SCIENTIFIC ARTICLE
Anatomic Findings and Complications After Surgical Treatment of Chronic, Partial Distal Biceps Tendon Tears: A Case Cohort Comparison Study David S. Ruch, MD, Tyler Steven Watters, MD, Daniel A. Wartinbee, MD, Marc J. Richard, MD, Fraser J. Leversedge, MD, Suhail K. Mithani, MD Purpose To describe pertinent anatomic findings during repair of chronic, partial distal biceps tendon tears and to compare the complications of surgery with a similar cohort of acute, complete tears. Methods Group 1 included 14 patients (15 elbows) with partial tears managed operatively an average of 10 months from onset of injury or symptoms. Group 2 included a matched cohort of 16 patients (17 elbows) treated for complete, acute tears an average of 19 days from injury. A retrospective review of all 30 patients focused on demographic data, intraoperative findings, and postoperative complications. A single, anterior incision was used in all cases with multiple suture anchors or a bicortical toggling button for fixation of the repair. Results We evaluated 27 men and 3 women with an average age of 55 years (group 1) and 48 years (group 2). Intratendinous ganglion formation at the site of rupture of the degenerative tendon was observed in 5 cases of partial tears and none of the complete tears. Partial tears involved the lateral aspect or short head of the biceps tendon insertion in all cases. Postoperative complications included lateral antebrachial cutaneous nerve neuritis in 8 group 1 patients and 6 group 2 patients and transient posterior interosseus nerve palsy in 3 group 1 patients. Conclusions Partial distal biceps tendon ruptures showed a consistent pattern of pathology involving disruption of the lateral side of the tendon insertion involving the small head of the biceps. Degenerative intratendinous ganglion formation was present in one third of cases. Repair of chronic, partial distal biceps tendon injuries may have a higher incidence of posterior interosseous and lateral antebrachial cutaneous nerve palsies. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic III. Key words Chronic tear, distal biceps, partial tear, repair.
From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC; and the South Carolina Sports Medicine and Orthopaedic Center, Charleston, SC. Received for publication December 18, 2013; accepted in revised form April 12, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Tyler Steven Watters, MD, Department of Orthopaedic Surgery, Duke University Medical Center, DUMC 3000, Durham, NC 27710; e-mail: tyler.watters@ dm.duke.edu. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.023
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complete distal biceps tendon rupture have associated higher complication rates with increasing time interval from injury to repair.1e6 However, Cain et al7 reported no difference in the occurrence of posterior interosseous nerve (PIN) palsy, heterotopic ossification, and re-rupture relative to the interval from injury to repair in a series of repairs performed using an anterior approach. Despite a reasonable understanding of the treatment for acute biceps repair and the EPORTS OF SURGICAL REPAIR FOR
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Published by Elsevier, Inc. All rights reserved.
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MATERIALS AND METHODS Study population After institutional review board approval, all patients treated surgically for partial distal biceps tendon injuries between October 2006 and January 2012 by 2 fellowship-trained hand and upper extremity surgeons were identified through our institutional surgical database. Group 1 patients were included in the study only if they had surgical confirmation of a partial distal biceps tendon rupture. A total of 14 patients (15 elbows) met inclusion criteria and were included in the study. Over this same study period, approximately 5 times as many repairs were performed for complete distal biceps tears. Sixteen patients (17 elbows) who underwent surgical treatment of acute, complete injuries (group 2) were included in the study as a matched group for comparison of postoperative complications identified randomly within our institutional database who underwent surgery during the same period, to comprise a total study population of 30 patients (32 elbows). We performed a retrospective review for all patients. Demographic information, including patient sex, age, mechanism of injury, surgical timing, and intraoperative findings and postoperative complications, was gathered. For all patients, an anterior, single incision surgical technique was used. Distal biceps tendon repair was done using suture anchors or a bicortical toggling button.
