1
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Jain S, Patkar H, Mohan R. Is the Complication Rate in the Surgical Repair of the Distal Biceps Tendon Rupture Influenced by the Timing, Type of Incision and Method of Fixation? Indian J Orthop 2024; 58:79-88. [PMID: 38161394 PMCID: PMC10754795 DOI: 10.1007/s43465-023-01057-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/12/2023] [Indexed: 01/03/2024]
Abstract
Background Distal biceps tears are uncommon injuries, typically leading to significant loss of elbow flexion and supination strength; surgical repairs restore muscular strength and endurance. The aim of this study was to compare the complication rate of early (< 21 days) vs delayed (> 21 days) repair and the effect of types of incision and fixation methods used in the repair. Methods A total of 86 cases were retrospectively reviewed, and 66 cases were included in the study after exclusion. Different preoperative and intraoperative variables and postoperative outcome measures were recorded. We analysed the effects of early and delayed repair, types of incision and fixation methods on the complications. Results 31 had an early, and 35 had delayed distal biceps repair. The mean follow-up was 14.92 weeks. 13.6% had major, and 40.9% had minor complications. No significant difference was noted in complications between the two groups (54.8% vs 54.3%). Higher complications were observed when surgery was done using a single anterior incision compared to 2 anterior incisions (68.8% vs 16.7%, p=0.0002). Overall, higher (76.3% vs 25.9%, p=0.0001) complications were noted in patients where fixation was done using a cortical button & interference screw in comparison to the cortical button alone. Conclusion No significant difference in complication was noted between early and delayed repair. However, more complications were noted in the single anterior incision compared to the two anterior incision technique. Higher complications were also observed with the cortical button and interference screw fixation method compared to the cortical button alone.
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Affiliation(s)
- Sanjay Jain
- Department of Trauma and Orthopaedics, North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB UK
| | - Harshal Patkar
- Department of Trauma and Orthopaedics, Cumberland Infirmary, Newton Road, Carlisle, CA2 7HY Cumbria UK
| | - Rama Mohan
- Department of Trauma and Orthopaedics, North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB UK
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2
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Tate Q, Ferreira-Dos-Santos G, Vydra D, Ferreira-Silva N, Gupta S, Hurdle MFB. Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation of the Musculocutaneous Nerve for Refractory Antecubital ElbowPain-Brief Technical Report and Illustrative Case Report. Can J Pain 2023; 7:2249054. [PMID: 37771636 PMCID: PMC10524777 DOI: 10.1080/24740527.2023.2249054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/16/2023] [Indexed: 09/30/2023]
Abstract
Chronic pain following distal biceps rupture (DBR) is often nonspecific in that it may arise due to the injury, subsequent surgical repair, or a combination of factors, making the painful symptoms challenging to treat. Peripheral nerve injury in the setting of DBR most commonly affects the musculocutaneous nerve or one of its terminal branches and may lead to chronic neuropathic pain involving the elbow and lateral/radial aspect of the forearm. In this brief technical report, we describe an ultrasound-guided (USG) technique for percutaneous implantation of a peripheral nerve stimulator (PNS) targeting the musculocutaneous nerve, along with an illustrative case report of successful treatment of chronic refractory pain following DBR utilizing this technique. Six months postimplantation, the patient reported a greater than 60% baseline pain intensity reduction, and no complications were noted.
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Affiliation(s)
- Quinn Tate
- Department of Physical Medicine and Rehabilitation, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Guilherme Ferreira-Dos-Santos
- Division of Pain Medicine, Department of Anesthesiology, Reanimation, and Pain Medicine, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Darrell Vydra
- Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Nuno Ferreira-Silva
- Department of Physical Medicine and Rehabilitation, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Sahil Gupta
- Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
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3
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Alamir MA, Alotaibi KM. Chronic Distal Biceps Tendon Rupture With Allograft Reconstruction. Cureus 2022; 14:e30805. [DOI: 10.7759/cureus.30805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 11/07/2022] Open
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4
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Boyle AB, George CM, MacLean SBM. Anatomic factors associated with partial distal biceps tendon tears: a comparative control study. J Shoulder Elbow Surg 2022; 31:1224-1230. [PMID: 35247572 DOI: 10.1016/j.jse.2022.01.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/17/2022] [Accepted: 01/23/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is minimal literature on the anatomic factors associated with partial distal biceps tendon (DBT) tears. It has been proposed that a larger radial tuberosity size-and, therefore, a smaller radioulnar space during pronation-may cause mechanical impingement of the DBT predisposing to tears. We sought to investigate the anatomic factors that may be associated with partial DBT tears by retrospectively reviewing the DBT anatomy using 3-T magnetic resonance imaging (MRI) scans of elbows with partial DBT tears and a comparison group of normal elbows. METHODS Two independent observers retrospectively reviewed 3-T MRI scans of elbows with partial DBT tears and elbows without visible pathology. Basic demographic data were collected, and measurements of radial tuberosity length, radial tuberosity thickness, radioulnar space, and radial tuberosity-ulnar space were made using simultaneous tracker lines and a standardized technique. The ratio of radial tuberosity thickness to radial diameter and the ratio of radioulnar space to radial tuberosity-ulnar space were calculated. The presence or absence of enthesophytes and the presence of a single DBT vs. double DBTs were noted. RESULTS This study included twenty-six 3-T MRI scans of 26 elbows with partial DBT tears and thirty 3-T MRI scans of 30 elbows without pathology. Basic demographic data were comparable between the 2 groups. The tear group showed statistically significantly larger mean measurements for radial tuberosity length (24.3 mm vs. 21.3 mm, P = .002) and radial tuberosity thickness (5.5 mm vs. 3.7 mm, P < .0001). The tear group also showed statistically significantly smaller measurements for radioulnar space (8.2 mm vs. 10.0 mm, P = .010) and radial tuberosity-ulnar space (7.2 mm vs. 9.1 mm, P = .013). The ratio of radial tuberosity thickness to radial diameter was statistically significantly larger in the tear group (0.389 vs. 0.267, P < .0001). There was a statistically significant positive correlation between partial DBT tears and the presence of enthesophytes (P = .007), as well as between partial DBT tears and the presence of 2 discrete DBTs rather than a single tendon or 2 DBTs that interdigitated prior to insertion (P < .0001). CONCLUSION Larger radial tuberosities and smaller radioulnar and radial tuberosity-ulnar spaces are associated with partial DBT tears. Larger tuberosities and a smaller functional space for the DBT may lead to chronic impingement, tendon delamination, and consequent weakness, which ultimately lead to tears. Enthesophytes may be associated with tears for the same reason. The presence of 2 discrete DBTs that do not interdigitate prior to insertion is also associated with partial tears. This study will help clinicians understand the pathogenesis of partial DBT tears.
