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Boufadel P, Daher M, Lopez R, Fares MY, Lawand J, Khan AZ, Abboud JA. Return to Sport After Distal Biceps Tendon Repair: A Systematic Review. Am J Sports Med 2025:3635465241295618. [PMID: 39836380 DOI: 10.1177/03635465241295618] [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: 01/22/2025]
Abstract
BACKGROUND Ruptures of the distal biceps tendon (DBT) can affect the range of motion and strength of the elbow, raising concerns for patients seeking to restore normal function and engage in their regular activities, particularly returning to previous levels of sport participation. PURPOSE To characterize and assess the rate and timing of return to sport (RTS) after DBT repair. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS PubMed, Embase, and Google Scholar (pages 1-20) were searched from database inception to December 6, 2023 for clinical studies reporting RTS outcomes after DBT repair. The extracted data consisted of patient characteristics; information on the incision approach, fixation method, and rehabilitation protocol; and outcome data including RTS rates, patient-reported outcome measure scores, and complications. RESULTS A total of 42 studies, including 1093 patients (1100 elbows), met the inclusion criteria. The mean age of patients was 44.9 years, and 99.2% of patients were male. The mean follow-up time was 31.5 months. Ruptures were acute in 87.6% of cases, the dominant arm was injured in 64.9%, and the cause of the injury was sport related in 43.5%. The overall RTS rate was 91.5%, with 85.2% of patients returning to preinjury levels or higher, at a mean time of 6.3 months. Patients had excellent functional outcomes, irrespective of the incision approach or fixation method, although trends associated with a higher RTS rate were observed with bone tunnel fixation, ≤2 weeks of postoperative immobilization, early initiation of active range of motion postoperatively, and initiation of strengthening at ≤10 weeks. Single-incision repair had higher rates of nerve-related complications and reruptures compared with double-incision repair, and cortical button fixation had a higher rate of nerve-related complications among the fixation methods. CONCLUSION There was a high rate of RTS after DBT repair at 6 months postoperatively. A positive trend for RTS was observed with respect to rehabilitation protocols favoring earlier active mobility.
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Affiliation(s)
- Peter Boufadel
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Mohammad Daher
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Ryan Lopez
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Mohamad Y Fares
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Jad Lawand
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Adam Z Khan
- Southern California Permanente Medical Group, Panorama City, California, USA
| | - Joseph A Abboud
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
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Baylor JL, Kloc A, Delma S, Foster BK, Grandizio LC. Impact of Bracing and Therapy Services on Perioperative Costs for Patients Undergoing Distal Biceps Tendon Repair. J Hand Surg Am 2025; 50:94.e1-94.e8. [PMID: 37294236 DOI: 10.1016/j.jhsa.2023.04.019] [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: 06/24/2022] [Revised: 04/11/2023] [Accepted: 04/25/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE This study aimed to quantify and assess perioperative costs in an integrated healthcare system for patients undergoing distal biceps tendon (DBT) repair with and without the use of postoperative bracing and formal physical (PT) or occupational (OT) therapy services. In addition, we aimed to define clinical outcomes after DBT repair using a brace-free, therapy-free protocol. METHODS We retrospectively reviewed all cases of DBT repairs within our integrated system from 2015 to 2021. We performed a retrospective review of a series of DBT repairs utilizing the brace-free, therapy-free protocol. For patients with our integrated insurance plan, a cost analysis was conducted. Claims were subdivided to assess total charges, costs to the insurer, and patient costs. Three groups were created for comparisons of total costs: (1) patients who had both postoperative bracing and PT/OT, (2) patients who had either postoperative bracing or PT/OT, and (3) patients who had neither postoperative bracing nor PT/OT. RESULTS A total of 36 patients had our institutional insurance plan and were included in the cost analysis. For patients using both bracing and PT/OT, these services contributed 12% and 8% of the total perioperative costs, respectively. Implant costs accounted for 28% of the overall cost. Forty-four patients were included in the retrospective review with a mean follow-up of 17 months. The overall QuickDASH was 12; two cases resulted in unresolved neuropraxia, and there were no cases of re-rupture, infection, or reoperation. CONCLUSIONS Within an integrated healthcare system, postoperative bracing and PT/OT services increase the cost of care for DBT repair and account for 20% of the total perioperative charges in cases where bracing and therapy are used. Considering the results of prior investigations indicating that formal PT/OT and bracing offer no clinical advantages over immediate range of motion (ROM) and self-directed rehabilitation, upper-extremity surgeons should forego routine brace and PT/OT utilization after DBT repair. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jessica L Baylor
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Austin Kloc
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Stephanie Delma
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Brian K Foster
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA.
