Distal biceps hook test - Sensitivity in acute and chronic tears and ability to predict the need for graft reconstruction

Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures

PURPOSE

Although the initial description of the distal biceps tendon (DBT) hook test (HT) reported 100% sensitivity (Sn) and specificity (Sp), subsequent retrospective series have demonstrated imperfect validity. The purpose of this investigation was to prospectively assess the validity and reliability of the HT for complete DBT ruptures. We aimed to determine the Sn/Sp and interrater reliability for the HT.

METHODS

A consecutive series of adult patients presenting to our outpatient clinics with an elbow complaint was prospectively examined. Patients were included if they had undergone advanced imaging (magnetic resonance imaging or ultrasound) that imaged the DBT and underwent DBT repair. There were four participating surgeons, all of whom were blinded to magnetic resonance imaging/ultrasound prior to performing the HT. To determine the Sn/Sp of the HT and advanced imaging, intraoperative findings served as the primary reference standard. The interrater reliability of the HT was calculated for cases in which a primary examiner (surgeon) and secondary examiner (physician assistant or resident) performed the HT.

RESULTS

Of 64 patients who had undergone advanced imaging, 28 (44%) underwent DBT surgery and were included in the assessment of Sn/Sp. The mean age was 49 years, and all patients were men. The Sn and Sp of the HT were 96% and 67%, respectively. Advanced imaging demonstrated 100% Sn and Sp. Twenty-five patients were evaluated by a primary and secondary examiner. The interrater reliability was substantial (Cohen kappa, 0.71).

CONCLUSIONS

The Sn and Sp of the HT were 96% and 67%, respectively, when assessed prospectively. Advanced imaging findings (magnetic resonance imaging/ultrasound) demonstrated 100% Sn and Sp. The HT can be performed reliably by examiners with varying experience levels. Considering the imperfect validity of the HT, we caution against the use of this examination alone to diagnose DBT ruptures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Acute Distal Biceps Tendon Injury: Diagnosis and Treatment

Acute distal biceps injuries clinically present with sudden pain and acute loss of flexion and supination strength. The main injury mechanism occurs during the eccentric load of the biceps. The hook test is the most significant examination test, presenting the highest sensibility and specificity for this lesion. Magnetic resonance imaging, the gold standard imaging test, can provide information regarding integrity and identify partial and/or complete tears. The surgical treatment uses an anterior or double approach and several reattachment techniques. Although there is no clinical evidence to recommend one fixation method over the other, biomechanical studies show that the cortical button resists better to failure. Although surgical treatment led to an 89% rate of return to work in 14 weeks, the recovery of high sports performance occurred in 1 year, with unsustainable outcomes.

Anatomical considerations and clinical implications of bicipital aponeurosis: A magnetic resonance imaging study

The bicipital aponeurosis (BA) is the distal aponeurosis of the biceps brachii which usually covers the median nerve (MN), and the brachial artery (BrA) and sometimes causes compression of these structures. Since these situations are rarely reported in the literature, BA frequently does not come to mind as a cause of such compression. Therefore, the diagnosis may be delayed. In this study, we aimed to investigate the morphometry of BA and its relationship with the surrounding neurovascular structures and to draw attention to BA as a structure that can cause entrapment of the MN and rarely, the BrA. We examined the MRIs of the elbow of 279 patients (107 women, 172 men) aged between 18 and 72 years. We measured the thickness, length and width of BA, and investigated the anatomical relationship between BA, BrA, and MN. The respective median thickness, width, and length of BA were 0.7 (0.4-1.8 mm), 18.0 (6.0-34.0 mm), and 32.0 (18.0-50.0 mm), respectively. In all sections examined, the BA covered the BrA and MN, and was located immediately anterior to the BrA. In 225 (80.6%) of 279 MRIs, the BrA was located anterior to the MN and posterior to the BA. In the remaining 54 (19.4%) MRIs, the MN was located anterior to the BrA and posterior to the BA. The respective median thickness, width, and length of the BA were 0.7 mm, 18.0 mm, and 32.0 mm, respectively. It covered the BrA and MN and was located immediately anterior to the BrA. The BA sometimes causes compression syndromes of these structures, therefore, for physicians, it is important to understand the anatomy of the BA.

Distal Biceps Tendon Ruptures: Diagnostic Strategy Through Physical Examination

BACKGROUND

Distinguishing a complete from a partial distal biceps tendon rupture is essential, as a complete rupture may require repair on short notice to restore function, whereas partial ruptures can be treated nonsurgically in most cases. Reliability of physical examination is crucial to determine the right workup and treatment in patients with a distal biceps tendon rupture.

PURPOSES

The primary aim of this study was to find a (combination of) test(s) that serves best to diagnose a complete rupture with certainty in the acute phase (≤1 month) without missing any complete ruptures. The secondary aims were to determine the best (combination of) test(s) to identify a chronic (>1 month) rupture of the distal biceps tendon and indicate additional imaging in case partial ruptures or tendinitis are suspected.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

A total of 86 patients with anterior elbow complaints or suspected distal biceps injury underwent standardized physical examination, including the Hook test, passive forearm pronation test, biceps crease interval (BCI), and biceps crease ratio. Diagnosis was confirmed intraoperatively (68 cases), by magnetic resonance imaging (13 cases), or by ultrasound (5 cases).

