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Hochreiter B, Eckers F, Calek AK, Cassidy JT, Amaranath JE, Leung M, Ek ET. Distal biceps tendon repair using a double intracortical button anatomic footprint repair technique. J Shoulder Elbow Surg 2024; 33:2243-2251. [PMID: 38688419 DOI: 10.1016/j.jse.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/26/2024] [Accepted: 03/05/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Distal biceps tendon repair is usually performed via a double-incision or single-incision bicortical drilling technique. However, these techniques are associated with specific complications and usually do not allow for anatomic footprint restoration. It was the aim of this study to report the clinical results of a double intracortical button anatomic footprint repair technique for distal biceps tendon tears. We hypothesized that this technique would result in supination strength comparable to the uninjured side with a low rerupture rate and minimal bony or neurologic complications. MATERIAL AND METHODS This was a retrospective, single-surgeon cohort study of a consecutive series of 22 patients with a mean (standard deviation) age of 50.7 (9.4) years and at least 1-year follow-up after distal biceps tendon repair. At final follow-up, complications, range of motion (ROM), the Patient-rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS) for pain, patient satisfaction, and supination strength in neutral as well as 60° of supination were analyzed. Radiographic evaluation was performed on a computed tomography scan. RESULTS One patient (4.5%) experienced slight paresthesia in the area of the lateral antebrachial cutaneous nerve. Heterotopic ossification was seen in 1 patient (4.5%). All patients recovered full ROM except for 1 who had 10° of loss of flexion and extension. Median PREE score was 4.6 (0-39.6), median MEP was 100 (70-100), and median DASH score was 1.4 (0-16.7). All but 1 patient were very satisfied with the outcome. The affected arm had a mean of 98% (±13%) of neutral supination strength (P = .633) and 94% (±12%) of supination strength in 60° (P = .054) compared with the contralateral, unaffected side. There were 4 cases (18.2%) of cortical thinning due to at least 1 button and 1 case of button pullout (4.5%). CONCLUSIONS The double intracortical button anatomic footprint repair technique seems to provide reliable restoration of supination strength and excellent patient satisfaction while minimizing complications, particularly nerve damage and heterotopic ossification.
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Affiliation(s)
- Bettina Hochreiter
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC, Australia; Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Franziska Eckers
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC, Australia; Department of Orthopedics, University Hospital Basel, Basel, Switzerland
| | - Anna-Katharina Calek
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC, Australia; Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | | | - Megan Leung
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC, Australia; Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Eugene T Ek
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC, Australia; Department of Surgery, Monash University, Melbourne, VIC, Australia
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Ford BT, Caputo AE. Painful Entrapment of the Lateral Antebrachial Cutaneous Nerve After Distal Biceps Repair: A Case Report. JBJS Case Connect 2024; 14:01709767-202409000-00045. [PMID: 39241097 DOI: 10.2106/jbjs.cc.24.00165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2024]
Abstract
CASE A 46-year-old man presented with continued pain after distal biceps repair. On revision surgery, he was found to have entrapment of the lateral antebrachial cutaneous nerve (LABCN). After nerve transection, relocation to its native course, and subsequent repair, the patient experienced complete resolution of his preoperative symptomatology. CONCLUSION To the author's knowledge, the current study is the first to describe symptomatic entrapment of the LABCN after distal biceps repair with a satisfying outcome after nerve transection, relocation, and repair.
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Affiliation(s)
- Brian T Ford
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut
| | - Andrew E Caputo
- Orthopedic Associates of Hartford, Farmington, Connecticut
- Bone and Joint Institute, Hartford, CT
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Roblot G, Seguret Q, Léon M, David E. A postoperative heterotopic ossification leading to radial palsy. HAND SURGERY & REHABILITATION 2024; 43:101627. [PMID: 38104769 DOI: 10.1016/j.hansur.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023]
Abstract
We report the case of a 58-year-old man who developed radial palsy three months after surgical reinsertion of the distal biceps brachii through a single anterior approach. Radiographs and ultrasound examinations revealed heterotopic ossification compressing the deep branch of the radial nerve. Surgical excision and neurolysis were performed. At the two-month follow-up, the patient was asymptomatic. Practitioners and orthopedic surgeons should be aware of the risk of heterotopic ossification after distal biceps reinsertion and its possible atypical clinical presentation.
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Affiliation(s)
- Galdéric Roblot
- CHU Amiens-Picardie, SOS Mains, CHU Amiens Sud, 1 Rue du Pr Christian Cabrol, 80000 Amiens, France.
| | - Quentin Seguret
- CHU Amiens-Picardie, SOS Mains, CHU Amiens Sud, 1 Rue du Pr Christian Cabrol, 80000 Amiens, France.
| | - Mathilde Léon
- CHU Amiens-Picardie, SOS Mains, CHU Amiens Sud, 1 Rue du Pr Christian Cabrol, 80000 Amiens, France.
| | - Emmanuel David
- CHU Amiens-Picardie, SOS Mains, CHU Amiens Sud, 1 Rue du Pr Christian Cabrol, 80000 Amiens, France.
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Moroski N, Eskew JR, Marston G, Martin S. Distal Biceps Repair Using an All-Suture Anchor Technique. Arthrosc Tech 2024; 13:102841. [PMID: 38435242 PMCID: PMC10907892 DOI: 10.1016/j.eats.2023.09.016] [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: 07/09/2023] [Accepted: 09/20/2023] [Indexed: 03/05/2024] Open
Abstract
Distal biceps ruptures are common injuries that lead to significant decrease in elbow supination strength and pain. This Technical Note describes a single-incision distal biceps tendon repair using 2 knotless suture anchors. This technique is easily reproducible, is efficient, and has the unique benefits of decreasing the risk of heterotopic ossification and damage to neurovascular structure while providing similar outcomes to other described fixation techniques.
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Affiliation(s)
- Nathan Moroski
- Prisma Health Blue Ridge Orthopedics – Seneca, Seneca, South Carolina, U.S.A
| | - Joshua R. Eskew
- Prisma Health Blue Ridge Orthopedics – Seneca, Seneca, South Carolina, U.S.A
| | - Geoffrey Marston
- Prisma Health Blue Ridge Orthopedics – Seneca, Seneca, South Carolina, U.S.A
| | - Steven Martin
- Prisma Health Blue Ridge Orthopedics – Seneca, Seneca, South Carolina, U.S.A
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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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Geuskens W, Caekebeke P, VAN Riet R. Prevalence and clinical implications of heterotopic ossification after distal biceps tendon repair. Acta Orthop Belg 2023; 89:695-700. [PMID: 38205763 DOI: 10.52628/89.4.12447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Complete distal biceps tendon ruptures are relatively uncommon. Conservative treatment may result in persistent pain and weakness. Therefore, surgical repair is usually indicated in order to restore strength. Different surgical techniques and fixation methods have been described. The most reported complications after surgery are iatrogenic nerve damage, heterotopic ossification (HO) and re-rupture. Heterotopic ossification can be variable in size. Significant HO can limit range of motion while minor HO often remains asymptomatic. The overall presence of HO is likely underreported in literature, as imaging is reserved for symptomatic patients. The purpose of this study is to report the prevalence and clinical implications of heterotopic ossification after surgical repair of the distal biceps tendon. This retrospective study assessed the prevalence and clinical relevance of postoperative HO after distal biceps tendon repair. CT-scans were used to evaluate size and location of the HO. VAS scores, DASH scores, MEPI, and range of motion (ROM) were assessed to evaluate pain, patient satisfaction and elbow function. HO was observed on CT images of 19 out of 35 patients (54%). The use of interference screws, timing of surgery after rupture and timing of radiographic assessment postoperatively did not influence the prevalence of HO. The presence of HO had no statistically significant impact on the VAS scores, ROM measurements and MEPI and DASH scores. According to our findings, the overall incidence of HO is higher than previously reported but there are no differences in clinical outcomes when compared to patients without HO.
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Wörner EA, Nagel M, Kodde IF, Eygendaal D, The B. Return to sports following distal biceps tendon repair: A current concepts review. J ISAKOS 2023; 8:227-231. [PMID: 36924828 DOI: 10.1016/j.jisako.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/07/2023] [Accepted: 02/19/2023] [Indexed: 03/17/2023]
Abstract
Distal biceps tendon ruptures are relatively rare injuries but tend to occur in active and athletic populations, especially in weightlifting and contact sports. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow, thus an injury to this ligament can be invalidating for athletes. The aim of this review was to determine the ability and the time to return to sports following distal biceps tendon repair in athletes and the level of performance. The literature is scarce about the return to sports among athletes. Most studies include athletes are National Football League (NFL) players, others are weightlifters and a few recreational athletes. The return to play rate after distal biceps tendon repair is high. The performances of the returned players were similar to matched players and most players returned to the same level. Most players-depending on the sport-were not able to return to competition within the same season. In order to manage expectations, it should be discussed preoperatively with the athlete (and their coach) that the return to sports rate is high, but the return will probably be the following season.
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Affiliation(s)
- E A Wörner
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, Netherlands; Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, Netherlands.
| | - M Nagel
- Department of Orthopaedic Surgery, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - I F Kodde
- Department of Orthopaedic and Trauma Surgery, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, Netherlands
| | - D Eygendaal
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, Netherlands
| | - B The
- Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, Netherlands
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Ernstbrunner L, Almond M, Rupasinghe HS, Jo OI, Zbeda RM, Ackland DC, Ek ET. Biomechanical Comparison of Distal Biceps Tendon Repair Techniques: Extracortical Single-Button Inlay Fixation Versus Intracortical Double-Button Onlay Anatomic Footprint Fixation. Am J Sports Med 2023:3635465231171131. [PMID: 37184036 DOI: 10.1177/03635465231171131] [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] [Indexed: 05/16/2023]
Abstract
BACKGROUND Extracortical single-button (SB) inlay repair is a commonly used distal biceps tendon technique. However, complications (eg, neurovascular injury) and nonanatomic repairs have led to the development of intracortical fixation techniques. PURPOSE To compare the biomechanical stability of extracortical SB repair with an anatomic intracortical double-button (DB) repair technique. STUDY DESIGN Controlled laboratory study. METHODS The distal biceps tendon was transected in 18 cadaveric elbows from 9 donors. One elbow of each donor was randomly assigned to the extracortical SB or anatomic DB group. Both groups were cyclically loaded with 60 N over 1000 cycles between 90° of flexion and full extension. The elbow was then fixed in 90° of flexion and the repair construct loaded to failure. Gap formation and construct stiffness during cyclic loading and ultimate load to failure were analyzed. RESULTS When compared with the extracortical SB technique after 1000 cycles, the anatomic DB technique showed significantly less gap formation (mean ± SD, 2.7 ± 0.8 vs 1.5 ± 0.9 mm; P = .017) and significantly more construct stiffness (87.4 ± 32.7 vs 119.9 ± 31.6 N/mm; P = .023). Ultimate load to failure was not significantly different between the groups (277 ± 93 vs 285 ± 135 N; P = .859). The failure mode in the anatomic DB group was significantly different from that of the extracortical SB technique (P = .002) and was due to fracture avulsion of the cortical button in 7 of 9 specimens (vs none in the SB group). CONCLUSION Our study shows that the intracortical DB technique produces equivalent or superior biomechanical performance to that of the SB technique. The DB technique may offer a clinically viable alternative to the SB repair technique. CLINICAL RELEVANCE This study suggests, at worst, an equivalent and, at best, a superior biomechanical performance of intracortical anatomic DB footprint repair at the time of surgery. However, the mode of failure suggests that this technique should not be used in patients with poor bone quality.
