Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series

Bell-Tawse procedure with cortical fixation using endo-button in anterior radial head dislocation: A case report

INTRODUCTION

Anterior radial head dislocations are rare in adults. Misdiagnosis to Monteggia fracture-dislocation can occur up to 28 %, which results in failed detection of the misaligned radiocapitellar joint. Anterior radial head dislocation is treatable using the Bell Tawse technique. However, reports regarding the technique are rare in adults, with no endo-button use.

CASE PRESENTATION

A 26-year-old male came to the orthopedic outpatient clinic with left elbow pain as his chief complaint. The affected hand was a non-dominant hand. The patient had a work-related injury where the fractures were already immediately treated with open reduction internal fixation (ORIF) 4 months prior. Radiograph images showed anterior radial head dislocation with internally fixated distal-third humerus and proximal-third ulnar fractures. The patient was diagnosed with recurrent radial head dislocation post-Monteggia facture. The patient underwent Bell Tawse with cortical fixation using an endo-button.

DISCUSSION

After 1 year, the patient felt no more pain (visual analog scale (VAS) score 0). The patient was satisfied with the one-year outcome with improved elbow function. The American Shoulder and Elbow Surgeons (ASES) score and the disabilities of the arm, shoulder, and hand (DASH) score improved.

CONCLUSION

Endo-button hadn't been used in annular ligament reconstruction, especially the Bell Tawse procedure. In our report, we used endo-button cortical fixation to compensate for the inadequate graft length in an adult case. At the one-year follow-up, the patient had no complaints of pain and could do normal activities.

Outcomes of utilizing double-incision technique with combination of cortical button and interference screw fixation for distal biceps rupture: A case series

Background

Distal biceps tendon rupture is an injury that causes a significant reduction in strength and endurance. Combined cortical button and interference screw fixation has been utilized via single-incision technique. There are limited data describing this technique utilizing a double-incision approach. This study describes patient outcomes for primary distal biceps repair with combined cortical button and interference screw fixation via double-incision approach.

Methods

This is a case series analysis of patients within a single Midwest institution between January 2006 and February 2020. We examined patient demographics, intraoperative efficiency variables, patient outcomes, and postoperative complications.

Results

Sixty-two cases were included (62 males; 44 acute complete ruptures, 1 acute partial rupture, 8 chronic complete ruptures, 9 chronic partial ruptures). Average operative time was 48 ± 23 min. Nonformal manner postoperative range of motion (ROM) results show 89%-92% within satisfactory elbow ROM parameters. There were two reported postoperative complications, but no instances of neurapraxia, wound dehiscence, synostosis, proximal radius fracture, or fixation failure.

Conclusion

The findings of this study demonstrate that the described technique is safe, reliable, and effective. This will help surgeons determine the best method of fixation and approach with the goal of minimizing postoperative complications in patients with distal biceps ruptures.

Return to Sport After Distal Biceps Tendon Repair: A Systematic Review

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.

Retrospective Study on the Risk of Nerve Injury After Distal Biceps Tendon Repair Using Cortical Button

BACKGROUND

Distal biceps tendon ruptures are relatively rare injuries that typically require surgical intervention to restore flexion and supination strength. Concerns have been raised regarding the risk of nerve injuries, particularly the posterior interosseous nerve (PIN), associated with the use of cortical buttons in distal biceps repair. This study aimed to estimate the incidence of PIN injury as well as injuries to the lateral cutaneous nerve of the forearm and superficial branch of the radial nerve following distal biceps repair using cortical buttons.

METHODS

A retrospective review was conducted on all patients who underwent distal biceps repair with cortical buttons at a district general hospital between January 2014 and May 2022. Patient data, including age, gender, time from injury to surgery, type of procedure, and postoperative nerve injuries, were collected. The incidence of nerve injuries was analyzed, and the outcomes were assessed during postoperative follow-up visits.

