Is Immobilization Necessary for Early Return to Work Following Distal Biceps Repair Using a Cortical Button Technique?: A Randomized Controlled Trial

No Clinically Significant Differences in Patient-Reported Outcomes and Range of Motion Between Early and Delayed Mobilization After Primary Distal Biceps Tendon Repair: A Systematic Review and Meta-analysis

BACKGROUND

Currently, there is no uniform rehabilitation program concerning mobilization after a distal biceps tendon repair. A systematic review was conducted to investigate the effect of restrictions within the immediate postoperative period to evaluate clinical outcomes relative to mobilization after surgical repair of complete distal biceps tendon tears.

HYPOTHESIS

Early mobilization will not have a significant difference on outcomes compared with delayed mobilization.

STUDY DESIGN

Meta-analysis; Level of evidence, 3.

METHODS

The authors performed a systematic review in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines of studies reporting outcomes of the distal biceps tendon repair. The early mobilization cohort included studies with no restrictions beyond 2 weeks after surgery, and the delayed mobilization cohort included studies with continued restrictions beyond 2 weeks after surgery.

RESULTS

A total of 26 studies with 1114 patients (643 in the delayed mobilization cohort and 471 in the early mobilization cohort) met the inclusion criteria, with a weighted mean patient age of 45.14 years (range, 18-76 years) and a mean follow-up of 27.9 months (range, 3-120 months). Meta-analysis at the 24-month follow-up found that range of motion (ROM) was not significantly different across early and delayed mobilization cohorts for flexion (mean, 137.38° vs 140.42°; P = .34) and extension (mean, 3.23° vs 1.5°; P = .91). Early mobilization was found to be significantly associated with less pronation (mean, 75.68° vs 83.18°; P = .0019) and supination (mean, 76.38° vs 83.93°; P = .0049). Analysis of patient-reported outcomes (PROs) found that Disabilities of the Arm, Shoulder and Hand scores (mean, 3.93 vs 4.21; P = .77) and Mayo Elbow Performance Score values (mean, 96.33 vs 97.11;P = .65) were not significantly different across cohorts. Failure analysis found a significant difference when comparing proportion (mean, 0.0006 vs 0.0185; P = .0029) but no difference when comparing incidence rate (mean, 0.0001 vs 0.0001; P = .647). Complication analysis found no statistical difference in proportion (mean, 0.2181 vs 0.1918; P = .7388) or incidence rate (mean, 0.0012 vs 0.008; P = .344).

CONCLUSION

These results suggest there may be no clinically significant difference in failure rates, complications, ROM, or PROs for early versus delayed mobilization after primary distal biceps tendon repair.

Impact of Bracing and Therapy Services on Perioperative Costs for Patients Undergoing Distal Biceps Tendon Repair

PURPOSE

This study aimed to quantify and assess perioperative costs in an integrated healthcare system for patients undergoing distal biceps tendon (DBT) repair with and without the use of postoperative bracing and formal physical (PT) or occupational (OT) therapy services. In addition, we aimed to define clinical outcomes after DBT repair using a brace-free, therapy-free protocol.

METHODS

We retrospectively reviewed all cases of DBT repairs within our integrated system from 2015 to 2021. We performed a retrospective review of a series of DBT repairs utilizing the brace-free, therapy-free protocol. For patients with our integrated insurance plan, a cost analysis was conducted. Claims were subdivided to assess total charges, costs to the insurer, and patient costs. Three groups were created for comparisons of total costs: (1) patients who had both postoperative bracing and PT/OT, (2) patients who had either postoperative bracing or PT/OT, and (3) patients who had neither postoperative bracing nor PT/OT.

RESULTS

A total of 36 patients had our institutional insurance plan and were included in the cost analysis. For patients using both bracing and PT/OT, these services contributed 12% and 8% of the total perioperative costs, respectively. Implant costs accounted for 28% of the overall cost. Forty-four patients were included in the retrospective review with a mean follow-up of 17 months. The overall QuickDASH was 12; two cases resulted in unresolved neuropraxia, and there were no cases of re-rupture, infection, or reoperation.

CONCLUSIONS

Within an integrated healthcare system, postoperative bracing and PT/OT services increase the cost of care for DBT repair and account for 20% of the total perioperative charges in cases where bracing and therapy are used. Considering the results of prior investigations indicating that formal PT/OT and bracing offer no clinical advantages over immediate range of motion (ROM) and self-directed rehabilitation, upper-extremity surgeons should forego routine brace and PT/OT utilization after DBT repair.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of distal biceps tendon ruptures: a survey of fellowship-trained subspecialist elbow surgeons

BACKGROUND

There are several approaches to the management of distal biceps tendon ruptures, with no consensus on what constitutes best practice.

METHODS

An online survey queried the perceptions and management of distal biceps tendon ruptures amongst fellowship-trained subspecialty elbow surgeons, which primarily comprised of members of the Shoulder and Elbow Society of Australia, the national subspecialist interest group of the Australian Orthopaedic Association and the Mayo Clinic Elbow Club (Rochester, MN, USA).

