Best approach for the repair of distal biceps tendon ruptures

Higher failure rate of suture anchors in partial distal biceps tendon ruptures in comparison with Endobutton fixation

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.

Suture anchor reinsertions of distal biceps rupture: a histologic analysis of a torn tendon and clinical results at short- and long-term follow-up

BACKGROUND

Distal biceps brachii tendon (DBBT) rupture is a relatively rare injury. Nonsurgical treatment determines 30%-40% power loss of elbow flexion and up to 50% of forearm supination. Therefore, refixation of the DBBT is recommended. The DBBT is exposed to tension and compression loading. It is known that the tendon under compression might develop fibrocartilaginous metaplasia that improves the resistance to compression but reduces the resistance to tension. To test this hypothesis, the present study evaluated the presence of cartilage in DBBT samples. Furthermore, the present study evaluated the clinical and functional outcomes of anatomic reinsertion through suture anchors in a cohort of patients after 1, 3, and 5 years of follow-up.

METHODS

Between 2011 and 2014, 21 patients with DBBT tear underwent a suture anchor reattachment. Histochemical and immunohistochemical analysis of torn samples of DBBT collected at the time of surgical repair were performed to test the presence of cartilage. During the follow-up examination, mobility, elbow radiographs, Mayo Elbow Performance Score, and isokinetic analysis were prospectively evaluated.

RESULTS

Fibrocartilage was detected in all tendon samples collected. Two cases of transient paresthesia in the lateral antebrachial cutaneous nerve occurred, but they resolved in 6 weeks. There were no vascular deficits, re-ruptures, radioulnar synostoses, or infective complications at follow-up. Three patients reported loss of supination. Mayo Elbow Performance Score showed good and excellent clinical and functional results. No significant differences about strength and fatigue in flexion-supination were recorded between the surgical and contralateral side at 3 and 5 years of follow-up. Arm dominance influenced supination but not flexion.

CONCLUSION

On the basis of our results, we find that the presence of cartilage metaplasia might make the DBBT at higher risk of rupture assuming the compression loading and the hypovascular zone of the tendon. However, concerning the lack of histologic analysis of the healthy DBBT, its role in tendon pathology remains to be clearly defined. The technique of suture anchor reinsertion by a single incision was shown to be safe, with few complications and good functional results at 5 years of follow-up. No significant differences were reported between the injured and noninjured side in terms of flexion and supination isokinetic analysis, whereas arm dominance had a positive effect on supination.

A comparative clinical and functional assessment of cortical button versus suture anchor in distal biceps brachii tendon repair

PURPOSE

The studies comparing the fixation methods being used for the ruptured distal biceps brachii tendon reinsertion show similar outcomes of cortical button and suture anchors usage, however, longer follow-up studies remain necessary. The goal of this study was to compare the clinical and functional three-year outcomes of the cortical button in contrast to the suture anchor fixation.

METHODS

A retrospective cohort study comprised of 28 males on average 3 years after surgical reinsertion of the distal biceps brachii tendon with the use of a cortical button (Group I, n = 11) or a suture anchor (Group II, n = 17). The outcomes assessed were range of elbow joint and forearm motion (ROM), arm circumferences, visual analogue scale (VAS), Mayo Elbow Performance Index (MEPI), Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) and forearm flexor and supinator muscle torques measured under isometric and isokinetic conditions.

RESULTS

The comparison between the two studied groups revealed no statistically significant differences in ROM (p = 0.24-1.00), circumferences (p = 0.15-0.50), VAS (p = 0.71), MEPI (p = 0.23), Quick DASH (p = 0.61) or in the obtained muscle torque values (p = 0.07-1.00). However, differences in supination ROM between the surgical and non-surgical side were found in both groups (p = 0.01-0.02), and differences in pronation (p = 0.02) were found in Group II. The muscle torque values obtained in the surgical, dominant limb were lower than those in the nonsurgical, nondominant limb.

CONCLUSION

The comprehensive comparison of three-year outcomes of cortical button versus suture anchor fixations did not favour one fixation method over the other, and the results justify the clinical usage of both methods.