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Affiliation(s)
| | - Cherrelle M George
- Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand
| | - Simon B M MacLean
- Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand
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5
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Metikala S, Portnoff B, Herickhoff P. Staged Achilles Allograft Reconstruction of Chronic Bilateral Simultaneous Tears of the Retracted Distal Biceps Tendon Using a Novel Fixation Technique. Cureus 2022; 14:e25172. [PMID: 35747037 PMCID: PMC9206879 DOI: 10.7759/cureus.25172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/05/2022] Open
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6
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Boonrod A, Harasymczuk M, Ramazanian T, Boonrod A, Smith J, O’Driscoll SW. The Turtle Neck Sign: Identification of Severe Retracted Distal Biceps Tendon Rupture. Orthop J Sports Med 2022; 10:23259671211065030. [PMID: 35071656 PMCID: PMC8777348 DOI: 10.1177/23259671211065030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Chronic tendon retraction subsequent to distal biceps tendon rupture significantly increases repair difficulty and potential for tendon grafting. Biceps tendons that appear short or absent with magnetic resonance imaging (MRI) or that cannot be readily identified at surgery may erroneously be classified as irreparable. These apparent “absent” biceps tendons may actually be retracted and curled up inside the muscle, visually resembling the head-neck of a turtle retracted inside its shell (the “turtle neck sign”). When located, these tendons could be unfolded and repaired primarily. This type of tendon retraction seems to be associated with high-degree ruptures and larcertus fibrosus tears. Purpose: To test the hypothesis that tendon retractions with a turtle neck sign on MRI are more associated with high-degree ruptures and larcertus fibrosus tears versus tendon tears with simple linear retraction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Retracted distal biceps tendon ruptures on sagittal MRI were categorized as linear retraction or curled-up (turtle neck) retraction. Retraction length, injury severity, and lacertus fibrosus tears were analyzed. Results: The authors retrospectively analyzed the patient records of 85 consecutive traumatic distal biceps tendon ruptures from 2003 to 2019; the final study cohort was 37 patients. Injury-to-surgery timing was as follows: <3 weeks, 43% (16 cases); 3 weeks to 3 months, 32% (12 cases); and >3 months, 24% (9 cases). Overall, 19 patients had linear retraction <7 cm (mean, 3.3 ± 1.9 cm) and 18 patients had a turtle neck retraction ≥7 cm (mean, 9.1 ± 1.6 cm). The injury-to-surgery time (median [± interquartile range]) was 27 days (±90 days) in the linear retraction group and 23 days (±65 days) in the turtle neck retraction group. The turtle neck retraction group had a significantly higher occurrence of abnormal hook test findings, complete distal biceps tendon rupture, and lacertus fibrosus tears compared with the linear retraction group (100% vs 58%, 100% vs 68%, and 100% vs 37%, respectively; P ≤ .02). However, significant repairability differences were not found. Conclusion: Highly retracted distal biceps turtle neck sign tendon ruptures occur frequently in association with high-degree ruptures and lacertus fibrosus tears. The presence of a turtle neck retraction did not affect reparability. Surgeons should be aware of this curled-up retraction to avoid mistaking it for an absent tendon or a muscle-tendon disruption.
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Affiliation(s)
- Artit Boonrod
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopaedics, Khon Kaen University, Khon Kaen, Thailand
| | - Michal Harasymczuk
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Traumatology, Orthopedics and Hand Surgery, Poznań University of Medical Sciences, Poznań, Poland
| | - Taghi Ramazanian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arunnit Boonrod
- Department of Radiology, Srinagarind Hospital, Khon Kaen, Thailand
| | - Jay Smith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
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7
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Bajwa A, Simon MJK, Leith JM, Moola FO, Goetz TJ, Lodhia P. Surgical Results of Chronic Distal Biceps Ruptures: A Systematic Review. Orthop J Sports Med 2022; 10:23259671211065772. [PMID: 35005052 PMCID: PMC8738885 DOI: 10.1177/23259671211065772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/10/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Distal biceps tendon tears can cause weakness and fatigue with activities requiring elbow flexion and supination. Surgical management of chronic tears (>21 days) is not well described in the literature. Purpose: To determine the clinical outcomes of chronic distal biceps repairs and reconstructions. Study Design: Systematic review; Level of evidence, 4. Methods: We performed a search of Medline (PubMed and Ovid), EMBASE, CINAHL physical therapy, Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, and PubMed Central from inception until September 29, 2020, to identify articles on chronic distal biceps ruptures. The inclusion criteria were studies with at least 1 outcome measure and 10 patients with chronic distal biceps ruptures treated surgically. The quality of the included studies was assessed with the methodological index for nonrandomized studies (MINORS) score. Functional outcomes and complications were reviewed. Results: A total of 12 studies were included after systematic database screenings. The MINORS scores ranged from 5 to 19. There were a total of 1704 distal biceps ruptures, of which 1270 were acute and 434 were chronic. Average follow-up time was 12 months to 5.1 years. Single-incision (n = 3), 2-incision (n = 2), or both (n = 6) surgical techniques were used in these studies. Four studies described the use of autografts, and 4 articles used allografts in the chronic repair. Range of motion, function, and strength outcomes were similar when compared with the contralateral arm. Pain was reduced to minimal levels. Main postoperative complications were of paresthesia (specifically to the lateral antebrachial cutaneous nerve), which were temporary in 69.1% of cases. Conclusion: The results of this review indicate that surgical management of chronic distal biceps ruptures demonstrates improvement in outcomes including pain reduction and functional ability. Although there may be a slightly higher immediate complication rate, the functional outcomes remain comparable with those seen in the patient population with acute distal biceps.
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Affiliation(s)
- Arpun Bajwa
- Gray's Harbor Medical Group, Gray's Harbor Orthopedics, Aberdeen, Washington, USA
| | - Maciej J K Simon
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Orthopaedics and Trauma Surgery, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jordan M Leith
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Footbridge Clinic for Integrated Orthopaedic Care, Vancouver, British Columbia, Canada
| | - Farhad O Moola
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Fraser Orthopaedic Institute, New Westminster, British Columbia, Canada
| | - Thomas J Goetz
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Parth Lodhia
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Fraser Orthopaedic Institute, New Westminster, British Columbia, Canada
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8
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Greif DN, Huntley SH, Alidina S, Muñoz J, Huntley JH, Greditzer HG, Jose J. MRI findings of chronic distal tendon biceps reconstruction and associated post-operative findings. Skeletal Radiol 2021; 50:1095-1109. [PMID: 33236235 DOI: 10.1007/s00256-020-03676-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/29/2020] [Accepted: 11/15/2020] [Indexed: 02/02/2023]
Abstract
Rupture of the distal biceps tendon is becoming increasingly diagnosed due to an active aging population and an increase in diagnostic imaging opportunities. While physical exam may help in diagnosis, magnetic resonance imaging (MRI) is particularly useful in evaluating chronic rupture. Although partial tears can be managed conservatively, the gold standard treatment for a chronic distal biceps tear is anatomic reinsertion with additional use of an allograft or autograft. No study has highlighted the normal appearance and postsurgical complications seen on MRI associated with allograft or autograft usage. Clinicians and radiologists may be unaware of the normal and abnormal post-operative imaging findings and their clinical relevance. The purpose of this manuscript is to discuss the epidemiology, clinical presentation, and preoperative MRI findings of distal biceps ruptures necessitating reconstruction, to explain distal biceps tendon surgical reconstruction technique with allograft or autograft usage, to display the normal and abnormal post-operative MRI findings, and to review the clinical outcomes associated with the procedure.