nature of tendon-to-bone healing in acute injury models, there is little information regarding the optimal timing of repair for partial distal biceps tendon ruptures or the indications for surgical management, particularly when considering acute injury versus the presence of chronic tendinosis-related alterations of the distal tendon insertion. Some authors concluded that surgical treatment of partial biceps rupture at the elbow is safe and effective and that partial distal biceps tendon tears often do not respond favorably to conservative treatment.8e11 Previous assessments of the pathoanatomy of partial distal biceps tendon ruptures implicate progressive failure initially involving the radial aspect of the biceps insertional footprint. The tendon passes over the radial tuberosity from proximal to distal, and potential attritional changes resulting from the tendon’s impingement at the tuberosity and associated hypoperfusion may contribute to progressive tendon insufficiency.12e14 Isolated short head ruptures have been described, although because of the difficulty in differentiating the discrete bundles of the long and short heads of the distal biceps, these single-bundle ruptures may be underreported.15 Also, pathological changes involving the distal biceps insertion may include bursitis that might present with an enlarging mass,16 such as a ganglion cyst, or mechanical symptoms owing to bursal impingement with forearm rotation. Patients with a complete distal biceps tendon rupture typically present with acute pain in the antecubital fossa, ecchymosis, localized tenderness, swelling, palpable defect, and weakness in both forearm supination and elbow flexion. However, patients with a partial distal biceps tendon injury may present with nonspecific problems and chronic pain in the antecubital fossa.10 Many patients with a partial rupture do not recall an isolated trauma; as a result, the diagnosis may not be readily appreciated or may not be made in a timely manner. Vardakas et al10 found that the average duration of symptoms and conservative care for patients with partial distal biceps tendon injury was 38 weeks; similarly, Dellaero and Mallon8 reported an average symptomatic period of 25 weeks. The purposes of this study were to describe pertinent pathology and anatomic findings during repair or reconstruction of chronic, partial distal biceps tendon tears in a consecutive series of patients at a single institution and to compare the reported complications of surgery with those from a similar cohort of acute, complete tears, to improve our understanding and clinical awareness of this often challenging condition. J Hand Surg Am.
Clinical diagnosis Clinical examination included standardized clinical tests developed to evaluate the biceps, including assessing for antecubital fossa pain exacerbated with forced supination, which has been suggested to be a reliable diagnostic maneuver in detecting partial biceps tendon tears.8,13 On preoperative examination, all patients had reproducible pain with this maneuver. All patients had full range of motion and no elbow instability. The hook test was used to evaluate for a complete biceps rupture.1 Testing was completed with the patient actively supinating the forearm with the elbow in 90 flexion. The test is positive for a complete tear when the tendon cannot be felt. A positive test for a partial tear occurs when the tendon is hooked by the tip of the examiner’s finger but the test produces pain.1 In cases of suspected acute complete tears, no advanced imaging was performed. However, patients with chronic, partial tears underwent magnetic resonance imaging to evaluate the degree of separation and ensure that primary repair was possible and free tendon graft reconstruction was not needed. r
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Surgical technique Patients were placed in the supine position with the forearm on a hand table. A tourniquet was used and an L-shaped incision was made across the antecubital fossa with the transverse limb placed in the elbow flexion crease and the longitudinal limb extending distally along the medial border of the brachioradialis, in line with the anatomic course of the distal biceps tendon. The lateral antebrachial cutaneous nerve (LABCN) was identified and carefully dissected, and was cautiously retracted throughout the procedure. When intact, the lacertus fibrosus was released to gain exposure. The biceps tendon was exposed and traced distally toward its insertion. In patients with partial distal biceps rupture, the torn portion of the tendon varied from 75% to 90%. We estimated this using a surgical ruler to measure the remaining intact tendon fibers relative to the cross-sectional area of the entire tendon immediately proximal to the insertion on the radius. In patients with complete tear, the ruptured tendon was debrided sharply to healthy-appearing tendinous tissue. For partial tears, the attached fibers were