Distal Biceps Tendon Rupture Surgery: Changing Incidence in Finnish and Swedish Men Between 1997 and 2016

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.

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.

A Novel Reconstruction Technique for Chronic Distal Biceps Tendon Rupture: A Case Report

CASE

A 71-year-old otherwise healthy man presented with an 8-week history of elbow pain and weakness in both elbow flexion and forearm supination. Magnetic resonance imaging revealed complete rupture of the distal biceps tendon insertion associated with 65 mm of proximal retraction. At 10 weeks after initial injury, the patient underwent a novel reconstruction technique using a periosteal flap from the iliac crest; subsequently, all symptoms resolved.

CONCLUSION

Chronic distal biceps tendon injuries can be reconstructed safely and effectively using a periosteal flap from the iliac crest that allows not only rigid but also biological graft attachment.

Management of Partial-Thickness Tears of the Distal Bicep Tendon: Evaluation of 111 Patients With 10-Year Follow-up

Background

There is a paucity of research on the management of partial-thickness tears of the distal bicep tendon, and even less is known about the long-term outcomes of this condition.

Purpose

To identify patients with partial-thickness distal bicep tendon tears and determine (1) patient characteristics and treatment strategies, (2) long-term outcomes, and (3) any identifiable risk factors for progression to surgery or complete tear.

Study Design

Case-control study; Level of evidence, 3.

Methods

A fellowship-trained musculoskeletal radiologist identified patients diagnosed with a partial-thickness distal bicep tendon tear on magnetic resonance imaging between 1996 and 2016. Medical records were reviewed to confirm the diagnosis and record study details. Multivariate logistic regression models were created using baseline characteristics, injury details, and physical examination findings to predict operative intervention.

Results

In total, 111 patients met inclusion criteria (54 treated operatively, 57 treated nonoperatively), with 53% of tears in the nondominant arm and a mean follow-up time after surgery of 9.7 ± 6.5 years. Only 5% of patients progressed to full-thickness tears during the study period, at a mean of 35 months after the initial diagnosis. Patients who were nonoperatively treated were less likely to miss time from work (12% vs 61%; P < .001) and missed fewer days (30 vs 97 days; P < .016) than those treated surgically. Multivariate regression analyses demonstrated increased risk of progression to surgery with older age at initial consult (unit odds ratio [OR], 1.1), tenderness to palpation (OR, 7.5), and supination weakness (OR, 24.8). Supination weakness at initial consult was a statistically significant predictor for surgical intervention (OR, 24.8; P = .001).

Conclusion

Clinical outcomes were favorable for patients regardless of treatment strategy. Approximately 50% of patients were treated surgically; patients with supination weakness were 24 times more likely to undergo surgery than those without. Progression to full-thickness tear was a relatively uncommon reason for surgical intervention, with only 5% of patients progressing to full-thickness tears during the study period and the majority occurring within 3 months of initial diagnosis.

Patient-Reported Outcome Measures of a Novel Cortical Button System for Distal Biceps Tendon Repair: A Retrospective Study

Background There are a number of different techniques available for the repair of distal biceps tendon ruptures. Recent evidence has revealed satisfactory clinical outcomes for suture button techniques. Aims The aim of this study was to determine if the ToggleLoc^TM soft tissue fixation device (Zimmer Biomet, Warsaw, Indiana) confers satisfactory clinical outcomes in the surgical management of distal biceps ruptures. Methods Twelve consecutive patients underwent distal biceps repair using the ToggleLoc^TM soft tissue fixation device over a two-year period. Patient-Reported Outcome Measures (PROMs) were collected by means of validated questionnaires on two occasions. Symptoms and function were quantified using the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Oxford Elbow Score (OES). Patient-reported health scores were determined using the EQ-5D-3L (European Quality of Life 5 Dimensions 3 Level Version) questionnaire. Results The mean initial follow-up time was 10.4 months and the mean final follow-up time was 34.6 months. The mean DASH score at the initial follow-up was 5.9 (se = 3.6), compared to 2.9 (se = 1.0) at the final follow-up (p = 0.30). The mean OES at the initial follow-up was 91.5 (se = 4.1); and 91.5 (se = 5.2) at the final follow-up (p = 0.23). The mean EQ-5D-3L level sum score at the initial follow-up was 5.3 (se = 0.3); and 5.8 (se = 0.5) at the final follow-up (p = 0.34). Discussion The ToggleLoc^TM soft tissue fixation device confers satisfactory clinical outcomes, as determined by PROMS, in the surgical management of distal biceps ruptures.

