Delayed onset of posterior interosseous nerve palsy after distal biceps tendon repair

An intact lacertus fibrosus improves strength after reinsertion of the distal biceps tendon

PURPOSE

The importance of an intact lacertus fibrosus in distal biceps tendon injury is uncertain. This study aimed to assess long-term outcome following distal biceps tendon repair with focus on the significance of the lacertus fibrosus.

METHODS

Thirty-six patients surgically treated for primary distal biceps tendon rupture were identified. Medical records were reviewed for patient demographics in addition to surgery-related data. All patients underwent a targeted clinical examination to assess elbow function and they completed a patient reported questionnaire. Radiographs were obtained at time of follow-up and evaluated for the presence of osteoarthritis (OA) and heterotopic ossification (HO).

RESULTS

All patients were male. Median age at injury was 48 years (34-69) and median time of follow-up of was 71 months (23-165). All patients presented functional range of motion in the elbow. Median flexion strength was 76 Nm (45-135) (median 99% of uninjured side; range 66-128) with intact lacertus fibrosus and 70 Nm (43-124) (88%, 62-114) with torn lacertus fibrosus. Median supination strength was 6 Nm (3-11) (86%, range 36-144) with intact lacertus fibrosus and 8 Nm (3-17) (67%, 28-118) with torn lacertus fibrosus. No signs of OA were revealed, but three patients had major HO of which one patient had minor limitations in range of elbow motion.

CONCLUSION

An intact lacertus fibrosus contributes to elbow strength and should be preserved in distal biceps tendon repair.

LEVEL OF EVIDENCE

III.

Posterior interosseous nerve incarceration with endobutton repair of distal biceps

Distal biceps ruptures are uncommon injuries that comprise approximately 3% of all biceps pathology. This injury is most commonly seen in 40- to 60-year-old men, and the mechanism of injury involves a forceful extension movement to a flexed elbow. Without surgical intervention, patients are left with measurable weakness in elbow flexion and supination as well as a cosmetic deformity that often leaves them dissatisfied. Consequently, early surgical repair is advocated for physically active individuals. A variety of surgical approaches and fixation devices are currently used for distal biceps repair. The single-incision cortical button repair for distal biceps avulsions has become popular since Bain introduced the technique in 2000. The advantage of the cortical button biceps repair technique is the significantly higher failure strength than either the 2-incision technique or the suture anchor repair. The initial repair strength of the cortical button technique allows immediate active elbow range of motion and accelerated rehabilitation. Additionally, the single-incision anterior approach is less invasive than the 2-incision biceps repair and results in a lower incidence of heterotopic ossification. One disadvantage of this approach, however, is the risk of injury to the posterior interosseous nerve. The authors report a case in which the posterior interosseous nerve was incarcerated between the cortical button and the radius during acute distal biceps repair, resulting in complete posterior interosseus nerve palsy. This case report details the surgery leading to the nerve palsy and the subsequent nerve exploration that identified the cause of the nerve palsy. Recommendations are made on how to avoid this complication during distal biceps tendon repairs.

Tardy posterior interosseous nerve palsy following total elbow arthroplasty: report of a case, literature review and a classification system

We present an unusual case of tardy posterior interosseous nerve palsy in a female patient following total elbow arthroplasty for rheumatoid arthritis. The patient was neurologically intact immediately following surgery but developed loss of active finger and thumb extension within 12 hours following surgery. Expectant management was adapted. The palsy recovered fully without the need of surgical intervention. A literature review is presented and a classification system proposed.

Technique and results after distal braquial biceps tendon reparation, through two anterior mini-incisions

OBJECTIVE:

Evaluation of postoperative results of repair of distal biceps brachii ruptures through a two anterior mini-incisions.

METHODS:

Nine patients with clinical and imaging (MRI) diagnosis of total lesion of the biceps brachii at its insertion were operated with a surgical technique with two mini-incisions between 2008 and 2011. The patients were evaluated after three months of evolution and all of them recovered the fully flexion-extension arch.

RESULTS:

Two patients (22.2%) presented a limitation of 20 degrees of supination. One patient (11.1%) had radial nerve palsy, but was totally recovered after five months. In one patient (11.1%) the muscle remained retracted, but the insertion was recovered. In three patients (33.3%) adhesion was observed on the proximal scar. There was no clinical or radiographic evidence of radioulnar synostosis after six months of evolution. All patients reported satisfaction with the treatment.