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Affiliation(s)
- Lukas Ernstbrunner
- Melbourne Orthopaedic Group, Melbourne, Australia
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute / St Vincent's Institute, Fitzroy, Australia
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Australia
| | - Mitchell Almond
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
| | - Harshi S Rupasinghe
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
| | - Olivia I Jo
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Australia
| | | | - David C Ackland
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
| | - Eugene T Ek
- Melbourne Orthopaedic Group, Melbourne, Australia
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute / St Vincent's Institute, Fitzroy, Australia
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Australia
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Tovar-Bazaga M, Llaneras MPC, Badia A. Reconstruction of chronic distal biceps ruptures by dermal matrix. HAND SURGERY AND REHABILITATION 2023; 42:243-249. [PMID: 37004984 DOI: 10.1016/j.hansur.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/22/2023] [Accepted: 03/25/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVES Distal biceps tear is uncommon, with well-recognized risk factors and typical clinical presentation. Delays in surgical treatment lead to several challenges, such as tendon retraction and tendon degeneration. We present a surgical technique using a sterilized acellular dermal matrix, which provides a solution for a challenging pathology. MATERIAL AND METHODS We present a detailed surgical technique of distal biceps reconstruction with acellular dermal matrix, performed in 4 patients, with an average time to diagnosis of 36 days (range, 28-45 days). Demographics, clinical data, range of motion and subjective satisfaction were collected. RESULTS At a mean follow-up of 18 months, all 4 patients showed full range of motion and strength, complete recovery and previous work resumed without pain. No complications appeared during this time. CONCLUSIONS Delayed distal biceps tear reconstruction by acellular dermal matrix showed promising results. Meticulous surgical technique using this matrix provided excellent reconstruction, with very solid anatomical repair and exceptionally good fixation, good clinical outcome and satisfied patients. LEVEL OF EVIDENCE IV.
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Cheng C, Dong O, Klyce W, Lee A, Bafus BT. Short-term outcome of unicortical, intramedullary repair of distal biceps ruptures - A retrospective cohort study. JSES Int 2023; 7:348-350. [PMID: 36911763 PMCID: PMC9998733 DOI: 10.1016/j.jseint.2022.10.012] [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: 11/11/2022] Open
Abstract
Background Modern distal biceps reconstruction techniques generally have satisfactory outcomes, but are not without complications. Posterior interosseous nerve (PIN) palsy is a rare but potentially devastating complication of bicortical metal button fixation. Recently, a unicortical, intramedullary, repair technique utilizing a suture anchor has been described. The primary aim of this study was to compare short-term functional and patient-reported outcomes and complication rates in patients receiving unicortical intramedullary repair (UR) with suture anchor against those receiving bicortical repair (BR) with metallic button. We hypothesized that UR would have equally satisfactory outcomes without the complication profile. Methods Retrospective chart review was conducted for all patients undergoing operative fixation of distal biceps tendon ruptures from 2015 to 2021 at our tertiary referral center. Twenty patients received BR, and eight patients received UR. Patient demographics and surgical complications were compared. QuickDASH scores at two-month and latest in-person and telehealth postoperative visits, as well as elbow and forearm range of motion at last clinical visit, were collected and analyzed. Results Average patient age in the BR & UR cohorts were 49.3 ± 9.3 and 42.1 ± 6.2 years, respectively, with a male predominance. There was no statistical difference in patient age, sex, hand dominance, injury laterality, injury chronicity, and follow-up duration. Range of motion was comparable and excellent in both groups. Latest follow-up was 3.0 ± 0.5 years in the BR and 1.5 ± 0.4 years in the UR cohorts. QuickDASH scores improved between the two-month and latest time points in each cohort however did not differ significantly in head-to-head comparison. Complications included a case of PIN palsy, distal biceps tendon rerupture, and lateral antebrachial cutaneous nerve (LABC) neuropraxia in the BR group and two cases of LABC neuropraxia in the UR group. The number needed to treat (NNT) for the prevention of one additional case of PIN palsy using UR is 22 patients. Discussion Short-term functional and patient-reported outcomes in traditional BR and newly reported UR of distal biceps tendon ruptures are comparable and excellent. UR did not have higher failure rate despite follow-up periods beyond what is typically reported for tendon reruptures. In this limited retrospective cohort study, UR also did not encounter postoperative PIN palsy and had an NNT of 22 patients. In the appropriate clinical setting, this provides early evidence supporting the utilization of unicortical intramedullary suture anchor fixation of distal biceps tendon ruptures as well as associated perioperative interventions such as preoperative nerve blocks.
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Affiliation(s)
- Christopher Cheng
- Department of Orthopaedic Surgery, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Oliver Dong
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Walter Klyce
- Department of Orthopaedic Surgery, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Adrienne Lee
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Blaine Todd Bafus
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
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Trends and complications of distal biceps tendon repair among American Board of Orthopaedic Surgery part II oral examination candidates. J Shoulder Elbow Surg 2023; 32:348-352. [PMID: 36273792 DOI: 10.1016/j.jse.2022.09.014] [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: 08/12/2022] [Revised: 09/19/2022] [Accepted: 09/28/2022] [Indexed: 12/08/2022]
Abstract
BACKGROUND Surgical fixation of distal biceps tendon ruptures can restore supination strength and minimize biceps fatigue, resulting in high patient satisfaction rates. Surgical approaches can vary (single incision vs. double incision), and the number of fixation techniques has increased in recent years. The reported rate of postoperative complications after surgical repair of distal biceps tendon injuries is high, ranging from 15% to 35%. The purpose of this study was to assess the trends and postoperative complication profile among newly trained surgeons who performed distal biceps tendon repairs utilizing the American Board of Orthopaedic Surgery database. METHODS The American Board of Orthopaedic Surgery database was retrospectively queried for patients treated with distal biceps tendon repair by part II examination candidates between 2017 and 2020. Distal biceps tendon repairs were isolated using the Current Procedural Terminology code 24,342. Distal triceps tendon injuries were excluded with International Classification of Diseases code S46.3∗∗. Patient demographics, intraoperative data, and surgeon fellowship training were collected. Surgeon-reported postoperative 90-day complications, including general anesthetic, medical, and surgical complications, rates of readmission, and rates of reoperation were recorded. Comparisons of rates among patient groups organized by surgeon fellowship training were performed using the chi-squared test. RESULTS A total of 2089 distal biceps tendon repairs were included in the analysis. The average patient age was 47.5 yr, and 97.3% of patients were men. The majority of cases was performed by surgeons with fellowship training in sports medicine, hand/upper extremity, and shoulder and elbow, with 867 (41.5%) cases performed by sports medicine-trained surgeons, 740 (35.4%) by hand/upper extremity-trained surgeons, and 313 (15.0%) by shoulder and elbow-trained surgeons. In total, 608 (29.1%) patients experienced an anesthetic (0.2%), medical (1.1%), or surgical (28.2%) complication. The most common surgical complications were nerve injury (20.6%), failure of tendon repair or fixation (2.4%), and infection (1.7%). The overall reoperation rate was 2.4%. There were no significant differences in complication or reoperation rates among subspecialty training received. DISCUSSION AND CONCLUSION Among newly trained surgeons, those with fellowship training in sports medicine, hand/upper extremity, and shoulder and elbow performed the most distal biceps tendon repairs, and there was no difference in complication rates among subspecialty training received. Complication rates after distal biceps tendon repair performed by newly trained surgeons were similar to those previously reported in large cohort studies, with nerve injury as the most common complication.
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Forlenza EM, Lavoie-Gagne O, Parvaresh KC, Berlinberg EJ, Agarwalla A, Forsythe B. Two Intramedullary and 1 Extramedullary Cortical Button, With or Without Interference Screw, Show Biomechanical Properties Superior to Native Tendon in Repair of the Distal Biceps Tendon: A Systematic Review and Network Meta-analysis of Biomechanical Performance. Arthroscopy 2023; 39:390-401. [PMID: 36243288 DOI: 10.1016/j.arthro.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/05/2022] [Accepted: 08/17/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE The aim of this study was to use a systematic review and network meta-analysis (NMA) to compare the failure strength, maximum strength, stiffness, and displacement of available constructs for distal biceps repair. METHODS An NMA was conducted to determine the performance of 2 all-suture suture anchors (2x ASA), 2 intramedullary cortical buttons (2x IM CB), 2 suture anchors (2x SA), extramedullary cortical buttons (EM CB), extramedullary cortical button plus interference screw (EM CB+IFS), interference screw (IFS), single intramedullary cortical button (IM CB), single suture anchor (SA), transosseous suture (TOS), tension slide technique (TST), and tension slide technique plus suture tape (TST+ST). Analysis consisted of arm-based network meta-analysis under Bayesian random-effects model with Markov Chain Monte Carlo (MCMC) sampling. Biomechanical outcomes were summarized as treatment effects and their corresponding 95% confidence intervals (CI). Rank probabilities were calculated and used to generate each treatment's surface under the cumulative ranking (SUCRA) curve. Biomechanical properties were compared to native tendon. Displacement >10 mm was defined as clinical failure. RESULTS Twenty-one studies were included. For failure strength, no construct outperformed the native tendon but 2× SA, IFS, SA, and TOS demonstrated poorer failure strength. For the maximum load to failure, EM CB+IFS outperformed the native tendon. Compared to native tendon, EM CB+IFS, EM CB, and 2×IM CB were stiffer, while 2x SA and IFS were less stiff. No construct demonstrated >10 mm of displacement, but constructs with displacement above the mean (3.5 mm) included 2× ASA, 2xIM CB, and TOS. CONCLUSIONS The fixation constructs that consistently demonstrated comparable or better biomechanical properties (failure strength, maximum strength, and stiffness) to native tendon in distal biceps tendon repair were the extramedullary cortical button with or without interference screw and two intramedullary cortical buttons. No construct demonstrated displacement beyond standard definitions for clinical failure. CLINICAL RELEVANCE This network meta-analysis of biomechanical studies suggests that extramedullary cortical button and two intramedullary cortical buttons may be the most stable construct for distal biceps repair fixation, with equivalent or better biomechanical properties compared to native tendon.
