Repair of avulsed insertion of biceps. A new technique in four cases

Double Tension Slide Technique as a Novel Repair for Distal Biceps Tendon Tear: A Biomechanical Evaluation

Background

A comparative biomechanical analysis of two distal biceps tendon repair techniques was performed: a single suture tension slide technique (TST) and two suture double tension slide (DTS) technique.

Methodology

Ten matched pairs of fresh frozen human cadaveric elbows (20 elbows) were randomly separated into two cohorts for distal biceps tendon repair. One cohort underwent the TST, and the other underwent the DTS technique. The tendon was preconditioned with cyclic loading from 0° to 90° at 0.5 Hz for 3,600 cycles with a 50 N load. The specimens were then loaded to failure at a rate of 1 mm/s. The difference in the load to failure between the groups was analyzed using the Student’s t test. The mode of failure was compared between groups using the chi-square test. All p-values were reported with significance set at p < 0.05.

Results

Overall, 77.8% of the included matched pairs demonstrated greater load to failure in the DTS group. The mean load to failure in the DTS group was 383.3 ± 149.3 N compared to 275.8 ± 98.1 N in the TST group (p = 0.13). The DTS specimens failed at the tendon (5/9), suture (3/9), and bone (1/9). The TST specimens failed at the tendon (4/9) and suture (5/9) only. There was no significant difference in failure type between groups (p = 0.76).

Conclusions

DTS demonstrates a similar to greater load to failure compared to TST with a trend towards statistical significance. The redundancy provided by the second suture has an inherent advantage without compromising the biomechanical testing.

Acute distal biceps tendon ruptures: anatomy, pathology and management - state of the art

All patients with acute complete distal biceps tendon ruptures who are not low demand or medically unfit to proceed with surgery are offered operative repair. This restores arm shape, supination strength and function, and decreases their cramping symptoms. Surgical repair technique varies significantly depending on location and training centre. Nuances in technique and appropriate implant selection need to be noted in order to achieve a strong repair allowing early active range of motion. Intimate knowledge of distal biceps tendon anatomy is key to avoid complications associated with the different approaches. The cumulative body of evidence on complications, coupled with knowledge of the different biomechanical construct strengths of the alternative methods of fixation, points to the use of the cortical button technique without the addition of an interference screw. Subtle variations in drill hole positioning on the bicipital tuberosity secures either an anatomic or non-anatomic repair. Anatomic repair results in greater supination peak torque and fatigue strength, and in greater flexion fatigue strength. It is advisable to perform an anatomic repair in elite athletes or those patients who significantly rely on supination strength and endurance for their livelihood. A universal postoperative protocol is suggested for all repairs.

Chronic distal biceps avulsion treated with suture button

BACKGROUND

Distal biceps tendon avulsions account for 3%-10% of all biceps ruptures. Treated nonoperatively, these injuries lead to a loss of endurance, supination strength, and flexion strength compared with operative repair or reconstruction. Operative management of chronic injury has classically been with graft tissue to augment the contracted muscle. We present our results for chronic distal biceps avulsions secured with suture button through a single transverse incision in high flexion without the need for allograft augmentation.

MATERIALS AND METHODS

This was a retrospective review of 20 patients with 21 injuries who underwent primary surgical repair of chronic distal biceps tendon avulsions at an average of 10 weeks (range 4-42 weeks). All patients were treated with a single transverse incision with a suture button armed with nonabsorbable no. 2 core sutures. Postoperatively patients were found to have 50°-90° flexion contracture. All patients were placed in a simple sling postoperatively with gentle extension to gravity as tolerated immediately and no formal physical therapy. Patients were surveyed regarding pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, visual analog scale (VAS) score, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and overall satisfaction. Range of motion (ROM), flexion, and supination strength compared to the contralateral uninjured extremity were evaluated at final follow-up.

RESULTS

Mean clinical follow-up was 26 months. All patients regained full ROM and 5/5 flexion and supination strength at final follow-up. MEPSs were 100 for all responding patients compared with an average 47.5 preoperatively (P < .0001). The mean postoperative ASES score was 97.2 compared with 41.9 preoperatively (P < .0001). Mean OESs pre- and postoperatively were 24.2 and 48, respectively (P < .0001). The mean VAS score was 4.4 preoperatively and was reported as 0 by all patients at final follow-up (P < .0001). Two patients had transient sensory radial nerve neuropathy, and 1 patient has persistent palsy. No synostoses occurred. Four patients reported supination fatigue postoperatively compared with the uninjured extremity.

CONCLUSION

Given these results, we feel that chronic distal biceps tendon ruptures can be repaired successfully with a single incision using suture button technique without the use of a graft. Though the flexion contracture is significant postoperatively, all patients regained full ROM and had excellent postoperative functional outcome scores.

Reinsertion of distal biceps ruptures with a single anterior approach: analysis of 14 cases using tension-slide technique and interference screw

Background:

Several techniques of surgical repair of biceps tendon ruptures are described in literature. Cortical button repair have shown minimal loss of elbow flexion, supination and strength. In this retrospective study we report the outcomes in terms of elbow function and complications of tension-slide technique and interference screw.

Matherials and methods:

14 patients with complete distal biceps tendon rupture were included in the retrospective study and treated with the same tension-slide technique (BicepsButton® - Arthrex, Inc, Naples, Florida) evaluating the clinical and functional outcomes and the complication rate with a follow-up average of 18 months.