released and any pseudotendon was excised. The tendon was debrided back to healthy tissue based on visual inspection and recognition of grossly normal tendon morphology. The radial tuberosity was prepared with small curettes and rongeurs to expose the tendon’s footprint. In 27 cases, 3 Mitek GII suture anchors with number 2 Ethibond suture (Mitek, DePuy, Warsaw, IN) were inserted at the anatomical footprint in a triangular configuration. In the remaining 5 cases, we used EndoButton (Acufex Microsurgical, Mansfield, MA) bicortical fixation. Then a running locked Krackow stitch was placed into the tendon, the elbow was fully flexed, and the forearm was supinated to verify that the tendon was reducible to its insertion without excessive tension and then was repaired in standard fashion. The elbow was fully extended with the forearm in full supination and the repair site was assessed to confirm that there was no gapping at the tendonebone junction. Postoperatively, the extremity was immobilized for 6 weeks with a well-padded, long-arm orthosis with the elbow in 90 flexion and the forearm in full supination. After 6 weeks, gentle active assisted motion was allowed, going from 30 to full flexion and gradually out to full extension over the course of 2 weeks. Patients added resistance training with weights up to 1 kg for 3 weeks and then increased the weights to come to full strength with no restrictions on activity. The postoperative protocol was identical for both groups.
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Statistical methods The distribution of continuous data is described as means and standard deviations. We analyzed continuous data using the Wilcoxon rank sum test, a nonparametric test. For categorical data, possible differences between groups were analyzed use of the Fisher exact test. RESULTS Patient demographics There were 15 cases (14 patients: 11 men and 3 women) in the partial tear group (group 1). Seventeen cases involving complete distal biceps tears (16 patients, all men) were reviewed as a matched control cohort (group 2). The mean age at the time of surgery was 55 years (range, 38e75 y) in group 1 and 48 years (range, 25e69 y) in group 2. Although the partial rupture group was slightly older, the age difference was not statistically significant (P ¼ .120). In this series, all patients with complete ruptures recalled a specific incident associated with the tendon rupture. Although the exact activity leading to rupture was variable, almost all acute injuries occurred during resisted elbow flexion. In the partial rupture group, 13 of the 15 patients described a repetitive activity that was subjectively thought to have led to the injury. In group 1, surgery was performed at an average of 10 months after the onset of symptoms (range, 9 d to 3.4 y; SD, 0.9 y), usually after a lengthy period of nonsurgical treatment including physical therapy. The nonsurgical treatment regimen for partial tears was highly variable because patients were often treated elsewhere or misdiagnosed before referral. In general, all patients were treated with activity modification and nonsteroidal anti-inflammatory medications before presenting to our clinic. After our assessment, all patients with chronic injuries were sent to physical therapy for a minimum of 4 to 6 weeks. Surgery was performed an average of 19 days (range, 5e44 d; SD, 13 d) after the acute rupture in group 2 patients. Anatomical findings In 14 cases involving partial tendon rupture, intraoperative evaluation of the biceps insertion demonstrated disruption of the lateral fibers. In all partial rupture cases, the medial fibers remained intact. In 1 of the cases, the fibers of the short head of the distal biceps tendon were disrupted whereas the more proximal fibers of the long head of the biceps remained intact (Fig. 1). Intratendinous ganglions at
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In 3 group 1 patients, PIN palsy was identified after surgery. Fortunately, full motor recovery returned at an average of 5 months postoperatively (range, 4e7 mo). No patients with complete ruptures developed PIN palsy. This finding approached statistical significance (P ¼ .090). Whereas the mean time from symptoms to surgery for the partial tear group was 10 months, the mean time to surgery for patients who experienced LABCN irritation was 16 months, and was 25 months for those who experienced PIN palsy; this suggests a higher risk of postoperative nerve injury with longer time to surgery. One patient with complete distal biceps rupture with a history of chronic steroid use and smoking developed superficial wound dehiscence, which healed by secondary intention with wound care alone. No other surgical site complications were identified. No differences in outcome or complications were observed in the 3 patients who underwent EndoButton fixation compared with suture anchors, although this study was not designed to investigate such differences.