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Affiliation(s)
| | - Ophelie Lavoie-Gagne
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Wörner EA, Kodde IF, Spaans AJ, Colic N, Hilgersom N, van Oost I, The B, Eygendaal D. Three weeks of indomethacin is not superior to 1 week of meloxicam as prophylaxis for heterotopic ossifications after distal biceps tendon repair with a single-incision technique. J Shoulder Elbow Surg 2022; 31:2157-2163. [PMID: 35872167 DOI: 10.1016/j.jse.2022.06.002] [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: 01/24/2022] [Revised: 05/22/2022] [Accepted: 06/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to assess the efficacy of 3 weeks of indomethacin, a nonselective nonsteroidal anti-inflammatory drug, in comparison to 1 week of meloxicam as prophylaxis for heterotopic ossifications (HOs) after distal biceps tendon repair. METHODS A single-center retrospective study was performed on 78 patients undergoing distal biceps tendon repair between 2008 and 2019. From 2008 to 2016, patients received meloxicam 15 mg daily for the period of 1 week as usual care. From 2016 onward, the standard protocol was changed to indomethacin 25 mg 3 times daily for 3 weeks. All patients underwent a single-incision repair with a cortical button technique. The postoperative rehabilitation protocol was similar for all patients. The postoperative radiographs at 8-week follow-up were assessed blindly by 7 independent assessors. If HOs were present, it was classified according to the Ilahi-Gabel classification for size and according to the Gärtner-Heyer classification for density. Statistical analysis was performed to analyze the difference in HO between the patients who were treated with indomethacin and with meloxicam. RESULTS Seventy-eight patients, with a mean age of 48.8 years (range 30-72) were included. The mean follow-up after surgery was 12 months (range 2-45). Indomethacin (21 days, 25 mg 3 times per day) was prescribed to 26 (33%) patients. The 52 other patients (67%) were prescribed meloxicam 15 mg daily for 7 days. HOs were seen in 19 patients 8 weeks postoperatively. Five of 26 patients treated with indomethacin developed HO, and 14 of 52 patients treated with meloxicam developed HO (P = .5). Two patients had symptomatic HO with minor restrictions in movement; neither patient was treated with indomethacin. Significantly more HOs were seen in patients with a longer time from injury to surgery (P = .01) The intraclass correlation score for reliability between assessors for HO scoring on postoperative radiographs was good to excellent for both classifications. CONCLUSION In this study, HOs were seen in 24% of postoperative radiographs. Three weeks of indomethacin was not superior to meloxicam for 1 week for the prevention of HO after single-incision distal biceps tendon repair.
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Affiliation(s)
- Elisabeth A Wörner
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Foundation for Orthopaedic Research, Care & Education (FORCE), Amphia Hospital, Breda, Netherlands.
| | - Isaak F Kodde
- Department of Orthopaedic and Trauma Surgery, Deventer Ziekenhuis, Deventer, Netherlands
| | - Anne J Spaans
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen/Boxmeer, Netherlands
| | - Nicola Colic
- Department of Orthopaedic Surgery, Institute for Orthopaedic Surgery, Banjica, Belgrade, Serbia
| | - Nick Hilgersom
- Foundation for Orthopaedic Research, Care & Education (FORCE), Amphia Hospital, Breda, Netherlands
| | - Iris van Oost
- Foundation for Orthopaedic Research, Care & Education (FORCE), Amphia Hospital, Breda, Netherlands
| | - Bertram The
- Foundation for Orthopaedic Research, Care & Education (FORCE), Amphia Hospital, Breda, Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Foundation for Orthopaedic Research, Care & Education (FORCE), Amphia Hospital, Breda, Netherlands
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Fitzgerald MJ, Mullen JR, Starecki MJ, Greenberg A, Tuckman DV. Single Incision Modified Tension Slide Technique in Distal Biceps Repair: Improved Load to Failure While Reducing Surgical Pitfalls. Tech Hand Up Extrem Surg 2022; 26:152-156. [PMID: 34923560 DOI: 10.1097/bth.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Historically, distal biceps tendon repair through the tension slide technique (TST) using a cortical button has yielded the strongest published repair measured by observed gap formation in both cyclic and maximal load to failure. The modified tension slide technique (MTST) was developed in order to provide the surgeon with a technically simpler and biomechanically more effective way to reduce gap formation and consistently seat/bottom-out the tendon within the bone tunnel through a more direct line of pull. In order to compare the biomechanics of the MTST to the TST, we used 24 matched bovine extensor tendons, and conducted maximal load to failure and cyclical load to failure testing using an Instron 5566 machine. The mean maximal load to failure for the MTST was 444 N versus 229 N for the TST ( P <0.004) while no gap formation was observed in either group after cyclic load testing. These findings indicate that the MTST has a statistically significant increased load to gap formation of ∼2-fold in comparison to TST. In the MTST both limbs of suture are passed back through the tendon, before button implantation, eliminating the "operating in a hole" effect required in the TST, and making for a simpler surgical procedure.
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Affiliation(s)
- Michael J Fitzgerald
- Department of Orthopaedic Surgery, Northwell/Northshore University Hospital-Long Island Jewish Medical Center, Manhasset
| | - James R Mullen
- Heritage Valley Health System, Hand and Upper Extremity Center, Wexford, PA
| | | | - Andrew Greenberg
- Department of Orthopaedic Surgery, Northwell/Northshore University Hospital-Long Island Jewish Medical Center, Manhasset
- Orthopaedic Associates of Manhasset, Great Neck, NY
| | - David V Tuckman
- Department of Orthopaedic Surgery, Northwell/Northshore University Hospital-Long Island Jewish Medical Center, Manhasset
- Orthopaedic Associates of Manhasset, Great Neck, NY
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15
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Kolaczko JG, Knapik DM, McMellen CJ, Mengers SR, Gillespie RJ, Voos JE. Complete Isolated Ruptures of the Distal Biceps Brachii During Athletic Activity: A Systematic Review. Cureus 2022; 14:e27899. [PMID: 35971400 PMCID: PMC9371626 DOI: 10.7759/cureus.27899] [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: 08/11/2022] [Indexed: 11/05/2022] Open
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16
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Synovec JD, Traven SA, Griffith AT, Novikov D, Li X, Woolf SK, Eichinger JK, Slone HS. Outcomes and complications after different surgical techniques for the treatment of chronic distal biceps tendon ruptures: a systematic review and quantitative synthesis. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:323-331. [PMID: 37588857 PMCID: PMC10426634 DOI: 10.1016/j.xrrt.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Hypothesis The purpose of this study was to perform a systematic review of the available literature evaluating surgical outcomes after chronic distal biceps tendon rupture. Surgical techniques, including primary repair, autograft reconstruction, and allograft reconstruction, were compared, as well as subjective and objective clinical outcomes and complication rates. Methods A systematic literature search of Level I-IV studies reporting outcomes of surgically treated chronic distal biceps tendon ruptures were performed via PubMed, Cochrane Collaboration, Science Direct, and Google Scholar databases. Twenty-two papers were identified in the review, with 236 patients. A Modified Coleman Methodological Score (CMS) was determined for every article to assess study quality. Patient-reported outcomes, postoperative range of motion, flexion and supination strength, and postoperative complications were recorded. MAYO elbow scores (MEPS) were reported more consistently than the other outcome tools. Results No Level I or level II studies were identified in our search, and the heterogeneity of outcome measures precluded meta-analysis. Studies demonstrated mean MEPS scores ranging between 86 and 100, regardless of the surgical technique utilized. All studies reported a mean flexion-extension arc equal to or greater than 5-130°. The reported mean postoperative flexion strength was within 10% of the unaffected contralateral side. The most common complication for both direct repair and reconstruction groups was paresthesia of the lateral antebrachial cutaneous nerve [direct repair: 18-16.8%; reconstruction: 8-6.2% (allograft: 4-6%; autograft: 4-7%)]. Rerupture was uncommon and occurred in three patients who had undergone direct repair and in one patient after autograft reconstruction. Conclusions Surgical treatment of chronic distal biceps injuries yields favorable objective and subjective outcomes. Currently, available evidence suggests that direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes.
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Affiliation(s)
| | | | | | | | - Xinning Li
- Boston University Medical Center, Boston, MA, USA
| | - Shane K. Woolf
- Medical University of South Carolina, Charleston, SC, USA
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17
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Cheng C, Bafus BT. Intramedullary, unicortical repair of distal biceps tendon rupture. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:238-242. [PMID: 37587954 PMCID: PMC10426579 DOI: 10.1016/j.xrrt.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Historically-used bicortical repair of distal biceps tendon rupture are at risk for posterior interosseous nerve palsy. Here we present a technique, and associated case report, utilizing unicortical repair with a suture cortical button device for this injury. The described technique provides robust fixation and avoids the rare, but potentially devastating complication of posterior interosseous nerve palsy.
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Affiliation(s)
- Christopher Cheng
- Department of Orthopaedic Surgery, Case Western Reserve University/University Hospitals, Cleveland, OH, USA
| | - Blaine Todd Bafus
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
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18
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Anatomical intramedullary distal biceps tendon fixation. Our first experience. JSES Int 2022; 6:530-534. [PMID: 35572426 PMCID: PMC9091800 DOI: 10.1016/j.jseint.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Hypothesis Study Design Methods Results Conclusions
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19
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Colantonio DF, Le AH, Keeling LE, Slaven SE, Vippa TK, Helgeson MD, Chang ES. Intramedullary Unicortical Button and All-Suture Anchors Provide Similar Maximum Strength for Onlay Distal Biceps Tendon Repair. Arthroscopy 2022; 38:287-294. [PMID: 34332050 DOI: 10.1016/j.arthro.2021.06.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/03/2021] [Accepted: 06/27/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the biomechanical profile of onlay distal biceps repair with an intramedullary unicortical button versus all-suture anchors under cyclic loading and maximal load to failure. METHODS Twenty paired fresh-frozen human cadaveric elbows were randomized to onlay distal biceps repair with either a single intramedullary button or with two 1.35-mm all-suture anchors. A 1.3-mm high tensile strength tape was used in a Krackow stitch to suture the tendons in both groups. Specimens and repair constructs were loaded for 3,000 cycles and then loaded to failure. Maximum load to failure, mode of failure, and construct elongation were recorded. RESULTS Mean (± standard deviation) maximum load to failure for the unicortical intramedullary button and all-suture anchor repairs were 503.23 ± 141.77 N and 537.33 ± 262.13 N (P = .696), respectively. Mean maximum displacement after 3,000 cycles (± standard deviation) was 4.17 ± 2.05 mm in the button group and 2.06 ± 1.05 mm in the suture anchor group (P = .014). Mode of failure in the button group was suture tape rupture in 7 specimens, failure at the tendon-suture interface in 2 specimens, and button pullout in 1 specimen. Anchor pullout was the mode of failure in all suture anchor specimens. There were no tendon ruptures or radial tuberosity fractures in either group. CONCLUSIONS This study demonstrates that onlay distal biceps repair with 2 all-suture anchors has similar maximum strength to repair with an intramedullary button and that both are viable options for fixation. CLINICAL RELEVANCE All-suture anchors and unicortical intramedullary button have similar maximum strength at time zero. Both constructs provide suitable fixation for onlay distal biceps repair.