RESULTS

A combination of the Hook test and BCI (ie, both tests are positive) was most accurate for both acute and chronic ruptures but with a different purpose. For acute complete ruptures, sensitivity was 94% and specificity was 100%. In chronic cases, specificity was also 100%. Weakness on active supination and palpation of the tendon footprint provided excellent sensitivity of 100% for chronic complete ruptures and partial ruptures, respectively.

CONCLUSION

The combination of a positive Hook test and BCI serves best to accurately diagnose acute complete ruptures of the distal biceps tendon. Weakness on active supination and pain on palpation of the tendon footprint provide excellent sensitivity for chronic complete ruptures and partial ruptures. Using these tests in all suspected distal biceps ruptures allows a physician to refrain from imaging for a diagnostic purpose in certain cases, to limit treatment delay and thereby provide better treatment outcome, and to avoid hospital and social costs.

Treatment of acute distal biceps tendon ruptures - A survey of the British Elbow and Shoulder Society surgical membership

Background

Acute distal biceps tendon ruptures result in weakness and deformity. While in other jurisdictions the rate of surgical repair has outpaced rises in incidence, UK practice for distal biceps tendon ruptures is unknown. The aim of this survey was to characterise current UK clinical practice.

Methods

An online survey was sent to the surgeon members of the British Elbow and Shoulder Society. Questions covered respondent demographics, clinical decision making, surgical experience and willingness to be involved in future research.

Results

A total of 242 surgeons responded; 99% undertook acute distal biceps tendon repairs with 83% repairing at least half of all distal biceps tendon ruptures, and 84% of surgeons would have their own, hypothetical, acute distal biceps tendon rupture repaired in their dominant arm and 67% for their non-dominant arm. Patient age, occupation and restoration of strength were the commonest factors underpinning a recommendation of surgical fixation. Most surgeons (87%) supported a national trial to study operative and non-operative treatments.

Conclusions

UK upper limb surgeons currently advise surgical repair of acute distal biceps tendon ruptures for the majority of their patients. This is despite a paucity of evidence to support improved outcomes following surgical, rather than non-operative, management. There is a clear need for robust clinical evaluation in this area.

Common tendinopathies around the elbow; what does current evidence say?

Tendinopathies are common causes of pain around the elbow resulting in significant functional impairment in athletes or the working-age population. Patients complain of a gradual onset pain with or without any specific trauma. Tissue histology shows chronic fibroblast and vascular proliferation, with a disorganized collagen pattern and absence of inflammatory mediators. Currently, numerous treatment options are described, but many of these are only supported by a heterogenous evidence base. Thus, management guidelines are difficult to define. Surgery is mostly indicated in selected cases that have failed non-operative management. This article reviews the pathophysiology and natural history of lateral and medial elbow tendinopathies, as well as distal biceps and triceps tendinopathies, and their current treatment options.

Higher failure rate of suture anchors in partial distal biceps tendon ruptures in comparison with Endobutton fixation

Background

Little is known about the preferred repair technique of partial tears of the distal biceps tendon. In this study, suture anchors were compared with the Endobutton technique for repair of partial distal biceps tendon ruptures, especially regarding failure rate.

Methods

A total of 59 patients with 62 partial distal biceps ruptures underwent surgical treatment between 2008 and 2019. Repair of the partially ruptured distal biceps tendon was performed using suture anchors (n = 21) or an Endobutton (n = 41). Postoperative evaluation consisted of integrity and physical examination of the distal biceps tendon, range of motion, stability, neurologic status, and radiographs in AP view and lateral direction of the elbow.

Results

At a median follow-up of 14 (1-82) months in all patients, a total of 5 patients had a rerupture of the reconstructed distal biceps tendon (8.1%). A significant higher rerupture rate was seen in the suture anchor group (n = 4) than in the Endobutton group (n = 1) (P = .04). The other outcome measures were similar between groups. Other than rerupture rate, there were complications in 21 patients (34%). The major symptomatic complication was attributed to lateral antebrachial cutaneous nerve neuropraxia (n = 8, 15%). Heterotopic ossifications were seen in 12 patients (34%), and ossifications were symptomatic in 4 of these patients (33%).

Conclusion

A significantly higher failure rate was seen after repair of a partial distal biceps rupture using suture anchors than by using an Endobutton technique. Overall, both techniques were accompanied with complications, in particular, lateral antebrachial cutaneous nerve neuropraxia neuropraxia and the formation of heterotopic ossifications, though clinically less relevant than a rerupture.

BET 1: Best Evidence Topic Report: is the hook test sensitive enough to be used to exclude distal biceps tendon rupture?

A shortcut review was carried out to see whether the hook test is sensitive enough for a negative result to exclude complete distal biceps tendon rupture (DBTR) in adults. 3 papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that the hook test is moderately sensitive at detecting complete DBTR when carried out by skilled clinicians in specialist upper limb clinics. As a single test, it is not sensitive enough to be used to exclude complete DBTR.