FIGURE 1: Intraoperative photograph showing the torn, more distal short head biceps tendon fibers in the vessel loop. The arrow points to the intact long head of the distal biceps tendon.
DISCUSSION Acute, complete rupture of the distal biceps tendon is associated with disability and is often treated with acute surgical repair.4 Morrey et al17 reported 97% flexion strength and 95% supination strength compared with the uninvolved extremity after surgical repair. The operative indications for partial ruptures are not as well defined; in general, an initial nonsurgical approach is recommended. Because partial rupture of the distal biceps tendon occurs in about 3% of all biceps tendon injuries, the diagnosis is often unrecognized or an accurate diagnosis may be delayed.8 Historically, partial tears of the distal biceps tendon were thought to be insidious, associated with chronic tendinopathy.2,10 In this series, however, 13 of 15 patients with partial ruptures recalled a specific activity, although chronic tendinopathy could have been associated with progressive insertional site strength and insufficiency. Similarly, Dellaero and Mallon8 reported that 5 of 7 patients recalled a specific traumatic event. Based on the variability in patient histories and symptoms and in intraoperative findings, the mechanical failure of the partial distal biceps tendon injury is likely multifactorial in nature.18 For partial distal biceps tendon ruptures, we consistently observed that the remaining intact fibers of the distal tendon were of the medial border of the tendon and connected to fibers of the lacertus fibrosus
FIGURE 2: An extensive scar, cyst formation, and adhesions are seen in the case of a delayed surgical repair of a partial biceps tendon tear.
the detachment of the distal tendon were observed in 5 cases of partial tendon rupture (Fig. 2). In addition, the degenerative changes noted in group 1 patients included a patulous, amorphous appearance to the collagen of the tendon with a grossly visible loss of collagen macrostructure. This finding was not seen in any case of complete biceps tear. This was a significant difference between the 2 groups (P ¼ .015). Complications We observed transient irritation of the LABCN in 8 group 1 patients (57%) and 6 group 2 patients (38%). This difference did not reach statistical significance (P ¼ .480). The dysesthesia resolved in all patients an average of 4 months (range, 2e10 mo). J Hand Surg Am.
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or Sharpey fibers on the medial side of the radial tuberosity, preventing retraction of the tendon proximally. Morphologically, the biceps tendon is composed of 2 portions. There is a traction-type portion on the medial aspect of the tendon and a gliding portion on the radial side, which abuts the bursa.19,20 Chronic inflammation of the bursa may predispose this lateral portion of the tendon to rupture.18 Also, Mazzocca et al18 demonstrated that the shape of the bicipital tuberosity may act in a knifelike fashion to cause erosion of the overlying biceps tendon. This theory may explain the pathoanatomy observed at the time of surgery in this series, in which bursal inflammation may have resulted in tearing of the lateral fibers while leaving the tractiontype medial fibers intact. There are several limitations to this study. With the retrospective nature of the study and the limited number of patients evaluated for this uncommon condition, the findings would be strengthened by greater numbers or prospective investigation. Although this study was observational in nature and did not focus on treatment outcomes, it may be useful to incorporate surgeries performed through a 2-incision or posterior technique to be able to draw more defined conclusions. However, the results of this study provide insight regarding anatomical findings and complication risks that can be anticipated in patients with partial tear repairs. In the treatment of complete distal biceps tears, some authors noted that complications increase as the time interval between injury and surgery increases.1e6 In this series there were more cases of both sensory and motor nerve complications postoperatively in patients with partial ruptures, who were treated in a delayed fashion compared with those with complete ruptures. Although more cases of LABCN irritation and postoperative PIN palsy were observed in the partial rupture group, neither met statistical significance. The number of postoperative nerve complications described in this study is relatively high, but the state of altered anatomy in partial ruptures, especially those that undergo late operative treatment, requires a more tedious dissection and may warrant a slightly larger exposure than usual to identify and protect the structures at risk. One weakness of this study was the small number of partial rupture cases for comparison with a matched cohort of acute ruptures. If sample sizes were larger, perhaps these differences would become more apparent and meaningful. Our surgical technique included formal dissection of the LABCN, which may be considered controversial. It is our opinion that this technique allows for the safest management of this nerve throughout the procedure. The reported incidence of postoperative J Hand Surg Am.