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Affiliation(s)
- Donald F Colantonio
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A..
| | - Anthony H Le
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Laura E Keeling
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, U.S.A
| | - Sean E Slaven
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Tarun K Vippa
- Department of Orthopaedic Surgery, Inova Health System, Fairfax, Virginia, U.S.A
| | - Melvin D Helgeson
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Edward S Chang
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A.; Department of Orthopaedic Surgery, Inova Health System, Fairfax, Virginia, U.S.A
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20
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Lynch B, Duke A, Komatsu D, Wang E. Risk of Posterior Interosseous Nerve Injury During Distal Biceps Tendon Repair Using a Cortical Button. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:14-18. [PMID: 35415600 PMCID: PMC8991717 DOI: 10.1016/j.jhsg.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/28/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose To evaluate the possibility of posterior interosseous nerve (PIN) injury during cortical button deployment and seating associated with bicortical drilling and passage of the cortical button across the distal cortex when repairing a distal biceps rupture in a cadaveric model. Methods Each cadaver was placed in the supine position with the arm extended. A single 4 cm transverse incision was made in the region of the radial tuberosity, 3–4 cm distal to the antecubital fossa flexion crease, and dissected down to the radial tuberosity. A #2 looped nonabsorbable suture was used to baseball stitch the musculotendinous junction to the distal 2.5 cm end of the tendon. A 3.2 mm cannulated drill bit (Arthrex) was used to create a bicortical drill hole in the center of the radial tuberosity aiming 30° ulnar to maximize the distance from the PIN. Fluoroscopy was used to confirm drill placement in the radial tuberosity for all specimens. The posterior aspect of the elbow in all cadavers was subsequently dissected out to directly visualize how far the cannulated drill was from the PIN. Results Twelve cadavers, average age 57.4 years (range, 27–83 years), were dissected. During deployment, the cortical button contacted the PIN directly in 6 extremities. The cortical button came within 6 mm of the PIN in eleven extremities. In 8 specimens, the cortical button was within 2 mm of the PIN. The PIN was caught directly under the cortical button in one specimen. Conclusions Placement of a biceps cortical button bicortically when repairing a distal biceps tendon may increase the risk of injury to the PIN during cortical button deployment and seating. Type of study/level of evidence Therapeutic IV.
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21
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Caekebeke P, Vande Voorde K, Duerinckx J, van Riet R. In vivo evaluation of a new intramedullary distal biceps tendon fixation device. J Shoulder Elbow Surg 2021; 30:2869-2874. [PMID: 34273537 DOI: 10.1016/j.jse.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/31/2021] [Accepted: 06/07/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intramedullary fixation in distal biceps tendon repair may be a solution to address specific shortcomings of current fixation techniques. Most investigations are limited to biomechanical evaluation. The purpose of this study was to report the short-term outcomes of an intramedullary fixation device. METHODS We evaluated functional and radiographic outcomes at up to 6 months of follow-up. Patients with an acute distal biceps tendon rupture eligible for surgical repair were invited to take part in the study. Ten patients were included in the final analysis. All patients were evaluated both clinically and radiographically at 2 weeks, 6 weeks, 3 months, and 6 months. Outcomes were recorded using a visual analog scale score for pain, the Mayo Elbow Performance Score, and the Disabilities of the Arm, Shoulder and Hand score. Radiographic evaluation comprised radiographic and computed tomography evaluation. RESULTS There were no failures of fixation in the patient group examined. Elbow mobility was symmetrical for all patients from 3 months onward. Supination strength was 86% of the uninjured side at final follow-up. The mean Disabilities of the Arm, Shoulder and Hand score and Mayo Elbow Performance Score at final follow-up were 0 and 100, respectively. Computed tomography images showed no signs of button migration, cortical thinning due to button pressure, or button breakout. The tendon could be followed to the button in all cases. CONCLUSIONS The intramedullary fixation button technique to repair the distal biceps tendon has excellent functional outcomes at 6 months. No adverse reactions of the button on the bone were seen. As this technique minimizes the risk of posterior interosseous nerve injury and has a sufficient bone tunnel to avoid gap formation, this may be a promising new technique for distal biceps tendon rupture refixation.
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Affiliation(s)
- Pieter Caekebeke
- Department of Orthopaedic Surgery and Traumatology, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Kira Vande Voorde
- Department of Orthopaedic Surgery and Traumatology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Joris Duerinckx
- Department of Orthopaedic Surgery and Traumatology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Roger van Riet
- Department of Orthopedic Surgery, AZ Monica, Deurne, Antwerp, Belgium; Department of Orthopaedic Surgery, University Hospital Antwerp, Edegem, Belgium
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22
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Parikh P, MacDermid JC, Tuli V, Manley M. Distal biceps tendon rupture: Is surgery the best course of treatment? Two case reports. J Hand Ther 2021; 34:463-468. [PMID: 32565099 DOI: 10.1016/j.jht.2020.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Repeated case study. INTRODUCTION Complete rupture of the distal biceps tendon occurs mostly within the middle-aged male population. Surgical repair is traditionally recommended. Given the potential for complications, questions remain whether surgical repair is indicated. PURPOSE To explore non-operative management for full distal biceps tendon ruptures. CASES Two participants with complete tears of the distal biceps tendon confirmed with magnetic resonance imaging/ultrasound had chosen to not undergo surgical repair. First, a 48-year-old police officer was an avid weight lifter and recreational athlete. Second, a 43-year-old detailer has minimal physical activity participation other than work duties and light recreational sports. Strength testing was performed immediately after rupture and at 24 weeks after a structured physical therapy program focused on strengthening and stretching the elbow flexors and supinator. OUTCOMES Initial strength deficits of 17/21% in flexion and 13/19% for supination were detected. In both patients, flexion and supination strength returned to normal limits when compared with the opposite upper extremity. After intervention, functional and disability scores were normal in both cases, and both patients reported return to preinjury repetitive work and weight training. DISCUSSION Although patients are typically counseled that a reason for surgical repair after biceps rupture is substantial loss of flexion and supination strength, these cases indicate that full recovery of strength and function is possible through rehabilitation. CONCLUSION These cases question the traditional wisdom that a surgical repair is needed for all distal biceps ruptures. LEVEL OF EVIDENCE Therapy, level 5. ICD-10 Code: M66.3.
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Affiliation(s)
- Pulak Parikh
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
| | - Joy C MacDermid
- Hand and Upper Limb Centre, St. Joseph Hospital, London, ON, Canada
| | - Vikas Tuli
- Full Radius Orthopaedics, Newmarket, ON, Canada
| | - Michelle Manley
- Spectrum Institute for Health and Rehabilitation, Newmarket, ON, Canada
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Cuzzolin M, Secco D, Guerra E, Altamura SA, Filardo G, Candrian C. Operative Versus Nonoperative Management for Distal Biceps Brachii Tendon Lesions: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:23259671211037311. [PMID: 34734095 PMCID: PMC8558817 DOI: 10.1177/23259671211037311] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Both nonoperative and operative treatments have been proposed to manage distal biceps brachii tendon avulsions. However, the advantages and disadvantages of these approaches have not been properly quantified. PURPOSE To summarize the current literature on both nonoperative and operative approaches for distal biceps brachii tendon ruptures and to quantify results and limitations. The advantages and disadvantages of the different surgical strategies were investigated as well. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic literature search was performed in March 2020 using PubMed Central, Web of Science, Cochrane Library, MEDLINE, Iscrctn.com, clinicaltrials.gov, greylit.org, opengrey.eu, and Scopus literature databases. All human studies evaluating the clinical outcome of nonoperative treatment as well as different surgical techniques were included. The influence of the treatment approach was assessed in terms of the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Mayo Elbow Performance Index; extension, flexion, supination, and pronation range of motion (ROM); and flexion and supination strength ratio between the injured and uninjured arms. Risk of bias and quality of evidence were assessed using the Cochrane guidelines. RESULTS Of 1275 studies, 53 studies (N = 1380 patients) matched the inclusion criteria. The results of the meta-analysis comparing operative versus nonoperative approaches for distal biceps tendon avulsion showed significant differences in favor of surgery in terms of DASH score (P = .02), Mayo Elbow Performance Index (P < .001), flexion strength (94.7% vs 83.0%, respectively; P < .001), and supination strength (89.2% vs 62.6%, respectively; P < .001). The surgical approach presented 10% heterotopic ossifications, 10% transient sensory nerve injuries, 1.6% transient motor nerve injuries, and a 0.1% rate of persistent motorial disorders. Comparison of the different surgical techniques showed similar results for the fixation methods, whereas the single-incision technique led to a better pronation ROM versus the double-incision approach (81.5° vs 76.1°, respectively; P = .01). CONCLUSION The results of this meta-analysis showed the superiority of surgical management over the nonoperative approach for distal biceps tendon detachment, with superior flexion and supination strength and better patient-reported outcomes. The single-incision surgical approach demonstrated a slightly better pronation ROM compared with the double-incision approach, whereas all fixation methods led to similar outcomes.
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Affiliation(s)
- Marco Cuzzolin
- Orthopedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Davide Secco
- Orthopedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
| | - Enrico Guerra
- Shoulder and Elbow Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Giuseppe Filardo
- Orthopedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Christian Candrian
- Orthopedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland
- Facoltà di Scienze Biomediche, USI–Università della Svizzera Italiana, Lugano, Switzerland
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Gowd AK, Liu JN, Maheshwer B, Garcia GH, Beck EC, Cohen MS, Nicholson GP, Cole BJ, Verma NN. Return to sport and weightlifting analysis following distal biceps tendon repair. J Shoulder Elbow Surg 2021; 30:2097-2104. [PMID: 33667641 DOI: 10.1016/j.jse.2021.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/16/2021] [Accepted: 01/31/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rupture of the distal biceps tendon is an increasingly frequent injury sustained predominantly by middle-aged men. Despite the prevalence of sport in this age group, little is known regarding return to sport outcomes following surgery. METHODS Patients undergoing distal biceps tendon repair (DBR) between January 2015 and January 2017 were contacted electronically via e-mail and via telephone to administer a previously validated and standard return to sport survey. Patients self-reported preinjury and current level of sport and activity as well as preinjury and current level of select weightlifts. RESULTS A total of 77 of 124 patients were available for follow-up (62.1%). Of these patients, 61 endorsed preoperative sport and were included for analysis. Average follow-up was 38.7 ± 6.7 months. The mean age at surgery was 47.5 ± 8.8 years, and the mean body mass index was 30.3 ± 5.1. The dominant side was affected in 25 of 61 cases. Of the 61 included patients, 57 (93.4%) were able to return to sport at any level (lower, same, or higher intensity than preinjury activity level). Forty of the patients (65.6%) were able to return to sport at same or higher intensity. Mean time to return to sport was 6.0 ± 2.8 months. Days from injury to surgery (odds ratio [OR] 0.999, 95% confidence interval [CI] 0.998-0.999), suture anchor fixation in comparison to suture button (OR 0.602, 95% CI 0.427-0.850), and dominant-side surgery (OR 0.749, 95% CI 0.582-0.963) were associated with a decreased likelihood to return to sport at same or higher level of duty. Single-sided incision in comparison to double (OR 5.209, 95% CI 1.239-20.903) and dominant-side surgery (OR 6.370, 95% CI 1.639-24.762) were associated with increased duration to return to sport. CONCLUSION Distal biceps tendon rupture is a significant injury; however, patients can expect high levels of return to sport following DBR with some residual impairment compared with baseline. It is important to counsel patients on their expectations while taking into account the results of this study: that there will be a small but appreciable decrease in strength compared with preinjury levels.