RESULTS

Ninety-six male patients were included in the study, with an average age of 45.6 years. The average time from injury to surgery was 22.6 days. All patients underwent primary repair except for two patients who underwent reconstruction with hamstring grafts. None of the patients experienced a PIN injury. However, 16 patients (16.7%) developed lateral cutaneous nerve injuries of the forearm, and three patients (3.1%) had superficial radial nerve injuries.

CONCLUSION

Our study, encompassing a large cohort of patients over an eight-year period, demonstrates the safety of distal biceps repair using cortical buttons with regard to PIN nerve injury. However, there were incidences of lateral cutaneous nerve of the forearm and superficial radial nerve injuries, consistent with previous studies.

Computer-Assisted Surgical Anatomical Mapping of the Antebrachial Cutaneous Nerves: An Anatomical Study with a Proposition for Alternative, Cutaneous Nerve-Sparing Anterior Elbow Incisions

It is common practice to assess the distance from nerves to anatomical structures in centimeters, but patients have various body compositions and anatomical variations are common. The purpose of this study was therefore to assess the relative distance from cutaneous nerves around the elbow to surrounding anatomical landmarks by providing a stacked image that displays the average position of cutaneous nerves around the elbow. The aim was to research possibilities for adjusting common skin incisions in the anterior elbow so that cutaneous nerve injury may be avoided.

Methods

The lateral antebrachial cutaneous nerve (LABCN) and medial antebrachial cutaneous nerve (MABCN) were identified in the coronal plane around the elbow joint in 10 fresh-frozen human arm specimens. Marked photographs of the specimens were analyzed using computer-assisted surgical anatomical mapping (CASAM). Common anterior surgical approaches to the elbow joint and the distal humerus were then compared with merged images, and nerve-sparing alternatives are proposed.

Results

The arm was divided longitudinally, from medial to lateral in the coronal plane, into 4 quarters. The LABCN crossed the central-lateral quarter of the interepicondylar line (i.e., was somewhat lateral to the midline at the level of the elbow crease) in 9 of 10 specimens. The MABCN ran medial to the basilic vein and crossed the most medial quarter of the interepicondylar line. Thus, 2 of the quarters were either free of cutaneous nerves (the most lateral quarter) or contained a distal cutaneous branch in only 1 of 10 specimens (the central-medial quarter).

Conclusions

The Boyd-Anderson approach, which is often used to access anteromedial structures of the elbow, should be placed slightly further medially than traditionally advised. The distal part of the Henry approach should deviate laterally, so that it runs over the mobile wad. In distal biceps tendon surgery, the risk of cutaneous nerve injury may be reduced if a single distal incision is placed slightly more laterally (in the most lateral quarter), as in the modified Henry approach. If proximal extension is required, LABCN injury may be prevented by using the modified Boyd-Anderson incision, which runs in the central-medial quarter.

Clinical Relevance

Cutaneous nerve injury may be prevented by slightly altering the commonly used skin incisions around the elbow on the basis of the safe zones that were identified by depicting the cumulative course of the MABCN and LABCN using CASAM.

Anatomy of the biceps brachii osseous footprint: study of 100 radii and literature review

Biceps brachii (BB) tendon rupture is frequent in young males and may require surgical repair. Non-anatomic reinsertion leads to loss of strength in supination. The main aim of the present study was to describe the anatomy of the osseous footprint of the distal BB tendon. The dimensions of the footprint of the distal BB insertion were analyzed in 100 dry cadaver radii, using MicroScribe 3D software. Insertion area, assimilated to an ellipse, was calculated from 4 points (medial, lateral, cranial and caudal) determining the two axes of the ellipse. Mean footprint length, width and area were 18 mm (range, 7-24 mm), 9 mm (range, 4-15 mm), and 129 mm² (range, 46-266 mm²), respectively. Intra- and inter-observer correlation coefficients were satisfactory: κ = 0.75 and κ = 0.7, respectively. The present study reported BB footprint dimensions in 100 radii, providing a basis to guide surgical treatment of distal BB tendon rupture. Non-anatomical restoration of the BB tendon footprint leads to poorer clinical and biomechanical results; precise knowledge of the footprint is necessary for anatomical repair.