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3
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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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Li J, Seiler LM, Hoekzema NA, Johnson TR, Lee J, Ridenauer JL, Tanner CM. Distal biceps reconstruction: a long-term follow-up of the complications and durability of the single-incision power optimizing cost-effective (SPOC) repair. JSES Int 2023; 7:2547-2552. [PMID: 37969532 PMCID: PMC10638596 DOI: 10.1016/j.jseint.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background The Single-Incision Power Optimizing Cost-Effective Repair (SPOC) method reattaches the distal biceps tendon to its original posterior anatomic footprint and utilizes the anterior cortex of the supinated radius for fixation. The purpose of the study was to define the long-term complications and durability of the SPOC method. Methods Two hundred and eighteen patients underwent the SPOC repair of distal biceps ruptures from 2008 to 2020, with 185 having at least 1-year follow-up data. The average follow-up was 50.1 months. Information regarding smoking, body mass index, interval between injury and surgery, peripheral nerve injury, heterotopic ossification, vascular injury, re-rupture, chronic regional pain syndrome, fracture of the radius, loss of motion, pain with use, and deformity were acquired. Results No complication occurred beyond the third postoperative month. No patient complained of severe lateral antebrachial cutaneous nerve-related symptoms. Major complications exclusive of re-rupture occurred include 1 case of heterotopic ossification and 1 deep infection. Major complications with re-ruptures occurred in 9 patients (4.8%). Seven of the re-ruptures (78%) were associated with an unexpected forceful contraction within the first 4 weeks postop. All complications aside from 1 minor complication occurred in the chronic group. Long term follow-up revealed no re-ruptures and high satisfaction rate with return of strength, motion, and biceps profile. Conclusion The safety profile of the SPOC repair is consistent with those of other published repairs. Major complications were associated with prolonged intervals between injury and reconstruction. Re-ruptures were associated with worker's compensation status and patient noncompliance with postoperative protocols.
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Affiliation(s)
- Jefferson Li
- University of California-Fresno, Fresno, CA, USA
| | | | | | | | - Julia Lee
- Sierra Pacific Orthopedics, Fresno, CA, USA
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5
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Ribas LHBV, Schor B, Filho GDRM, Belangero PS. Acute Distal Biceps Tendon Injury: Diagnosis and Treatment. Rev Bras Ortop 2023; 58:e689-e697. [PMID: 37908533 PMCID: PMC10615608 DOI: 10.1055/s-0043-1771488] [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: 06/04/2022] [Accepted: 04/12/2023] [Indexed: 11/02/2023] Open
Abstract
Acute distal biceps injuries clinically present with sudden pain and acute loss of flexion and supination strength. The main injury mechanism occurs during the eccentric load of the biceps. The hook test is the most significant examination test, presenting the highest sensibility and specificity for this lesion. Magnetic resonance imaging, the gold standard imaging test, can provide information regarding integrity and identify partial and/or complete tears. The surgical treatment uses an anterior or double approach and several reattachment techniques. Although there is no clinical evidence to recommend one fixation method over the other, biomechanical studies show that the cortical button resists better to failure. Although surgical treatment led to an 89% rate of return to work in 14 weeks, the recovery of high sports performance occurred in 1 year, with unsustainable outcomes.