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Affiliation(s)
- Anirudh K Gowd
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Joseph N Liu
- Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | | | - Edward C Beck
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Mark S Cohen
- Rush University Medical Center, Chicago, IL, USA
| | | | - Brian J Cole
- Rush University Medical Center, Chicago, IL, USA
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Weißenberger M, Klug A, Heinz T, Rueckl K, Kollenda H, Rudert M, Hoffmann R, Schmidt-Horlohé K. No functional differences in anatomic reconstruction using a one- versus a two-point fixation for distal biceps tendon rupture through a single-incision anterior approach: A prospective randomized trial. Technol Health Care 2021; 29:575-588. [PMID: 33492254 DOI: 10.3233/thc-202476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The distal biceps brachii tendon rupture is a rare injury of the musculoskeletal system. Multiple surgical techniques have been described for distal biceps brachii tendon repairs including suture anchors. OBJECTIVE The aim of this study was to evaluate the outcome of anatomical distal biceps tendon refixation using either one or two suture anchors for reattachment and to determine whether there are significant clinically important differences on the number of anchors used for refixation. METHODS A monocentric, randomized controlled trial was conducted, including 16 male patients with a mean age of 47.4 years (range, 31.0 to 58.0) in Group 1 (two suture anchors for refixation) and 15 male patients with a mean age of 47.4 (range, 35.0 to 59.0) in Group 2 (one suture anchor for refixation). All surgeries were performed through an anterior approach. The outcome was assessed using the Oxford Elbow Score (OES), the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Andrews Carson Score (ACS) and by isokinetic strength measurement for the elbow flexion after six, twelve, 24 and 48 weeks. Radiographic controls were performed after 24 and 48 weeks. RESULTS No significant differences between both groups were evident at any point during the follow-up period. A continuous improvement in outcome for both groups could be detected, reaching an OES: 46.3 (39.0 to 48.0) vs. 45.5 (30.0 to 48.0), MEPS: 98.0 (85.0 to 100.0) vs. 99.0 (85.0 to 100.0), DASH: 3.1 (0.0 to 16.7) vs. 2.9 (0.0 to 26.7), ACS: 197.0 (175.0 to 200.0) vs. 197.7.
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Affiliation(s)
- Manuel Weißenberger
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany.,Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Germany.,Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany
| | - Alexander Klug
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany.,Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Germany
| | - Kilian Rueckl
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Germany
| | - Hans Kollenda
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany.,Supervisory Center North for Public Law Tasks of the Bundeswehr Medical Service, Kronshagen, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Germany
| | - Reinhard Hoffmann
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany
| | - Kay Schmidt-Horlohé
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany.,Orthopaedicum Wiesbaden, Wiesbaden, Germany
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26
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Albishi W, Agenor A, Lam JJ, Elmaraghy A. Distal Biceps Tendon Tears: Diagnosis and Treatment Algorithm. JBJS Rev 2021; 9:01874474-202107000-00002. [PMID: 34260471 DOI: 10.2106/jbjs.rvw.20.00151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Distal biceps tendon (DBT) tears occur most commonly in middle-aged men after a sudden, forced eccentric contraction of the flexed elbow. » An understanding of the multiple risk factors, mechanisms, and pathophysiological causes is essential for proper and timely diagnosis. » High clinical suspicion and routine physical examination with appropriate special examination tests, including the hook test, the passive forearm pronation test, the biceps crease interval test, and the bicipital aponeurosis flex test, can help with rapid and accurate diagnosis and guide appropriate and timely management. » Treatment for DBT tears depends on the extent (complete versus incomplete) and timing (acute versus chronic) of the injury, and options include nonoperative management, repair, and reconstruction with or without repair of the bicipital aponeurosis.
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Affiliation(s)
- Waleed Albishi
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Aouod Agenor
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jason J Lam
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Amr Elmaraghy
- Department of Orthopaedic Surgery, Unity Health, St. Joseph's Health Centre, Toronto, Ontario, Canada
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27
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Berthold DP, Muench LN, Cusano A, Uyeki CL, Slater M, Tamburini LM, Geyer S, Cote MP, Arciero RA, Mazzocca AD. Clinical and Functional Outcomes After Operative and Nonoperative Treatment of Distal Biceps Brachii Tendon Ruptures in a Consecutive Case Series. Orthop J Sports Med 2021; 9:2325967120984841. [PMID: 34179199 PMCID: PMC8193667 DOI: 10.1177/2325967120984841] [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: 10/08/2020] [Accepted: 11/24/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Patients with ruptures of the distal biceps brachii tendon (DBBT) have traditionally been treated via surgical repair, despite limited patient data on nonoperative management. Purpose/Hypothesis: To determine the clinical and functional outcomes for patients with partial and complete DBBT injuries treated nonoperatively or surgically through an anatomic single-incision technique. We hypothesized that there would be no difference in outcomes in patients treated with nonoperative or operative management. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective chart review identified all patients with a partial or complete DBBT injury sustained between 2003 and 2017. Surgically treated patients underwent DBBT repair using an anatomic single-incision technique. Nonoperative management consisted of formal physical therapy. The following clinical outcome measures were included for analysis: American Shoulder and Elbow Surgeons (ASES) score; the Disabilities of the Arm, Shoulder and Hand (DASH) upper extremity patient questionnaire; the Single Assessment Numeric Evaluation (SANE) score; and the 36-Item Short Form Health Survey. Results: A total of 60 patients (mean ± SD age, 47.8 ± 11.5 years; range, 18-70 years) sustained DBBT ruptures (38 complete and 22 partial) during the study period. Of patients with complete DBBT, 34 were treated operatively and 4 nonoperatively; of those with partial DBBT, 11 were treated operatively and 11 nonoperatively. At a mean follow-up of 5.4 ± 4.0 years (range, 0.5-16.6 years), patients with complete DBBT ruptures achieved overall similar improvements with respect to mean ASES pain, ASES function, SANE, and DASH scores, regardless of whether they were treated operatively or nonoperatively. Subjective satisfaction and functional scores were comparable between the groups. Similarly, at a mean follow-up of 4.1 ± 3.8 years (range, 0.5-11.3 years), patients with partial DBBT injuries had improved mean ASES pain, ASES function, SANE, and DASH scores, regardless of operative or nonoperative treatment. Subjective satisfaction and functional scores were comparable between these groups. For those treated surgically, 5 patients (11.1%) sustained a surgical postoperative complication. Conclusion: In our case series, patients were able to achieve satisfactory outcomes regardless of whether they were treated nonoperatively or with an anatomic single-incision approach for complete or partial DBBT ruptures.
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Affiliation(s)
- Daniel P Berthold
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Lukas N Muench
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Antonio Cusano
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Colin L Uyeki
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Maria Slater
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Lisa M Tamburini
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Stephanie Geyer
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Robert A Arciero
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
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28
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Wörner E, van Oost I, Eygendaal D, The B. Higher failure rate of suture anchors in partial distal biceps tendon ruptures in comparison with Endobutton fixation. JSES Int 2021; 5:821-826. [PMID: 34223437 PMCID: PMC8245990 DOI: 10.1016/j.jseint.2021.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Little is known about the preferred repair technique of partial tears of the distal biceps tendon. In this study, suture anchors were compared with the Endobutton technique for repair of partial distal biceps tendon ruptures, especially regarding failure rate. Methods A total of 59 patients with 62 partial distal biceps ruptures underwent surgical treatment between 2008 and 2019. Repair of the partially ruptured distal biceps tendon was performed using suture anchors (n = 21) or an Endobutton (n = 41). Postoperative evaluation consisted of integrity and physical examination of the distal biceps tendon, range of motion, stability, neurologic status, and radiographs in AP view and lateral direction of the elbow. Results At a median follow-up of 14 (1-82) months in all patients, a total of 5 patients had a rerupture of the reconstructed distal biceps tendon (8.1%). A significant higher rerupture rate was seen in the suture anchor group (n = 4) than in the Endobutton group (n = 1) (P = .04). The other outcome measures were similar between groups. Other than rerupture rate, there were complications in 21 patients (34%). The major symptomatic complication was attributed to lateral antebrachial cutaneous nerve neuropraxia (n = 8, 15%). Heterotopic ossifications were seen in 12 patients (34%), and ossifications were symptomatic in 4 of these patients (33%). Conclusion A significantly higher failure rate was seen after repair of a partial distal biceps rupture using suture anchors than by using an Endobutton technique. Overall, both techniques were accompanied with complications, in particular, lateral antebrachial cutaneous nerve neuropraxia neuropraxia and the formation of heterotopic ossifications, though clinically less relevant than a rerupture.
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Affiliation(s)
- Elisabeth Wörner
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands.,Department of Orthopaedic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Iris van Oost
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands.,Department of Orthopaedic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bertram The
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
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29
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Yetter T, Patton AG, Mansi A, Maassen N, Somerson JS. Low mental health scores are associated with worse patient-reported outcomes and difficulty with return to work and sport after distal biceps repair. JSES Int 2021; 5:597-600. [PMID: 34136876 PMCID: PMC8178588 DOI: 10.1016/j.jseint.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Most patients have successful outcomes with minimal limitations after distal biceps repair, but a minority continues experiencing functional constraints. We hypothesize that low scores on a validated mental health measure correlate with worse patient-reported outcomes and increased difficulty with return to work and sport. Methods We conducted a retrospective review of a consecutive series of patients who underwent distal biceps repair with a single-incision cortical button technique and immediate mobilization. Patient-reported outcome data were available at 1 year or later for 33 (85%) patients. The primary outcomes were American Shoulder and Elbow Surgeons-Elbow (ASES-E) score, Single Assessment Numeric Evaluation score, Visual Analog Scale for pain, Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), and Veterans RAND 12 (VR-12) quality-of-life assessment. Results All patients were male, with a median age of 49 years (range, 28-65). None had reruptures, and 1 (3%) had superficial wound dehiscence that healed without further surgery. Eleven (33%) had postoperative neuropraxia, 6 of which resolved completely. At latest follow-up, the median Visual Analog Scale was 0 (range, 0-5; mean, 1), and median ASES-E functional score was 36 (range, 24-36; mean, 34). Median Single Assessment Numeric Evaluation score was 92 (range, 41-100). The median QuickDASH was 5 (range, 0-50; mean, 11). More than half of the patients with VR-12 mental component score (MCS) < 50 (5 of 9, 56%) reported difficulty with work activities, compared with 4% (1 of 24) of patients with an MCS ≥ 50 (P = .001). Most patients (8 of 9, 89%) with an MCS < 50 also reported difficulty with return to sporting activities, compared with only 8% (2 of 24) of patients with MCS ≥ 50 (P < .0001). Patients with an MCS < 50 (n = 9) had significantly worse ASES-E functional scores (median, 34; range, 27-36) and QuickDASH scores (median 23, range 0-43), compared with those with an MCS ≥ 50 (ASES-E: median, 36; range, 24-36; P = .033; QuickDASH: median, 2; range, 0-50; P = .026). Most patients (17 of 24, 71%) with MCS ≥ 50 had a perfect score of 36 on the ASES-E functional outcome score, compared with only 22% (2 of 9) among patients with MCS < 50. Conclusion Patients who undergo distal biceps repair show excellent functional patient-reported outcomes at 1-year and later follow-up. Lower scores on the VR-12 MCS are associated with worse patient-reported outcome scores and difficulty with return to work and sporting activities.