Surgical Management of Distal Biceps Tendon Anatomical Reinsertion Complications: Iatrogenic Posterior Interosseous Nerve Palsy

Background

Although iatrogenic posterior interosseous nerve (PIN) palsy is an uncommon complication of ruptured distal biceps brachii tendon surgical anatomical reinsertion, it is the most severe complication leading to functional limitation. The present study investigated possible types of PIN palsy as a postoperative complication of anatomical distal biceps tendon reinsertion, and aimed to clinically assess patients at 2 years after its surgical treatment.

Material/Methods

The studied sample comprised 7 male patients diagnosed with an iatrogenic PIN palsies after anatomical reinsertion of the distal biceps tendon, who were referred to the reference center for management of a peripheral nervous system injury. The nerve injury was intraoperatively evaluated. The clinical assessment used the Medical Research Council (MRC) System for motor recovery, and the Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) was performed before the surgical treatment of the PIN injuries and at 2 years postoperatively. In all studied cases, electromyography was performed preoperatively and postoperatively.

Results

The comparison of the preoperative (x=1.43±0.53) and postoperative (x=4.71±0.49) results of the motor recovery of the PIN demonstrated a statistically significant improvement (p<0.001). Moreover, the results of functional assessments with the use of the Quick DASH questionnaire significantly improved (p<0.001) postoperatively (x=6.14±6.86) compared to the preoperative evaluations (x=54.29±12.05).

Conclusions

The PIN palsies as complications of the surgical anatomical reinsertion of ruptured distal biceps brachii resulted from mechanical nerve compression or direct intraoperative damage. The 2-year outcomes justified the clinical use of surgical management for iatrogenic PIN palsy.

A functional analysis of distal biceps tendon repair: single-incision Endobutton technique vs. two-incision modified Boyd-Anderson technique

INTRODUCTION

The optimal surgical technique for a distal biceps tendon rupture repair still remains controversial. Current biomechanical evidence shows Endobutton fixation to have the highest load-to-failure testing, but clinical results of this are limited. The purpose of this study was to compare patient-oriented functional outcome between a modified Boyd-Anderson two-incision technique and repair with a single-incision Endobutton technique.

METHODS

All patients who underwent distal biceps tendon repair with a two-incision or Endobutton technique between 2000 and 2010 with two-year follow-up at our institution were identified. Their clinical, operative, and follow-up data was collected and analyzed. The primary outcome was a patient-oriented functional outcome measure (Disabilities of the Arm, Shoulder, and Hand: DASH). Secondary outcomes were evaluated using a subjective questionnaire.

RESULTS

Thirty-three patients were repaired with the two-incision technique and twenty-five patients had a repair with a single incision Endobutton technique. All patients receiving the two-incision repair were male, while there were 2 females who had an Endobutton procedure. There was no significant difference between the two-incision and the Endobutton groups in regards to mean DASH score (6.31 versus 5.91, p = 0.697), mean Work DASH score (10.49 versus 0.93, p = 0.166), and mean Sports DASH score (10.54 versus 9.56, p = 0.987). Regardless of technique, most patients were "extremely satisfied" (n = 42, or 72.41%) or "satisfied" (n = 10, or 17.24%) postoperatively, and returned to pre-operative activity in approximately 6 months (6.87 months versus 6.82 months, respectively) (p = 0.457). There was no significant difference in the prevalence of complications (39.39% versus 32.0%, respectively for two incision versus single incision) (p = 0.594).

CONCLUSION

Patients from both surgical groups were satisfied with their post-operative function and had similar functional outcomes and complication rates. Both surgical techniques for distal biceps tendon repair are effective and are similarly safe methods of treatment.

Clinical relevance of distal biceps insertional and footprint anatomy

PURPOSE

The aim of this review was to present an overview, based on a literature search, of surgical anatomy for distal biceps tendon repairs, based on the current literature.

METHODS

A narrative review was performed using Pubmed/Medline using key words: Search terms were distal biceps, insertional, and anatomy.

RESULTS

Last decade, the interest in both reconstruction techniques, as well as surgical anatomy of the distal biceps tendon, has increased. The insights into various aspects of distal biceps tendon anatomy (two tendons, bicipital tuberosity, lacertus fibrosis, bicipital-radial bursa, posterior interosseous nerve, and lateral antebrachial cutaneous nerve) have evolved significantly in the last years.