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Affiliation(s)
- Luiz Henrique Boraschi Vieira Ribas
- Aluno do Programa de Pós-Graduação do Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
- Médico ortopedista, especialista em Ombro e Cotovelo, Instituto Vita, São Paulo, SP, Brasil
| | - Breno Schor
- Médico ortopedista, especialista em Ombro e Cotovelo, Instituto Vita, São Paulo, SP, Brasil
| | - Geraldo da Rocha Motta Filho
- Médico ortopedista, especialista em Ombro e Cotovelo, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Paulo Santoro Belangero
- Cirurgião ortopçdico, Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
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6
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Qazi S, Regal S, Greco V, Wroblewski A, Schimoler PJ, Miller MC, Hammarstedt JE. Biomechanical analysis of single-incision anatomic repair technique for distal biceps tendon rupture using tunneling device. Shoulder Elbow 2023; 15:195-206. [PMID: 37035614 PMCID: PMC10078820 DOI: 10.1177/17585732211034818] [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: 05/22/2021] [Accepted: 07/04/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Sohail Qazi
- Department of Orthopaedic Surgery, Allegheny General
Hospital, Pittsburgh, PA, USA
| | - Steven Regal
- Department of Orthopaedic Surgery, Allegheny General
Hospital, Pittsburgh, PA, USA
| | - Victor Greco
- Department of Orthopaedic Surgery, Allegheny General
Hospital, Pittsburgh, PA, USA
| | - Andrew Wroblewski
- Department of Orthopaedic Surgery, Allegheny General
Hospital, Pittsburgh, PA, USA
| | - Patrick J Schimoler
- Department of Orthopaedic Surgery, Allegheny General
Hospital, Pittsburgh, PA, USA
| | - Mark C Miller
- Department of Orthopaedic Surgery, Allegheny General
Hospital, Pittsburgh, PA, USA
| | - Jon E Hammarstedt
- Department of Orthopaedic Surgery, Allegheny General
Hospital, Pittsburgh, PA, USA
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Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis. J Shoulder Elbow Surg 2022; 31:e169-e189. [PMID: 34999236 DOI: 10.1016/j.jse.2021.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 11/22/2021] [Accepted: 12/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND HYPOTHESIS Ruptures of the distal biceps tendon are most commonly due to traumatic eccentric loading in the middle-aged male population and can result in functional deficits. Although surgical repair has been demonstrated to result in excellent outcomes, there are few comparative studies that show clear functional benefits over nonoperative management. The aim of this systematic review and meta-analysis is to compare the functional outcomes of operative and nonoperative management for these injuries. We hypothesized that operative treatment would be associated with significantly superior outcomes. METHODS According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed using MEDLINE, SPORTDiscus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Registry of Controlled Trials), Embase, and Web of Science databases. Outcomes of interest included range of motion (ROM), strength, endurance, and patient-reported outcomes including Disabilities of the Arm, Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) for pain scores. Summary effect estimates of the mean difference between operative and nonoperative management for each outcome were estimated in mixed effects models. RESULTS Of an initially identified 6478 studies, 62 reported outcomes for a total of 2481 cases (2402 operative, 79 nonoperative), with an overall average age of 47.4 years (47.3 for operative, 50.3 for nonoperative). There were 2273 (98.5%) males and 35 (1.5%) females among operative cases, whereas all 79 (100%) nonoperative cases were males. Operative management was associated with a significantly higher flexion strength (mean difference, 25.67%; P < .0001), supination strength (mean difference, 27.56%; P < .0001), flexion endurance (mean difference, 11.12%; P = .0268), and supination endurance (mean difference, 33.86%; P < .0001). Patient-reported DASH and MEPS were also significantly superior in patients who underwent surgical repair, with mean differences of -7.81 (P < .0001) and 7.41 (P = .0224), respectively. Comparative analyses for ROM and pain VAS were not performed because of limited reporting in the literature for nonoperative management. CONCLUSION This study represents the first systematic review and meta-analysis to compare functional and clinical outcomes following operative and nonoperative treatment of distal biceps tendon ruptures. Operative treatment resulted in superior elbow and forearm strength and endurance, as well as superior DASH and MEPS.