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Affiliation(s)
- Dylan N Greif
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL, USA.,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Samuel H Huntley
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL, USA.,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Sameer Alidina
- University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Julianne Muñoz
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL, USA.,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | | | - Harry G Greditzer
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Jean Jose
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL, USA. .,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA. .,Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
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9
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Schickendantz MS, Yalcin S. Conditions and Injuries Affecting the Nerves Around the Elbow. Clin Sports Med 2020; 39:597-621. [PMID: 32446578 DOI: 10.1016/j.csm.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Sports-related peripheral neuropathies account for 6% of all peripheral neuropathies and most commonly involve the upper extremity. The routes of the median, radial, and ulnar nerves are positioned in arrangements of pulleys and sheaths to glide smoothly around the elbow. However, this anatomic relationship exposes each nerve to risk of compression. The underlying mechanisms of the athletic nerve injury are compression, ischemia, traction, and friction. Chronic athletic nerve compression may cause damage with moderate or low pressure for long or intermittent periods of time.
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Affiliation(s)
- Mark S Schickendantz
- Cleveland Clinic Sports Health Center, 5555 Transportation Boulevard, Garfield Heights, Ohio 44125, USA.
| | - Sercan Yalcin
- Cleveland Clinic Sports Health Center, 5555 Transportation Boulevard, Garfield Heights, Ohio 44125, USA
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10
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Bucci G, Morgan B, Smith RR, Snelus PJ, Singleton SB. Proximal radial fracture as a complication of distal biceps tendon repair: a case report. J Shoulder Elbow Surg 2020; 29:e205-e210. [PMID: 32305109 DOI: 10.1016/j.jse.2019.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/29/2019] [Indexed: 02/01/2023]
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11
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Prokuski V, Leung NL, Leslie BM. Diagnosis, Etiology and Outcomes of Revision Distal Biceps Tendon Reattachment. J Hand Surg Am 2020; 45:156.e1-156.e9. [PMID: 31248679 DOI: 10.1016/j.jhsa.2019.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/18/2019] [Accepted: 05/03/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | - Nicky L Leung
- Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA
| | - Bruce M Leslie
- Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA.
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12
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Abstract
Distal biceps injuries are a relatively uncommon clinical condition that typically affect middle-aged males. They commonly occur due to an eccentric overload as the arm is forced from a flexed to extended position. Patients may experience an acute 'pop' and present with arm pain, swelling, and ecchymosis. Treatment options include nonoperative management or surgical repair. The aim of this concise review of distal biceps ruptures is to examine the relevant anatomy, clinical evaluation, diagnosis, and treatment options for these injuries.
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Affiliation(s)
- Drew Krumm
- Michigan State University College of Medicine, Grand Rapids, MI, USA
| | - Peter Lasater
- Michigan State University College of Medicine, Grand Rapids, MI, USA.,Spectrum Health Medical Group Orthopedics & Sports Medicine, Grand Rapids, MI, USA
| | - Guillaume Dumont
- University of South Carolina Orthopaedics & Sports Medicine, Columbia, SC, USA
| | - Travis J Menge
- Michigan State University College of Medicine, Grand Rapids, MI, USA.,Spectrum Health Medical Group Orthopedics & Sports Medicine, Grand Rapids, MI, USA
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13
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Holder NG, Schneider AK, Ek ET. Protuberant heterotopic ossification following distal biceps tendon repair. ANZ J Surg 2017; 89:E208-E209. [PMID: 29124838 DOI: 10.1111/ans.14232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/07/2017] [Accepted: 08/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Nicholas G Holder
- Melbourne Orthopaedic Group, Melbourne, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adrian K Schneider
- Melbourne Orthopaedic Group, Melbourne, Victoria, Australia.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital, St. Gallen, Switzerland
| | - Eugene T Ek
- Melbourne Orthopaedic Group, Melbourne, Victoria, Australia.,Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
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14
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Dunphy TR, Hudson J, Batech M, Acevedo DC, Mirzayan R. Surgical Treatment of Distal Biceps Tendon Ruptures: An Analysis of Complications in 784 Surgical Repairs. Am J Sports Med 2017; 45:3020-3029. [PMID: 28837369 DOI: 10.1177/0363546517720200] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Distal biceps brachii tendon ruptures lead to substantial deficits in elbow flexion and supination; surgical repair restores muscle strength and endurance. PURPOSE To examine clinical and surgical outcomes for distal biceps tendon repairs in a large, multispecialty, integrated health care system. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Retrospective cohort study of distal biceps tendon repairs performed between January 1, 2008, and December 31, 2015. The repair methods were classified as double-incision approach using bone tunnel-suture fixation or anterior single-incision approach. Anterior single incisions were further classified according to the fixation method: cortical button alone, cortical button and interference screw, or suture anchors alone. Patient demographics, surgeon characteristics, range of motion, and complications were analyzed for all repair types. RESULTS Of the 784 repairs that met the inclusion criteria, 639 (81.5%) were single-incision approaches. When comparing double-incision and single-incision repairs, there was a significantly higher rate of posterior interosseous nerve palsy (3.4% vs 0.8%, P = .010), heterotopic bone formation (7.6% vs 2.7%, P = .004), and reoperation (8.3% vs 2.3%, P < .001). The most common nerve complication encountered was a lateral antebrachial cutaneous nerve palsy (n = 162), which was significantly more common in the single-incision repairs than in the double-incision repairs (24.4% vs 4.1%, P < .001). When excluding lateral antebrachial cutaneous nerve palsies, there was no significant difference in the overall nerve palsies between single-incision and double-incision (5.8% vs 6.9%, P = .612). The overall rate of tendon rerupture was 1.9% (single incision, 1.6%; double incision, 2.8%; P = .327). The overall rate of postoperative wound infection was 1.5% (single incision, 1.3%; double incision, 2.8%; P = .182). The average time from surgery to release from medical care was 14.4 weeks (single incision, 14 weeks; double incision, 16 weeks; P = .286). Patients treated with cortical button plus interference screw were released significantly sooner than were patients with other single-incision repair types (13.1 ± 8.01 weeks, P = .011). There were no significant differences in rates of motor neurapraxia, infection, rerupture, and reoperation with regard to surgeon's years of practice, fellowship training, or case volume. CONCLUSION The surgical repair of distal biceps tendon ruptures has an overall low rate of serious complications, regardless of approach or technique. However, the double-incision technique has a higher rate of posterior interosseous nerve palsy, heterotopic bone formation, and reoperation rate. Surgeon's years of practice, fellowship training, and case volume do not affect the rate of major complications.