Trends and complications of distal biceps tendon repair among American Board of Orthopaedic Surgery part II oral examination candidates

BACKGROUND

Surgical fixation of distal biceps tendon ruptures can restore supination strength and minimize biceps fatigue, resulting in high patient satisfaction rates. Surgical approaches can vary (single incision vs. double incision), and the number of fixation techniques has increased in recent years. The reported rate of postoperative complications after surgical repair of distal biceps tendon injuries is high, ranging from 15% to 35%. The purpose of this study was to assess the trends and postoperative complication profile among newly trained surgeons who performed distal biceps tendon repairs utilizing the American Board of Orthopaedic Surgery database.

METHODS

The American Board of Orthopaedic Surgery database was retrospectively queried for patients treated with distal biceps tendon repair by part II examination candidates between 2017 and 2020. Distal biceps tendon repairs were isolated using the Current Procedural Terminology code 24,342. Distal triceps tendon injuries were excluded with International Classification of Diseases code S46.3∗∗. Patient demographics, intraoperative data, and surgeon fellowship training were collected. Surgeon-reported postoperative 90-day complications, including general anesthetic, medical, and surgical complications, rates of readmission, and rates of reoperation were recorded. Comparisons of rates among patient groups organized by surgeon fellowship training were performed using the chi-squared test.

RESULTS

A total of 2089 distal biceps tendon repairs were included in the analysis. The average patient age was 47.5 yr, and 97.3% of patients were men. The majority of cases was performed by surgeons with fellowship training in sports medicine, hand/upper extremity, and shoulder and elbow, with 867 (41.5%) cases performed by sports medicine-trained surgeons, 740 (35.4%) by hand/upper extremity-trained surgeons, and 313 (15.0%) by shoulder and elbow-trained surgeons. In total, 608 (29.1%) patients experienced an anesthetic (0.2%), medical (1.1%), or surgical (28.2%) complication. The most common surgical complications were nerve injury (20.6%), failure of tendon repair or fixation (2.4%), and infection (1.7%). The overall reoperation rate was 2.4%. There were no significant differences in complication or reoperation rates among subspecialty training received.

DISCUSSION AND CONCLUSION

Among newly trained surgeons, those with fellowship training in sports medicine, hand/upper extremity, and shoulder and elbow performed the most distal biceps tendon repairs, and there was no difference in complication rates among subspecialty training received. Complication rates after distal biceps tendon repair performed by newly trained surgeons were similar to those previously reported in large cohort studies, with nerve injury as the most common complication.

The incidence of musculoskeletal injuries: a systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Methods

PubMed (National Library of Medicine) and Scopus (Elsevier) databases were searched. Articles were eligible for inclusion if they reported incidence rate (or count with population at risk), contained data on adult population, and were written in English language. The number of cases and population at risk were collected, and the pooled incidence rates (per 100,000 person-years) with 95% confidence intervals (CIs) were calculated by using either a fixed or random effects model.

Results

The screening of titles yielded 206 articles eligible for inclusion in the study. Of these, 173 (84%) articles provided sufficient information to be included in the pooled incidence rates. Incidences of fractures were investigated in 154 studies, and the most common fractures in the whole adult population based on the pooled incidence rates were distal radius fractures (212.0, 95% CI 178.1 to 252.4 per 100,000 person-years), finger fractures (117.1, 95% CI 105.3 to 130.2 per 100,000 person-years), and hip fractures (112.9, 95% CI 82.2 to 154.9 per 100,000 person-years). The most common sprains and dislocations were ankle sprains (429.4, 95% CI 243.0 to 759.0 per 100,000 person-years) and first-time patellar dislocations (32.8, 95% CI 21.6 to 49.7 per 100,000 person-years). The most common injuries were anterior cruciate ligament (17.5, 95% CI 6.0 to 50.2 per 100,000 person-years) and Achilles (13.7, 95% CI 9.6 to 19.5 per 100,000 person-years) ruptures.

Conclusion

The presented pooled incidence estimates serve as important references in assessing the global economic and social burden of musculoskeletal injuries. Cite this article: Bone Joint Res 2022;11(11):814–825.

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.

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.