Results of single-incision distal biceps tendon repair for early-career upper-extremity surgeons

Background

The purpose of this investigation was to assess surgical outcomes after distal biceps tendon (DBT) repair for upper-extremity surgeons at the beginning of their careers, immediately following fellowship training. We aimed to determine if procedure times, complication rates, and clinical outcomes differed during the learning curve period for these early-career surgeons.

Methods

All cases of DBT repairs performed by 2 fellowship-trained surgeons from the start of their careers were included. Demographic data as well as operative times, complication rates, and patient reported outcomes were retrospectively collected. A cumulative sum chart (CUSUM) analysis was performed for the learning curve for both operative times and complication rate. This analysis continuously compares performance of an outcome to a predefined target level.

Results

A total of 78 DBT repairs performed by the two surgeons were included. In the CUSUM analysis of operative time for surgeon 1 and 2, both demonstrated a learning curve until case 4. In CUSUM analysis for complication rates, neither surgeon 1 nor surgeon 2 performed significantly worse than the target value and learning curve ranged from 14 to 21 cases. Mean Disabilities of Arm, Shoulder, and Hand score (QuickDASH) (10.65 ± 5.81) and the pain visual analog scale scores (1.13 ± 2.04) were comparable to previously reported literature.

Conclusions

These data suggest that a learning curve between 4 and 20 cases exists with respect to operative times and complication rates for DBT repairs for fellowship-trained upper-extremity surgeons at the start of clinical practice. Early-career surgeons appear to have acceptable clinical results and complications relative to previously published series irrespective of their learning stage.

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.

Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis

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.

Operative Versus Nonoperative Management for Distal Biceps Brachii Tendon Lesions: A Systematic Review and Meta-analysis

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.

Distal Biceps Tendon Tears: Diagnosis and Treatment Algorithm

»

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.

Results of Arthroscopic Treatment of Acute Posterior Cruciate Ligament Avulsion Fractures With Suspensory Fixation

PURPOSE

This study aimed to evaluate the clinical outcomes for arthroscopic treatment for acute posterior cruciate ligament (PCL) avulsion fractures with a suspensory technique.

METHODS

A total of 30 acute (<3 weeks) isolated PCL tibial avulsion fractures were fixed under arthroscopy using the Endobutton device. After arthroscopic exploration and reduction of the bony fragment, a single tibia tunnel was established; then, the titanium button was guided through the tunnel and flipped onto the bony fragment to stabilize the fracture. Finally, an interference screw was squeezed into the tunnel to fix the end of the loop. Clinical and functional outcomes were evaluated using the Lysholm score, the 2000 International Knee Documentation Committee (IKDC) subjective score, and the IKDC examination form.

RESULTS

The mean follow-up time was 32 months (range, 24-47 months). The mean age of the patients was 41 years (range, 21-65 years). All patients achieved bony union and regained satisfactory knee function. No popliteal neurovascular complications or implant loosening was observed. The mean Lysholm score increased from 20.9 ± 7.0 before operation to 97.1 ± 2.7 at the final follow-up. The mean 2000 IKDC subjective score improved from 17.2 ± 5.2 to 96.8 ± 2.6. The IKDC examination grade also improved significantly.

CONCLUSIONS

This suspensory technique under arthroscopy is a simple, safe, and minimally invasive treatment for PCL tibial avulsion fracture. Suspensory fixation resulted in satisfactory outcomes, including good knee stability and fracture union; this technique can be a reliable alternative to various surgical methods.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Distal biceps ruptures repair: Experience with 80 cases

INTRODUCTION AND OBJECTIVES

Rupture of distal biceps has a frequency of 1.2 cases per 100,000 population. Conservative treatment presents a loss in supination of 40% and flexion of 30%, like transfers to the brachialis. Our goal is to review our experience with anatomical reattachment.