Results:

The flexion recovered compare to the healthy contralateral was 96% (min 115° - max 135°; average 128°), the extension was 97% (min: -2° - max 15°; average 4°), the supination was 90% (min 20° - max 90°; average 75°), the pronation was 95% (min 15° - max 90°; average 76°). The mean Disabilities of Arm, Shoulder and Hand (DASH) score was 8.1 ± 10.5 and Mayo Elbow Performance Score overall (MEPS) score was 97.6 ± 8.2. Two patients had LABCN paresthesia, one case, treated 2 months after injury, had posterior interosseus nerve palsy. One patient had heterotopic ossification at the radiological examination without consequences for the clinical performances. No case of non-traumatic tendon re-rupture and no case of ROM deficiency > 20%. In all case the cortical button remains well positioned and no case of osteolysis were reported.

Conclusions:

Distal biceps tendon repair with BicepsButton® system seems to be a safe, relyable and reproducible technique providing excellent clinical, functional and radiological outcomes. Comparing with other techniques the BicepsButton® system has the advantages of the single approach procedures, the reduction of surgical time and risk of heterotopic ossifications. (www.actabiomedica.it)

Distal Biceps Tendon Repair Using a Double Tension Slide Technique

Distal biceps tendon ruptures are thought to be secondary to an acute forceful eccentric load on a degenerative tendon. Nonoperative treatment following rupture leads to significantly decreased forearm supination and elbow flexion strength. There are several techniques described in the literature for repair. This article describes, with video illustration, distal biceps tendon repair using a double tension slide technique with 2 No. 2 high-tension nonabsorbable composite sutures.

Outcomes and Complications After Repair of Complete Distal Biceps Tendon Rupture with the Cortical Button Technique

Numerous surgical techniques have been described for the repair of complete distal biceps tendon ruptures. However, the outcome of repair with cortical button fixation has not been extensively evaluated. The hypothesis of the present study was that elbow strength and range of motion would be less than normal after repair but that ongoing disability would be minimal as measured with use of the Disabilities of the Arm, Shoulder and Hand (DASH) score.

Methods

We performed a retrospective cohort study of patients with complete distal biceps tendon rupture that was repaired with cortical button fixation via a 1-incision anterior approach. Outcome was assessed on the basis of elbow range-of-motion and strength measurements, DASH scores, and radiographs of the operatively treated elbow. Descriptive statistics were generated for patient demographics and outcome variables. Strength was assessed with limb-symmetry index, and range of motion was evaluated with paired t tests.

Results

Sixty male patients consented to this study. The average age at the time of follow-up was 49.6 ± 7.8 years, and the average time from injury to follow-up was 3.7 ± 1.7 years. The mechanism of injury included lifting heavy objects (62%) and sporting activities (25%). Elbow flexion and supination range of motion were not different between the operatively treated and contralateral arms. The operatively treated elbow demonstrated decreased flexion strength (96% of that on the contralateral side) and supination strength (91% of that on the contralateral side). The findings did not change when controlling for hand dominance. The mean DASH score was 7.9 ± 11.4, which is not significantly different from the normative value for the general population. Postoperative complications included heterotopic ossification (Brooker class I [29 patients] or II [5 patients]), neurapraxia (7 patients), and rerupture (3 patients).

Conclusions

The repair of complete distal biceps tendon ruptures with cortical button fixation was associated with decreased strength in elbow flexion and forearm supination compared with the contralateral arm, although the differences were small and likely were not clinically important. The complication rate was relatively high; however, most complications were minor and were associated with minimal disability, as reflected by the DASH scores.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Improved anchoring nails: design and analysis of resistance ability : Tensile test and finite element analysis (FEA) of improved anchoring nails used in temporomandibular joint (TMJ) disc anchor

Background

Anchorage is one of the most important treatments for severe temporomandibular joint disorder (TMD). Anchoring nails have shown great success in clinical trials; however, they can break under pressure and are difficult to remove. In this study, we aimed to evaluate an improved anchoring nail and its mechanical stability.

Methods

The experiment consisted of two parts: a tensile test and finite element analysis (FEA). First, traditional and improved anchoring nails were implanted into the condylar cortical bone and their tensile strength was measured using a tension meter. Second, a three-dimensional finite element model of the condyles with implants was established and FEA was performed with forces from three different directions.

Results

The FEA results showed that the total force of the traditional and improved anchoring nails is 48.2 N and 200 N, respectively. The mean (±s.d.) maximum tensile strength of the traditional anchoring nail with a 3–0 suture was 27.53 ± 5.47 N. For the improved anchoring nail with a 3–0 suture it was 25.89 ± 2.64 N and with a 2–0 suture it was above 50 N. The tensile strengths of the traditional and improved anchoring nails with a 3–0 suture was significantly different (P = 0.033–< 0.05). Furthermore, the difference between the traditional anchoring nail with a 3–0 suture and the improved anchoring nail with a 2–0 suture was also significantly different (P = 0.000–< 0.01).

Conclusion

The improved anchoring nail, especially when combined with a 2–0 suture, showed better resistance ability compared with the traditional anchoring nail.

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.

Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting-2015

Understanding of the distal biceps anatomy, mechanics, and biology during the last 75 years has greatly improved the physician's ability to advise and to treat patients with ruptured distal tendons. The goal of this paper is to review the past and current advances on complete distal biceps ruptures as well as controversies and future directions that were discussed and debated during the closed American Shoulder and Elbow Surgeons meeting in 2015.