CONCLUSIONS:

We conclude that the presented method shows good results as well as other techniques, with less risk of adhesion on the flexor fold of the elbow. Level of Evidence IV, Case Series.

Distal biceps and triceps ruptures

Biceps and triceps tendon ruptures are rather uncommon injuries and are most commonly diagnosed clinically. Magnetic resonance imaging can help the clinician to differentiate an incomplete tear and define any degeneration of the tendon. Surgical anatomical repair is typically performed in acute complete ruptures whereas nonoperative treatment can be used for partial ruptures, as well as for patients unfit for surgery. Single incision techniques are associated with a higher rate of nerve injuries, while double incision repairs have a higher prevalence of heterotopic ossification. Although various fixation methods have been applied including bone tunnels, interference screws, suture anchors, cortical button fixation, the current evidence does not support the superiority of one method over the other. A well-planned postoperative rehabilitation programme is essential for a good final outcome. As better fixation devices are being used, more aggressive rehabilitation programmes have been applied. Epidemiology, clinical evaluation, diagnosis, surgical and conservative management of these injuries are presented in this review along with the authors' preferred technique for the anatomical repair of acute complete ruptures.

Prognosis for recovery of posterior interosseous nerve palsy after distal biceps repair

BACKGROUND

There is very little information on the incidence of and usual recovery period for posterior interosseous nerve (PIN) palsies after distal biceps repair. This study examined the incidence and the time to resolution of PIN palsies in a large consecutive series of primary distal biceps repairs.

MATERIALS AND METHODS

A retrospective review was performed of a consecutive series of patients treated by 34 fellowship-trained upper extremity surgeons with primary distal biceps repair through a single anterior incision technique. Patients' records were reviewed to determine how many experienced a postoperative PIN palsy, defined as postoperative digital extension weakness on clinical examination. Demographic information, surgical fixation used, and clinical resolution was collect for these patients. All patients had clinical follow-up until complete resolution of PIN palsy symptoms.

RESULTS

We found 280 patients who were treated with a single-incision technique and 1 of 2 methods of biceps tendon fixation. Of these, 9 (3.2%) developed a postoperative PIN palsy after primary distal biceps repair. These 9 patients had complete lack of finger and thumb extension at the first postoperative visit and had complete resolution of symptoms at an average of 86 days (range, 41-145 days).

CONCLUSIONS

The incidence of PIN palsy after a single-incision distal biceps repair was 3.2% in our series. These injuries typically resolve within 3 months, and at the latest, 5 months after surgery.

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

BACKGROUND

This clinical trial was done to evaluate outcomes of the single and double-incision techniques for acute distal biceps tendon repair. We hypothesized that there would be fewer complications and less short-term pain and disability in the two-incision group, with no measureable differences in outcome at a minimum of one year postoperatively.

METHODS

Patients with an acute distal biceps rupture were randomized to either a single-incision repair with use of two suture anchors (n = 47) or a double-incision repair with use of transosseous drill holes (n = 44). Patients were followed at three, six, twelve, and twenty-four months postoperatively. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) elbow score. Secondary outcomes included muscle strength, complication rates, and Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Elbow Evaluation (PREE) scores.

RESULTS

All patients were male, with no significant differences in the mean age, percentages of dominant hands affected, or Workers' Compensation cases between groups. There were also no differences in the final outcomes (at two years) between the two groups (p = 0.4 for ASES pain score, p = 0.10 for ASES function score, p = 0.3 for DASH score, and p = 0.4 for PREE score). In addition, there were no differences in isometric extension, pronation, or supination strength at more than one year. A 10% advantage in final isometric flexion strength was seen in the patients treated with the double-incision technique (104% versus 94% in the single-incision group; p = 0.01). There were no differences in the rate of strength recovery. The single-incision technique was associated with more early transient neurapraxias of the lateral antebrachial cutaneous nerve (nineteen of forty-seven versus three of forty-three in the double-incision group, p < 0.001). There were four reruptures, all of which were related to patient noncompliance or reinjury during the early postoperative period and appeared to be unrelated to the fixation technique (p = 0.3).