CONCLUSION

Thorough knowledge of the anatomy is essential for the surgeon in order to understand the biomechanics of rupture and reconstruction of the distal biceps tendon and to avoid injuries of the nerves. Some tips and tricks are provided, and some pitfalls were described to avoid complications and optimize surgical outcome.

LEVEL OF EVIDENCE

IV.

Single and dual incision technique for acute distal biceps rupture: clinical and functional outcomes

BACKGROUND

Distal bicep tendon injuries are a traumatic event though rather rare. The pathogenesis is not entirely clear. The most common cause for injury is an unexpected load on the biceps when the elbow is in an extended position. Although several studies have provided insight into the pathogenetic processes of the lesion, the literature suggests to treat all injuries surgically (whether partial or total) if there is high functional demand.

METHODS

Between January 2006 and March 2016 were studied 20 patients surgically treated for a disconnected distal bicep, 15 with a total lesion and 5 with a partial lesion. The patients were divided into 2 groups. Surgical access with single incision was performed on 13 patients while a double surgical access was performed on 7 patients. The clinical and functional results were studied using an Ewald System Score (ESS).

RESULTS

In both groups, the most rapid improvement was achieved for the parameters of pain and deformity with excellent results, while those of function and movement were normalized as gradual and progressive over next 2 months.

CONCLUSION

The clinical and functional outcomes during the follow-up examination after surgery showed excellent results in patients treated with both types of surgical procedures.

Refixation techniques and approaches for distal biceps tendon ruptures: a systematic review of clinical studies

BACKGROUND

Surgical fixation is the preferred method of treatment for the ruptured distal biceps tendon in active patients. To date, no fixation technique has been proven superior in a clinical setting. The purpose of the study was to systematically review the available literature on approach and fixation methods for distal biceps tendon repair in a clinical setting and to determine the optimal fixation methods of the distal biceps tendon on the radial tuberosity. Our hypothesis was that the outcomes would not be significantly different among the various fixation techniques and approaches.

METHODS

A systematic review of the available literature on anatomic reconstruction methods for distal biceps tendon ruptures was performed. The outcome measures evaluated were postoperative range of motion, elbow flexion and supination strength, and complication rates and types.

RESULTS

Forty articles were included, representing 1074 patients divided into 4 fixation groups: suture anchors, bone tunnels, interference screws, and cortical buttons. There was no significant difference in range of motion and strength between the different approaches and fixation techniques. Complications were significantly less common after the double-incision approach with bone tunnel fixation (P < .0005).

CONCLUSIONS

There were significantly fewer complications after the double-incision approach with bone tunnel fixation. The double-incision approach had significantly fewer complications than the single-incision anterior approach, and the bone tunnel fixation had significantly fewer complications than the other 3 fixation techniques. However, as the double-incision approach was used with bone tunnel fixation in 84% of cases, there was a strong interrelationship between these variables.

Reconstruction of distal biceps tendon ruptures with a cortical button

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Radioulnar space available at the level of the biceps tuberosity for repaired biceps tendon: a comparison of 4 techniques

HYPOTHESIS

It is unknown whether certain methods of distal biceps tendon repair lead to an increased propensity of impingement of the repaired tendon. The purpose of this study was to evaluate various repair techniques in a cadaveric model to determine the radioulnar space available for the repaired biceps tendons.

METHODS

Nine matched pairs of quartered, fresh-frozen cadaveric arms were transected at the level of the humeral mid shaft and the distal radiocarpal joint. Distance measurements and the angular relation of the bicipital tuberosity were measured at 5 forearm pronation-supination positions. These measurements were taken under each of the following conditions: intact native biceps, resected native tendon, suture anchor fixation of the biceps, suspensory suture device fixation of the biceps, tendon repair using a tenodesis technique, and fixation of the tendon using a trough technique.

RESULTS

There were no significant differences in radioulnar space available after biceps tendon repair with the forearm in a supinated position. However, when the forearm was in a neutral or pronated position, the suture anchor method consistently had the lowest biceps insertion-to-ulna distance (0.6 to 2.1 cm). All forearm positions, except full supination, showed significant differences in terms of radioulnar space available for the repaired biceps.

DISCUSSION

This study shows that the space available for the biceps tendon decreases with forearm pronation after reconstruction for all repair techniques. It appears that using suture anchors to repair the biceps tendon may predispose the repaired tendon to impingement when compared with other fixation techniques.