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Affiliation(s)
- Thomas Yetter
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Andrew G Patton
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
| | - Ahmed Mansi
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Nicholas Maassen
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL, USA
| | - Jeremy S Somerson
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
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30
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Castioni D, Mercurio M, Fanelli D, Cosentino O, Gasparini G, Galasso O. Single- versus double-incision technique for the treatment of distal biceps tendon rupture. Bone Joint J 2020; 102-B:1608-1617. [PMID: 33249900 DOI: 10.1302/0301-620x.102b12.bjj-2020-0822.r2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIMS The aim of this systematic review and meta-analysis is to evaluate differences in functional outcomes and complications between single- (SI) and double-incision (DI) techniques for the treatment of distal biceps tendon rupture. METHODS A comprehensive search on PubMed, MEDLINE, Scopus, and Cochrane Central databases was conducted to identify studies reporting comparative results of the SI versus the DI approach. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for search strategy. Of 606 titles, 13 studies met the inclusion criteria; methodological quality was assessed with the Newcastle-Ottawa scale. Random- and fixed-effects models were used to find differences in outcomes between the two surgical approaches. The range of motion (ROM) and the Disabilities of the Arm, Shoulder and Hand (DASH) scores, as well as neurological and non-neurological complications, were assessed. RESULTS A total of 2,622 patients were identified. No significant differences in DASH score were detected between the techniques. The SI approach showed significantly greater ROM in flexion (standardized mean difference (SMD) -0.508; 95% confidence interval (CI) -0.904 to -0.112) and pronation (SMD -0.325, 95% CI -0.637 to -0.012). The DI technique was associated with significantly less risk of lateral antebrachial cutaneous nerve damage (odds ratio (OR) 4.239, 95% CI 2.171 to 8.278), but no differences were found for other nerves evaluated. The SI group showed significantly fewer events of heterotopic ossification (OR 0.430, 95% CI 0.226 to 0.816) and a lower reoperation rate (OR 0.503, 95% CI 0.317 to 0.798). CONCLUSION No significant differences in functional scores can be expected between the SI and DI approaches after distal biceps tendon repair. The SI approach showed greater flexion and pronation ROM and a lower risk of heterotopic ossification and reoperation. The DI approach was favourable in terms of lower risk of neurological complications. Cite this article: Bone Joint J 2020;102-B(12):1608-1617.
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Affiliation(s)
- Davide Castioni
- Department of Orthopaedic and Trauma Surgery, "Magna Graecia" University and "Mater Domini" University Hospital of Catanzaro, Catanzaro, Italy
| | - Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, "Magna Graecia" University and "Mater Domini" University Hospital of Catanzaro, Catanzaro, Italy
| | - Daniele Fanelli
- Department of Rehabilitation Medicine, Woodend Hospital, Aberdeen, UK
| | - Orlando Cosentino
- Department of Orthopaedic and Trauma Surgery, "Magna Graecia" University and "Mater Domini" University Hospital of Catanzaro, Catanzaro, Italy
| | - Giorgio Gasparini
- Department of Orthopaedic and Trauma Surgery, "Magna Graecia" University and "Mater Domini" University Hospital of Catanzaro, Catanzaro, Italy
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, "Magna Graecia" University and "Mater Domini" University Hospital of Catanzaro, Catanzaro, Italy
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31
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Amarasooriya M, Bain GI, Roper T, Bryant K, Iqbal K, Phadnis J. Complications After Distal Biceps Tendon Repair: A Systematic Review. Am J Sports Med 2020; 48:3103-3111. [PMID: 32091914 DOI: 10.1177/0363546519899933] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [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 tendon injuries typically occur in the dominant arm of men in their fourth decade of life. Surgical repair restores flexion and supination strength, resulting in good functional outcome. The complication profile of each surgical approach and fixation technique has not been widely studied in the literature. PURPOSE To report the rate of complications after repair of complete distal biceps ruptures, to classify them according to surgical approach and fixation technique, and to analyze risk factors and outcomes of the individual complications. STUDY DESIGN Systematic review. METHODS Studies published in English on primary repair of the distal biceps between January 1998 and January 2019 were identified. Data on complications were extracted and classified as major and minor for analysis. A quantitative synthesis of data was done to compare the complication rates between (1) limited anterior incision, extensile anterior incision, and double incision and (2) 4 fixation methods. RESULTS Seventy-two articles including 3091 primary distal biceps repairs were identified. The overall complication rate was 25% (n = 774). The major complication rate was 4.6% (n = 144) and included a 1.6% (n = 51) rate of posterior interosseous nerve injury; 0.3% (n = 10), median nerve injury; 1.4% (n = 43), rerupture; and a 0.1% (n = 4), synostosis. Brachial artery injury, ulnar nerve injury, compartment syndrome, proximal radius fracture, and chronic regional pain syndrome occurred at a rate of <0.1% each. The majority of nerve injuries resolved with an expectant approach. The minor complication rate was 20.4% (n = 630). The most common complication was lateral cutaneous nerve injury (9.2%, n = 283). An extensile single incision was associated with a higher rate of superficial radial nerve injury when compared to limited single incision(6% vs 2.1%, P = .002). Limited anterior single incision technique had a higher rate of lateral antebrachial cutaneous nerve injury compared to extensile single incision. (9.7% vs 5.2%, P = .03). Synostosis occurred only with double incision. Fixation technique had no significant effect on rerupture rate and posterior interosseous nerve injury rate. CONCLUSION This is the largest analysis of complications after distal biceps repair, indicating a major complication rate of 4.6%. This study provides valuable data with regard to the choice of technique, surgical approach, and rate of complications, which is essential for surgical planning and patient consent. REGISTRATION CRD42017074066 (PROSPERO).
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Affiliation(s)
- Melanie Amarasooriya
- Base Hospital Diyatalawa, Diyatalawa, Sri Lanka.,University of Colombo, Colombo, Sri Lanka
| | - Gregory Ian Bain
- Department of Orthopaedic and Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Tom Roper
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Kimberley Bryant
- Department of Orthopaedic and Trauma Surgery, Flinders University, Adelaide, Australia
| | - Karim Iqbal
- Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, UK
| | - Joideep Phadnis
- Brighton and Sussex University Hospitals and Brighton & Sussex Medical School, Brighton, UK
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32
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Freislederer F, Papillo D, Glanzmann M, Scheibel M. Distale Bizepssehnen- und Trizepssehnenrupturen. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 158:663-682. [DOI: 10.1055/a-0999-8250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
ZusammenfassungRupturen der distalen Bizeps- und Trizepssehne sind selten, treten jedoch gehäuft bei männlichen, sportlichen und körperlich schwer arbeitenden Patienten auf. Dieser Übersichtsartikel beschreibt Ätiologie und Pathogenese sowie Diagnostik, Behandlungsmöglichkeiten, das zu erwartende Outcome dieser Verletzungen und gibt Einblicke in das eigene Vorgehen.
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Micheloni GM, Tarallo L, Porcellini G, Novi M, Catani F. Reinsertion of distal biceps ruptures with a single anterior approach: analysis of 14 cases using tension-slide technique and interference screw. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:183-188. [PMID: 32555095 PMCID: PMC7944842 DOI: 10.23750/abm.v91i4-s.9551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 12/05/2022]
Abstract
Background: Several techniques of surgical repair of biceps tendon ruptures are described in literature. Cortical button repair have shown minimal loss of elbow flexion, supination and strength. In this retrospective study we report the outcomes in terms of elbow function and complications of tension-slide technique and interference screw. Matherials and methods: 14 patients with complete distal biceps tendon rupture were included in the retrospective study and treated with the same tension-slide technique (BicepsButton® - Arthrex, Inc, Naples, Florida) evaluating the clinical and functional outcomes and the complication rate with a follow-up average of 18 months. Results: The flexion recovered compare to the healthy contralateral was 96% (min 115° - max 135°; average 128°), the extension was 97% (min: -2° - max 15°; average 4°), the supination was 90% (min 20° - max 90°; average 75°), the pronation was 95% (min 15° - max 90°; average 76°). The mean Disabilities of Arm, Shoulder and Hand (DASH) score was 8.1 ± 10.5 and Mayo Elbow Performance Score overall (MEPS) score was 97.6 ± 8.2. Two patients had LABCN paresthesia, one case, treated 2 months after injury, had posterior interosseus nerve palsy. One patient had heterotopic ossification at the radiological examination without consequences for the clinical performances. No case of non-traumatic tendon re-rupture and no case of ROM deficiency > 20%. In all case the cortical button remains well positioned and no case of osteolysis were reported. Conclusions: Distal biceps tendon repair with BicepsButton® system seems to be a safe, relyable and reproducible technique providing excellent clinical, functional and radiological outcomes. Comparing with other techniques the BicepsButton® system has the advantages of the single approach procedures, the reduction of surgical time and risk of heterotopic ossifications. (www.actabiomedica.it)
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Affiliation(s)
- Gian Mario Micheloni
- Department of Orthopedics and Traumatology, Policlinic of Modena, University of Modena and Reggio Emilia.
| | - Luigi Tarallo
- Department of Orthopedics and Traumatology, Policlinic of Modena, University of Modena and Reggio Emilia.
| | - Giuseppe Porcellini
- Department of Orthopedics and Traumatology, Policlinic of Modena, University of Modena and Reggio Emilia..
| | - Michele Novi
- Department of Orthopedics and Traumatology, Policlinic of Modena, University of Modena and Reggio Emilia..
| | - Fabio Catani
- Department of Orthopedics and Traumatology, Policlinic of Modena, University of Modena and Reggio Emilia..
