Is it safe to perform aggressive rehabilitation after distal biceps tendon repair using the modified 2-incision approach? A biomechanical study

Return to sports following distal biceps tendon repair: A current concepts review

Distal biceps tendon ruptures are relatively rare injuries but tend to occur in active and athletic populations, especially in weightlifting and contact sports. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow, thus an injury to this ligament can be invalidating for athletes. The aim of this review was to determine the ability and the time to return to sports following distal biceps tendon repair in athletes and the level of performance. The literature is scarce about the return to sports among athletes. Most studies include athletes are National Football League (NFL) players, others are weightlifters and a few recreational athletes. The return to play rate after distal biceps tendon repair is high. The performances of the returned players were similar to matched players and most players returned to the same level. Most players-depending on the sport-were not able to return to competition within the same season. In order to manage expectations, it should be discussed preoperatively with the athlete (and their coach) that the return to sports rate is high, but the return will probably be the following season.

Failure of the Interference Tenodesis Screw After Distal Bicep Tendon Repair With a Suture Button Technique: A Report of Two Cases

Distal bicep tendon rupture is an uncommon form of bicep rupture which is typically seen in middle-aged men. We identified two cases in which the distal bicep tendon rupture was repaired with an EndoButton™ (Smith and Nephew, Watford, UK) and interference screw with preservation of the EndoButton™​ but a failure of the interference screw. This report highlights the addition of a FiberWire^® (Arthrex, Inc., Naples, Florida, USA) construct to secure the interference screw from backing out and emphasizes the EndoButton™ as the primary biomechanical anchor in maintaining a successful distal bicep tendon repair. We question the necessity of both the interference screw and EndoButton™ in the fixation of the distal bicep tendon and recommend that securing the interference tenodesis screw with an additional FiberWire^® may provide a more secure fixation of the screw as compared to traditional approaches.

Distale Bizepssehnen- und Trizepssehnenrupturen

Rupturen der distalen Bizeps- und Trizepssehne sind selten, treten jedoch gehäuft bei männlichen, sportlichen und körperlich schwer arbeitenden Patienten auf. Dieser Übersichtsartikel beschreibt Ätiologie und Pathogenese sowie Diagnostik, Behandlungsmöglichkeiten, das zu erwartende Outcome dieser Verletzungen und gibt Einblicke in das eigene Vorgehen.

Diagnosis and Management Strategies for Distal Biceps Rupture

Rupture of the distal biceps tendon most commonly is secondary to mechanical overload during eccentric muscle contraction. Due to deficits of strength and endurance, surgical repair usually is recommended. Although both single- and double-incision approaches have been described, double-incision techniques have been shown to better re-create the native anatomic insertion. However, excellent and comparable clinical outcomes have been demonstrated with both techniques. Fixation with a cortical button and interference screw has been shown to be the strongest construct biomechanically; however, several modern constructs provide adequate strength. Surgical technique should focus on restoration of anatomy, early range of motion, and prevention of complications. [Orthopedics. 2019; 42(6):e492-e501.].

The Fragility Index in Hand Surgery Randomized Controlled Trials

PURPOSE

Randomized controlled trials (RCTs) are the gold standard for comparing clinical interventions. Statistical significance as reported via a P value has been used to determine if a difference between clinical interventions exists in an RCT. However, P values do not clearly convey information about the robustness of a study's conclusions. An emerging metric, called the fragility index (the number of subjects who would need to change outcome category to raise the P value above the .05 threshold), is an indirect measure of how likely a repeat of the trial would reach the same conclusions. This study addressed the fragility of RCTs using dichotomous outcomes in hand surgery.

METHODS

Using systematic searching of the MEDLINE database, we identified hand surgery RCTs published in 11 high-impact journals published in the last decade (2007-2017). Studies were identified that involved 2 parallel arms, allocated patients to treatment and control in a 1:1 ratio, and reported statistical significance for a dichotomous variable. The fragility index was calculated using Fisher's exact test, using previously published methods.

RESULTS

Five hand surgery RCTs were identified for inclusion reporting a range of fragility indices from 0 to 26. Two of the trials (40%) had a fragility index of 2 or less. Two of the trials (40%) reported that the number of patients lost to follow-up exceeded the fragility index, meaning that results of the patients lost to follow-up could theoretically completely reverse the study conclusions.

