Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial

Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw

BACKGROUND

The use of cortical suspensory fixation in conjunction with an interference screw to treat distal biceps ruptures has yielded favorable results. However, literature examining the incidence of fixation failure in a large consecutive series of patients treated with this technique is lacking.

METHODS

A retrospective review of electronic medical records identified 170 distal biceps ruptures in 168 consecutive patients (164 men and 4 women) treated using a cortical button in conjunction with an interference screw. The study group was an average age of 48 years (range, 20-71 years). Records were reviewed from the time of the initial clinic visit to the most recent follow-up. Early failures were defined as those that occurred within 12 weeks of the index procedure. Failed repair was defined as tendon defect, deformity, or significant weakness in supination.

RESULTS

The early incidence of failure was 1.2%, with 2 of the fixations meeting the criteria for failure. One patient had significant brachial artery thrombosis. Other complications included posterior interosseous nerve palsy, lateral antebrachial cutaneous nerve-related complication, and numbness about the radial nerve.

CONCLUSION

The use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure.

Distal biceps tendon rupture reconstruction using muscle-splitting double-incision approach

AIM: To evaluate the clinical and functional results after repair of distal biceps tendon tears, following the Morrey’s modified double-incision approach.

METHODS: We retrospectively reviewed 47 patients with distal rupture of biceps brachii treated between 2003 and 2012 in our Orthopedic Department with muscle-splitting double-incision technique. Outcome measures included the Mayo elbow performance, the DASH questionnaire, patient’s satisfaction, elbow and forearm motion, grip strength and complications occurrence.

RESULTS: At an average 18 mo follow-up (range, 7 mo-10 years) the average Mayo elbow performance and DASH score were respectively 97.2 and 4.8. The elbow flexion range was 94%, extension was -2°, supination was 93% and pronation 96% compared with the uninjured limb. The mean grip strength, expressed as percentage of respective contralateral limb, was 83%. The average patient satisfaction rating on a Likert scale (from 0 to 10) was 9.4. The following complications were observed: 3 cases of heterotopic ossification (6.4%), one (2.1%) re-rupture of the tendon at the site of reattachment and 2 cases (4.3%) of posterior interosseous nerve palsy. No complication required further surgical treatment.

CONCLUSION: This technique allows an anatomic reattachment of distal biceps tendon at the radial tuberosity providing full functional recovery with low complication rate.

[Surgical treatment of distal biceps tendon ruptures with bone anchors using a single anterior approach]

PURPOSE

To evaluate the clinical results of reinsertion of the distal biceps tendon with anterior bone anchors.

MATERIAL AND METHODS

A retrospective study was conducted on 79 patients who underwent reinsertion of the distal biceps tendon with anterior bone anchors. The mean age was 46 years (range, 32-64). Two anchors were used in 57% of cases, and one anchor in 43%. The same postoperative protocol was performed in all patients. Functional assessment was made using a Motor evoked potentials (MEPS) functional scale. The mean of follow-up time was 20 months (range, 12 -28 months).

RESULTS

The final mean of MEPS score was 95.2 points (SD 6.8). Almost all (94%) patients had excellent and good results, and 6% a bad result. No differences were observed when comparing functional outcome among patients in whom one anchor was used (96 points) with those in whom two anchors were used (95 points), p=0.5. The mean time off work was 14 weeks (range, 5-56) and 100% of patients were able to return to work. The incidence of complications was 13%. The most frequent was neuropraxia of the lateral antebrachial cutaneous nerve.

CONCLUSION

The anatomic re-attachment of the distal biceps tendon with bone anchors using a single anterior approach is a safe technique that offers excellent and good functional results in the medium term.

Re-rupture rate of primarily repaired distal biceps tendon injuries

BACKGROUND

Distal biceps tendon rupture is a common injury, and primary repair results in excellent return of function and strength. Complications resulting from distal biceps tendon repairs are well reported, but the incidence of re-ruptures has never been investigated.

METHODS

A search of the Mayo Clinic's Medical/Surgical Index was performed, and all distal biceps tendon repairs from January 1981 through May 2009 were identified. All patients who completed 12 months or more of follow-up were included. All charts were reviewed and patients contacted as necessary to identify a re-rupture. We also investigated the situation causing the re-rupture.