CONCLUSIONS

There were no significant differences in outcomes between the single and double-incision distal biceps repair techniques other than a 10% advantage in final flexion strength with the latter. Most complications were minor, with a significantly greater prevalence in the single-incision group.

Repair of the torn distal biceps tendon by endobutton fixation

BACKGROUND

A number of techniques have been described to reattach the torn distal biceps tendon to the bicipital tuberosity. We report a retrospective analysis of single incision technique using an endobutton fixation in sports persons.

MATERIALS AND METHODS

The present series include nine torn distal biceps tendons in eight patients, fixed anatomically to the radial tuberosity with an endobutton by using a single incision surgical technique; seven patients had suffered the injuries during contact sports. The passage of the endobutton was facilitated by using a blunt tipped pin in order to avoid injury to the posterior interosseous nerve. The patients were evaluated by Disabilities of the Arm, Shoulder and Hand (DASH) score and Mayo elbow score.

RESULTS

The average age of the patients was 27.35 years (range 21-42 years). Average follow-up was 41.5 months (range 24-102 months). The final average flexion extension arc was 0°-143°, while the average pronation and supination angles were 77° (range 70°-82°) and 81° (range 78°-85°), respectively at the last followup. All the patients had a Disabilities of the Arm, Shoulder and Hand (DASH) score of 0 and a Mayo elbow score of 100 each. All the seven active sports persons were able to get back to their respective game. There was no nerve injury or any other complication.

CONCLUSIONS

The surgical procedure used by us is a simple, safe and reproducible technique giving minimal morbidity and better cosmetic results.

Distal biceps tendon injuries

Distal biceps tendon ruptures present with an initial tearing sensation accompanied by acute pain; weakness may follow. The hook test is very reliable for diagnosing ruptures, and magnetic resonance imaging can provide information about the integrity and any intrasubstance degeneration of the tendon. There are subtle differences between the outcomes of single and modified two-incision operative repairs. With regard to complications, there is a higher prevalence of nerve injuries in association with single-incision techniques and a higher prevalence of heterotopic ossification in association with two-incision techniques. Fixation techniques include the use of bone tunnels, suture anchors, interference screws, and cortical fixation buttons. There is no clinical evidence supporting the use of one fixation method over another, although cortical button fixation has been shown to provide the highest load tolerance and stiffness. Postoperative rehabilitation has become more aggressive as fixation methods have improved.

Tardy palsy of descending branch of posterior interosseous nerve: sequela to plate osteosynthesis of forearm bones

We report a case of tardy paralysis of the descending branch of the posterior interosseous nerve as a consequence of plate osteosynthesis for fracture of both bone forearms. The patient had been operated on 23 years earlier and palsy occurred after a gap of 19 years. The most probable antecedent cause of the palsy was the use of a high-profile implant. The patient was treated by removal of the plate and tendon transfer.

Biceps tendon injuries in athletes

Although rare, athletes involved in competitive strength training and contact sports may sustain distal tendon biceps injuries. Treatment of complete distal biceps tendon ruptures in athletes is primarily surgical. Early repair, through either one-incision or two-incision techniques with anatomic reinsertion of the ruptured tendon to the bicipital tuberosity, is highly recommended. In this article the etiology and pathophysiology of distal biceps tendon ruptures, current diagnostic modalities, and surgical indications are discussed. Also, treatment options, surgical techniques, outcomes, and potential complications are reviewed.

Reconstruction of posterior interosseous nerve injury following biceps tendon repair: case report and cadaveric study

Surgical repair of distal biceps tendon rupture is a technically challenging procedure that has the potential for devastating and permanently disabling complications. We report two cases of posterior interosseous nerve (PIN) injury following successful biceps tendon repair utilizing both the single-incision and two-incision approaches. We also describe our technique of posterior interosseous nerve repair using a medial antebrachial cutaneous nerve graft (MABC) and a new approach to the terminal branches of the posterior interosseous nerve that makes this reconstruction possible. Finally, we advocate consideration for identification of the posterior interosseous nerve prior to reattachment of the biceps tendon to the radial tuberosity.

Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: a possible mechanism of palsy after two-incision repair for distal biceps rupture--clinical experience and a cadaveric investigation

Posterior interosseous nerve palsy is a recognized complication of 2-incision distal biceps tendon repair. We hypothesize that intraoperative forearm pronation can cause compression of the posterior interosseous nerve beneath the supinator and arcade of Frohse. Six human male cadaver upper extremities were dissected. Pressure on the posterior interosseous nerve beneath the arcade of Frohse and supinator was measured with a Swan-Ganz catheter connected to a pressure transducer. Pressure was significantly elevated in maximal pronation in all specimens with the elbow in both flexion and extension. Pressures at full pronation were significantly higher than pressures measured at 60 degrees of pronation (5 +/- 2 mm Hg in 60 degrees of pronation and 90 degrees of flexion, P < .0001; 7 +/- 3 mm Hg in 60 degrees of pronation and extension, P < 005). Maximal pronation can cause increased pressure on the posterior interosseous nerve. The safety of 2-incision distal biceps repair may be increased by avoiding prolonged, uninterrupted periods of hyperpronation.

Distal biceps rupture

Recognition and treatment of distal biceps tendon ruptures is increasing, likely because of greater clinical awareness and the greater activity and demands of the middle-aged population. This article focuses on the proper evaluation and treatment of distal biceps tendon ruptures with special attention focused on recently developed techniques. A review of the recent clinical literature will accompany an overview of pertinent biomechanical studies and an explanation of the risks and benefits of the most popular surgical techniques for distal biceps repair.

Complications associated with repair of a distal biceps rupture using the modified two-incision technique

Reinsertion of a ruptured distal biceps through a modified 2-incision approach is a well-accepted method of repair. Only 1 large series has focused specifically on the complications associated with this approach, and the authors found no instances of radioulnar synostosis. In a retrospective review of 45 consecutive cases, 12 of 45 patients (27%) experienced 14 postoperative complications, including nerve dysfunction in 7, functional radioulnar synostosis in 3, loss of motion unrelated to heterotopic ossification in 2, early rerupture in 1, and reflex sympathetic dystrophy in 1. The incidence of complications for patients having surgery from 0 to 14 days after injury was 20% (6 of 30), whereas that of patients having surgery 15 or more days from injury was 40% (6 of 15); however, this difference was not significant (P = .16). Reinsertion of a distal biceps through a 2-incision approach should be performed within 2 weeks of the injury, when possible. Functional synostosis occurs more frequently than previously reported (7%).

Distal biceps tendon repair: a biomechanical comparison of intact tendon and 2 repair techniques

BACKGROUND

A variety of techniques have been described for distal biceps tendon reattachment-bone tunnel with transosseous sutures, suture anchors, and interference screw techniques.

HYPOTHESIS

There will be no significant difference between the mean failure strength, maximum strength, and stiffness of the intact specimen and repair techniques tested: bone tunnel with transosseous sutures and interference screw.

STUDY DESIGN

Controlled laboratory study.

METHODS

Nine matched pairs of fresh-frozen human cadaveric elbows were prepared. The intact tendon was pulled from the radial tuberosity; the right and left elbows were randomized to bone tunnels with transosseous sutures or interference screw repair techniques. The repaired specimens were pulled using the same regimen for the intact tendon. Failure strength, maximum strength, and stiffness were measured and compared.

RESULTS

The mean failure strength, maximum strength, and stiffness of intact tendons were 204.3 +/- 76.9 N, 221.7 +/- 65.9 N, and 30.1 +/- 12.4 N/mm, respectively; for the interference screw specimens, 178.0 +/- 54.5 N, 192.1 +/- 53.1 N, and 30.4 +/- 9.5 N/mm, respectively; and for the bone tunnel specimens, 124.9 +/- 22.8 N, 206.6 +/- 49.8 N, and 15.9 +/- 5.6 N/mm, respectively. There were no significant differences between measures in the intact and interference screw specimens. Mean failure strength and stiffness of the bone tunnel specimens were significantly lower than those of the intact and interference screw specimens; there was no significant difference between the maximum strengths of the treatments. Interference screw failure occurred abruptly with little plastic deformation in nearly all specimens with the tendon and screw pulling out as a unit, often involving fracture of the radial wall. Two of the bone tunnels failed at the bony bridge; the remainder lost bone-tendon contact as the distal tendon was shredded by the suture.

CONCLUSION

The results suggest interference screw fixation repair is nearly as strong and stiff as the intact tendon and stronger than the bone tunnel repair technique.