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LABCN complications in this series was relatively high, but our definition of LABCN irritation was liberal so as not to miss any instances. All patients were specifically examined for nerve irritation and any mention of dysesthesia, regardless of severity or duration, was recorded as a complication. Other authors may not use such liberal criteria, which explains the difference between our report and prior ones. All surgeries in this series were performed through a single anterior incision. Using this technique, some authors have noted high rates of radial nerve palsy, although in most reports this deficit resolved.21,22 A 2-incision technique can be used, although historically there have been reported complications of proximal radioulnar synostosis that may stem from subperiosteal ulna dissection.17,23 Three patients with partial ruptures in this series developed PIN palsy after surgery, which may be related to delay in surgical treatment. For complete biceps tears that are more than 4 weeks old, surgical dissection may be difficult because of extensive scarring of the biceps tendon to the brachialis muscle.4 Similarly, we often found extensive scar tissue at the site of injury. In 5 cases, we encountered intratendinous ganglions and extensive degenerative changes with gross friability of the tendon. One of these cases was complicated by a postoperative PIN palsy. Perhaps more retraction and dissection than was required in that particular case that led to a traction injury of the nerve. For this reason, we avoid using deep self-retaining retractors during this procedure and also the use of Hohmann retractors because of the risk of levering the nerve against the proximal radius. Our preference is to use deep handheld retractors when feasible. Our opinion is that the nerve injuries observed in this series nonetheless likely resulted from excessive retraction in trying to free the residual tendon, made difficult by scarring. We now believe this complication can be avoiding by not dissecting the residual tendon, and instead transecting it where it is visible, because the unhealthy end of the tendon is debrided anyway. This is now our preferred technique. We did not observe elbow stiffness in these patients despite our postoperative protocol including 6 weeks of immobilization. We are now using more toggle button fixations for these injuries and have accelerated the rehabilitation protocol. We believe that this fixation modality is stronger and safer for early motion, although this is relatively new and would not affect most patients in this cohort. It has been our experience with tendon injuries about the elbow (unlike fractures) that stiffness is uncommon. These are extra-articular injuries, and the elbow seems r
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to be tolerant of brief immobilization in these cases compared with intra-articular injuries. Our consistent observations of the pathologic alterations in the distal biceps tendon insertion associated with partial distal biceps injury in this case series support the anatomical reports in the literature: specifically, that partial ruptures have disruption of the tendinous fibers on the lateral side of the insertion or are isolated to the small head insertion. We also identified the common finding of intratendinous ganglion cysts, most likely associated with degenerative, tendinosis-related changes in the tendon, probably a factor in insufficiency of the tendonebone junction. Technically, the study findings point out the relatively high incidence of transient nerve injury, particularly involving the LABCN and postoperative PIN palsy. This observation highlights the importance of a preoperative informed consent that reviews these risks with the patient and suggests careful reevaluation of surgical technique to minimize traction on the nerves during surgical exposure and soft tissue retraction. These findings can help the surgeon better understand the intraoperative pathology from an anatomical perspective and educate patients about potential risks of surgery in the course of shared decision making.
5. Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis of distal biceps tendon ruptures. Clin Orthop Relat Res. 2005;(437):128e131. 6. Aldridge JW, Bruno RJ, Strauch RJ, et al. Management of acute and chronic biceps tendon ruptures. Hand Clin. 2000;16(3):497e503. 7. Cain RA, Nydick JA, Stein MI. Complications following distal biceps repair. J Hand Surg Am. 2012;37(10):2112e2117. 8. Dellaero DT, Mallon WJ. Surgical treatment of partial biceps tendon ruptures at the elbow. J Shoulder Elbow Surg. 2006;15(2):215e217. 9. Rokito AS, McLaughlin JA, Gallagher MA, et al. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg. 1996;5(1):73e75. 10. Vardakas DG, Musgrave DS, Varitimidis SE, et al. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg. 2001;10(4): 377e379. 11. Karanjia ND, Stiles PJ. Cubital bursitis. J Bone Joint Surg Br. 1988;70(5):832e833. 12. Davis WM, Yassine Z. An etiological factor in tear of the distal tendon of the biceps brachii; report of two cases. J Bone Joint Surg Am. 1956;38(6):1365e1368. 13. Kelly EW, Steinmann S, O’Driscoll SW. Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision. J Shoulder Elbow Surg. 2003;12(5):456e461. 14. Sieler JG III, Parker LM, Chamberland PD, et al. The distal biceps tendon: two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg. 1995;4(3):149e156. 15. Koulouris G, Malone W, Omar IM, et al. Bifid insertion of the distal biceps brachii tendon with isolated rupture: magnetic resonance findings. J Shoulder Elbow Surg. 2009;18(6):e22ee25. 16. Durr HR, Stabler A, Pfahler M, et al. Partial rupture of the distal biceps tendon. Clin Orthop Relat Res. 2000;(374):195e200. 17. Morrey BF, Askew LJ, An KN, et al. Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg Am. 1985;67(3):418e421. 18. Mazzocca AD, Cohen M, Berkson E, et al. The anatomy of the bicipital tuberosity and distal biceps tendon. J Shoulder Elbow Surg. 2007;16(1):122e127. 19. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg Am. 1991;73(10):1507e1525. 20. Koch S, Tillmann B. The distal tendon of the biceps brachii: structures and clinical correlations. Ann Anat. 1995;177(5):467e474. 21. Boucher PR, Morton KS. Rupture of the distal biceps brachii tendon. J Trauma. 1967;7(5):626e632. 22. Friedmann E. Rupture of the distal biceps brachii tendon: report on 13 cases. JAMA. 1963;184:60e63. 23. Dobbie RP. Avulsion of the lower biceps brachii tendon: analysis of fifty-one previously unreported cases. Am J Surg. 1941;51:662e683.
REFERENCES 1. O’Driscoll S, Goncalves L, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med. 2007;35(11):1865e1869. 2. Kelly E, Morrey D, O’Driscoll S. Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am. 2000;82(11):1575e1581. 3. Levy HJ, Mashoof AA, Morgan D. Repair of chronic ruptures of the distal biceps tendon using flexor carpi radialis tendon graft. Am J Sports Med. 2000;28(4):538e540. 4. Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg. 1999;7(3):199e207.
J Hand Surg Am.
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Anatomic Findings and Complications After Surgical Treatment of Chronic, Partial Distal Biceps Tendon Tears: A Case Cohort Comparison Study David S. Ruch, MD, Tyler Steven Watters, MD, Daniel A. Wartinbee, MD, Marc J. Richard, MD, Fraser J. Leversedge, MD, Suhail K. Mithani, MD Purpose To describe pertinent anatomic findings during repair of chronic, partial distal biceps tendon tears and to compare the complications of surgery with a similar cohort of acute, complete tears. Methods Group 1 included 14 patients (15 elbows) with partial tears managed operatively an average of 10 months from onset of injury or symptoms. Group 2 included a matched cohort of 16 patients (17 elbows) treated for complete, acute tears an average of 19 days from injury. A retrospective review of all 30 patients focused on demographic data, intraoperative findings, and postoperative complications. A single, anterior incision was used in all cases with multiple suture anchors or a bicortical toggling button for fixation of the repair. Results We evaluated 27 men and 3 women with an average age of 55 years (group 1) and 48 years (group 2). Intratendinous ganglion formation at the site of rupture of the degenerative tendon was observed in 5 cases of partial tears and none of the complete tears. Partial tears involved the lateral aspect or short head of the biceps tendon insertion in all cases. Postoperative complications included lateral antebrachial cutaneous nerve neuritis in 8 group 1 patients and 6 group 2 patients and transient posterior interosseus nerve palsy in 3 group 1 patients. Conclusions Partial distal biceps tendon ruptures showed a consistent pattern of pathology involving disruption of the lateral side of the tendon insertion involving the small head of the biceps. Degenerative intratendinous ganglion formation was present in one third of cases. Repair of chronic, partial distal biceps tendon injuries may have a higher incidence of posterior interosseous and lateral antebrachial cutaneous nerve palsies. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic III. Key words Chronic tear, distal biceps, partial tear, repair.