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34
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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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35
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de Mattos CA, Maia D, Castro R, Etchebehere M. Reinsertion of Distal Brachial Biceps Tendon Rupture through Single Incision Using Anchors. Rev Bras Ortop 2020; 55:191-197. [PMID: 32346195 PMCID: PMC7186078 DOI: 10.1055/s-0039-3400525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 12/04/2018] [Indexed: 11/28/2022] Open
Abstract
Objective
To evaluate 15 patients with ruptured distal biceps tendon submitted to reinsertion via a single, anterior and transverse approach using two anchors. They were submitted to a rehabilitation protocol and, within six months, to an evaluation of the range of motion and strength intensity during flexion and supination of the operated elbow.
Methods
The data were collected prospectively, and were analyzed through the Mann-Whitney test and the mixed-model test to evaluate the force between the operated and non-operated elbows.
Results
A total of 80% of the patients were men, 60% were injured on the dominant side, 46% were manual workers, and 73% led sedentary lifestyles. The use of anabolic steroids was reported by two patients. After the treatment, the patients recovered supination strength by 98% and flexion by 94%. According to the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, 73% of the patients presented the score expected of a normal population.
Conclusion
The single, anterior and transverse approach associated with tendon repair using anchors was esthetically satisfactory, with good strength recovery during flexion and supination, and no occurrence of heterotopic ossification.
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Affiliation(s)
- Carlos Augusto de Mattos
- Departamento de Ortopedia, Pontifícia Universidade Católica de Campinas, Campinas, São Paulo, Brasil
| | - Danilo Maia
- Departamento de Ortopedia, Pontifícia Universidade Católica de Campinas, Campinas, São Paulo, Brasil
| | - Rodolfo Castro
- Departamento de Ortopedia, Pontifícia Universidade Católica de Campinas, Campinas, São Paulo, Brasil
| | - Maurício Etchebehere
- Departamento de Ortopedia, Universidade Estadual de Campinas, Campinas, SP, Brasil
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Weißenberger M, Heinz T, Rueckl K, Rudert M, Klug A, Hoffmann R, Schmidt-Horlohé K. No functional differences in anatomic reconstruction with one vs. two suture anchors after non-simultaneous bilateral distal biceps brachii tendon rupture: a case report and review of the literature. BMC Musculoskelet Disord 2020; 21:270. [PMID: 32340623 PMCID: PMC7187509 DOI: 10.1186/s12891-020-03304-3] [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: 11/16/2019] [Accepted: 04/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical reattachment of the tendon is still the gold standard for ruptures of the distal biceps brachii tendon. Several fixation techniques have been described in the literature, with suture anchors being one of the most common fixation techniques. Currently, there is no data available on how many anchors are required for a safe and stable refixation. In this case report clinical data of a patient with non-simultaneous bilateral distal biceps tendon ruptures treated with a different number of suture anchors for each side (one vs. two) are demonstrated. CASE PRESENTATION A 47-year-old factory worker suffered a rupture of the distal biceps tendon on both arms following two different occasions. The left side was fixed using a single suture anchor, while refixation on the right side was performed with two anchors. The patient was prospectively followed for one year. Functional outcome was assessed using the Andrews Carson Score (ACS), the Oxford Elbow Score (OES), and the Disabilities of Arm, Shoulder and Hand (DASH) Score after six, twelve, 24 and 48 weeks. Furthermore, an isokinetic strength measurement for flexion strength was performed after 24 and 48 weeks. After 48 weeks the patient presented with excellent functional outcome scores and no follow-up complications. During the follow-up period, no differences in the functional scores nor in the isokinetic flexion strength measurement could be detected. Furthermore, no radiological complications (like heterotopic ossifications) could be detected in the postoperative radiographs after one year. CONCLUSIONS Anatomic reattachment of the distal biceps tendon is a successful operative treatment option for distal biceps tendon ruptures. Suture anchor fixation remains one of the most common techniques, as it allows fast surgery and provides good results with respect to range of motion (ROM) and functional scoring according to the current literature. However, the number of anchors required for a stable fixation remains unclear. As indicated by our presented case, we hypothesize, that there are no significant differences between a one-point or a two-point fixation. In the presented case report, no intraindividual differences between the usage of one versus two suture anchors were evident in the short-term follow-up.
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Brettreichstr. 11, D-97074, Wuerzburg, Germany. .,Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany.
| | - Tizian Heinz
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Brettreichstr. 11, D-97074, Wuerzburg, Germany
| | - Kilian Rueckl
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Brettreichstr. 11, D-97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Brettreichstr. 11, D-97074, Wuerzburg, Germany
| | - Alexander Klug
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Kay Schmidt-Horlohé
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany.,Orthopaedicum Wiesbaden, Wiesbaden, Germany
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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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Holt J, Preston G, Heindel K, Preston H, Hill G. Diagnosis and Management Strategies for Distal Biceps Rupture. Orthopedics 2019; 42:e492-e501. [PMID: 31355900 DOI: 10.3928/01477447-20190723-05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 12/12/2018] [Indexed: 02/03/2023]
Abstract
Rupture of the distal biceps tendon most commonly is secondary to mechanical overload during eccentric muscle contraction. Due to deficits of strength and endurance, surgical repair usually is recommended. Although both single- and double-incision approaches have been described, double-incision techniques have been shown to better re-create the native anatomic insertion. However, excellent and comparable clinical outcomes have been demonstrated with both techniques. Fixation with a cortical button and interference screw has been shown to be the strongest construct biomechanically; however, several modern constructs provide adequate strength. Surgical technique should focus on restoration of anatomy, early range of motion, and prevention of complications. [Orthopedics. 2019; 42(6):e492-e501.].
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Cerciello S, Visonà E, Corona K, Ribeiro Filho PR, Carbone S. The Treatment of Distal Biceps Ruptures: An Overview. JOINTS 2019; 6:228-231. [PMID: 31879719 PMCID: PMC6930125 DOI: 10.1055/s-0039-1697615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 08/07/2019] [Indexed: 11/16/2022]
Abstract
Traumatic lesions of the distal biceps brachii are uncommon. They often result from rapid elbow flexion against resistance. Conservative treatment is only indicated in low-demanding patient and in those who have severe comorbidities. Regarding the surgical approach, two options are available: the single- and the double-incision techniques. The former has been the first to be described and was associated with significant rate of neurologic complications. The second showed less frequent neurologic lesions, but considerable rate of heterotopic ossifications with reduced forearm movement. The choice of fixation device is another important issue. Cortical buttons, transosseous repair, suture anchors, and interference screws have shown satisfactory outcomes. However, cortical buttons have the best mechanical properties. Although a lack of high methodological quality studies emerges in the available literature, three recent systematic reviews and meta-analysis show interesting findings. Surgical reinsertion of the distal biceps brachii yields satisfactory clinical outcomes both with the single- and double-incision techniques. Higher prevalence of nerve injuries is associated with the single-incision techniques, whereas higher prevalence of heterotopic ossification is reported with double-incision techniques. Thus far, there is no sufficient evidence to support one option and the choice is mainly based on surgeon's experience.
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Affiliation(s)
- Simone Cerciello
- Ortopedia, Casa di Cura Villa Betania, Rome, Italy.,Ortopedia, Marrelli Hospital, Crotone, Italy
| | - Enrico Visonà
- Ortopedia 1-Istituto Clinico Città di Brescia, Brescia, Italy
| | - Katia Corona
- Dipartimento di Statistica, Università degli Studi del Molise, Campobasso, Italy
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Völk C, Siebenlist S, Kirchhoff C, Biberthaler P, Buchholz A. [Rupture of the distal biceps tendon]. Unfallchirurg 2019; 122:799-811. [PMID: 31535172 DOI: 10.1007/s00113-019-00717-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
With an incidence of 3% of all biceps tendon injuries, rupture of the distal biceps tendon is a rare injury but can be associated with significant functional impairment of the elbow. In case of a complete rupture, the diagnosis can be made clinically with a pronounced power deficit, in particular for supination of the forearm. In cases of unclear symptoms magnetic resonance imaging should be included. Regarding the therapeutic approach, there is general consensus in the current literature that surgical treatment with anatomical reconstruction of the tendon footprint is superior to the conservative approach. Various surgical techniques with good biomechanical and clinical results are currently available but no clear superiority of a single technique has so far been demonstrated.
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Affiliation(s)
- C Völk
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - S Siebenlist
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - C Kirchhoff
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P Biberthaler
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - A Buchholz
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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Andritsos GC, Skouteris DG, Psychoyios V. Distal biceps tendon repair using both an anchor and a bone tunnel via one and a second stab incision: A retrospective study. J Orthop Surg (Hong Kong) 2019. [PMID: 29514543 DOI: 10.1177/2309499018757531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Our aim was to evaluate the outcome of our surgical technique for the repair of complete distal biceps tendon rupture in nonprofessional athletes. We examined the effect of our surgical technique in restoring the functionality of 11 injured limbs by correlating the total functional outcome of the repaired limb with their contralateral side.