CLINICAL RELEVANCE

The interference screw provides better stiffness and failure strength compared with the bone tunnel technique for distal biceps tendon repair. Given the superior mechanical properties, the interference screw technique is recommended as the treatment of choice for biceps tendon rupture repair.

Biceps tendon and triceps tendon injuries

Injuries to the biceps and triceps tendons about the elbow are relatively infrequent. Typically, they are traumatic events that occur as a result of a forceful eccentric contraction. Early recognition of these injuries and prompt intervention are the cornerstones to a successful outcome. Acute anatomic repair of complete injuries offers predictably good results. Conservative management, on the other hand, is typically reserved for partial injuries with little functional compromise, and for patients unfit for surgery. The challenges posed by chronic injuries can be addressed with a variety of surgical options. This article focuses on the timely identification and diagnosis of these injuries and specific indications and guidelines for their treatment.

Outcome of Surgical Treatment in Posterior Interosseous Nerve Syndrome

Isolated paralysis of muscles innervated by the posterior interosseous nerve (PIN) is rare. Nine such cases of PIN palsy were reviewed over a period of seven years. Apart from one case with a traumatic etiology, the remaining cases did not have a significant clinical history identifying the cause of their neuropathy. Seven cases underwent surgical decompression, five of which improved dramatically. The remaining two patients required tendon transfers, resulting in a fully functional recovery.

Comparing and contrasting methods for tenodesis of the ruptured distal biceps tendon

The evidence is clear that anatomic reinsertion is the best treatment for an active, compliant patient with an acute distal biceps rupture or a subacute rupture without significant proximal retraction of the tendon. Patients with partial tears and chronic ruptures require surgical attention when persistently symptomatic. Biceps tenodesis through dual incisions or a single anterior incision is a safe, highly reliable, and effective operation. The posterior interosseous nerve is potentially at risk with either approach. This risk is minimized by avoiding exposure and retraction of the nerve. Heterotopic ossification and subsequent proximal radio-ulnar synostosis are reported complications of the two-incision technique. The incidence of this devastating complication has been reduced, but not eliminated, by using a limited posterior forearm muscle-splitting incision and by not exposing the ulna. It is the authors' belief that a single anterior incision with suture anchor fixation of the distal biceps (in the manner described herein) is the surgical treatment of choice for most distal biceps ruptures. Compared with the two-incision method, the posterior interosseous nerve is at no more risk and the chance of heterotopic ossification is diminished. The secure fixation obtained and the limited surgical exposure required allow for early mobilization and rapid return of function.

Complications of repair of the distal biceps tendon with the modified two-incision technique

BACKGROUND

The purpose of this paper is to describe the complications that we encountered after using a muscle-splitting two-incision technique to repair avulsed distal biceps tendons.

METHODS

We conducted a retrospective review of the results of seventy-eight consecutive anatomical repairs of the distal biceps tendon performed through a muscle-splitting two-incision technique at our institution between 1981 and 1998. Four of the patients required a graft to restore length. The seventy-four tendons that were repaired primarily through the modified Boyd-Anderson approach were analyzed in detail and form the basis of this report.

RESULTS

Complications developed after twenty-three (31 percent) of the seventy-four repairs. The complications included five sensory nerve paresthesias (three lateral antebrachial cutaneous and two superficial radial nerve paresthesias) in five patients. A temporary palsy of the posterior interosseous nerve developed in one patient; it resolved in six months. Six patients complained of persistent anterior elbow pain. Heterotopic ossification that did not limit forearm rotation developed in four patients, a superficial wound infection developed in three, one tendon reruptured, three patients lost forearm rotation, and reflex sympathetic dystrophy developed in one patient. No radioulnar synostoses were observed in our series. Complications developed after ten (24 percent) of the forty-one acute repairs (performed fewer than ten days after the injury), six (38 percent) of the sixteen subacute repairs (performed ten to twenty-one days after the injury), and seven (41 percent) of the seventeen delayed repairs (performed more than twenty-one days after the injury). The surgeon's experience with this procedure had no apparent effect on complication rates.

CONCLUSIONS

Most of the morbidity from repair of the distal biceps tendon can be attributed primarily to a delay in the timing of the repair and secondarily to an extensive anterior exposure. More importantly, radioulnar synostosis is rare following the muscle-splitting modification of the two-incision technique, which can be performed safely even by surgeons with limited experience with this procedure.