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Affiliation(s)
- Taylor R Dunphy
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Justin Hudson
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Michael Batech
- Department of Orthopaedic Surgery, Kaiser Permanente, Southern California, Baldwin Park, California, USA
| | - Daniel C Acevedo
- Department of Orthopaedic Surgery, Kaiser Permanente, Southern California, Panorama City, California, USA
| | - Raffy Mirzayan
- Department of Orthopaedic Surgery, Kaiser Permanente, Southern California, Baldwin Park, California, USA
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15
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Alentorn-Geli E, Assenmacher AT, Sánchez-Sotelo J. Distal biceps tendon injuries: A clinically relevant current concepts review. EFORT Open Rev 2017; 1:316-324. [PMID: 28461963 PMCID: PMC5367534 DOI: 10.1302/2058-5241.1.000053] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Distal biceps tendon (DBT) conditions comprise a spectrum of disorders including bicipitoradial bursitis, partial tears, acute and chronic complete tears. In low-demand patients with complete DBT tears, non-operative treatment may be entertained provided the patient understands the potential for residual weakness, particularly in forearm supination. Most acute tears are best treated by primary repair using either single-incision or double-incision techniques with good clinical outcomes. Single-incision techniques may carry a higher risk of nerve-related complications, whereas double-incision techniques have historically been considered to carry a higher risk of heterotopic ossification, particularly if the ulna is exposed. Various fixation techniques, including bone tunnels, cortical buttons, suture anchors, interference screws or a combination seem to provide different fixation strength but similar clinical outcomes. Some chronic tears may be repaired primarily, provided tendon tissue can be identified; alternatively, autograft or allograft reconstruction can be considered, and good outcomes have been reported with both techniques.
Cite this article: Alentorn-Geli E, Assenmacher AT, Sanchez-Sotelo J. Distal biceps tendon injuries: a clinically relevant current concepts review. EFORT Open Rev 2016;1:316-324. DOI: 10.1302/2058-5241.1.000053.
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Bhatia DN, Kandhari V, DasGupta B. Cadaveric Study of Insertional Anatomy of Distal Biceps Tendon and its Relationship to the Dynamic Proximal Radioulnar Space. J Hand Surg Am 2017; 42:e15-e23. [PMID: 28052833 DOI: 10.1016/j.jhsa.2016.11.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 08/08/2016] [Accepted: 11/02/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify and assess the relationship between the insertional dimensions of the distal biceps tendon (DBT) and radioulnar space (RUS) in 3 rotational positions. We hypothesized that in all positions RUS would be adequate for the DBT and would remain adequate even after an incremental increase (1 to 3 mm) in tendon thickness. METHODS Eleven fresh-frozen cadaveric elbows were dissected; DBT dimensions and bicipital tuberosity measurements were performed and insertional footprints were quantified using a distal biceps footprint index. The RUS was measured at 3 levels of the bicipital tuberosity and in 3 positions of forearm rotation. We performed statistical analysis to analyze differences in RUS (positional and inter-level). In addition, significant differences between DBT thickness (native and incremental) and RUS were analyzed to identify potential sites of radioulnar impingement. RESULTS The DBT had a mean length of 92 mm; thickness ranged from 2.9 to 6.1 mm. Three variations in DBT insertional footprint were observed and quantified. The RUS linear distance reduced significantly from a supinated to a pronated position at each of 3 bicipital tuberosity levels; the reduction was statistically significant at the lower tuberosity level (45%). Pronation RUS distance was adequate for native DBT thickness and was significantly less when DBT thickness increased by 2 and 3 mm. CONCLUSIONS Radioulnar space reduces significantly from the supinated to the pronated position and is most evident in the lower aspect of the tuberosity. In addition, the RUS in pronation is inadequate for incremental increases in DBT thickness. CLINICAL RELEVANCE Postoperative DBT impingement in the RUS may be prevented by avoiding techniques that increase the thickness of the tendon and by using a reattachment site at the proximal aspect of the tuberosity.
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Affiliation(s)
- Deepak N Bhatia
- Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Mumbai, India.
| | - Vikram Kandhari
- Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Bibhas DasGupta
- Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Mumbai, India
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Endoscopic Repair of Acute and Chronic Retracted Distal Biceps Ruptures. J Hand Surg Am 2016; 41:e501-e507. [PMID: 27743752 DOI: 10.1016/j.jhsa.2016.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 06/04/2016] [Accepted: 09/13/2016] [Indexed: 02/02/2023]
Abstract
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.
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Amin NH, Volpi A, Lynch TS, Patel RM, Cerynik DL, Schickendantz MS, Jones MH. Complications of Distal Biceps Tendon Repair: A Meta-analysis of Single-Incision Versus Double-Incision Surgical Technique. Orthop J Sports Med 2016; 4:2325967116668137. [PMID: 27766276 PMCID: PMC5056595 DOI: 10.1177/2325967116668137] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Anatomic reinsertion of the distal biceps is critical for restoring flexion and supination strength. Single- and double-incision surgical techniques have been reported, analyzing complications and outcomes measures. Which technique results in superior clinical outcomes and the lowest associated complications remains unclear. Hypothesis: We hypothesized that rerupture rates would be similar between the 2 techniques, while nerve complications would be higher for the single-incision technique and heterotopic ossification would be more frequent with the double-incision technique. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic review was conducted using the PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SPORTSDiscus, and the Cochrane Central Register of Controlled Trials databases to identify articles reporting distal biceps ruptures up to August 2013. We included English-language articles on adult patients with a minimum of 3 cases reporting single- and double-incision techniques. Frequencies of each complication as a percentage of total cases were calculated. Fisher exact tests were used to test the association between frequencies for each repair method, with P < .05 considered statistically significant. Odds ratios with 95% CIs were also computed. Results: A total of 87 articles met the inclusion criteria. Lateral antebrachial cutaneous nerve neurapraxia was the most common complication in the single-incision group, occurring in 77 of 785 cases (9.8%). Heterotopic ossification was the most common complication in the double-incision group, occurring in 36 of 498 cases (7.2%). Conclusion: The overall frequency of reported complications is higher for single-incision distal biceps repair than for double-incision repair. The frequencies of rerupture and nerve complications are both higher for single-incision repairs while the frequency of heterotopic ossification is higher for double-incision repairs. These findings can help surgeons make better-informed decisions about surgical technique and provide their patients with detailed information about expected outcomes and possible complications.