Repair of Distal Biceps Tendon Ruptures Using a Suture Anchor and an Anterior Approach

In a prospective study, eight consecutive patients with nine ruptures of the distal biceps tendon underwent repair through a single incision. All patients were satisfied with their clinical results and had full ranges of elbow and forearm motion. There were no radial nerve injuries and no radio-ulnar synostoses. Isokinetic testing, after correction for dominance, demonstrated a 6% strength deficit, but 7% higher endurance in the repaired extremity for the flexion-concentric test, and no strength deficit and 13% higher endurance for supination. The improved endurance is probably explained by initial reduced effort due to apprehension which minimized subsequent fatigue.

Repair of distal biceps brachii tendon assessed with 3-T magnetic resonance imaging and correlation with functional outcome

OBJECTIVE

Objectives were to study the MRI appearance of the repaired distal biceps tendon (DBT), anatomically reinserted, and to search for a correlation between tendon measurements and functional results.

MATERIALS AND METHODS

Twenty-five patients (mean age, 49 ± 4.9 years old) who benefited from 3-T MRI follow-up of the elbow after surgical reinsertion of the DBT were retrospectively included and compared to a control group (n = 25; mean age, 48 ± 10 years old). MRI was performed during the month of clinical follow-up and on average 22 months after surgery. Delayed complications (secondary avulsion, new rupture), intratendinous osteoma, tendinous signal on T1-weighted (T1w) and fat-suppressed proton density-weighted (FS-PDw) images as well as DBT measurements were recorded. The maximum isometric elbow flexion strength (MEFS) and range of motion of the elbow were assessed.

RESULTS

Repaired DBT demonstrated a heterogeneous but normally fibrillar structure. Its low T1w signal was less pronounced than that of normal tendons, and the FS-PDW image signal was similar to that of T1w images. MRI detected seven osteomas (Se = 53 % vs. plain radiography), one textiloma and one secondary avulsion. Repaired DBT measurements were significantly correlated with MEFS (dominant arm R2: 0.38; nondominant arm R2: 0.54); this correlation involved the insertion surface (Δ = -75.7 mm(2), p = 0.046), transverse diameter (Δ = -2.6 mm, p = 0.018), anteroposterior diameter at the level of the radial head (Δ = -3.9 mm, p = 0.001) and DBT cross-sectional area (Δ = -50.2 mm(2), p = 0.003).

CONCLUSION

The quality of functional outcome after anatomical elbow rehabilitation of DBT correlates with the extent of tendinous hypertrophy during the healing process.

Mini-open incision for distal biceps repair by suture anchors: follow-up of eighteen patients

BACKGROUND

This clinical trial was done to describe a mini approach for distal biceps repair using two or three suture anchors.

PATIENTS AND METHODS

Twenty patients have undergone surgical repair over the last 10 years. All patients were males with mean age 46.8 (range 35-72), and dominant arm was involved in 70 %. Eighteen patients were evaluated with subjective and objective criteria including patient's satisfaction, active range of motion (ROM), and maximum isometric strength (in supination and flexion) using Cybex dynamometer. Functional scoring included Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score and Oxford Elbow Score.

RESULTS

Eighty percent of patients were highly satisfied, with excellent results as defined by Mayo and Oxford Elbow score. Compared to contralateral, the active ROM was not affected in flexion and extension, but pronation and supination were decreased by 5°-10° in two cases. One of eighteen showed hypoesthesia of first and second fingers, and one of eighteen showed a symptomatic heterotopic ossification. There were no reruptures.

CONCLUSIONS

Surgical repair of distal biceps tendon with a mini-single-incision as we described provides patient's satisfaction and very good results with respect to ROM and functional scoring, with a low complication rate.

Radioulnar space available at the level of the biceps tuberosity for repaired biceps tendon: a comparison of 4 techniques

HYPOTHESIS

It is unknown whether certain methods of distal biceps tendon repair lead to an increased propensity of impingement of the repaired tendon. The purpose of this study was to evaluate various repair techniques in a cadaveric model to determine the radioulnar space available for the repaired biceps tendons.

METHODS

Nine matched pairs of quartered, fresh-frozen cadaveric arms were transected at the level of the humeral mid shaft and the distal radiocarpal joint. Distance measurements and the angular relation of the bicipital tuberosity were measured at 5 forearm pronation-supination positions. These measurements were taken under each of the following conditions: intact native biceps, resected native tendon, suture anchor fixation of the biceps, suspensory suture device fixation of the biceps, tendon repair using a tenodesis technique, and fixation of the tendon using a trough technique.

RESULTS

There were no significant differences in radioulnar space available after biceps tendon repair with the forearm in a supinated position. However, when the forearm was in a neutral or pronated position, the suture anchor method consistently had the lowest biceps insertion-to-ulna distance (0.6 to 2.1 cm). All forearm positions, except full supination, showed significant differences in terms of radioulnar space available for the repaired biceps.

DISCUSSION

This study shows that the space available for the biceps tendon decreases with forearm pronation after reconstruction for all repair techniques. It appears that using suture anchors to repair the biceps tendon may predispose the repaired tendon to impingement when compared with other fixation techniques.