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Tadevich JT, Bhagat ND, Lim BH, Gao J, Chen WW, Merrell GA. Power-Optimizing Repair for Distal Biceps Tendon Rupture: Stronger and Safer. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2021; 3:266-271. [PMID: 35415576 PMCID: PMC8991521 DOI: 10.1016/j.jhsg.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/08/2021] [Indexed: 11/27/2022] Open
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Hinckel BB, Baumann CA, Ejnisman L, Cavinatto LM, Martusiewicz A, Tanaka MJ, Tompkins M, Sherman SL, Chahla JA, Frank R, Yamamoto GL, Bicos J, Arendt L, Fithian D, Farr J. Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00083. [PMID: 33986224 PMCID: PMC7537824 DOI: 10.5435/jaaosglobal-d-20-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.
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Affiliation(s)
- Betina B Hinckel
- From the Oakland University, Rochester (Dr. Hinckel, and Dr. Cavinatto); Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak (Dr. Hinckel, Dr. Cavinatto), MI; the University of Missouri-School of Medicine, Columbia, MO (Mr. Baumann); the Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR (Dr. Ejnisman); the Shoulder and Elbow Surgery, Beaumont Orthopaedic Associates, Beaumont Health (Dr. Martusiewicz); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Tanaka); the Department of Orthopedic Surgery, TRIA Orthopedic Center, University of Minnesota, Gillette Children's Specialty Healthcare, MN (Dr. Tompkins); the Department of Orthopedic Surgery, Stanford University, CA (Dr. Sherman); the Rush University Medical Center, Chicago, IL (Dr. Chahla); the Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, Aurora, CO (Dr. Frank); the Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Yamamoto); CEGH-CEL, Instituto de Biociências, Universidade de São Paulo (Dr. Yamamoto); DASA Laboratories, Sao Paulo, Brazil (Dr. Yamamoto); the Michigan Orthopedic Surgeons, Fellowship Director William Beaumont Sports Medicine Fellowship, Assistant Professor Oakland University William Beaumont School of Medicine, MI (Dr. Bicos); the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Arendt); the Southern California Permanente Medical Group and Torrey Pines Orthopaedic Medical Group, San Diego, CA (Dr. Fithian); and the Knee Preservation, Cartilage Regeneration and OrthoBiologics, Department of Orthopedic Surgery, Indiana University School of Medicine, OrthoIndy and OrthoIndy Hospital, Greenwood and Indianapolis, IN (Dr. Farr)
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10
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Kruger N, Phadnis J, Bhatia D, Amarasooriya M, Bain GI. Acute distal biceps tendon ruptures: anatomy, pathology and management - state of the art. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
All patients with acute complete distal biceps tendon ruptures who are not low demand or medically unfit to proceed with surgery are offered operative repair. This restores arm shape, supination strength and function, and decreases their cramping symptoms. Surgical repair technique varies significantly depending on location and training centre. Nuances in technique and appropriate implant selection need to be noted in order to achieve a strong repair allowing early active range of motion. Intimate knowledge of distal biceps tendon anatomy is key to avoid complications associated with the different approaches. The cumulative body of evidence on complications, coupled with knowledge of the different biomechanical construct strengths of the alternative methods of fixation, points to the use of the cortical button technique without the addition of an interference screw. Subtle variations in drill hole positioning on the bicipital tuberosity secures either an anatomic or non-anatomic repair. Anatomic repair results in greater supination peak torque and fatigue strength, and in greater flexion fatigue strength. It is advisable to perform an anatomic repair in elite athletes or those patients who significantly rely on supination strength and endurance for their livelihood. A universal postoperative protocol is suggested for all repairs.