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Affiliation(s)
- Nirav H Amin
- Loma Linda University, Loma Linda, California, USA
| | - Alex Volpi
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - T Sean Lynch
- Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York, USA
| | - Ronak M Patel
- Illinois Bone and Joint Institute, Chicago, Illinois, USA
| | - Douglas L Cerynik
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Mark S Schickendantz
- Cleveland Clinic Center for Sports Health, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Morgan H Jones
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Beks RB, Claessen FMAP, Oh LS, Ring D, Chen NC. Factors associated with adverse events after distal biceps tendon repair or reconstruction. J Shoulder Elbow Surg 2016; 25:1229-34. [PMID: 27107731 DOI: 10.1016/j.jse.2016.02.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 02/17/2016] [Accepted: 02/24/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Factors associated with adverse events after distal biceps tendon repair or reconstruction are incompletely understood. This study examined factors associated with adverse events, prevalence of adverse events, and rate of second surgeries after distal biceps repair or reconstruction. METHODS Between January 2002 and March 2015, 373 adult patients who underwent repair or reconstruction of the distal biceps tendon at 1 of 3 area hospitals were analyzed to determine factors associated with adverse events after surgical repair or reconstruction of the distal biceps tendon. RESULTS Of 373 distal biceps tendon repairs or reconstructions, 82 (22%) had an adverse event; 5.3% were major adverse events. In multivariable analysis, a single-incision anterior approach and obesity were associated with a higher rate of adverse events. Fifteen patients (18% of patients with an adverse event and 4% of all patients) had a second surgery after distal biceps tendon surgery. CONCLUSION Patients should be counseled that 1 in 5 patients will have a minor complication and 1 in 20 patients will have a major complication after surgery on the distal biceps tendon. The most common adverse event is lateral antebrachial cutaneous neurapraxia.
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Affiliation(s)
- Reinier B Beks
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Femke M A P Claessen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Luke S Oh
- Sports Medicine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School-The University of Texas at Austin, Austin, TX, USA.
| | - Neal C Chen
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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van den Bekerom MPJ, Kodde IF, Aster A, Bleys RLAW, Eygendaal D. Clinical relevance of distal biceps insertional and footprint anatomy. Knee Surg Sports Traumatol Arthrosc 2016; 24:2300-7. [PMID: 25231429 DOI: 10.1007/s00167-014-3322-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 09/10/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this review was to present an overview, based on a literature search, of surgical anatomy for distal biceps tendon repairs, based on the current literature. METHODS A narrative review was performed using Pubmed/Medline using key words: Search terms were distal biceps, insertional, and anatomy. RESULTS Last decade, the interest in both reconstruction techniques, as well as surgical anatomy of the distal biceps tendon, has increased. The insights into various aspects of distal biceps tendon anatomy (two tendons, bicipital tuberosity, lacertus fibrosis, bicipital-radial bursa, posterior interosseous nerve, and lateral antebrachial cutaneous nerve) have evolved significantly in the last years. CONCLUSION Thorough knowledge of the anatomy is essential for the surgeon in order to understand the biomechanics of rupture and reconstruction of the distal biceps tendon and to avoid injuries of the nerves. Some tips and tricks are provided, and some pitfalls were described to avoid complications and optimize surgical outcome. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michel P J van den Bekerom
- Shoulder and Elbow Unit, Department of Orthopedic Surgery, OLVG, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.
| | - Izaäk F Kodde
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
| | - Asir Aster
- Department of Orthopaedic Surgery, Salford Royal NHS Foundation Trust Hospital, Bolton, UK
| | | | - Denise Eygendaal
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
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Wang D, Joshi NB, Petrigliano FA, Cohen JR, Lord EL, Wang JC, Jones KJ. Trends associated with distal biceps tendon repair in the United States, 2007 to 2011. J Shoulder Elbow Surg 2016; 25:676-80. [PMID: 26853757 DOI: 10.1016/j.jse.2015.11.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/02/2015] [Accepted: 11/10/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Current studies investigating surgical treatment of distal biceps tendon tears largely consist of small, retrospective case series. The purpose of this study was to investigate the current patient demographics, surgical trends, and postoperative complication rates associated with operative treatment of distal biceps tendon tears using a large database of privately insured, non-Medicare patients. METHODS Patients who underwent surgical intervention for distal biceps tendon tears from 2007 to 2011 were identified using the PearlDiver database. Demographic and surgical data as well as postoperative complications were reviewed. Statistical analysis was performed using linear regression analysis and χ(2) tests, with statistical significance set at P < .05. RESULTS A total of 1443 patients underwent surgical treatment for distal biceps tendon tears. Men and patients aged 40 to 59 years accounted for 98% and 72% of the cohort, respectively. Regarding surgical technique, reinsertion to the radial tuberosity was preferred (95%) over tenodesis to the brachialis (5%) (P < .01). In total, revision surgery for tendon rerupture occurred in 5.4% of treated patients. The incidence of revision surgery for rerupture in acute and chronic distal biceps tears was 5.1% and 7.0%, respectively (P = .36). Postoperative infection and peripheral nerve injury rates were 1.1% and 0.6%, respectively. CONCLUSION Surgeons strongly preferred anatomic reinsertion to the radial tuberosity for treatment, regardless of the chronicity of the injury. Postoperative complication rates were similar to those found in prior studies, although the true rate of rerupture may be higher than previously thought.
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Affiliation(s)
- Dean Wang
- Sports Medicine Service, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nirav B Joshi
- Sports Medicine Service, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Frank A Petrigliano
- Sports Medicine Service, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jeremiah R Cohen
- Sports Medicine Service, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Elizabeth L Lord
- Sports Medicine Service, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jeffrey C Wang
- Orthopaedic Spine Service, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kristofer J Jones
- Sports Medicine Service, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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Yakob H, Bhalaik V. Protection of soft tissue and avoidance of inadvertent neurovascular injury in repair of the distal biceps. Ann R Coll Surg Engl 2016; 98:157-8. [PMID: 26741673 DOI: 10.1308/rcsann.2016.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- H Yakob
- Wirral University Teaching Hospital NHS Foundation Trust , UK
| | - V Bhalaik
- Wirral University Teaching Hospital NHS Foundation Trust , UK
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Abstract
Distal biceps ruptures occur from eccentric loading of a flexed elbow. Patients treated nonoperatively have substantial loss of strength in elbow flexion and forearm supination. Surgical approaches include 1-incision and 2-incision techniques. Advances in surgical technology have facilitated the popularity of single-incision techniques through a small anterior incision. Recently, there is increased focus on the detailed anatomy of the distal biceps insertion and the importance of anatomic repair in restoring forearm supination strength. Excellent outcomes are expected with early repair of the distal biceps, with restoration of strength and endurance to near-normal levels with minimal to no loss of motion.
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Bhatia DN. Endoscopic Distal Biceps Repair: Endoscopic Anatomy and Dual-Anchor Repair Using a Proximal Anterolateral "Parabiceps Portal". Arthrosc Tech 2015; 4:e785-93. [PMID: 27284512 PMCID: PMC4886957 DOI: 10.1016/j.eats.2015.07.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 07/31/2015] [Indexed: 02/03/2023] Open
Abstract
Distal biceps rupture is associated with significant functional disability, and surgical treatment involves open or endoscopic-assisted repair of the ruptured tendon through an anterior incision. This report describes an endoscopic approach that is performed with 2 portals for visualization and instrumentation. Preoperative sonography is used to identify bony and soft-tissue landmarks. The viewing portal is a proximal anterolateral "parabiceps portal" developed by the author, and the landmarks and relevant anatomic relations have been derived from a preliminary anatomic study. The working portal is a distal anterior portal and permits access to the radial tuberosity through the internervous muscular plane. The parabiceps portal permits visualization of the anterior and medial region of the radial tuberosity. A detailed description of the endoscopic pathoanatomy of the distal biceps tendon region is presented. The distal anterior portal is used for retrieval of the ruptured tendon, and thereafter the tuberosity is debrided and anchors are placed under vision. The ruptured tendon is whipstitched and docked onto the tuberosity, and nonsliding knots are used to securely reattach the tendon to bone. Overall, the 2-portal technique provides a method for tendon repair under direct visualization and is safe and reproducible.