Distal biceps tendon rupture: current concepts

BACKGROUND

Distal biceps tendon rupture is not a very common injury and the literature remains scarce, mainly limited to case series. While surgical repair has become popular, it is not universally accepted and there are insufficient data regarding patient satisfaction following repair. The purpose of this study was to assess the results of anatomical reinsertion according to objective muscle strength testing and patient-reported outcome measures.

PATIENTS AND METHODS

Twenty-four patients underwent surgical repair over the last 10 years. All patients underwent clinical assessment using the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score and Oxford Elbow score. Measurement of range of motion, supination and flexion strength testing was done using a Biodex isokinetic dynamometer.

RESULTS

Ninety-five percent of the patients had good or excellent results following surgery as defined by Mayo and Oxford Elbow scores. The average DASH score following surgery was 7.1, nearly the same as the score of 6.2 in the normal population. The mean elbow flexion arc was 134° ± 10.8 (range, 125-150°; 95% confidence interval (CI) 129.6-137.8) with no flexion contractures in the operated side compared with the unaffected elbow. The range of pronation-supination was also comparable in both sides. The average torque in flexion improved by 19.8% (p = 0.25) while supination torque was reduced by 4% (p = 0.12) when compared to the uninjured side. There was 8% incidence of persistent neuropraxia of the antebrachial cutaneous nerve of the forearm and 4% incidence of asymptomatic heterotopic ossification.

CONCLUSION

Surgical repair of distal biceps ruptures provides consistently good results in terms of patient-scored outcomes. Objective muscle strength testing does not reveal statistical difference between the injured and the opposite side.

Use of suture anchors and new suture materials in the upper extremity

Suture anchors are an important tool in the orthopedist's armamentarium. Their use is prevalent in surgery of the entire upper limb. Suture anchors have mostly obviated the need for multiple drill holes when striving for secure fixation of soft tissue to bone. As with most other orthopedic products, the designs of these anchors and the materials used to fabricate them have evolved as their use increased and their applications became more widespread. It is ultimately the surgeon's responsibility to be familiar with these rapidly evolving technologies and to use the most appropriate anchor for any given surgery.

Suture anchor reinsertion of distal biceps rupture: clinical results and radiological assessment of tendon healing

INTRODUCTION

The present study consisted in a clinical follow-up of patients with distal rupture of the biceps brachii tendon managed by suture anchor reinsertion to the radial tuberosity. Tendon apposition on the cortical bone is the least resistant reinsertion technique according to biomechanical studies. A parallel radiological (X-ray and MRI) study was therefore performed to assess the exact quality of tendon healing and its correlation to clinical results.

PATIENTS AND METHODS

Twenty-eight patients were followed up retrospectively at a mean 22 months (minimum FU: six months) with clinical examination (mobility, force, satisfaction, residual pain, and return to work) and radiological assessment (standard X-ray exploration for heterotopic ossification, and MRI for quality of healing of the tendon apposed to the cortical bone).

RESULTS

Forty percent of cases showed complications (mainly neurological) which resolved without sequelae under medical treatment. Mobility was normal in all but eight patients who showed -5° to -20° supination loss. Force in flexion-supination was 91% of that on the contralateral side. On X-ray, only 46% of patients were free of ossification. On MRI, reinsertion was judged anatomic in 19 patients (70%), moderate in six and poor in two, with one iterative rupture. Statistical analysis revealed that the greater the number of suture tacks through the tendon, the greater the force in patients with less than two weeks' interval to surgery and satisfactory reinsertion on MRI.

DISCUSSION

Many reinsertion techniques have been reported, giving clinical results similar to one another and to the present findings. The complications rate, in contrast, varies according to technique and surgical approach. Radiologically, 70% of reinsertions were satisfactory: healing with the tendon apposed on the cortical bone is thus a reliable technique. Heterotopic ossification is considered benign in the literature. The present radiological study refined this notion by identifying three types of ossification: pure asymptomatic intratendon ossification; pure asymptomatic tuberosity ossification without impact on healing on the radial tuberosity; and tuberosity ossification with associated boney metaplasia of the terminal part of the reinserted tendon, impairing healing and leading to less satisfactory clinical results. To ensure anatomic healing of the distal biceps tendon, we recommend less than two weeks' interval to surgery and at least two suture tacks to obtain good apposition on the radial tuberosity.

[Results of transosseous reattachment for distal rupture of the biceps tendon. Evaluation of results]

Avulsion of the distal biceps brachii tendon is an uncommon injury. This is a retrospective review of cases operated in our department by transosseous suture fixation on the radial tuberosity, using the single anterior incision. Between 2000 and 2007, a total of 10 patients with distal biceps tendon injury were included. All were men, with an average age of 39 years. The most common mechanism was passive extension against active flexion. The dominant limb was affected in all patients. Clinical diagnosis was the rule. Surgical reattachment to the radial tuberosity through the anterior approach to the elbow was performed. The preoperative period was one week in three cases, between one and three weeks in five cases, and superior to three weeks in two cases. Clinical and instrumental evaluation of the results was done. Average follow-up was 48 months. Subjective results were good in seven cases, acceptable in two cases and poor in one case. Nine patients return to their previous level activity with no limitations. The average range of motion was 0° of extension to 135° of flexion. Strength testing of the injured limbs, compared to the contralateral, using the criteria described by Baker and Bierwagen, revealed a loss of 22% of supination strength and 32% of supination endurance. There was a loss of 14% of flexion strength and 27% of flexion endurance. There were two cases of superficial surgical site infection. There were no cases of nerve damage or heterotopic bone formation. Two main factors were found to explain the poor outcomes: experience of the surgeon and a long preoperative delay. Despite the limitations of this study, we found that transosseous reattachment of the biceps' distal tendon to the radial tuberosity can restore supination. Strength and endurance for supination can be better restored by early intervention. Complications are easily avoided if surgery is performed early and by experts.