From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC; and the South Carolina Sports Medicine and Orthopaedic Center, Charleston, SC. Received for publication December 18, 2013; accepted in revised form April 12, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Tyler Steven Watters, MD, Department of Orthopaedic Surgery, Duke University Medical Center, DUMC 3000, Durham, NC 27710; e-mail: tyler.watters@ dm.duke.edu. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.023
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complete distal biceps tendon rupture have associated higher complication rates with increasing time interval from injury to repair.1e6 However, Cain et al7 reported no difference in the occurrence of posterior interosseous nerve (PIN) palsy, heterotopic ossification, and re-rupture relative to the interval from injury to repair in a series of repairs performed using an anterior approach. Despite a reasonable understanding of the treatment for acute biceps repair and the EPORTS OF SURGICAL REPAIR FOR
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
FINDINGS IN PARTIAL DISTAL BICEPS TEARS
MATERIALS AND METHODS Study population After institutional review board approval, all patients treated surgically for partial distal biceps tendon injuries between October 2006 and January 2012 by 2 fellowship-trained hand and upper extremity surgeons were identified through our institutional surgical database. Group 1 patients were included in the study only if they had surgical confirmation of a partial distal biceps tendon rupture. A total of 14 patients (15 elbows) met inclusion criteria and were included in the study. Over this same study period, approximately 5 times as many repairs were performed for complete distal biceps tears. Sixteen patients (17 elbows) who underwent surgical treatment of acute, complete injuries (group 2) were included in the study as a matched group for comparison of postoperative complications identified randomly within our institutional database who underwent surgery during the same period, to comprise a total study population of 30 patients (32 elbows). We performed a retrospective review for all patients. Demographic information, including patient sex, age, mechanism of injury, surgical timing, and intraoperative findings and postoperative complications, was gathered. For all patients, an anterior, single incision surgical technique was used. Distal biceps tendon repair was done using suture anchors or a bicortical toggling button.
nature of tendon-to-bone healing in acute injury models, there is little information regarding the optimal timing of repair for partial distal biceps tendon ruptures or the indications for surgical management, particularly when considering acute injury versus the presence of chronic tendinosis-related alterations of the distal tendon insertion. Some authors concluded that surgical treatment of partial biceps rupture at the elbow is safe and effective and that partial distal biceps tendon tears often do not respond favorably to conservative treatment.8e11 Previous assessments of the pathoanatomy of partial distal biceps tendon ruptures implicate progressive failure initially involving the radial aspect of the biceps insertional footprint. The tendon passes over the radial tuberosity from proximal to distal, and potential attritional changes resulting from the tendon’s impingement at the tuberosity and associated hypoperfusion may contribute to progressive tendon insufficiency.12e14 Isolated short head ruptures have been described, although because of the difficulty in differentiating the discrete bundles of the long and short heads of the distal biceps, these single-bundle ruptures may be underreported.15 Also, pathological changes involving the distal biceps insertion may include bursitis that might present with an enlarging mass,16 such as a ganglion cyst, or mechanical symptoms owing to bursal impingement with forearm rotation. Patients with a complete distal biceps tendon rupture typically present with acute pain in the antecubital fossa, ecchymosis, localized tenderness, swelling, palpable defect, and weakness in both forearm supination and elbow flexion. However, patients with a partial distal biceps tendon injury may present with nonspecific problems and chronic pain in the antecubital fossa.10 Many patients with a partial rupture do not recall an isolated trauma; as a result, the diagnosis may not be readily appreciated or may not be made in a timely manner. Vardakas et al10 found that the average duration of symptoms and conservative care for patients with partial distal biceps tendon injury was 38 weeks; similarly, Dellaero and Mallon8 reported an average symptomatic period of 25 weeks. The purposes of this study were to describe pertinent pathology and anatomic findings during repair or reconstruction of chronic, partial distal biceps tendon tears in a consecutive series of patients at a single institution and to compare the reported complications of surgery with those from a similar cohort of acute, complete tears, to improve our understanding and clinical awareness of this often challenging condition. J Hand Surg Am.