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Bellringer SF, Phadnis J, Human T, Redmond CL, Bain GI. Biomechanical comparison of transosseous cortical button and Footprint repair techniques for acute distal biceps tendon ruptures. Shoulder Elbow 2020; 12:54-62. [PMID: 32010234 PMCID: PMC6974884 DOI: 10.1177/1758573218815312] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/03/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The biceps brachii is the main forearm supinator, which is a direct consequence of its anatomic arrangement. The primary aim of distal biceps rupture is to restore supination strength and function. Cadaveric studies demonstrate that anatomic repairs significantly improve the supination moment when compared to more anterior repairs; however, this has not been tested in the clinical setting. The aim of this study was to compare biomechanical and clinical outcomes of an anatomic repair (Footprint), with a widely used transosseous technique (Endobutton). METHODS Twenty-two patients were retrospectively identified from a clinical database (11 Footprint versus 11 Endobutton). Biomechanical performance of strength and endurance for flexion and supination was assessed using a validated isokinetic dynamometry protocol and clinical outcome scores (Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure and the Mayo Elbow Performance Score) were collected for all patients. RESULTS For supination, the Footprint group demonstrated a superior trend for all biomechanical parameters tested. This was statistically significant for mean peak torque, total work of maximal repetition and work in the last third of repetitive testing (p = 0.031, p = 0.036 and p = 0.048). For flexion, the Footprint group demonstrated a superior trend for all biomechanical parameters tested but this was only statistically significant for work in the last third of repetitive testing (p = 0.039). The clinical outcomes were good or excellent for all patients in both groups. CONCLUSION This study is the first to demonstrate that an anatomic Footprint repair restores superior biomechanical supination strength and endurance compared to a conventional Endobutton technique in a clinical setting. Both techniques, however, provide good or excellent clinical outcomes.
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Affiliation(s)
- Simon F Bellringer
- Department of Trauma and Orthopaedics,
Brighton and Sussex University Hospitals, Brighton, UK,Simon F Bellringer, Brighton and Sussex
University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road,
Brighton, BN2 5BE, UK.
| | - Joideep Phadnis
- Department of Trauma and Orthopaedics,
Brighton and Sussex University Hospitals, Brighton, UK
| | - Taaibos Human
- Department of Trauma and Orthopaedics,
Flinders University, Adelaide, Australia
| | - Christine L Redmond
- Discipline of Physiotherapy, School of
Medicine, Nursing and Health Sciences, Flinders University, Adelaide,
Australia
| | - Gregory I Bain
- Department of Trauma and Orthopaedics,
Flinders University, Adelaide, Australia
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12
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Srinivasan RC, Pederson WC, Morrey BF. Distal Biceps Tendon Repair and Reconstruction. J Hand Surg Am 2020; 45:48-56. [PMID: 31901332 DOI: 10.1016/j.jhsa.2019.09.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 08/05/2019] [Accepted: 09/01/2019] [Indexed: 02/02/2023]
Abstract
Distal biceps tendon ruptures can result in functionally significant loss of supination and flexion strength, as well as decreased resistance to fatigue. Although the diagnosis of distal biceps tendon ruptures remains straightforward, substantial debate continues with regards to surgical indications, pertinent surgical anatomy, single- versus double-incision surgical technique, and fixation options. This review discusses the latest evidence-based literature regarding distal biceps tendon repair/reconstruction including types of tears, demographics, clues for diagnosis, surgical indications, anatomy with special attention to how the distal tendon inserts distally and the relevant tuberosity anatomy (height and cam effect), common reconstruction techniques (single- vs double-incision and single-incision power optimizing cost-effective technique), fixation techniques (bone tunnels, distal biceps button, interference screw, button plus screw), surgical technique pearls, postoperative rehabilitation, postoperative outcomes, as well as the treatment of chronic tears with special reconstruction techniques including Achilles allograft, pedicled latissimus transfer, and the use of a free innervated gracilis.
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Affiliation(s)
- Ramesh C Srinivasan
- The Hand Center of San Antonio, San Antonio, TX; Department of Orthopedic Surgery, UT Health San Antonio, San Antonio, TX.