Reinsertion of the distal head of the biceps using mini-anchors and the anterior access: a retrospective study

The authors describe their experience in the treatment of the lesions of the distal tendon of the biceps through the anatomic insertion with Mitek mini-anchors using Henry anterior single-incision access. From 1996 to 2007, 12 patients, all male, average age 51.2 years, were treated for a lesion of the distal tendon of the biceps. In all cases, post-operative pain according to the visual analogical scale, the articular motion of the elbow, the occurrence of neurological disorders and the formation of ectopic ossifications appreciated by radiographies were evaluated. Furthermore, the patient's satisfaction and the impact on his quality of life were assessed using the DASH questionnaire. The results that were evaluated at an average follow-up of 65.6 months were satisfactory: in two cases a temporary deficit in the innervation area of the radial nerve occurred; in two cases ossifications formed at the tendon insertion level but with no clinical repercussions. All patients returned to their previous working activity and their level of satisfaction was good in five cases and very good in the other seven cases. In agreement with literature data, this technique, when compared with other treatment methods, proved effective and safe in the treatment of acute lesions of the distal tendon of the biceps brachii.

A combined technique for distal biceps repair using a soft tissue button and biotenodesis interference screw

BACKGROUND

There are many techniques described to repair acute distal biceps tendon ruptures. The authors' objective is to report the results of a single-incision technique using a combination of a soft tissue button and biotenodesis interference screw with accelerated rehabilitation.

HYPOTHESIS

Dual fixation of a distal biceps rupture will allow for early return to function.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From February 2004 to July 2007, 41 elbows in 40 patients had repair of an acute distal biceps tendon rupture (<6 weeks) through an anterior incision using a soft tissue button and interference screw combined technique. The patients were evaluated pre- and postoperatively with a physical examination, radiographs, and the Andrews-Carson elbow score. Nine patients were unavailable for follow-up. The remaining 31 patients (32 elbows) were contacted for a telephone interview at an average of 24 months postoperatively.

RESULTS

The preoperative Andrews-Carson score averaged 168 and the postoperative Andrews-Carson score averaged 196 points at final clinical follow-up. There was a statistically significant difference between the pre- and postoperative Andrews-Carson scores (P < .001). One patient had heterotopic ossification associated with decreased pronation and supination. Two superficial radial nerve palsies completely resolved by final follow-up. The average postoperative time to resume normal activities or return to work was 6.5 weeks.

CONCLUSION

Repair of acute distal biceps tendon ruptures using a soft tissue button and interference screw technique through a limited anterior incision can allow for accelerated rehabilitation and early return to function.

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.

One- versus two-incision technique for distal biceps tendon repair

There are several techniques that have been described for distal biceps tendon repair but there is still controversy regarding the optimal technique. Our hypothesis is that the single-incision technique will have a similar complication rate and functionally equivalent restoration of function compared with the two-incision approach. A retrospective review of consecutive biceps tendon repairs was performed at one institution over a 5-year period. Thirty-six patients met the inclusion criteria and 26 were available for follow-up including subjective assessment, physical examination, and strength testing. Patients were divided into two groups based on the surgical approach utilized: 12 patients underwent single-incision repair and 14 had a two-incision repair. The average follow-up was 33 months (minimum 13; maximum 75). There were no statistically significant differences in regards to flexion strength or endurance, supination strength or endurance, or complication rates between the two techniques. In conclusion, both surgical techniques led to adequate restoration of strength with a low complication rate. Both techniques are safe to perform and should be guided by surgeon comfort with the approach.

Anatomical refixation for acute ruptures of the distal biceps tendon using a novel transcortical refixation system

INTRODUCTION

In this study, minimally invasive CurvTek refixation is introduced as a novel approach for repair of distal biceps tendon ruptures. Exploration at the radial tuberosity is minimized using CurvTek, thereby reducing operative trauma. Treatment outcomes were compared for this technique against the conventional technique. In addition, we introduce position-dependent isometric myometry to allow quantitative measures of post-operative strength at specific elbow joint positions, for improved comparative analyses.

MATERIALS AND METHODS

Eighteen patients were included in this study and the mean follow-up was 17.6 months (range 6-35, SD +/- 6.9). Nine patients underwent conventional anatomical refixation, while the remaining nine patients underwent anatomical refixation using CurvTek-sutures. Clinical results and position-dependent strength were compared.

RESULTS

Mean age was 49.8 years (range 38-61; SD +/- 5.8). The average EFA-score was 82.2 (range 61-97; SD +/- 9.8). The CurvTek group scored a mean 87.0 (range 77-97; SD +/- 7.0) and the conventional anatomical refixation group a mean 77.4 (range 61-93; SD +/- 10.2) (P = 0.091). Position-dependent dynamic myometry revealed a loss of strength at end stage flexion and supination in the injured arm. Comparison of the two groups, revealed a statistically significant improvement in relative supination strength in the maximally supinated position for patients of the CurvTek group over those undergoing conventional refixation (P = 0.009).