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Affiliation(s)
- Deepak N. Bhatia
- Address correspondence to Deepak N. Bhatia, M.S.(Orth), D.N.B.(Orth), Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Parel, Mumbai 400012, India.
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Barker SL, Bell SN, Connell D, Coghlan JA. Ultrasound-guided platelet-rich plasma injection for distal biceps tendinopathy. Shoulder Elbow 2015; 7:110-4. [PMID: 27582965 PMCID: PMC4935115 DOI: 10.1177/1758573214567558] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 10/17/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Distal biceps tendinopathy is an uncommon cause of elbow pain. The optimum treatment for cases refractory to conservative treatment is unclear. Platelet-rich plasma has been used successfully for other tendinopathies around the elbow. METHODS Six patients with clinical and radiological evidence of distal biceps tendinopathy underwent ultrasound-guided platelet-rich plasma (PRP) injection. Clinical examination findings, visual analogue score (VAS) for pain and Mayo Elbow Performance scores were recorded. RESULTS The Mayo Elbow Performance Score improved from 68.3 (range 65 to 85) (fair function) to 95 (range 85 to 100) (excellent function). The VAS at rest improved from a mean of 2.25 (range 2 to 5) pre-injection to 0. The VAS with movement improved from a mean of 7.25 (range 5 to 8) pre-injection to 1.3 (range 0 to 2). No complications were noted. DISCUSSION Ultrasound-guided PRP injection appears to be a safe and effective treatment for recalcitrant cases of distal biceps tendinopathy. Further investigation with a randomized controlled trial is needed to fully assess its efficacy.
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Affiliation(s)
- Scott L Barker
- Melbourne Shoulder and Elbow Centre, Brighton,
Melbourne, VIC, Australia,Monash University Department of Surgery,
Monash Medical Centre, Clayton, Melbourne, VIC, Australia,Mr Scott L Barker, Woodend Hospital, Eday Road,
Aberdeen, AB15 6XS, Scotland, UK. Tel: +44 (0)1224 556508. Fax: +44 1224 556376.
| | - Simon N Bell
- Melbourne Shoulder and Elbow Centre, Brighton,
Melbourne, VIC, Australia,Monash University Department of Surgery,
Monash Medical Centre, Clayton, Melbourne, VIC, Australia
| | - David Connell
- Olympic Park Imaging, AAMI Park, Melbourne,
VIC, Australia
| | - Jennifer A Coghlan
- Melbourne Shoulder and Elbow Centre, Brighton,
Melbourne, VIC, Australia,Monash University Department of Surgery,
Monash Medical Centre, Clayton, Melbourne, VIC, Australia
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Abstract
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.
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Thumm N, Hutchinson D, Zhang C, Drago S, Tyser AR. Proximity of the posterior interosseous nerve during cortical button guidewire placement for distal biceps tendon reattachment. J Hand Surg Am 2015; 40:534-6. [PMID: 25510155 DOI: 10.1016/j.jhsa.2014.10.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 10/10/2014] [Accepted: 10/13/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the distance between the posterior interosseous nerve (PIN) and a distally and ulnarly directed guide pin for placement of a cortical button to reattach a distal biceps tendon. METHODS We used 10 fresh frozen cadaveric upper limbs without deformities and identified the PIN through a dorsal approach. We performed a single incision anterior surgical approach, detached the biceps tendon, and drilled a 1.6-mm K-wire from the base of the biceps tendon insertion in 3 different trajectories, sequentially, measuring the following drilling angles: 30° distal and 30° ulnar, 30° ulnar, and 30° distal. In each testing scenario, we measured the minimum distance in millimeters between the tip of the K-wire and the PIN using a digital caliper through the dorsal incision. RESULTS The mean and median distances from the guide wire to the PIN in each testing trajectory were each significantly different from each other, with the 30° ulnar direction leading to the greatest distance from the nerve. CONCLUSIONS We found that the 30° ulnar drilling direction resulted in a significantly greater distance from the guide wire to the PIN, in comparison with the distal-ulnar and the distal-only trajectories. CLINICAL RELEVANCE This study helps define the safe trajectory for guide wire placement in bicortical fixation of distal biceps tendon injuries.
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Affiliation(s)
- Nicolas Thumm
- University of Utah Department of Orthopedic Surgery, Salt Lake City, UT
| | | | - Chong Zhang
- University of Utah Department of Orthopedic Surgery, Salt Lake City, UT
| | - Sebastian Drago
- University of Utah Department of Orthopedic Surgery, Salt Lake City, UT
| | - Andrew R Tyser
- University of Utah Department of Orthopedic Surgery, Salt Lake City, UT.
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Virk MS, DiVenere J, Mazzocca AD. Distal Biceps Tendon Injuries: Treatment of Partial and Complete Tears. OPER TECHN SPORT MED 2014. [DOI: 10.1053/j.otsm.2014.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hinchey JW, Aronowitz JG, Sanchez-Sotelo J, Morrey BF. Re-rupture rate of primarily repaired distal biceps tendon injuries. J Shoulder Elbow Surg 2014; 23:850-4. [PMID: 24774620 DOI: 10.1016/j.jse.2014.02.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/28/2014] [Accepted: 02/10/2014] [Indexed: 02/01/2023]
Abstract
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
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Affiliation(s)
- John W Hinchey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Bernard F Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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30
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Primary repair of retracted distal biceps tendon ruptures in extreme flexion. J Shoulder Elbow Surg 2014; 23:679-85. [PMID: 24745316 DOI: 10.1016/j.jse.2013.12.030] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 12/17/2013] [Accepted: 12/25/2013] [Indexed: 02/01/2023]
Abstract
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.