RESULTS

We identified a total of 190 distal biceps tendon ruptures that underwent repair and met our inclusion and exclusion criteria. Of the 190 repairs, 172 (90.5%) were performed by the Mayo modification of the Boyd-Anderson 2-incision technique. Bilateral ruptures occurred in 13 patients (7.3%). Six primary ruptures (3.2%) occurred in women, 4 of the 6 being partial ruptures. Partial ruptures were found to be statistically more common than complete ruptures in women (P = .05). We identified 3 re-ruptures (1.5%), all occurring within 3 weeks of the index surgery.

CONCLUSION

The re-rupture rate after primary repair of the distal biceps tendon is low at 1.5% and occurs within 3 weeks of index repair. This appears to be due to patient compliance and excessive force placed on repairs. We also found the incidence of women who sustain a distal biceps tendon tear to be 3.2%, with partial tears being statistically more common than complete ruptures.

LEVEL OF EVIDENCE

Level IV, case series, treatment study

Repair of distal biceps tendon acute ruptures with two suture anchors and anterior mini-open single incision technique: clinical follow-up and isokinetic evaluation

BACKGROUND

All the techniques described in literature for treatment of acute distal biceps tendon ruptures provide good functional outcomes. The purpose of this study is to report the results of a single limited-incision technique for repair of acute distal biceps ruptures using two suture anchors.

MATERIALS AND METHODS

Fourteen patients, all man, were treated consecutively from one author between January 2009 and December 2011 and evaluated at a mean follow-up of 26 months. All patients were evaluated clinically, through DASH and MEPS score questionnaires, and with isokinetic biomechanical tests.

RESULTS

All patients achieved complete elbow flexion and extension. Deficit for supination of the forearm was found in only two patients (7° and 13°). Mean DASH score was 4.7 points, and mean MEPS was excellent (96.8 points). There was no nervous complication involving posterior interosseous nerve (PIN) and no case of failure of the sutures. The isokinetic evaluation detected an average flexion strength increase by 10.2 % compared to the opposite arm not operated.

CONCLUSION

Our study shows that mini-open access and fixation with two suture anchors achieved in medium-term excellent functional and cosmetic results needed short rehabilitation times and is minimally invasive.

The functional outcome of forty-nine single-incision suture anchor repairs for distal biceps tendon ruptures at the elbow

PURPOSE

The objective of this retrospective study was to evaluate the functional results of distal biceps tendon repair using suture anchors via a single-incision approach.

METHODS

Forty-nine patients were re-examined at a mean follow-up of 44.2 ± 32.1 months (range, 12-119 months). Subjective and objective criteria included patient's satisfaction, active range of motion (ROM), maximum isometric strength in flexion (at 45° and 90°), and supination of both arms. Functional scoring included the Morrey elbow score (MES) and the QuickDASH. Furthermore, follow-up radiographs were performed.

RESULTS

Eighty-six percent of patients were highly satisfied or satisfied with their outcome. Compared to contralateral, the active ROM of elbow flexion, extension, and pronation was not affected; however, supination was decreased by 3° (P < 0.001). The isometric maximum strengths showed significant deficits in all tested scenarios (at 45°, P = 0.002; at 90°, P < 0.001; for supination, P < 0.001). The MES and the QuickDASH were 97.2 ± 4.9 and 7.9 ± 13.9, respectively. Heterotopic ossifications (HO) were found in 39% of patients; however, with respect to scores and strength, no significant differences were seen compared to patients without HO. Moreover, four anchor failures were detected.

CONCLUSIONS

Single-incision suture anchor repair provides high patient's satisfaction and good results with respect to ROM and functional scoring. Nevertheless, based on presented data, the patient has to be informed of postoperative HO and especially for supination strength weakness after surgery. Distal biceps tendon repair should be reserved for experienced upper extremity surgeons to avoid procedure-related complications.

Clinical outcomes after chronic distal biceps reconstruction with allografts

BACKGROUND

Chronic ruptures of the distal biceps are often complicated by tendon retraction and fibrosis, precluding primary repair. Reconstruction with allograft augmentation has been proposed as an alternative for cases not amenable to primary repair.