CONCLUSION

Our results show that the CurvTek system leads to good post-operative strength and ROM without increasing the complication rate.

Cross-sectional anatomy of the bicipital tuberosity and biceps brachii tendon insertion: relevance to anatomic tendon repair

This study evaluated the insertional anatomy and orientation of the biceps tuberosity and tendon to assess the anatomic validity of repairs made with 1 incision vs 2 incisions. Computed axial tomography was used to image 30 cadaver radii, and each tendon insertion was measured with a digital micrometer. Specimens were sectioned and imaged with Faxitron radiography (Faxitron X-Ray Corp, Wheeling, IL) to determine the angular orientation of the biceps tendon insertion relative to the tuberosity apex. The tuberosity axis of orientation averaged 65 degrees (range, 15 degrees -120 degrees ) of pronation from anterior, with angular orientation encompassing a mean 59 degrees (range, 15 degrees -100 degrees ) arc with the midpoint of the insertion averaging 50 degrees (range, -5 degrees to 105 degrees ). Most biceps tendons inserted on the anterior aspect of the apex of the tuberosity, with an average width of 7 mm and length of 22 mm. The biceps tuberosity is oriented in more pronation than is typically described, prohibiting anatomic reinsertion of the tendon in 35% of specimens with current single-incision techniques.

Repair of distal biceps tendon ruptures using suture anchors through a single anterior incision

PURPOSE

The purpose of this study was to review the results of distal biceps tendon repair via suture anchors through a single anterior incision.

METHODS

This is a retrospective review of 17 patients (18 repairs) treated for complete distal biceps tendon rupture between 1998 and 2005 by use of G4 Superanchors (DePuy Mitek, Raynham, MA) in our unit. The length of follow-up was 14 to 70 months (mean, 45 months).

RESULTS

There was a mean loss of 5.3 degrees (range, 0 degrees to 50 degrees ; SD, 14.12) of extension when compared with the uninjured side. Of the 17 patients, 6 achieved full extension when compared with the uninvolved elbow. The mean loss of flexion was 6.2 degrees (range, 0 degrees to 15 degrees; SD, 6.11). There was a mean loss of 11.0 degrees of pronation (range, 0 degrees to 30 degrees; SD, 11.34) and 6.4 degrees of supination (range, 0 degrees to 45 degrees; SD, 17.45). Flexion in supination strength measured by a handheld dynamometer was 82.1% of that of the injured side (range, 59% to 102%; SD, 11.26). There were two complications in our series: transient superficial radial nerve palsy in one case and heterotopic ossification in the other. The mean Disabilities of the Arm, Shoulder and Hand score was 14.45 (range, 0 to 55.17; SD, 4.76). Six months after surgery, all patients but one returned to their preinjury levels of activity and employment.

CONCLUSIONS

Our study shows that repair of distal biceps tendon ruptures via suture anchors is safe and yields clinically objective and functional results comparable to measurements in the other, uninjured extremity.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Biomechanical analysis of distal biceps tendon repair methods

BACKGROUND

The 1-incision and 2-incision techniques are commonly used methods to repair a distal biceps rupture, and they differ in the location of reinsertion of tendon into bone.

HYPOTHESIS

The native distal biceps brachii tendon inserts on the posterior-ulnar aspect of the bicipital tuberosity, which functions as a cam, increasing the tendon's moment arm during its principal action of forearm supination. Repair of the distal biceps tendon to the anterior aspect of the tuberosity compromises forearm supination due to absence of the bicipital tuberosity's cam effect.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eleven matched pairs of fresh-frozen cadaveric upper extremities were prepared for repair of the distal biceps tendon using either anterior or posterior reattachment with transosseous suture fixation. Specimens were tested on a materials testing machine with intact distal biceps insertion and after repair. A load cell at the distal radial-ulnar joint measured resultant elbow flexion and forearm supination torque produced by 100-N force applied to the proximal aspect of the tendon.

RESULTS

Although there was a trend (P= .104) toward loss of supination torque with the anterior reconstruction method, no significant differences in torque (0.80 vs 0.89 N.m) or flexion force (11.87 vs 12.07 N) were found between the anterior and posterior reconstruction techniques.

CONCLUSION

There is no statistically significant difference in flexion force or supination torque between the anterior and posterior reconstruction techniques.

CLINICAL RELEVANCE

This study supports existing limited clinical data suggesting no functional differences exist between 2 common repair methods. Further biomechanical and clinical investigations directly comparing the results of distal biceps tendon repairs made to the anterior aspect versus the posterior aspect of the tuberosity are necessary to definitely determine if differences exist in resultant elbow flexion and forearm supination functions.

Single-incision repair of acute distal biceps ruptures by use of suture anchors

The purpose of this study is to report the results of a single limited-incision technique for repair of acute distal biceps ruptures by use of suture anchors. Sixty consecutive patients underwent distal biceps repair after an acute rupture between January 1997 and January 2001 by use of a limited antecubital incision and suture anchors. Fifty-three patients could be evaluated at a mean follow-up of 38.1 months. A limited transverse incision was made in the antecubital fossa. The retracted biceps tendon end was identified, retrieved, and lightly debrided. Two suture anchors were placed in the radial tuberosity, and the tendon was reapproximated. Final follow-up consisted of physical examination, radiographs, and Andrews-Carson elbow score tabulations. According to the Andrews-Carson scores, there were 46 excellent and 7 good results. In 2 patients, heterotopic ossification developed that resulted in a mild loss of forearm rotation and mild pain. In 1 patient, a temporary radial nerve palsy developed, which resolved completely within 8 weeks. Repair of acute distal biceps tears via a limited antecubital incision and suture anchors is a safe, effective technique.

