[Pathological rupture of the distal biceps tendon after long-term androgen substitution]

Testosterone replacement therapy is associated with increased odds of Achilles tendon injury and subsequent surgery: a matched retrospective analysis

BACKGROUND

Prescription of testosterone replacement therapy (TRT) has increased in the United States in recent years, and though anabolic steroids have been associated with tendon rupture, there is a paucity of literature evaluating the risk of Achilles tendon injury with TRT. This study aims to evaluate the associative relationship between consistent TRT, Achilles tendon injury, and subsequent surgery.

METHODS

This is a one-to-one matched retrospective cohort study utilizing the PearlDiver database. Records were queried for patients aged 35-75 who were prescribed at least 3 consecutive months of TRT between January 1, 2010 and December 31, 2019. Achilles tendon injuries and subsequent surgeries were identified using ICD-9, ICD-10, and CPT billing codes. Multivariable logistic regression was used to compare odds of Achilles tendon injury, Achilles tendon surgery, and revision surgery, with a p-value < 0.05 representing statistical significance.

RESULTS

A sample of 423,278 patients who filled a TRT prescription for a minimum of 3 consecutive months was analyzed. The 2-year incidence of Achilles tendon injury was 377.8 (95% CI, 364.8-391.0) per 100,000 person-years in the TRT cohort, compared to 245.8 (95% CI, 235.4-256.6) in the control (p < 0.001). The adjusted analysis demonstrated TRT to be associated with a significantly increased likelihood of being diagnosed with Achilles tendon injury (aOR = 1.24, 95% CI, 1.15-1.33, p < 0.001). Of those diagnosed with Achilles tendon injury, 287/3,198 (9.0%) of the TRT cohort subsequently underwent surgery for their injury, compared to 134/2,081 (6.4%) in the control cohort (aOR = 1.54, 95% CI, 1.19-1.99, p < 0.001).

CONCLUSIONS

There is a significant association between Achilles tendon injury and prescription TRT, with a concomitantly increased rate of undergoing surgical management. These results provide insight into the risk profile of TRT and further research into the science of tendon pathology in the setting of TRT is an area of continued interest.

The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair

BACKGROUND

In the United States, the use of testosterone therapy has increased over recent years. Anabolic steroid use has been associated with tendon rupture, although there is a paucity of evidence evaluating the risk of biceps tendon injury (BTI) with testosterone therapy. The aim of this study was to quantify the risk of BTI after the initiation of testosterone therapy.

METHODS

This was a retrospective cohort study using the PearlDiver database. Records between 2011 and 2018 were queried to identify patients aged 35-75 years who filled a testosterone prescription for a minimum of 3 months. A control group was created, comprising patients aged 35-75 years who had never filled a prescription for exogenous testosterone. International Classification of Diseases, Ninth Revision, International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes were used to identify patients with distal biceps injuries and those undergoing surgical repair. Three matching processes were completed: one for the overall cohort, one for the cohort comprising only male patients, and one for the cohort comprising only female patients. Each cohort was matched to its control on age, sex, Charlson Comorbidity Index, diabetes, tobacco use, and osteoporosis. Multivariate logistic regression was used to compare rates of distal BTI and subsequent surgical repair in the testosterone groups with their control groups.

RESULTS

A total of 776,974 patients had filled a prescription for testosterone for a minimum of 3 consecutive months. In the overall matched analysis between the testosterone and control groups (n = 291,610 in both), the mean age of the patients was 53.9 years and 23.1% were women. Within 1 year of filling exogenous testosterone prescriptions for a minimum of 3 consecutive months, 650 patients experienced a distal BTI compared with 159 patients in the control group (odds ratio [OR], 4.10; 95% confidence interval [CI], 3.45-4.89; P < .001). At any time after testosterone therapy, patients with testosterone use were more than twice as likely to experience a distal BTI as their matched controls (OR, 2.07; 95% CI, 1.94-2.38). Patients who filled prescriptions for testosterone were more likely to undergo surgical repair within a year of the injury compared with the control group. A similar trend was seen in the cohort comprising male patients (OR, 1.63; 95% CI, 1.29-2.07).

CONCLUSION

Patients with prior prescription testosterone exposure have an increased rate of BTI and biceps tendon repair compared with patients without such exposure. This finding provides insight into the risk profile of testosterone therapy, and doctors should consider counseling patients about this risk, particularly male patients.

Histologic Findings in Surgical Pathology Specimens From Individuals Taking Masculinizing Hormone Therapy for the Purpose of Gender Transition: A Systematic Scoping Review

CONTEXT.—

Transgender men and transmasculine persons experience a discordance between the female sex they were assigned at birth and their gender. They may choose to take hormone therapy and/or undergo surgery to masculinize the body. Understanding the common (and less common) histologic changes present in patients taking masculinizing hormones will empower pathologists to better serve this unique patient population.

OBJECTIVE.—

To summarize histologic findings in surgical pathology specimens from persons taking masculinizing hormones as a part of gender transition.

DATA SOURCES.—

A systematic review of the OVID Medline and PubMed databases was performed to identify all studies describing histologic findings in surgical pathology specimens from transgender men from January 1946 to January 2021.

CONCLUSIONS.—

Publication in this area has markedly increased in the last 2 decades. However, most of the studies identified were descriptive and case reports describing changes seen in specimens removed as a part of masculinizing surgical procedures. Benign histologic findings include stromal hyalinization and epithelial atrophy in the breast, polycystic ovarian syndrome-like changes in the ovary, and transitional cell metaplasia in the cervix. The most commonly reported neoplastic finding was adenocarcinoma of the breast, with rare cases of ovarian, endometrial, cervical, vaginal, pituitary, pancreatic, and cardiovascular neoplasia also reported. Ongoing research in this area is needed to better characterize the histologic findings in persons taking masculinizing hormones to provide a deeper understanding of the effect of these treatments on different tissues and facilitate better patient management.

Treatment of distal biceps tendon rupture: why, when, how? Analysis of literature and our experience

INTRODUCTION

The rupture of the distal biceps tendon is a relatively uncommon lesion. Even if conservative treatment may be an option in low demanding patients, young and active subjects may benefit from an early surgical reinsertion. Many techniques and fixation devices have been described, but in the literature, there are no clinical evidences that show the superiority of any of these. In this article, we report an analysis of the "state of the art" and our case series of surgical reinsertion with the double approach transosseous technique.

MATERIALS AND METHODS

Between 2003 and 2013, 26 patients underwent surgical reinsertion, either for acute or for chronic lesions of distal biceps tendon. We evaluated 21 acute cases treated with double approach using DASH and SECEC Elbow Scores. The mean follow-up was 22 months. Range of motion, supination and flexion strength were also recorded.

RESULTS

Mean final ROM was 6-132° in F/E and 89-0-87° in P/S; flexion and supination strength were 96 and 88 % compared to the opposite side. The main complications were two cases of heterotopic ossifications: one asymptomatic fracture of the proximal radius and one temporary neurapraxia of the radial nerve.

CONCLUSIONS

Analysing the literature and our outcomes, we underline the importance of timing for surgery, in young and compliant patients, with a valid rehabilitation protocol for excellent results. The choice of surgical technique remains controversial, and we believe that the double approach transosseous reinsertion is a safe, costless and relatively non-invasive technique, offering satisfactory results when performed early.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.