RESULTS

One hundred surgeons responded. The median (IQR) experience as orthopedic surgeons amongst respondents was 17 (10-23) years; 78% of respondents saw >10 cases of distal biceps tendon ruptures annually; 95% of respondents would recommend surgery for symptomatic radiologically-confirmed partial tears, the most common indications being pain (83%), weakness (60%), and tear size (48%). Forty-three percent of respondents would have grafts available for tears older than 6 weeks. The one-incision approach (70%) was preferred over two incisions (30%); 78% of one-incision users believed that their repair location was anatomic, compared to 100% of two-incision users. One-incision users were more likely to have encountered lateral antebrachial cutaneous nerve (78% vs. 46%) and superficial radial nerve palsies (28% vs. 11%). Two-incision users were more likely to have encountered posterior interosseus nerve palsy (21% vs. 15%), heterotopic ossification (54% vs. 42%), and synostosis (14% vs. 0%). Re-ruptures were the most common cause of reoperation. The more conservative a respondent's postoperative immobilization was, the less likely they were to have ever encountered re-rupture (14% amongst cast users, 29% amongst splint/brace users, 49% amongst sling users, 100% amongst non-immobilizers). Thirty percent of respondents who placed elbow strength restrictions for 6 months postoperatively encountered re-rupture, compared to 40% amongst those who restricted for 6-12 weeks postoperatively.

CONCLUSIONS

The operation rate for repair of distal biceps tendon ruptures amongst subspecialist elbow surgeons is high, as seen in our cohort. However, there is a large variation in the approach toward its management. One incision (anterior) was preferred over two incisions (anterior and posterior). Complications from repair of distal biceps tendon ruptures can be expected even amongst subspecialists, and are associated with surgical approach. The responses imply that more conservative postoperative rehabilitation may be associated with a lower risk of re-rupture.

Functional Considerations in Bilateral, Simultaneous Tendon Injuries of the Upper Extremity: A Narrative Review of Current Literature

» Bilateral, simultaneous same-tendon injuries of the upper extremity are rarely encountered, yet their unique complexity poses a substantial challenge for treating orthopaedic surgeons.» In general, extremities with more tendon retraction should be repaired acutely while contralateral injuries can be treated in a staged or simultaneous manner depending on injury morphology, location, and anticipated functional impairment.» Combinations of accelerated and conventional rehabilitation protocols can be used for individual extremities to minimize the length of functional impairment.

Distale Bizepssehnenruptur

Die Ruptur der distalen Bizepssehne tritt am häufigsten bei Männern im mittleren Alter auf (30 bis 50 Jahre). Der typische Mechanismus ist die exzentrische Belastung in strecknaher Ellbogenstellung in Supination, wobei diese Verletzung mit Kraftsport und körperlich belastender Tätigkeit assoziiert ist. Epidemiologische Daten weisen auf eine Zunahme von distalen Bizepsrupturen in den letzten Jahrzehnten hin. Risikofaktoren wie die Verwendung anaboler Steroide, Kraftsport und Nikotinabusus zeigen einen Zusammenhang mit der Verletzung. Bei reduziertem Patientenanspruch oder relevanten Komorbiditäten ist auch unter einer konservativen Behandlung ein gutes funktionelles Ergebnis mit subjektiv guter Patientenzufriedenheit zu erreichen, allerdings unter zu erwartender relevanter Kraftminderung in Flexion (20 %) und Supination (40 %). Durch eine operative Refixation lässt sich das beste funktionelle Resultat erzielen, allerdings einhergehend mit einem nicht unerheblichen Komplikationsrisiko.

Systematic review of distal biceps tendon rupture in athletes: treatment and rehabilitation

BACKGROUND

Distal biceps tendon rupture is a rare injury associated with decreased elbow flexion and forearm supination strength. This impairment is not tolerated by high-demand patients like athletes.

PURPOSE

To review treatment and rehabilitation applied to injured athletes and study their impact in return to sports.

METHODS

MEDLINE, Cochrane, Web of Science, and Scopus online databases were searched. A systematic review was conducted using the PRISMA guidelines; studies published on distal biceps tendon rupture treatment and rehabilitation of athletes until June 30, 2021, were identified. A quantitative synthesis of factor related to return to preinjury sport activity was made.

RESULTS

Ten articles were identified, including 157 athletes. Mean age was 40.5 years, and the dominant arm was injured in 103 cases (66%). Rupture was acute in 121 athletes (77%), and the mean follow-up was 25.7 months. A hundred and fifty-three athletes (97.5%) successfully returned to sport within a mean time of 6.2 months. Surgical treatment was followed in all cases. One-incision technique was chosen in 115 (73%) and suture anchor fixation in 52 (33%) cases. No postsurgical immobilization was reported in 38 (24%) and immobilization for 2 weeks in 124 (79%) athletes. Decreased supination-pronation and flexion-extension arc was found in 63 (40%) and 27 (17%) cases, respectively. Earlier return to sport was associated with nondominant-side (P = .007) and acute (P < .001) injuries, participation in weightlifting (P = .001), double-incision approach (P = .005), cortical button fixation (P < .001), and absence of supination-pronation restriction (P = .032). Time of return to sport activity was independent of rehabilitation, including immobilization (P = .539) and strengthening (P = .155), and decreased flexion-extension arc (P = .059).

CONCLUSION

Athletes sustaining distal biceps tendon rupture have a high postoperative return to sport rate, independently of selected surgical technique or rehabilitation program. However, a relation between the surgical technique and time of return to sport was found. Rehabilitation did not influence time of return to sport.