A biomechanical comparison of EndoButton versus suture anchor repair of distal biceps tendon injuries

The purpose of this study was to compare suture anchor and EndoButton repair of distal biceps injuries in a human bone-tendon model. Right and left arm repairs were alternately performed with either the EndoButton or 2 single-loaded 5-mm suture anchors. Each construct was cyclically loaded by use of a servohydraulic materials testing machine. Initial and final displacements were recorded. All repairs were then loaded to ultimate failure. Ten millimeters of displacement was designated the clinical failure point. The EndoButton group had more stiffness than the suture anchor group during initial cyclic loading (P = .01). There were no differences in final displacement measured after cyclic loading (2.06 mm for suture anchors and 2.58 mm for EndoButton). The EndoButton group had a 16% greater ultimate tensile load than the suture anchor group (274.77 N vs 230.06 N). The EndoButton group also had a 16% higher load to clinical failure (249.95 N vs 209.56 N). These differences were not statistically significant. The EndoButton and suture anchors provide comparable fixation strength for the repair and rehabilitation of distal biceps tendon ruptures.

Endoscopic repair of distal biceps tendon using an EndoButton

The technique of endoscopic repair of an acute rupture of the distal biceps tendon with a single anterior portal incision (1.5 cm) and fixation with an EndoButton (Acufex, Smith & Nephew, Andover, MA) is described. The ruptured biceps tendon is delivered through the portal wound and sutured to the EndoButton with a No. 5 Ethibond suture (Ethicon, Somerville, NJ). Endoscopic visualization of the tract of the avulsed biceps tendon guides the endoscopy cannula to the radial tuberosity. The endoscopy cannula serves to protect the adjacent neural structures while using the guidewire and drills for the EndoButton. The EndoButton delivers and locks the tendon into the hole in the radial tuberosity. This technique has been used in 2 patients who were allowed early active mobilization. All were satisfied, having regained a full range of elbow movement and flexion and supination strength. There have been no neurovascular complications with this technique. This report shows the utility of endoscopy in repair of the biceps tendon.

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.

Les ruptures du tendon bicipital distal et leur traitement chirurgical

PURPOSE OF THE STUDY

Avulsion of the distal biceps brachii tendon at the elbow is uncommon. We analyzed cases operated in our department in order to define etiological factors and surgical treatment outcome.

MATERIAL AND METHODS

We reviewed retrospectively eleven patients, ten male patients, average age 43 years (range 37-59) with distal biceps tendon ruptures repaired anatomically with a double-incision technique and one other male patient whose tendon was attached to the brachialis anterior. Nine patients were seen for clinical assessment at least two years after operation.

RESULTS

Average follow-up was 7 years (range 1-10). Patient satisfaction was good and all stated they would opt for surgical treatment again. The most common mechanism of injury was heavy weight lifting with the elbow at 90 degrees flexion or excentric loading on a flexed elbow. The dominant limb was injured in all patients. Eight patients had sustained injury during domestic activities and three during sports activities. Clinical diagnosis was the rule. MRI was useful in patients seen late after injury. We found nine cases of avulsion located at the bicipital tuberosity. All subjective results were good. Strength testing of the injured limbs revealed a loss of 30% supination strength and 40% supination endurance for the anatomic reinsertions. For the non-anatomic reinsertion, there was a 50% decrease in strength and 60% decrease in endurance. Clinical follow-up after seven years showed no nerve damage or heterotopic bone formation.

DISCUSSION

Anatomic repair of distal biceps tendon rupture provides consistently good results. Attachment of the brachial tendon to the brachial anterior muscle cannot restore supination force. The two-incision technique with the extensor mass-splitting approach described by Boyd and Anderson lessens the risk of radial nerve plasty.

CONCLUSION

Early anatomic reconstruction can restore more strength and endurance for supination. Attachment of the brachialis muscle must be considered in the event of late reconstruction. Subjective satisfaction with functional outcome has been excellent for all patients.

Radioulnar synostosis after the two-incision biceps repair: a standardized treatment protocol

The purpose of this study was to evaluate the results of a 1-incision posterolateral surgical approach with concomitant irradiation (700 rad) for early resection of synostosis after a 2-incision biceps repair. Between 1992 and 2000, 8 patients with radioulnar synostosis after a 2-incision biceps repair were evaluated and treated, with a mean age of 38 years (range, 29-47 years). The mean time between tendon repair and resection of the synostosis was 7 months (range, 4-14 months). The mean follow-up was 27 months (range, 13-36 months). All patients had 0 degrees of forearm rotation preoperatively. Postoperatively, all patients underwent postoperative radiotherapy in two divided doses for a total of 700 cGy. At a mean follow-up of 27 months, the rotation arc of the forearm improved to 155 degrees (range, 140 degrees -170 degrees ). The strength of supination was 80% (range, 70%-90%) of the contralateral limb. Seven of the eight patients had no pain after activities of daily living or work. One had mild pain after prolonged activity. No radiographic or clinical evidence of synostosis recurrence was seen at final follow-up. We believe that resection of most radioulnar synostoses after 2-incision biceps repair can be achieved safely and efficaciously through one posterolateral incision.