| | | | - Bernard F Morrey
- Department of Orthopedic Surgery, UT Health San Antonio, San Antonio, TX; Mayo Clinic, Rochester, MN
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Barret H, Winter M, Gastaud O, Saliken DJ, Gauci MO, Bronsard N. Double incision repair technique with immediate mobilization for acute distal biceps tendon ruptures provides good results after 2 years in active patients. Orthop Traumatol Surg Res 2019; 105:323-328. [PMID: 30528138 DOI: 10.1016/j.otsr.2018.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/23/2018] [Accepted: 10/05/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical treatment of distal biceps tendon ruptures is recommended in an active population to avoid loss of strength, especially in supination and flexion. HYPOTHESIS A double incision repair technique with immediate postoperative mobilization for acute distal biceps tendon ruptures is safe and provides good results after 2 years in active patients. MATERIAL AND METHODS Seventy-four men (47±7 years) with acute tears of the distal biceps tendon tears were included in this retrospective single-center study. All patients were operated using the double-incision repair technique described by Morrey. The tendon was inserted with transosseous sutures into the biceps tuberosity. Patients were allowed to perform immediate postoperative active mobilization. A minimum follow-up of two years was required including clinical and radiological evaluation. RESULTS Sixteen patients were lost to follow up leaving 58 (78%) patients for analysis with a mean follow-up of 53±19 months. At final follow-up, the mean evaluation for pain on the VAS scale was 0.22±0.7. Mean range of motion results included extension -1°±2°, flexion 138°±6°, pronation 72°±16° and supination 81°±10°. The strength ratio in flexion was 94±8% and in supination 90.5±12% compared to the contralateral limb. Subjective elbow value and DASH score were respectively 94±6% and 7.5±9%. All patients were satisfied or very satisfied and all except one returned to their previous sport. We noticed 2 heterotopic ossifications and one patient needed a reoperation for a radioulnar synostosis. Neither re-rupture nor nerve injury were observed. DISCUSSION A double incision technique for distal biceps tendon repair is a minimally invasive procedure with reliable results. Morrey's modification of the initial procedure associated with early mobilization is associated with a low rate of complications and limited the occurrence of synostosis or ossifications. LEVEL OF EVIDENCE IV, case series, with no comparison group.
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Affiliation(s)
- Hugo Barret
- CHU Nice, 30, voie romaine, 06000 Nice, France.
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Schmidt CC, Savoie FH, Steinmann SP, Hausman M, Voloshin I, Morrey BF, Sotereanos DG, Bero EH, Brown BT. Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting-2015. J Shoulder Elbow Surg 2016; 25:1717-30. [PMID: 27522340 DOI: 10.1016/j.jse.2016.05.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/10/2016] [Accepted: 05/26/2016] [Indexed: 02/01/2023]
Abstract
Understanding of the distal biceps anatomy, mechanics, and biology during the last 75 years has greatly improved the physician's ability to advise and to treat patients with ruptured distal tendons. The goal of this paper is to review the past and current advances on complete distal biceps ruptures as well as controversies and future directions that were discussed and debated during the closed American Shoulder and Elbow Surgeons meeting in 2015.
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Affiliation(s)
- Christopher C Schmidt
- Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Felix H Savoie
- Department of Orthopaedics, Tulane University, New Orleans, LA, USA
| | | | - Michael Hausman
- Department of Orthopaedics, Mount Sinai Hospital, New York, NY, USA
| | - Ilya Voloshin
- Department of Orthopaedics, University of Rochester, Rochester, NY, USA
| | - Bernard F Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dean G Sotereanos
- Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emily H Bero
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brandon T Brown
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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Cohen SB, Buckley PS, Neuman B, Leland JM, Ciccotti MG, Lazarus M. A functional analysis of distal biceps tendon repair: single-incision Endobutton technique vs. two-incision modified Boyd-Anderson technique. PHYSICIAN SPORTSMED 2016; 44:59-62. [PMID: 26641953 DOI: 10.1080/00913847.2016.1129260] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Steven B Cohen
- a Department of Orthopedic Surgery, Rothman Institute , Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Patrick S Buckley
- a Department of Orthopedic Surgery, Rothman Institute , Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Brian Neuman
- a Department of Orthopedic Surgery, Rothman Institute , Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - J Martin Leland
- a Department of Orthopedic Surgery, Rothman Institute , Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Michael G Ciccotti
- a Department of Orthopedic Surgery, Rothman Institute , Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Mark Lazarus