MATERIAL AND METHODS

Cohorts study. We analized an historic cohort, although recent, treated with double approach (Boyd-Anderson) compared to another prospective cohort (treated with single and double approach). Sample size of 80 patients. Mean age of 48.9±5.9years. We analyzed laterality, time to diagnosis, presurgery time, surgery time, approach, type of reintegration, rehabilitation time, Mayo Elbow Performance Score (MEPS), biomechanical study and complications. Follow up from 2 years to 7years.

RESULTS

Time for diagnosis was about 4days. Preoperative time: 12.2±6.4 days. Surgical time: 61.9±15.7minutes. We used the two-way surgical approach (Boyd-Anderson-Morrey) in 78.8% of patients, and the anterior surgical approach (Henry) in 21.2% of cases. Transosseous reinsertion was made in 45% of cases, with screw anchor in 40% and with cortical button in 15%. Rehabilitation time: 91±29.7 days. MEPS: 88±11.7 points. There was loss of flexor strength of 28±16.6%.

COMPLICATIONS

1case of proximal radioulnar synostosis, 2 radial transient paralysis and 5 cases with residual stiffness. Hypothesis contrast: We reached best results in MEPS with double surgical approach (P=.009), with fewer complications (P=.008). We observed increased pain with cortical buttons (P<.05) and less surgical time if patient was operated before 1week (P=.03). Relative risk of 0.2 when we compared type of approach with radial nerve lesion risk, considering that double approach had less cases, what it would be consider as a protective factor.

CONCLUSIONS

In our experience, we believe that anatomic reattachment is an effective treatment. Double surgical approach presents best result in MEPS, with fewer complications than with anterior approach.

Distal Biceps Tendon Rupture Surgery: Changing Incidence in Finnish and Swedish Men Between 1997 and 2016

PURPOSE

Distal biceps tendon rupture is a relatively rare injury usually occurring with excess external extension force applied to a flexed elbow. The aim of this study was to examine the incidence of distal biceps tendon rupture surgery in the Finnish and Swedish adult population between the years 1997 and 2016. A secondary aim was to investigate the distal biceps rupture incidence in the Swedish population in 2001 to 2016.

METHODS

We assessed the number and rate of distal biceps tendon rupture surgery using the Finnish and Swedish Hospital Discharge Register as databases. The study included the entire Finnish and Swedish adult population aged 18 years and older between January 1, 1997 and of December 31, 2016.

RESULTS

During the study period, 2,029 patients had a distal biceps tendon rupture in Finland, and the corresponding figure was 2,000 in Sweden. The rate of distal biceps tendon rupture surgery increased steeply, but equally, in both countries, in Finnish men from 1.3 per 100,000 person-years in 1997 to 9.6 in 2016, and in Swedish men from 0.2 in 1997 to 5.6 in 2016. The incidence of distal biceps tendon rupture in Sweden increased in men from 1.6 to 10.0 per 100,000 person-years from 2001 to 2016.

CONCLUSIONS

There was a 7-fold and a 28-fold increase in the incidence of distal biceps tendon rupture surgery in Finnish and Swedish men during 1997 to 2016. The incidence of distal biceps tendon rupture rose 6-fold in Swedish men in 2001 to 2016.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Mid-term clinical and functional outcomes of distal biceps tendon repair: A comparative study of two surgical fixation techniques

Objective:

Acute rupture of the distal biceps tendon is relatively uncommon, and surgical repair is advocated for acute injuries to restore strength and function. Numerous techniques are described in the literature, with no true consensus regarding the optimal method of fixation. The aim of this study was to evaluate patient-reported outcome measures, clinical outcomes and complications for patients undergoing distal biceps tendon repair using two fixation techniques: cortical button and suture anchor.

Methods:

A retrospective single-unit case series of 51 cases (50 patients) underwent distal biceps tendon repair, comprising 19 cortical button and 32 suture anchor fixations. Patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and overall satisfaction. Clinical outcomes and complications were reviewed from patient records.