CONCLUSIONS

The range of fragility indices reported in the recent hand surgery literature is consistent with previous reporting within orthopedic surgery.

CLINICAL RELEVANCE

The fragility index is a useful metric to analyze the robustness of the study conclusions that should complement other methods of critical evaluation including the P value or effect sizes. Our results emphasize the need for future efforts to strengthen the robustness of RCT conclusions.

ISOKINETIC AND FUNCTIONAL EVALUATION OF DISTAL BICEPS RECONSTRUCTION USING THE MAYO MINI-DOUBLE ROUTE TECHNIQUE

OBJECTIVE

To evaluate the functional outcome among patients with distal biceps injuries who were operated using the Mayo mini-double route technique, with a minimum follow-up of six months after surgery, through digital isokinetic dynamometry, goniometry and subjective scores in order to establish objective and subjective improvement patterns and discuss the effectiveness of the procedure.

METHODS

Nine patients who underwent surgery to treat distal biceps injury were evaluated by means of Cybex digital dynamometry using an angular velocity of 30°/s with five repetitions and 120°/s with 15 repetitions, in comparison with the uninjured side. DASH (Disabilities of the arm, shoulder and hand), Mayo elbow score and conventional goniometry were also used.

RESULTS

Digital dynamometer showed that using the angular velocity of 30°/s with five repetitions, there was an average flexion deficit of 9.6% and an average supination deficit of -28.97%. Using an angular velocity of 120°/s with fifteen repetitions, the average flexion deficit was 4.43% and the average supination deficit was -24.1%.

CONCLUSIONS

The loss of flexion followed the pattern already shown in the literature. However, in our series, there were supination strength gains, possibly due to the strict rehabilitation protocol. The technique used in this study was safe and low-cost, with few complications and good functional results.

Distal Biceps Injuries

A review of distal biceps tendon injuries is presented. Notable and recent studies on the incidence, presentation, diagnosis, and treatment are outlined. The benefits and risks of 1- and 2-incision techniques for repair are discussed, and classic studies are reviewed.

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

Introduction

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

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

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

Step 2 Single-Incision Technique Preparation of the Radius

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

Step 3 Single-Incision Technique Tendon Reattachment

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

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

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

Step 2 Double-Incision Technique Preparation of the Radius

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

Step 3 Double-Incision Technique Tendon Reattachment

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

Step 4 Postoperative Care

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

Results

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

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Biomechanical analysis suggests early rehabilitation is possible after single-incision EndoButton distal biceps repair with FiberWire

PURPOSE

Previous studies that have encouraged early postoperative motion after distal biceps repair shows little agreement on exactly when activity should be resumed after surgery or on the level of weight restriction that should be used. The aim of the current study was to define a service load that would permit, without failure, 2,000 cycles of immediate motion after single-incision EndoButton distal biceps repair with FiberWire.

METHODS

In each of 15 cadaveric elbows, the distal biceps tendon was divided at its insertion and then repaired using a single-incision EndoButton technique with FiberWire. The repairs were then challenged according to the "staircase method" by cyclically loading the biceps tendon, so that the forearm flexed between 0° and 90°.

RESULTS

The mean failure load of the repair was 166.7 N (95% confidence interval, 132.6-200.8). The data suggested that a 0.9 kg (9-N) weight at the hand was the limit for a 2,000-cycle early rehabilitation protocol after repair of a ruptured distal biceps tendon via a single-incision EndoButton repair technique.

CONCLUSION

Early active motion with a 0.9-kg weight restriction may therefore be possible in those patients undergoing distal biceps tendon repair using this technique.

Surgical treatment of distal biceps rupture

Rupture of the distal biceps tendon accounts for 10% of all biceps brachii ruptures. Injuries typically occur in the dominant elbow of men aged 40 to 49 years during eccentric contraction of the biceps. Degenerative changes, decreased vascularity, and tendon impingement may precede rupture. Although nonsurgical management is an option, healthy, active persons with distal biceps tendon ruptures benefit from early surgical repair, gaining improved strength in forearm supination and, to a lesser degree, elbow flexion. Biomechanical studies have tested the strength and displacement of various repairs; the suspensory cortical button technique exhibits maximum peak load to failure in vitro, and suture anchor and interosseous screw techniques yield the least displacement. Surgical complications include sensory and motor neurapraxia, infection, and heterotopic ossification. Current trends in postoperative rehabilitation include an early return to motion and to activities of daily living.

Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation

HYPOTHESIS

Tension slide repair maintains the strength of the standard cortical button repair but reduces gap formation at the repair. Distal biceps tendon repair with a suspensory cortical button has yielded the strongest published repair, despite observed gap formation and tendon pistoning. The tension slide technique (TST) was described to reduce gap formation while maintaining the strength of cortical button repair. This study evaluates the biomechanics of the TST compared with previously described EndoButton (Smith & Nephew, Memphis, TN) repair and the TST with and without an interference screw.

MATERIALS AND METHODS

The study used 20 matched specimens: 5 had a standard cortical button repair, and 5 had biceps repair with the TST. An additional 10 specimens underwent a TST, 5 with an interference screw and 5 without. All were cyclically loaded for 3600 cycles. Gap formation and load to failure were measured.

RESULTS

The mean (SD) load to failure for standard technique was at 389 (148) N vs 432 (66) N for the TST (P = .28). The mean (SD) gap formation was 2.79 (1.43) mm with the standard repair and 1.26 (0.61) mm with the TST (P = .03). The mean (SD) load to failure with TST repair was 436 (103) N without the interference screw and 439 (94) N (P = 0.48) with the screw. The mean gap formation was 1.63 (1.09) mm without the screw and 1.45 (0.67) mm with the screw (P = .38.)

CONCLUSION

This TST maintains the strength of the standard cortical button repair, but significantly reduces gap formation and motion at the repair site.

LEVEL OF EVIDENCE

Basic science study.

Immediate active range of motion after modified 2-incision repair in acute distal biceps tendon rupture

BACKGROUND

Different rehabilitation protocols have been used after repair of distal biceps ruptures.

PURPOSE

This study investigates the safety of immediate active range of motion protocol after modified 2-incision distal biceps tendon repair in acute ruptures.

STUDY DESIGN

Case series; Level of evidence, 4.

MATERIALS AND METHODS

Twenty-one patients with a minimum follow-up of 2 years were participants in this study. After repair, the upper extremities were placed in a sling for 1 to 2 days and then immediate active range of motion was started. For the first 6 weeks, the elbow was allowed activities of daily living as tolerated by the patient with a 1-lb weight-lifting restriction. Elbow range of motion, isometric and dynamic flexion, and supination strengths were recorded and Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained.

RESULTS

Mean follow-up extension was 0 degrees and mean follow-up flexion was 141 degrees on the operated side, with supination of 74 degrees and pronation of 75 degrees. The mean DASH score for 21 patients was 3.6 +/- 3.6 (range, 0-11.4). The mean follow-up isometric flexion strength was found to be 5% (P = .411), and the power (dynamic strength) of flexion was 12% greater on the operated side (P = .046). However, follow-up isometric supination strength was 9% less on the involved side than on the noninvolved side (P = .030), and the power of supination was 11% less on the operated side (P = .007). There were no tendon reruptures at follow-up, determined by physical examination.

CONCLUSION

A modified 2-incision distal biceps repair allows a safe immediate active range of motion protocol with early return of nearly full range of motion and strength, without any clinically significant disability.

The effect of repair of the lacertus fibrosus on distal biceps tendon repairs: a biomechanical, functional, and anatomic study

BACKGROUND

To date, repair of the lacertus in distal biceps tendon ruptures, recommended by some, has not been evaluated. The goal of these biomechanical experiments was to evaluate the degree to which its repair increases the strength of a distal biceps tendon repair.

HYPOTHESIS

An intact or repaired lacertus fibrosus will increase the strength of a distal biceps tendon repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

Four matched pairs of fresh-frozen human cadaveric upper extremities were prepared by isolating the lacertus fibrosus and the distal biceps tendon. The extremity was placed in a custom-built rig with the distal biceps brachii clamped and affixed to a stepper motor assembly. The distal biceps tendon was sharply removed directly from the radial tuberosity and repaired through a bony tunnel in all specimens. One side of each pair was randomized to also receive repair of the lacertus. The specimens were pulled at a constant rate until failure.