Rupture of the distal biceps brachii tendon: isokinetic power analysis and complications after anatomic reinsertion compared with fixation to the brachialis muscle

Anatomic reattachment of the distal biceps tendon is well established but bears the risk of complications including loss of motion and nerve damage. We questioned whether nonanatomic repair by tenodesis to the brachialis muscle is able to accomplish similar results with less risk. We compared the results of anatomic repair with suture anchors (n = 6) with the results of nonanatomic repair (n = 8). Anatomic reattachment of the biceps tendon can restore full power of flexion in most cases as determined by isokinetic muscle tests (mean, 96.8% compared with the contralateral side). Nonanatomic repair also restores flexion strength to a mean of 96%. Supination power averaged 91% after anatomic repair. Supination strength after nonanatomic repair did not improve in 4 of 8 patients (42%-56% of the uninjured arm). The other 4 patients were able to produce 80% to 150% of the strength of the contralateral side. Major complications such as radioulnar synostosis or motor nerve damage were not encountered in either group. Heterotopic ossification was seen in 4 cases after reinsertion to the tuberosity. One of these patients was not satisfied with the procedure because of anterior elbow pain, even at rest. After tenodesis to the brachialis, one patient was unsatisfied because of considerable weakness. We concluded that major complications after anatomic repair are rare but must not be ignored. Tenodesis of the distal biceps tendon is a safe alternative procedure. We inform our patients about the benefits and risks of anatomic and nonanatomic repair as well as those of nonoperative treatment. The decision concerning the type of therapy best suited for an individual patient should be made on an informed consent basis.

Distal biceps tendon repair: comparison of surgical techniques

PURPOSE

Various surgical repair techniques for distal biceps tendon ruptures have been reported, however, the optimal technique is unknown.

METHODS

Over a 4-year period 19 distal biceps tendon ruptures were repaired: 9 using a single anterior incision and 10 using a modified 2-incision Boyd and Anderson technique. The patients were followed-up prospectively and independently reviewed.

RESULTS

Patient-rated elbow evaluation and Short Form-36 (SF-36) scores improved with time independent of surgical technique. At 1 year the 1-incision group regained more flexion (142.8 degrees vs 131.1 degrees ) than the 2-incision group. There was no difference between groups in supination motion, supination strength, or flexion strength, although recovery of flexion strength was initially more rapid for the 2-incision group. Complications were encountered in 44% of cases treated with a 1-incision technique and in 10% of cases treated with the 2-incision technique; however, most of these were minor transient paresthesias.

CONCLUSIONS

The differences between the 2 groups were relatively minor with the Morrey 2-incision technique showing a slightly more rapid recovery of flexion strength and fewer complications as compared with the 1-incision technique.

Surgical repair of distal biceps tendon ruptures: a biomechanical comparison of two techniques

BACKGROUND

Rupture of the distal biceps brachii tendon has most commonly been repaired by anatomic reattachment of the tendon to the radial tuberosity by a single- or two-incision approach. Researchers have studied suture anchor attachment through a single incision, but the tendon-suture interface and bone quality have not previously been analyzed.

HYPOTHESIS

Suture anchor repair results in stiffness and tensile strength equal to that of bone-tunnel repair for biceps tendon rupture.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve matched pairs of fresh-frozen cadaveric elbow specimens were used. Suture anchor and bone-tunnel tendon repairs were performed in a randomized fashion. Each specimen was loaded to tensile failure. Load-displacement graphs were generated to calculate repair stiffness, yield strength, and ultimate strength. Computed tomography bone density measurements and additional statistical analyses were then performed after grouping the specimens by mode of failure.

RESULTS

The bone-tunnel repair was found to be significantly stiffer in all cases and to have significantly greater tensile strength than the suture anchor repair in the younger, nonosteoporotic elbows.

CONCLUSIONS

Suture anchor repairs were not as stiff or strong as bone-tunnel repairs.

CLINICAL RELEVANCE

Biceps tendon surgery using the traditional two-incision technique yields a stronger and stiffer repair in the typical patient with this injury.

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.

Facial reanimation surgery utilizing the Mitek anchor system: A case report

A flaccid hemi-face is frequently the most noticeable and cosmetically unacceptable consequence of facial nerve palsy, whether due to trauma, Bell's palsy or other etiologies. A variety of face-lift and reanimation techniques have been utilized in the past, but with time, these frequently require further surgery. We describe the use of Mitek (Norwood, MA) suture anchors for cheek resuspension in a patient with facial palsy. This system is composed of a drill guide, drill, inserter, and anchor. Although the titanium alloy anchors come in multiple sizes, the Mini GII Anchor is typically most appropriate for use in facial procedures. The actual size of the Mini GII Anchor is 1.8 mm in diameter and 5.4 mm in length. Two small arched prongs extend from the body of the anchor, and an eyelet at the superior surface is used for suture placement. When placed into a pre-drilled hole with the insertion tool, the prongs extend, effectively fixing the anchor in place. The drill guide protects adjacent soft tissues during the drilling process and allows drilling to a predetermined fixed depth. Sutures attached to the anchor may then be used for soft tissue fixation to bone.

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.