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Al-Taher M, Wouters DB. Fixation of acute distal biceps tendon ruptures using mitek anchors: a retrospective study. Open Orthop J 2014; 8:52-5. [PMID: 24741379 PMCID: PMC3988494 DOI: 10.2174/1874325001408010052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 03/02/2014] [Accepted: 03/10/2014] [Indexed: 11/22/2022] Open
Abstract
PURPOSE OF THIS STUDY The aim of this study was to evaluate the outcomes of surgical intra-osseous fixation of the distal tendon of the ruptured biceps brachii muscle using Mitek anchors. MATERIALS AND METHODS Between 2005 and 2011, seven patients underwent unilateral distal biceps tendon repair using Mitek anchors. All patients were men aged between 36 and 47 years. Six patients were assessed by physical examination and use of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS Surgery was performed within 3 to 17 days of rupture with a mean follow-up of 35 months. Of the six fully completed DASH questionnaires, three patients had a score of 0, and three patients had scores of 5.8, 10 and 10.8, respectively (10.1 is the mean score for the general population). Transient paraesthesias in the lateral antebrachial cutaneous nerve region occurred in two patients and one patient experienced a transient stiffness of the elbow due to scarring of the wound. No major complicatons have occurred. CONCLUSION The use of Mitek anchors for the re-insertion of the ruptured distal biceps tendon proved to be a safe and effective technique with excellent functional results in our series.
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Affiliation(s)
- M Al-Taher
- Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Diederick B Wouters
- Medical Centre Amstelveen, Burg. Haspelslaan 131, 1181NC Amstelveen, The Netherlands
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Repair and Rehabilitation of Distal Biceps Ruptures. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2014. [DOI: 10.1097/bte.0000000000000011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gasparella A, Katusic D, Perissinotto A, Miti A. Repair of distal biceps tendon acute ruptures with two suture anchors and anterior mini-open single incision technique: clinical follow-up and isokinetic evaluation. Musculoskelet Surg 2014; 99:19-25. [PMID: 24531927 DOI: 10.1007/s12306-014-0314-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND All the techniques described in literature for treatment of acute distal biceps tendon ruptures provide good functional outcomes. The purpose of this study is to report the results of a single limited-incision technique for repair of acute distal biceps ruptures using two suture anchors. MATERIALS AND METHODS Fourteen patients, all man, were treated consecutively from one author between January 2009 and December 2011 and evaluated at a mean follow-up of 26 months. All patients were evaluated clinically, through DASH and MEPS score questionnaires, and with isokinetic biomechanical tests. RESULTS All patients achieved complete elbow flexion and extension. Deficit for supination of the forearm was found in only two patients (7° and 13°). Mean DASH score was 4.7 points, and mean MEPS was excellent (96.8 points). There was no nervous complication involving posterior interosseous nerve (PIN) and no case of failure of the sutures. The isokinetic evaluation detected an average flexion strength increase by 10.2 % compared to the opposite arm not operated. CONCLUSION Our study shows that mini-open access and fixation with two suture anchors achieved in medium-term excellent functional and cosmetic results needed short rehabilitation times and is minimally invasive.
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Affiliation(s)
- A Gasparella
- Department of Orthopaedic and Trauma Surgery, University of Padua, Padua, Italy,
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Snir N, Hamula M, Wolfson T, Meislin R, Strauss EJ, Jazrawi LM. Clinical outcomes after chronic distal biceps reconstruction with allografts. Am J Sports Med 2013; 41:2288-95. [PMID: 24007757 DOI: 10.1177/0363546513502306] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Chronic ruptures of the distal biceps are often complicated by tendon retraction and fibrosis, precluding primary repair. Reconstruction with allograft augmentation has been proposed as an alternative for cases not amenable to primary repair. PURPOSE To investigate the clinical outcomes of late distal biceps reconstruction using allograft tissue. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 20 patients who underwent distal biceps reconstruction with allograft tissue between May 2007 and May 2012 were identified. Charts were retrospectively reviewed for postoperative complications, gross flexion and supination strength, and range of motion. Subjective functional outcomes were assessed prospectively with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS Eighteen patients with adequate follow-up were included in the study. All had undergone late distal biceps reconstruction with allografts (Achilles [n = 15], semitendinosus [n = 1], gracilis [n = 1], or anterior tibialis [n = 1]) for symptomatic chronic ruptures of the distal biceps. At a mean office follow-up of 9.3 months (range, 4-14 months), all patients had full range of motion and mean gross strength of 4.7 of 5 (range, 4-5) in flexion and supination. After a mean out-of-office follow-up at 21 months (range, 7-68.8 months), the mean DASH score was 7.5 ± 17.9, and the mean MEPS increased from 43.1 preoperatively to 94.2 postoperatively (P < .001). The only complication observed was transient posterior interosseous nerve palsy in 2 patients. Additionally, all but 1 patient reported a cosmetic deformity. However, all patients found it acceptable. CONCLUSION Late reconstruction for chronic ruptures of the distal biceps using allograft tissue is a safe and effective solution for symptomatic patients with functional demands in forearm supination and elbow flexion. While there are several graft options, the literature supports good results with Achilles tendon allografts. Further studies are needed to evaluate the clinical outcomes of other allograft options.
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Affiliation(s)
- Nimrod Snir
- Laith M. Jazrawi, Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 333 East 38th Street, New York, NY 10016.
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McDonald LCDRLS, Dewing CDRCB, Shupe LCDRPG, Provencher CDRMT. Disorders of the proximal and distal aspects of the biceps muscle. J Bone Joint Surg Am 2013; 95:1235-45. [PMID: 23824393 PMCID: PMC6948813 DOI: 10.2106/jbjs.l.00221] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PROXIMAL ASPECT OF BICEPS: Tenodesis of the long head of the biceps may offer improved cosmesis, improved strength, and diminished activity-related pain compared with tenotomy, although comparative studies have shown similar outcomes in some patient populations. DISTAL ASPECT OF BICEPS: Operative treatment of both partial and complete distal biceps ruptures results in better outcomes compared with nonoperative care, although the optimal technique and fixation are yet to be determined. Nonoperative management is an acceptable treatment for patients willing to accept some loss of forearm supination and elbow flexion strength as well as changes in endurance and cosmesis.
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Affiliation(s)
- LCDR Lucas S. McDonald
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
| | - CDR Christopher B. Dewing
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
| | | | - CDR Matthew T. Provencher
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
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Vidal AF, Koonce RC, Wolcott M, Gonzales JB. Extensive heterotopic ossification after suspensory cortical fixation of acute distal biceps tendon ruptures. Arthroscopy 2012; 28:1036-40. [PMID: 22738753 DOI: 10.1016/j.arthro.2012.03.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 03/18/2012] [Accepted: 03/21/2012] [Indexed: 02/02/2023]
Abstract
Suspensory cortical fixation is commonly used for distal biceps tendon repair and reconstruction with one of several commercially available devices. The single-incision approach typically used with these devices is believed to have a lower incidence of heterotopic ossification than the dual-incision technique, but the true incidence of heterotopic ossification is unknown. The role of chemotherapeutic or radiation prophylaxis is undefined. We have identified 4 cases of extensive heterotopic ossification after biceps fixation with a suspensory button and single-incision approach. Surgeons should be aware of this potential complication when using suspensory cortical buttons for distal biceps fixation.
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Affiliation(s)
- Armando F Vidal
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado 80222, USA.