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Affiliation(s)
- George C Andritsos
- 5th Orthopaedic Department, Hand Service, Asklepieion Voulas General Hospital, Athens, Greece
| | - Dimitrios G Skouteris
- 5th Orthopaedic Department, Hand Service, Asklepieion Voulas General Hospital, Athens, Greece
| | - Vassilios Psychoyios
- 5th Orthopaedic Department, Hand Service, Asklepieion Voulas General Hospital, Athens, Greece
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Distal Biceps Repair Using a Unicortical Intramedullary Button Technique: A Case Series. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2019. [DOI: 10.1016/j.jhsg.2019.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Liljeros M, Fagevik Olsén M, Kjellby Wendt G. Evaluation of function following rehabilitation after distal biceps tendon repair. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2019.1595132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Maria Liljeros
- Department of Physical Therapy, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Physical Therapy, Sahlgrenska University Hospital/Mölndal, Mölndal, Sweden
| | - Monika Fagevik Olsén
- Department of Physical Therapy, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Physical Therapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gunilla Kjellby Wendt
- Department of Physical Therapy, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Physical Therapy, Sahlgrenska University Hospital/Mölndal, Mölndal, Sweden
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Intramedullary Cortical Button Repair for Distal Biceps Tendon Rupture: A Single-Center Experience. J Hand Surg Am 2019; 44:418.e1-418.e7. [PMID: 30177359 DOI: 10.1016/j.jhsa.2018.07.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 05/26/2018] [Accepted: 07/13/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this retrospective study was to evaluate the clinical outcome and complication rate of intramedullary cortical button repair for distal biceps tendon rupture (partial and complete tears). METHODS Between 2010 and 2014, a total of 28 patients with an acute distal biceps tendon rupture underwent intramedullary cortical button repair. Twenty-four patients (mean age, 49 years) with a mean follow-up of 28 months were included in the study. Twenty patients were examined clinically and by maximum isometric strength testing in flexion (at 90°) and supination of both arms. Twenty-four patients completed functional scores including the Mayo Elbow Performance Score (MEPS), the Andrews-Carson-Score (ACS) and the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Furthermore, follow-up radiographs of 24 patients were analyzed. RESULTS Compared with the contralateral elbow, the active range of motion (ROM) was the same. The mean strength for flexion was 100.8% ± 14% and for supination 93.1% ± 22% compared with the uninjured side. The mean MEPS for all patients was 95.6 ± 8.2, the mean ACS 194.2 ± 9.4 and the QuickDASH 3.8 ± 7.6. Heterotopic ossification (HO) was seen on radiographs in 46% of patients, but was symptomatic in only 1 patient. One patient suffered a tendon rerupture, and 1 asymptomatic button migration was seen in the follow-up. CONCLUSIONS Intramedullary cortical button repair provides good results with respect to strength, ROM, and functional outcomes. Because the posterior cortex is not violated, the risk of iatrogenic posterior interosseous nerve injury is minimized. However, the patient should be warned of a high prevalence of postoperative HO. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Alech-Tournier F, Elkholti K, Locquet V, Ninou M, Gibert N, Pozzetto M, Breden F, Rostoucher P, Marc A, Erhard L, Vogels J. Outcomes of distal biceps tendon reattachment using the ToggleLoc™ fixation device with ZipLoop™ technology with single mini-open technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:925-931. [DOI: 10.1007/s00590-019-02376-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/04/2019] [Indexed: 11/28/2022]
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How to Avoid Posterior Interosseous Nerve Injury During Single-Incision Distal Biceps Repair Drilling. Clin Orthop Relat Res 2019; 477:424-431. [PMID: 30444757 PMCID: PMC6370103 DOI: 10.1097/corr.0000000000000534] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The posterior interosseous nerve (PIN) is occasionally damaged during distal biceps tendon repair. But to our knowledge, no studies have examined the position of the PIN in relation to the bicipital tuberosity in full supination, which is the recommended position during single-incision distal biceps repair or reconstruction QUESTIONS/PURPOSES: (1) What is the anterior safe zone when exposing the anterior tuberosity with the arm in supination? (2) When drilling the radial tuberosity for bicortical button placement in full supination, how should the drill be angled to avoid PIN injury? METHODS Fifteen adult cadaver elbows had the PIN dissected around the proximal radius. The position of the PIN was measured relative to the most ulnar aspect of the radius at three sites in full supination: at the bicipital tuberosity (bicipital tuberosity-PIN), 10 mm proximal to the bicipital tuberosity (bicipital tuberosity-proximal), and 10 mm distal to the bicipital tuberosity (bicipital tuberosity-distal). We made another measurement by drawing a line from the lateral humeral epicondyle to the radial styloid. The point where the PIN intersects this line, when viewed laterally and measured from the lateral humeral epicondyle, was marked and measured to indicate where it wraps around the radius laterally (PIN-lateral). The last measurement (bicipital tuberosity-lateral) was made where the line from the lateral humeral epicondyle to the radial styloid intersected the position of the bicipital tuberosity. This was determined by the point where a perpendicular line from the bicipital tuberosity was drawn laterally to meet with the lateral line. We did this to establish if the PIN adopts its most lateral position on the radius at the same level as the bicipital tuberosity. RESULTS The anterior safe zone in the approach to the biceps tuberosity extends approximately 15 mm from its prominence (mean, 20.7 mm; range, 16.0-24.1 mm). The PIN crosses the lateral midline from anterior to posterior at 46.0 mm (range, 31.2-67.0 mm) from the lateral epicondyle (lying directly opposite the bicipital tuberosity at nearly the same level); therefore, the drill exit should be posterior to lateral midline while aiming proximally to the bicipital tuberosity. CONCLUSION Our anterior safe zone found that the PIN travels from an anterior position on the radius, when measuring 1 cm proximal to the bicipital tuberosity to a lateral position on the radius at the level of the bicipital tuberosity prominence (on the contralateral cortex), to a slightly more posterior position on the radius 1 cm distal to the bicipital tuberosity. Typically, the PIN sits directly opposite the biceps tuberosity, often directly on the cortex of the radius when the forearm is in full supination. CLINICAL RELEVANCE Because of these findings, perpendicular bicortical drilling starting at the bicipital tuberosity should be avoided. A more proximal and ulnar drilling angle is recommended. Defining a safe zone for an anterior approach seems to be clinically unhelpful due to the high anatomical variability that exists for the position of the PIN around the proximal radius. Future studies could attempt to confirm our findings with the analysis of noncadaveric imaging in three different planes using such modalities as MRI to avoid the effects of tissue distortion during cadaveric preparation and dissection.
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Tarallo L, Lombardi M, Zambianchi F, Giorgini A, Catani F. Distal biceps tendon rupture: advantages and drawbacks of the anatomical reinsertion with a modified double incision approach. BMC Musculoskelet Disord 2018; 19:364. [PMID: 30305070 PMCID: PMC6180654 DOI: 10.1186/s12891-018-2278-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
Background Distal biceps tendon rupture occurs more often in middle-aged male population, involving the dominant arm. In this retrospective study, it’s been described the occurrence of the most frequent adverse events and the clinical outcomes of patients undergoing surgical repair of distal biceps tendon rupture with the modified Morrey’s double-incision approach, to determine better indications for patients with acute tendon injury. Methods Sixty-three patients with acute distal biceps tendon rupture treated with a modified double-incision technique between 2003 and 2015 were retrospectively evaluated at a mean 24 months of follow-up. Clinical evaluation including range of motion (ROM) and isometric strength recovery compared to the healthy contralateral side assessment, together with documentation of nerve injury, was performed. Patients were asked to answer DASH, OES and MEPS scores. Results The ROM recovery showed excellent results compared to the healthy contralateral side. The reported major complications included: one case of proximal radio-ulnar synostosis, 3 cases of posterior interosseous nerve (PIN) palsy and one case of a-traumatic tendon re-rupture. Concerning minor complications, intermittent pain, ROM deficiency < 30° in flexion/extension and pronation/supination, isometric flexion strength deficiency < 30% and isometric supination strength deficiency < 60%, lateral antebrachial cutaneous nerve (LACBN) injury, were observed. The average DASH score was 8.5; the average OES was 41.5 and the MEPS was 96.3. Conclusion The Morrey modified double-incision technique finds its indication in young and active patients if performed within 2 weeks from injury. If performed by experienced surgeons, the advantages can exceed the drawbacks of possible complications.
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Affiliation(s)
- L Tarallo
- Orthopaedics and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy.
| | - M Lombardi
- Orthopaedics and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - F Zambianchi
- Orthopaedics and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - A Giorgini
- Orthopaedics and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - F Catani
- Orthopaedics and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
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Individual Treatment of Delayed Distal Biceps Tendon Rupture: Case Report and Literature Review. Ann Plast Surg 2018; 82:277-283. [PMID: 30300219 DOI: 10.1097/sap.0000000000001624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Complicated elbow injuries (elbow injuries with bone and soft tissue injury) with distal biceps tendon ruptures (DBTRs) are not uncommon. There are several treatment modalities in different situations of injuries. In this article, we reported 3 successful individual treatments of delayed DBTR with complicated elbow injuries. MATERIALS AND METHODS Three cases of complicated elbow injuries treated between 2010 and 2016 were reviewed. The delayed DBTR cases were summarized and treated. Mayo Elbow Performance Score value, range of motion, and visual analog scale score were used to assess outcomes after a minimum follow-up of 12 months. RESULTS All 3 patients were male, aged 47 to 54 years (mean, 49.6 years). Patients received surgical treatments. After a mean follow-up of 13.7 months, in cases 1 and 2, Mayo Elbow Performance Score values improved by 50% and 100%, elbow flexion-extension arc were 115 degrees and 110 degrees, pronation-supination arc were 130 degrees and 120 degrees. Arthrodesis case reported pain relief; visual analog scale score for pain was 0 to 1. No postoperative complications were observed, and all patients were satisfied with the results. CONCLUSIONS Individual treatment is advised in DBTR with complicated elbow injuries. Secondary treatment of DBTR can achieve satisfactory results using individual strategies depending on patients' overall condition.
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Klebanov N, Wei DH, Harrison BJ, Kimball HL. Optimization of Anterior Incision Placement for Distal Biceps Repair. Cureus 2018; 10:e3141. [PMID: 30345198 PMCID: PMC6188161 DOI: 10.7759/cureus.3141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Damage to the posterior interosseous nerve (PIN) is a known complication when using a cortical button during distal biceps tendon repair. Prior studies show that the trajectory of the drill through the biceps tuberosity can affect the distance from the PIN. We develop a mathematical model to predict the location of the tuberosity based on a palpable bony landmark and patient demographic factors. Methods The medical charts and elbow radiographs of (n = 82) adult patients were retrospectively reviewed. Using standard radiographic software, two observers measured the distance from the olecranon tip to the center of the biceps tuberosity. Multivariate regression analysis was used to build a linear model. The model was cross-validated with five arms from three distinct cadavers. A surgical wire was guided into the volar aspect of each forearm using the model, and a dissection was then performed to assess the proximity of the surgical wire to the insertion of the biceps tendon on the radial tuberosity. Results Olecranon-tuberosity distance (OTD) ranged from 52.3 mm to 77.2 mm (mean 66.5 mm). Univariate analyses revealed males had significantly longer OTD (mean 69.3 mm) compared to females (mean 61.2 mm, t-test, p < 0.001). Increased body mass index (BMI) weakly correlated with increased distance (Pearson’s r = 0.22, p = 0.048). Height showed strong positive correlation with increased distance (r = 0.77, p < 0.001). Multivariate regression revealed that significant predictive factors for olecranon-tuberosity distance were height (coefficient = 35.8, p < 0.001), BMI (coefficient = 0.14, p = 0.032), and male sex (coefficient = 3.17, p = 0.0039). The average error in the cadaveric validation, measured as distance from the surgical wire to the distal biceps insertion was 1.8 mm. Conclusion A highly accurate mathematical model can be used to predict the location of the biceps tuberosity in relation to the palpable tip of the olecranon, based only on height, BMI, and sex of the patient. Knowledge of this distance can guide accurate placement of the skin incision when a transverse single-incision approach is utilized for repair of the distal biceps tendon using a cortical button. Diagnostics showed the model to be less accurate near the extremes of the measurement. Since patients with a target incision point far removed from average would most benefit from such a model, we will continue by identifying and enrolling patients at the low and high ends of the range. We further hypothesize that the technique described above could be similarly applied to benefit other procedures.
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Affiliation(s)
| | - David H Wei
- Orthopaedic Surgery, Greenwich Hospital, Greenwich, USA
| | - Brendan J Harrison
- Internal Medicine, Steward Carney Hospital/Tufts University School of Medicine, Dorchester, USA
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Colliton E, Scheiderer B. Distal Biceps Tendon Repair: Suture Anchor Technique. OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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