RESULTS

The mean failure strength, defined as maximal strength to 15 mm of displacement, was higher in specimens with a repaired lacertus (250.2 N vs 158.2 N; P =.012), as was mean maximum strength (256.8 N v. 164.5 N; P =.0058). Mean stiffness was not significantly different (16.36 N/mm vs 13.8 N/mm; P =.58). All specimens failed due to fracture at the bony bridge.

CONCLUSION

Repair of the lacertus strengthened distal biceps tendon repair in a controlled laboratory setting.

CLINICAL RELEVANCE

Repair of the lacertus fibrosus as an adjunct to distal biceps tendon repair strengthens the repair in the laboratory setting. Clinical testing is needed to verify that this increased strength improves clinical results. Surgeons should be cautioned to protect the underlying neurovascular structures during repair of the lacertus fibrosus and to avoid an overly tight repair.

Distal biceps repair using cortical button fixation

Various techniques have been described to repair the distal biceps tendon. The optimal technique would incorporate a limited 1-incision technique with maximal strength and minimal gapping of the repair to allow early range of motion. We describe a modified use of a cortical button, the tension-slide technique, which allows for a transverse anterior incision and the ability to tension and dock the repair through the anterior incision. There is no need to predetermine the length of suture between the button and the biceps and elimination of the technical concern for the button flipping.

Repair of the ruptured distal biceps tendon: a systematic review

BACKGROUND

Reinsertion of the acutely ruptured distal biceps is the preferred method of treatment for most patients and is designed to restore flexion and supination strength. It is not clear which, if any, method of fixation is superior or whether a 2-incision or single-incision approach is associated with fewer complications or better outcomes.

HYPOTHESES

(1) There is no difference in biomechanical performance between currently used fixation methods, (2) there is no difference in incidence of complications between the 2-incision and single-incision approach, and (3) there is no difference in clinical outcomes between the 2-incision and single-incision approach.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The authors performed a systematic review of the literature studying treatment of the ruptured distal biceps tendon to determine optimal fixation method as well as surgical approach with lowest incidence of complications and highest proportion of satisfactory results.

RESULTS

The review identified 8 articles that had relevant biomechanical data, 23 with relevant complication data, and 19 with relevant clinical results data. EndoButton fixation performed best in comparative biomechanical studies. There was no difference in overall incidence of complications between 2-incision approaches (16%) and single-incision approaches (18%), but there were significantly more instances of significant loss of forearm rotation with the 2-incision approach. There were significantly more unsatisfactory clinical results in the 2-incision repair group (31% vs 6%; odds ratio, 7.6; 95% confidence interval, 3.2-17.7), with the majority of unsatisfactory results in the 2-incision group due to loss of forearm rotation or rotational strength.

CONCLUSION

EndoButton fixation has the highest load and stiffness of currently available fixation methods. Two-incision repairs have a significantly greater proportion of unsatisfactory results than do single-incision repairs.

Influence of suture material on the biomechanical behavior of suture-tendon specimens: a controlled study in bovine rotator cuff

BACKGROUND

Despite technical advances in rotator cuff surgery, recurrent or persistent defects in the repaired tendon continue to occur. Improved strength of sutures and suture anchors has resulted in the most common site of failure being the suture-tendon interface.

HYPOTHESIS

The type of suture material used has a significant effect on the biomechanics of the suture-tendon interface.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty-two bovine infraspinatus specimens were randomly assigned to simple suture fixation using No. 2 Fiberwire, Ultrabraid, Orthocord, or Ethibond. Each specimen was subjected to cyclic testing from 5 to 30 N for 30 cycles, followed by load-to-failure testing.

RESULTS

Cyclic testing revealed significantly greater elongation with Ultrabraid, whereas peak-to-peak displacements were lowest for Fiberwire and greatest for Orthocord. Load-to-failure testing revealed no significant differences between any suture material for ultimate tensile load. Fiberwire and Orthocord repairs had the highest stiffness. The most common failure mode during load-to-failure testing was suture breakage in Ethibond specimens and suture cutting through the tendon in the polyblend suture specimens.

CONCLUSION

The type of suture material has a significant effect on the biomechanical behavior of the suture-tendon interface.

CLINICAL RELEVANCE

The type of suture may influence early gap formation and ultimate healing of rotator cuff repairs.