Results:

Thirty-eight (76.5%) patients responded to DASH questionnaires with a mean follow-up of 189 weeks (11.5–425 weeks). Mean DASH scores for cortical button and suture anchor groups were 6.2 (0–30.8) and 3.3 (0–16.7), respectively ( p = 0.21). Eight patients (16%) reported lateral cutaneous neuropraxia in the early post-operative period. All but two of these patients experienced complete resolution at the final follow-up. One patient had heterotrophic ossification, which did not require any further intervention. There was one re-rupture (suture anchor), but the patient declined further surgical intervention.

Conclusion:

There were no statistically significant differences in the patient-reported outcome measures, overall satisfaction and complication rate between patients undergoing either method of fixation.

Level of evidence:

III

Posterior Interosseous Nerve Proximity to Cortical Button Implant for Distal Biceps Repair With Single and 2-Incision Approaches

PURPOSE

Fixation with a cortical button is the biomechanically strongest surgical approach for distal biceps repair, and utilization of the 2-incision approach may provide a more anatomical repair and improved terminal supination strength. The risk of injury to the posterior interosseous nerve (PIN) associated with this approach requires further investigation.

METHODS

A distal biceps repair with a cortical button was performed on 10 cadavers, 5 utilizing the single-incision approach and 5 utilizing the 2-incision approach. Contrast was injected into the radial nerve and computed tomography scans were obtained. The distance between the drilled cortical perforation and the PIN was measured.

RESULTS

The mean distance from the cortical perforation to the PIN was not significantly different between approaches (9.4 mm and 8.8 mm). A PIN entrapment was seen in 0 out of 5 for the single-incision approach and 1 out of 5 for the 2-incision approach.

CONCLUSIONS

Distal biceps repair with cortical button fixation places the PIN at risk of injury regardless of the approach used. Methods of fixation that require bicortical drilling should be especially avoided when using the 2-incision approach.

CLINICAL RELEVANCE

Distal biceps repair utilizing bicortical drilling for fixation through a 2-incision approach poses high risk of injury to the PIN and should be avoided.

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.

Functional outcome in patients who underwent distal biceps tendon repair

INTRODUCTION

To asses physical function and quality of life after distal biceps tendon repair and compare suture anchor and cortical button fixation. Secondarily, we assessed the impact of other factors: acute repair, graft use, concomitant arm conditions, contralateral rupture, and complications.

METHODS

We approached all 50 patients that underwent distal biceps tendon rupture repair (2009-2016) to participate in our study and complete a questionnaire including: patient demographics, QuickDASH, Quality of life EQ-5D-5L, pain score, and Mayo Elbow Performance score (MEPS).

RESULTS

In total, 37 (76%) of 49 alive patients participated in our study. All were men, with a median age of 47 years. Median follow-up was 34 months (range 8-100 months). On average, we found perfect upper extremity (QuickDASH, median: 0, IQR 0-7.9; 53% had no [QuickDASH = 0] upper extremity disability) and elbow function (MEPS, median: 100, IQR 100-100; 83% had perfect [MEPS > 90] clinical elbow function), perfect quality of life (EQ-5D-5L, median: 1, IQR 0.85-1; 59% had perfect [EQ-5D-5L = 1] quality of life), and no pain (median 0, IQR 0-0; 68% had no pain). We found no difference in upper extremity (QuickDASH: anchor, median 1.1, IQR 0-6.8; endobutton, median 0, IQR 0-9.1, p = 0.972) and elbow (MEPS: anchor, median 100, IQR 100-100; endobutton, median 100, IQR 100-100, p = 0.895) function, quality of life (EQ-5D-5L: anchor, median 1, IQR 0.85-1; endobutton, median 1, IQR 0.84-1, p = 0.507), and pain score (anchor, median 0, IQR 0-0.5; endobutton, median 0, IQR 0-0, p = 0.742) when comparing the anchor to endobutton fixation technique.