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The double intramedullary cortical button fixation for distal biceps tendon repair. Knee Surg Sports Traumatol Arthrosc 2011; 19:1925-9. [PMID: 21655996 DOI: 10.1007/s00167-011-1569-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 05/26/2011] [Indexed: 12/18/2022]
Abstract
PURPOSE This study was designed to present the novel technique of intramedullary cortical button fixation for distal biceps tendon repair via a single-limited anterior portal. METHODS To reattach the ruptured biceps tendon at the radial tuberosity, two Bicepsbutton(™) (Arthrex, Naples, FL, USA) were intramedullary positioned to the anterior cortex. The surgical procedure is described in detail. This technique has been performed in a first series of 3 patients with acute distal biceps tendon ruptures. RESULTS All patients were very satisfied after surgery and would undergo the same surgical procedure again. All patients regained full range of elbow motion with comparable strength of forearm supination and elbow flexion measured against the uninjured arm at 6 months of follow-up. No neurovascular complications have been occured. CONCLUSION Double intramedullary cortical button repair has shown to be a safe and reliable fixation method for distal biceps tendon rupture in a small series of patients. Preliminary results are encouraging.
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Sherman SC, Afifi N. Distal biceps tendon rupture. J Emerg Med 2011; 43:e469-70. [PMID: 21996287 DOI: 10.1016/j.jemermed.2011.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 03/08/2011] [Accepted: 06/04/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Scott C Sherman
- Department of Emergency Medicine, Cook County Hospital (Stroger), Chicago, Illinois 60612, USA
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Gallinet D, Dietsch E, Barbier-Brion B, Lerais JM, Obert L. Suture anchor reinsertion of distal biceps rupture: clinical results and radiological assessment of tendon healing. Orthop Traumatol Surg Res 2011; 97:252-9. [PMID: 21450546 DOI: 10.1016/j.otsr.2010.11.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 11/06/2010] [Accepted: 11/18/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The present study consisted in a clinical follow-up of patients with distal rupture of the biceps brachii tendon managed by suture anchor reinsertion to the radial tuberosity. Tendon apposition on the cortical bone is the least resistant reinsertion technique according to biomechanical studies. A parallel radiological (X-ray and MRI) study was therefore performed to assess the exact quality of tendon healing and its correlation to clinical results. PATIENTS AND METHODS Twenty-eight patients were followed up retrospectively at a mean 22 months (minimum FU: six months) with clinical examination (mobility, force, satisfaction, residual pain, and return to work) and radiological assessment (standard X-ray exploration for heterotopic ossification, and MRI for quality of healing of the tendon apposed to the cortical bone). RESULTS Forty percent of cases showed complications (mainly neurological) which resolved without sequelae under medical treatment. Mobility was normal in all but eight patients who showed -5° to -20° supination loss. Force in flexion-supination was 91% of that on the contralateral side. On X-ray, only 46% of patients were free of ossification. On MRI, reinsertion was judged anatomic in 19 patients (70%), moderate in six and poor in two, with one iterative rupture. Statistical analysis revealed that the greater the number of suture tacks through the tendon, the greater the force in patients with less than two weeks' interval to surgery and satisfactory reinsertion on MRI. DISCUSSION Many reinsertion techniques have been reported, giving clinical results similar to one another and to the present findings. The complications rate, in contrast, varies according to technique and surgical approach. Radiologically, 70% of reinsertions were satisfactory: healing with the tendon apposed on the cortical bone is thus a reliable technique. Heterotopic ossification is considered benign in the literature. The present radiological study refined this notion by identifying three types of ossification: pure asymptomatic intratendon ossification; pure asymptomatic tuberosity ossification without impact on healing on the radial tuberosity; and tuberosity ossification with associated boney metaplasia of the terminal part of the reinserted tendon, impairing healing and leading to less satisfactory clinical results. To ensure anatomic healing of the distal biceps tendon, we recommend less than two weeks' interval to surgery and at least two suture tacks to obtain good apposition on the radial tuberosity.
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Affiliation(s)
- D Gallinet
- Saint-Vincent Private Hospital, 40, Chemin des Tilleroyes, 25000 Besançon, France.
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Bioabsorbable interference screw fixation of distal biceps ruptures through a single anterior incision: a single-surgeon case series and review of the literature. Arch Orthop Trauma Surg 2010; 130:875-81. [PMID: 19787360 DOI: 10.1007/s00402-009-0974-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2009] [Indexed: 02/09/2023]
Abstract
INTRODUCTION We present a single-surgeon series of 14 acute ruptured distal biceps tendons repaired using a biotenodesis screw through a single anterior incision. PATIENTS The demographics of this population reveal a typical injury pattern and reflect the preponderance of distal biceps ruptures in the middle aged, active male. Goniometric post-operative assessment of flexion, pronation and supination range demonstrates excellent clinical function in these patients. METHOD Subjective analysis is afforded by DASH and MEPS scoring at the 6-month follow-up. RESULTS The results are discussed in relation to previous studies utilising disparate repair methods. This is the first prospective clinical series to be reported using this combination of fixation and approach. Clinical and patient assessed functions are excellent and complications are minimal. CONCLUSION This is a safe and successful technique for the management of distal biceps tendon ruptures.
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Freeman CR, McCormick KR, Mahoney D, Baratz M, Lubahn JD. Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. J Bone Joint Surg Am 2009; 91:2329-34. [PMID: 19797566 DOI: 10.2106/jbjs.h.01150] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few data are available regarding the results of nonoperative treatment of distal biceps ruptures. The present study was designed to assess the outcomes associated with unrepaired distal biceps tendon ruptures. METHODS Eighteen patients with twenty unrepaired distal biceps tendon ruptures were assessed retrospectively. The median duration of follow-up was thirty-eight months. Sixteen of the eighteen patients were male, and the median age at the time of the injury was fifty years (range, thirty-five to seventy-four years). Supination strength and elbow flexion strength were measured bilaterally, and patient outcomes were assessed with use of the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire. Data were compared with historical controls compiled from six published series of operatively treated patients. RESULTS The median supination and elbow flexion strengths for the injured arm were 63% (mean, 74%; range, 33% to 162%) and 93% (mean, 88%; range, 58% to 110%) of those for the contralateral arm, compared with values of 92% (mean, 101%; range, 42% to 297%) and 95% (mean, 97%; range, 53% to 191%) for the historical controls that had been treated surgically. The difference between the mean values was significant for supination strength (p = 0.002) but not for flexion strength (p = 0.164). Patients had satisfactory outcomes overall, with median scores on the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire of 85, 95, and 9, respectively. CONCLUSIONS Nonoperative treatment of distal biceps tendon ruptures can yield acceptable outcomes with modestly reduced strength, especially supination.
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Affiliation(s)
- Carl R Freeman
- Department of Orthopaedic Surgery, Hamot Medical Center, 201 State Street, Erie, PA 16550, USA.
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Fogg QA, Hess BR, Rodgers KG, Ashwood N. Distal biceps brachii tendon anatomy revisited from a surgical perspective. Clin Anat 2009; 22:346-51. [DOI: 10.1002/ca.20786] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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