Biomechanical analysis of single-incision anatomic repair technique for distal biceps tendon rupture using tunneling device

Hypothesis

Single-incision biceps tendon repair with an arthrotunneling device has previously been shown to be a safe and effective technique that provides the anatomic restoration of a two-incision approach and a reduced complication profile. This repair provides adequate and comparable fixation to repairs utilizing anchors, buttons, screws, etc., at a lower cost.

Material and methods

This study utilized 10 cadaveric specimens. Native and repair specimens were cyclically loaded and graft displacement, flexion/extension (FE) and pronation/supination (PS) moment arms at 12.5° to 152.5° (in 5° increments) before and after repair, and maximum load to failure were measured.

Results

The FE and PS moment arms and overall maximum moment arms were both significantly larger in the repaired case than in the native case (p < 0.01). Moment arms for supinated specimens were significantly greater than neutral specimens, which in turn was greater than pronated specimens (p < 0.01). The maximum load up to 10 mm of repair displacement was 214.5.0 ± 66.6 N and the repair displacement due to 1000 cycles of 50 N was 2.56 ± 2.06 mm.

Conclusion

The single-incision arthrotunneling technique is a safe and effective repair that recreates the anatomic footprint and biomechanics of the native biceps and has a reduced complication profile compared to a two-incision approach.

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

BACKGROUND

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

QUESTIONS/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Restoration of peak strength and endurance following distal biceps reconstruction with allograft for chronic ruptures

BACKGROUND

Distal biceps reconstruction for chronic rupture often requires a graft to recover length and allow for distal tendon reattachment to bone. Our purpose was to assess peak strength and endurance recovery following biceps reconstruction with tendon grafts.

HYPOTHESIS

We hypothesized that allograft reconstruction would result in decreased flexion and supination peak strength and endurance.

METHODS

Consecutive distal biceps reconstructions with allograft, performed for chronic ruptures between January 2008 and March 2018 at a single institution, were reviewed. Isokinetic dynamometry for peak strength and endurance testing was performed on the operative and contralateral arms in flexion and supination. Functional outcomes and overall satisfaction with the operation were determined.

RESULTS

Eleven patients were available for a complete evaluation, including dynamometry, at a mean of 46 months postoperatively. Reconstructions demonstrated a nonsignificant trend toward decreased peak flexion strength (P = .06), and significantly decreased peak supination strength (P = .01) compared with the unaffected arm. There were no differences in flexion and supination endurance between the affected and unaffected arms. Using standardized outcome scales, patients reported excellent function.

CONCLUSION

Chronic biceps ruptures undergoing reconstruction are highly functional and patients are satisfied. Somewhat surprisingly, supination and flexion endurance were equal to the contralateral, uninvolved arm. However, this procedure does not restore peak supination strength.

Evaluation of common elbow pathologies: a focus on physical examination

Elbow tendinopathy accounts for the majority of elbow pathology in patients presenting to upper extremity and sports medicine surgeons. With increased participation in overhead sports in an aging population, the incidence of elbow injuries has risen. A comprehensive knowledge of elbow anatomy and biomechanical function of the elbow complex is prerequisite in the assessment of patients with elbow injuries; however, a thorough understanding of alternative and confounding pathologies is essential for accurate diagnosis. Because tendinopathy, tendonitis, and tendon tears have an anatomic basis for their pathology, a targeted history and meticulous physical examination often yields an accurate clinical diagnosis. The importance of physical examination and provocative examination maneuvers must be stressed in a technologically advanced era where clinical diagnosis is too commonly attained solely by advanced imaging modalities. A revived dedication to the physical examination may enhance our ability to correctly diagnose various pathologies about the elbow. Early and accurate clinical diagnosis is the first step in the proper initiation of treatment modalities and improvement in overall patient outcome.

Cadaveric Study of Insertional Anatomy of Distal Biceps Tendon and its Relationship to the Dynamic Proximal Radioulnar Space

PURPOSE

To quantify and assess the relationship between the insertional dimensions of the distal biceps tendon (DBT) and radioulnar space (RUS) in 3 rotational positions. We hypothesized that in all positions RUS would be adequate for the DBT and would remain adequate even after an incremental increase (1 to 3 mm) in tendon thickness.

METHODS

Eleven fresh-frozen cadaveric elbows were dissected; DBT dimensions and bicipital tuberosity measurements were performed and insertional footprints were quantified using a distal biceps footprint index. The RUS was measured at 3 levels of the bicipital tuberosity and in 3 positions of forearm rotation. We performed statistical analysis to analyze differences in RUS (positional and inter-level). In addition, significant differences between DBT thickness (native and incremental) and RUS were analyzed to identify potential sites of radioulnar impingement.

RESULTS

The DBT had a mean length of 92 mm; thickness ranged from 2.9 to 6.1 mm. Three variations in DBT insertional footprint were observed and quantified. The RUS linear distance reduced significantly from a supinated to a pronated position at each of 3 bicipital tuberosity levels; the reduction was statistically significant at the lower tuberosity level (45%). Pronation RUS distance was adequate for native DBT thickness and was significantly less when DBT thickness increased by 2 and 3 mm.

CONCLUSIONS

Radioulnar space reduces significantly from the supinated to the pronated position and is most evident in the lower aspect of the tuberosity. In addition, the RUS in pronation is inadequate for incremental increases in DBT thickness.

CLINICAL RELEVANCE

Postoperative DBT impingement in the RUS may be prevented by avoiding techniques that increase the thickness of the tendon and by using a reattachment site at the proximal aspect of the tuberosity.

Proper placement of the distal biceps tendon during repair improves supination strength--a biomechanical analysis

BACKGROUND

Anatomic repair of the distal biceps tendon can be difficult to achieve. This study was designed to compare the effect of anatomic and nonanatomic repairs on forearm supination torque. A nonanatomic repair re-establishes the footprint radial and more anterior to the tuberosity apex, whereas an anatomic repair re-establishes the footprint ulnar and more posterior to the tuberosity apex.

METHODS

Eight fresh frozen cadaver arms were surgically prepared and mounted on an elbow simulator. Controlled loads were applied to the long head and short head in positions of pronation, neutral, and supination. This was done with intact tendons and then repeated with repaired tendons that were repaired either anatomically (ulnar position) or nonanatomically (radial position).

RESULTS

All anatomic repairs showed no difference compared with intact tendon measurements. In comparing anatomic and nonanatomic repairs, we found no differences in the supination torque when the forearm was in 45° of pronation. However, when the arm was in neutral rotation, we found that 15% less supination torque was generated by the nonanatomic repair. When the arm was tested in 45° of supination, we found that 40% less supination torque was generated in the nonanatomic repair (P = .01).

CONCLUSION

This study supports the idea that an anatomic repair of the biceps tendon onto the ulnar side of the radial tuberosity is important. If the tendon is repaired too radially, the biceps will lose the cam effect and may not be able to generate full supination torque when the forearm is in neutral rotation or in supination.