CONCLUSIONS

Overall, patients have excellent outcome after distal biceps tendon rupture repair. There was no difference in patient-reported outcome measures between suture anchor and endobutton fixation.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment of primary total distal biceps tendon rupture using cortical button, transosseus fixation and suture anchor: A single center experience

INTRODUCTION

There remains as of yet no consensus on the optimal treatment for total or partial distal biceps tendon repairs. As such, the purpose of this study was to assess functional outcome, the impact of complications and cost effectiveness, in patients undergoing primary distal biceps tendon repair by either cortical button (CB), transosseous suture (TO) or suture anchor (SA).

HYPOTHESIS

There is no difference in functional outcome and cost effectiveness, in patients undergoing distal biceps tendon repair.

MATERIAL & METHODS

A retrospective analysis was performed on prospectively collected data from 47 consecutive patients treated for total or partial distal biceps tendon rupture. Functional outcome was assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Strength measurements (e.g., flexion, supination and pronation) in the operated and non-operated extremities were recorded with the use of a dynamometer. Furthermore, all complications, as well as their impact on functional outcome and costs for surgical intervention were evaluated.

RESULTS

Minimum follow-up time was 35 weeks, average 46.3±13.8 weeks. The overall DASH score was 7.9±4.7. There were no differences in functional outcome (i.e., DASH score) between CB, TO, SA (p=0.32), nor were there differences in regards to strength (supination, flexion and pronation) (p=0.60) and ability to return to work & sports activity. The total complication rate was 21.6%. Complications had a significant impact on functional outcome (p=0.003). Re-rupture occurred 2 times in the SA group. In 5 patients, revisional surgery had to be performed. The shortest operation times and the lowest material costs were observed in the TO group (p=0.004).

DISCUSSION

All reported fixation methods for total or partial distal biceps tendon rupture yielded good functional results. However, transosseous suture fixation for total distal biceps tendon rupture, performed through a double incision approach by an experienced surgeon, seems to be a simple, inexpensive and successful method, offering satisfying clinical results.

LEVEL OF EVIDENCE

IV, a retrospective, comparative study.

Major complications after distal biceps tendon repairs: retrospective cohort analysis of 970 cases

BACKGROUND

The major complication and reoperation rates after distal biceps repair are poorly defined. The purpose of this large retrospective cohort study of distal biceps repairs performed by multiple surgeons within a large orthopedic group was to more clearly define the rates and risk factors of clinically impactful major complications and reoperations.

METHODS

All distal biceps tendon repairs performed from January 2005 through April 2017 with a minimum 2-month follow-up were identified using Current Procedural Terminology code 24342. We included 970 patients. The primary outcome measure was the total major complication rate. Reoperations, minor complications, and risk factors were also tracked.

RESULTS

Repairs were performed via a single anterior incision in 652 cases and a 2-incision exposure in 318 cases. A 7.5% major complication rate and 4.5% reoperation rate were observed overall. Major complications occurred at the following rates: proximal radioulnar synostosis, 1.0%; heterotopic ossification or loss of range of motion with reoperation, 0.9%; tendon rerupture, 1.6%; deep infection, 0.5%; posterior interosseous nerve palsy, 1.9%; and complex regional pain syndrome, 0.6%. The 2-incision exposure was identified as a significant risk factor for the development of proximal radioulnar synostosis when compared with single-incision repair techniques (P = .0003; odds ratio, 19), occurring in 2.8% of 2-incision exposure cases. Lateral antebrachial cutaneous nerve neuritis or numbness and radial sensory nerve neuritis or numbness were documented more frequently in the postoperative period among patients treated with a single-incision exposure (P < .0001 and P = .034, respectively).

CONCLUSIONS

Distal biceps repair is associated with a 7.5% major complication rate and 4.5% reoperation rate. The use of a 2-incision technique for repair increases the risk of radioulnar synostosis.

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.