PURPOSE

To investigate the clinical outcomes of late distal biceps reconstruction using allograft tissue.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 20 patients who underwent distal biceps reconstruction with allograft tissue between May 2007 and May 2012 were identified. Charts were retrospectively reviewed for postoperative complications, gross flexion and supination strength, and range of motion. Subjective functional outcomes were assessed prospectively with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

Eighteen patients with adequate follow-up were included in the study. All had undergone late distal biceps reconstruction with allografts (Achilles [n = 15], semitendinosus [n = 1], gracilis [n = 1], or anterior tibialis [n = 1]) for symptomatic chronic ruptures of the distal biceps. At a mean office follow-up of 9.3 months (range, 4-14 months), all patients had full range of motion and mean gross strength of 4.7 of 5 (range, 4-5) in flexion and supination. After a mean out-of-office follow-up at 21 months (range, 7-68.8 months), the mean DASH score was 7.5 ± 17.9, and the mean MEPS increased from 43.1 preoperatively to 94.2 postoperatively (P < .001). The only complication observed was transient posterior interosseous nerve palsy in 2 patients. Additionally, all but 1 patient reported a cosmetic deformity. However, all patients found it acceptable.

CONCLUSION

Late reconstruction for chronic ruptures of the distal biceps using allograft tissue is a safe and effective solution for symptomatic patients with functional demands in forearm supination and elbow flexion. While there are several graft options, the literature supports good results with Achilles tendon allografts. Further studies are needed to evaluate the clinical outcomes of other allograft options.

[Treatment of proximal radioulnar synostosis using a posterior interosseous antegrade flow pedicled flap]

The aim of this study is to determine the different therapeutic options described for the treatment of radioulnar synostosis, and report our experience with posterior interosseous antegrade flow pedicled flap with technical amendments. Two patients, who were treated with the designed flap, and with more than one year of follow-up, were reviewed. The technical innovations, end result and complications are described. In the two cases described, there was no recurrence of synostosis, which is the most frequent complication described in this condition, and no postoperative complications were observed. In the literature, many filler materials, from artificial to biological free or vascularized, have been used the radioulnar space after excision of synostosis. The technique that provides the best results is the interposition of muscle or vascularized adipofascial flaps. The Interosseous posterior antegrade flow pedicled flap is reliable, with a low morbidity, and is an effective alternative for the treatment of proximal radioulnar synostosis.

Best approach for the repair of distal biceps tendon ruptures

The preferred treatment of distal biceps tendon ruptures is by operative repair. However, the best approach for repair (single vs double incision) is still subject of debate. Grewal and colleagues recently presented the results of a randomized clinical trial evaluating two different surgical approaches for the repair of distal biceps tendon ruptures. Despite the fact that this article currently presents the highest level of evidence for the surgical repair of distal biceps tendon ruptures, we have some comments on the study that might be interesting to discuss. We think that some of the results and conclusions presented in this study need to be interpreted in the light of these comments.

The distal biceps tendon

Distal biceps tendon ruptures continue to be an important injury seen and treated by upper extremity surgeons. Since the mid-1980s, the emphasis has been placed on techniques that limit complications or improve initial tendon-to-bone fixation strength. Recently, basic science research has expanded the knowledge base regarding the biceps tendon structure, footprint anatomy, and biomechanics. Clinical data have further delineated the results of conservative and surgical management of both partial and complete tears in acute or chronic states. The current literature on the distal biceps tendon is described in detail.

Surgical Technique for Single and Double-Incision Method of Acute Distal Biceps Tendon Repair

Introduction

Distal biceps tendon ruptures can be repaired with either a single or a double-incision technique.

Step 1 Single-Incision Technique Surgical Exposure and Preparation of the Tendon

Through a single anterior incision, identify the tendon and debride the distal degenerated portion.

Step 2 Single-Incision Technique Preparation of the Radius

Expose the bicipital tuberosity and prepare the bone for insertion of suture anchors.

Step 3 Single-Incision Technique Tendon Reattachment

Suture the tendon with a reduction knot technique that allows for anatomic tendon apposition to bone.

Step 1 Double-Incision Technique Surgical Exposure and Preparation of the Tendon

Through a small anterior incision retrieve the tendon, debride the distal degenerated portion of the tendon, and place your sutures.

Step 2 Double-Incision Technique Preparation of the Radius

Through a second posterolateral incision, expose the biceps tuberosity and, using a burr, create a trough for the tendon.

Step 3 Double-Incision Technique Tendon Reattachment

Pass the sutures through the transosseous tunnels and tension the sutures, allowing the biceps tendon to be pulled into the trough created in the bicipital tuberosity, and then tie the sutures.

Step 4 Postoperative Care

Assess tension across the repaired tendon, initiate prophylaxis against heterotopic ossification, and begin rehabilitation.

Results

We recently conducted a prospective randomized controlled trial at our center comparing the single and double-incision techniques for the repair of acute distal biceps tendon ruptures¹¹.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.