- a Department of Orthopedic Surgery, Rothman Institute , Thomas Jefferson University Hospital , Philadelphia , PA , USA
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Schmidt CC, Brown BT, Qvick LM, Stacowicz RZ, Latona CR, Miller MC. Factors That Determine Supination Strength Following Distal Biceps Repair. J Bone Joint Surg Am 2016; 98:1153-60. [PMID: 27440562 DOI: 10.2106/jbjs.15.01025] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Supination weakness commonly occurs after a distal biceps repair. The goal of this study was to identify factors that could influence postoperative supination strength through a full arc of forearm rotation. METHODS Fifteen patients were prospectively studied and underwent a biceps repair using a posterior approach; this cohort was compared with a randomized selection of 17 anterior repair subjects. All patients underwent postoperative magnetic resonance imaging (MRI). Quantitative MRI analysis determined the insertion site angle of the tendon and supinator fat content. Supination strength was measured in 3 forearm positions. A multiple linear regression analysis was performed to determine the effect of all factors on supination strength. RESULTS The anterior group had a significantly higher nonanatomic insertion site angle of the tendon than the control group and the posterior group (p < 0.001). The posterior group had significantly greater supinator fat content (p ≤ 0.019) than both the control group and the anterior group. After repair, the posterior group had significantly greater supination strength than the anterior group (p = 0.027). Multiple regression analysis (r = 0.765) found that an anatomic reinsertion of the ruptured tendon (β = 1.159; p < 0.001), posterior approach (β = 0.484; p = 0.043), and limited supinator muscle fat content (β = 0.360; p = 0.013) were significant predictors of the restoration of supination strength in 60° of supination. CONCLUSIONS Future directions for distal biceps tendon repair techniques should focus on restoring an anatomic reattachment site while limiting supinator damage. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher C Schmidt
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brandon T Brown
- Departments of Bioengineering (B.T.B.) and Mechanical Engineering and Materials Science (M.C.M.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lars M Qvick
- St. Mary's Center for Orthopaedics, Auburn, Maine
| | - Rafal Z Stacowicz
- Department of Orthopaedic Surgery, Crystal Clinic Orthopaedic Center, Kent, Ohio
| | - Carmen R Latona
- Department of Radiology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Mark Carl Miller
- Departments of Bioengineering (B.T.B.) and Mechanical Engineering and Materials Science (M.C.M.), University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
Distal biceps ruptures occur from eccentric loading of a flexed elbow. Patients treated nonoperatively have substantial loss of strength in elbow flexion and forearm supination. Surgical approaches include 1-incision and 2-incision techniques. Advances in surgical technology have facilitated the popularity of single-incision techniques through a small anterior incision. Recently, there is increased focus on the detailed anatomy of the distal biceps insertion and the importance of anatomic repair in restoring forearm supination strength. Excellent outcomes are expected with early repair of the distal biceps, with restoration of strength and endurance to near-normal levels with minimal to no loss of motion.
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Anatomic repair of the distal biceps tendon cannot be consistently performed through a classic single-incision suture anchor technique. J Shoulder Elbow Surg 2014; 23:1898-1904. [PMID: 25219473 DOI: 10.1016/j.jse.2014.06.051] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/23/2014] [Accepted: 06/27/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Distal biceps tendon ruptures commonly occur in active men, and surgical repair through a single-incision technique using suture anchors has become common. The current study assessed whether an anatomic repair of the biceps to the radial tuberosity can be consistently achieved through a single-incision technique. METHODS Acute distal biceps tendon repairs using the single-incision technique were retrospectively reviewed. Computed tomography (CT) scans were obtained to investigate tuberosity dimensions and the position of the suture anchors. An isokinetic dynamometer was used to obtain flexion and supination strength. Disabilities of the Arm, Shoulder and Hand (DASH) scores were collected. RESULTS CT scans were performed in 27 patients, of which, 21 underwent strength testing. The suture anchor placement averaged 50° radial to the apex of the tuberosity. Strength testing showed flexion strength of the repaired side was equal (97%-106%) to the normal side. Supination strength (80%-86%) and work (66%-75%) performed were both weaker on the repaired side (66%-75%; P < .05). The average DASH score was 10.7. CONCLUSIONS Ideal suture anchor placement, in the ulnar aspect of the tuberosity, could not be reliably achieved through this single-incision technique. This could have clinical importance because supination strength was not fully restored in this group of patients.
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