Retrospective Evaluation of Surgical Anatomical Repair of Distal Biceps Brachii Tendon Rupture Using Suture Anchor Fixation

BACKGROUND To date, no consensus has been reached regarding the preferred fixation method to use in the repair of distal biceps brachii tendon rupture. The aim of this study was to clinically and functionally (Mayo Elbow Performance Index, MEPI) assess the upper limb after surgical anatomic reinsertion of the distal biceps brachii tendon with the use of suture anchor fixation method with regard to postoperative time and limb dominance, and to assess postoperative complications. MATERIAL AND METHODS The sample comprised 18 males (age 52.09±8.89 years) after surgical anatomical distal biceps brachii reinsertion using suture anchor fixation. A comprehensive clinical and functional evaluation and pain assessment were performed. RESULTS In terms of postoperative complications, an isolated case of surgical site sensory disturbances was noted. Circumferences (p-value 0.21-1.00) and ROM (p-value 0.07-1.00) were similar in the operated and nonoperated limbs. The isometric torque (IT) values of muscles flexing and supinating the forearm were comparable in both limbs (p-value 0.14-0.95), but in patients with the operated dominant limb, the mean IT value was not higher than the value obtained in the nonoperated nondominant one. The MEPI indicated good and excellent results (80.00±15.00-90.00±8.66 points), but a detailed individual analysis showed that reported scores were not in line with objectively measured features. CONCLUSIONS The results of the comprehensive retrospective evaluation justify the clinical use of suture anchors fixation method in the surgical anatomical reinsertion of a ruptured distal biceps brachii tendon. The assessment of a patient should always report both subjective and objective measures.

Use of a Bicortical Button to Safely Repair the Distal Biceps in a Two-Incision Approach: A Cadaveric Analysis

PURPOSE

No consensus has been reached on the most effective anatomic approach or fixation method for distal biceps repair. It is our hypothesis that, using a cortical biceps button through a 2-incision technique, the distal biceps can be safely and anatomically repaired.

METHODS

A 2-incision biceps button distal biceps repair was completed on 10 fresh-frozen cadavers. The proximity of the guide pin to the critical structures of the forearm, including the posterior interosseous nerve and recurrent radial artery, was measured. The location of repair was mapped and compared with anatomic insertion.

RESULTS

The average distance from the tip of the guide pin to the posterior interosseous nerve was 11.4 mm (range, 8-14 mm). The average distance from the tip of the guide pin to the recurrent radial artery was 12.5 mm (range, 8-19 mm). The distal biceps tendon was repaired to the anatomic insertion site on the tuberosity using the biceps button technique in all specimens.

CONCLUSIONS

The 2-incision biceps button repair described here allows safe and accurate repair of the tendon to the radial tuberosity in this cadaveric study.

CLINICAL RELEVANCE

The goal of distal biceps repair is to safely, securely, and anatomically repair the torn biceps tendon to the radial tuberosity. The most commonly performed techniques (single anterior incision with cortical button and the double-incision procedure with bone tunnels and trough) have limitations. A 2-incision button repair safely and anatomically repairs the distal biceps tendon.

Radiological and Clinical Evaluation of the Transosseous Cortical Button Technique in Distal Biceps Tendon Repair

PURPOSE

One of the options to repair a ruptured distal biceps tendon to the radial tuberosity is by means of a transosseous cortical button. Although excellent functional outcomes have been reported, no studies have been performed to quantify the effect of the transosseous fixation technique on the radius. Our study evaluated the clinical outcome and radiological outcome of this technique. The main goal of this study was to evaluate the radiographic evolution of the bone tunnel in the radius.

METHODS

Patients with an acute distal biceps tendon rupture treated with a transosseous cortical button were invited to take part in the study. Fourteen patients were included in the final analysis. All patients were evaluated both clinically and by computed tomography scanning of the proximal radius after a minimum follow-up of 2 years. Outcomes were recorded using the visual analog scale score for pain, the Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand scores. Bone tunnel volume was measured with semiautomated computed tomography segmentation using image-processing software.

