion: an anatomic study

Knowledge of the exact location of the distal biceps brachii insertion is crucial when performing tendon reconstruction or repair. To quantitatively describe the morphology of the distal biceps brachii insertion, 20 cadaveric arms were examined. Linear and angular measurements, including the footprint dimensions and shape, radial tuberosity dimensions and irregularities, and the rotational position of the tuberosity and footprint, were obtained. The axial and transverse dimensions of the radial tuberosity and distal biceps tendon footprint measured 24.2 x 12 mm and 18.7 x 3.7 mm, respectively. The insertion footprint is on the posterior/ulnar aspect of the radial tuberosity centered at approximately 30 degrees anterior to the lateral/coronal plane with the forearm fully supinated. This explains why any preoperative limitation in supination may make an anatomic repair difficult through a single anterior incision. To our knowledge, this is the first study to quantitatively describe the angular location of the radial tuberosity and the relationship of the distal biceps tendon on the tuberosity.

Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair

BACKGROUND

Recent technical improvements have led the way to a resurgence of the single-incision approach for repair of distal biceps tendon injuries. There has been no biomechanical evaluation of all these techniques with comparison to the standard 2-incision bone tunnel technique.

HYPOTHESIS

There will be no difference under cyclic loading and ultimate failure between the 2-incision bone tunnel technique, suture anchor repair, interference screw, and EndoButton techniques for the repair of distal biceps tendon ruptures.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixty-three fresh-frozen cadaveric elbows were randomly assigned to 4 treatment groups (bone tunnel, EndoButton, suture anchor, interference screw). Cyclic loading was then performed from 0 degrees to 90 degrees at 0.5 Hz for 3600 cycles with a 50-N load. A differential variable reductance transducer was placed between the radius and distal tendon to determine displacement. The construct was then pulled to failure at 120 mm/min.

RESULTS

A multiple analysis of variance revealed no statistically significant difference for displacement among the 4 repair techniques. Displacement using the bone tunnel was 3.55 mm, EndoButton was 3.42 mm, suture anchor was 2.33 mm, and interference screw was 2.15 mm. There was a statistically significant greater load to failure with EndoButton (440 N) than suture anchor (381 N), bone tunnel (310 N), or interference screw (232 N) (P < .001).

CONCLUSION

The EndoButton technique had the highest load to failure.

CLINICAL RELEVANCE

These data demonstrate the EndoButton to be the strongest repair technique, with no failures during cycling at physiologic loads and with the largest load to failure. These findings are important in maximizing surgical results and stability and suggest that the construct can tolerate early postoperative active range of motion.

Complete rupture of the distal biceps tendon in a woman: case report

Complete ruptures of the distal biceps tendon are rare in women. The pathogenesis and gender bias of distal biceps ruptures remain poorly understood. We report a case of a woman with a complete distal biceps rupture who had a successful 1-incision repair with bone anchors.

Biceps tendon and triceps tendon injuries

Injuries to the biceps and triceps tendons about the elbow are relatively infrequent. Typically, they are traumatic events that occur as a result of a forceful eccentric contraction. Early recognition of these injuries and prompt intervention are the cornerstones to a successful outcome. Acute anatomic repair of complete injuries offers predictably good results. Conservative management, on the other hand, is typically reserved for partial injuries with little functional compromise, and for patients unfit for surgery. The challenges posed by chronic injuries can be addressed with a variety of surgical options. This article focuses on the timely identification and diagnosis of these injuries and specific indications and guidelines for their treatment.