RESULTS

There were no failures of fixation in the patient group examined. Elbow mobility, arm, and forearm circumference were symmetric for all patients. Average visual analog scale for pain was less than 2. Mean Disabilities of the Arm, Shoulder, and Hand score and Mayo Elbow Performance Score were 2.3 and 97.6, respectively. Computed tomography images showed an average closure of the radial bony tunnel of 64% of the initial volume.

CONCLUSIONS

Biceps tendon repair with cortical button fixation only shows partial tunnel closure. This could reduce the risk of potential complications due to osteolysis, such as radius fracture or hardware failure. Functional results were excellent and comparable to other fixation methods. The role of interference screws in transosseous cortical button techniques to strengthen the repair and to avoid osteolysis may therefore be questioned.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Clinical Outcomes and Complications of Cortical Button Distal Biceps Repair: A Systematic Review of the Literature

Objectives. The purpose of the present study was to investigate the clinical outcomes and complications of the cortical button distal biceps fixation method. Material and Methods. All methods followed the PRISMA guidelines. Included studies had to describe clinical outcomes and complications after acute distal biceps repair with cortical button fixation. Eligibility criteria also included English language, more than 5 cases with minimum follow-up of 6 months, and preferably usage of at least one relevant clinical score (MEPS, ASES, and/or DASH) for final outcome. A loss of at least 30° in motion—flexion, extension, pronation, or supination—and a loss of at least 30% of strength were considered an unsatisfactory result. Results. The review identified 7 articles including 105 patients (mean age 43.6 years) with 106 acute distal biceps ruptures. Mean follow-up was 26.3 months. Functional outcome of ROM regarding flexion/extension and pronation/supination was satisfactory in 94 (89.5%) and 86 (82%) patients in respect. Averaged flexion and supination strength had been reported in 6/7 studies (97 patients) and were satisfactory in 82.4% of them. The most common complication was transient nerve palsy (14.2%). The overall reoperation rate was 4.8% (5/105 cases). Conclusion. Cortical button fixation for acute distal biceps repair is a reproducible operation with good clinical results. Most of the complications can be avoided with appropriate surgical technique.

Distal biceps ruptures: open and endoscopic techniques

Distal biceps tendon ruptures are relatively rare. Patients are usually middle-aged men involved in heavy labor. Patients usually present with the history of a pop and a proximal migration of the biceps muscle belly. Clinical exam should be sufficient to diagnose a complete rupture. Several specific tests have been described. Ultrasound scanning or MRI can help confirm the diagnosis. Radiographs are not needed to diagnose distal biceps tendon rupture but may show typical findings. Imaging, more specifically the flexion-abduction-supination (FABS) view MRI, is particularly helpful in the case of a partial rupture or chronic rupture of the distal biceps tendon. Results of surgical reinsertion of the distal biceps have been shown to be superior to conservative treatment. Different techniques and approaches have been described with specific advantages and disadvantages. Primary repair of the tendon is preferred. If this is no longer possible in chronic tears, an augmentation can be done using tendon graft. Results of surgical treatment are good in the vast majority of patients. Reruptures are rare but minor complications are common. Major complications may include posterior interosseous nerve palsy or radioulnar synostosis, but the risk of these complications may be decreased by meticulous attention to detail during surgery.

Complications of Distal Biceps Repair

Modern techniques to repair the distal biceps tendon include one-incision and 2-incision techniques that use transosseous sutures, suture anchors, interference screws, and/or cortical buttons to achieve a strong repair of the distal biceps brachii. Repair using these techniques has led to improved functional outcomes when compared with nonoperative treatment. Most complications consist of neuropraxic injuries to the lateral antebrachial cutaneous nerve, posterior interosseous nerve, stiffness and weakness with forearm rotation, heterotopic ossification, and wound infections. Although complications certainly affect outcomes, patients with distal biceps repairs report a high satisfaction rate after repair.

Surgical Treatment of Distal Biceps Ruptures

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.