Clinical diagnosis Clinical examination included standardized clinical tests developed to evaluate the biceps, including assessing for antecubital fossa pain exacerbated with forced supination, which has been suggested to be a reliable diagnostic maneuver in detecting partial biceps tendon tears.8,13 On preoperative examination, all patients had reproducible pain with this maneuver. All patients had full range of motion and no elbow instability. The hook test was used to evaluate for a complete biceps rupture.1 Testing was completed with the patient actively supinating the forearm with the elbow in 90 flexion. The test is positive for a complete tear when the tendon cannot be felt. A positive test for a partial tear occurs when the tendon is hooked by the tip of the examiner’s finger but the test produces pain.1 In cases of suspected acute complete tears, no advanced imaging was performed. However, patients with chronic, partial tears underwent magnetic resonance imaging to evaluate the degree of separation and ensure that primary repair was possible and free tendon graft reconstruction was not needed. r
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Surgical technique Patients were placed in the supine position with the forearm on a hand table. A tourniquet was used and an L-shaped incision was made across the antecubital fossa with the transverse limb placed in the elbow flexion crease and the longitudinal limb extending distally along the medial border of the brachioradialis, in line with the anatomic course of the distal biceps tendon. The lateral antebrachial cutaneous nerve (LABCN) was identified and carefully dissected, and was cautiously retracted throughout the procedure. When intact, the lacertus fibrosus was released to gain exposure. The biceps tendon was exposed and traced distally toward its insertion. In patients with partial distal biceps rupture, the torn portion of the tendon varied from 75% to 90%. We estimated this using a surgical ruler to measure the remaining intact tendon fibers relative to the cross-sectional area of the entire tendon immediately proximal to the insertion on the radius. In patients with complete tear, the ruptured tendon was debrided sharply to healthy-appearing tendinous tissue. For partial tears, the attached fibers were released and any pseudotendon was excised. The tendon was debrided back to healthy tissue based on visual inspection and recognition of grossly normal tendon morphology. The radial tuberosity was prepared with small curettes and rongeurs to expose the tendon’s footprint. In 27 cases, 3 Mitek GII suture anchors with number 2 Ethibond suture (Mitek, DePuy, Warsaw, IN) were inserted at the anatomical footprint in a triangular configuration. In the remaining 5 cases, we used EndoButton (Acufex Microsurgical, Mansfield, MA) bicortical fixation. Then a running locked Krackow stitch was placed into the tendon, the elbow was fully flexed, and the forearm was supinated to verify that the tendon was reducible to its insertion without excessive tension and then was repaired in standard fashion. The elbow was fully extended with the forearm in full supination and the repair site was assessed to confirm that there was no gapping at the tendonebone junction. Postoperatively, the extremity was immobilized for 6 weeks with a well-padded, long-arm orthosis with the elbow in 90 flexion and the forearm in full supination. After 6 weeks, gentle active assisted motion was allowed, going from 30 to full flexion and gradually out to full extension over the course of 2 weeks. Patients added resistance training with weights up to 1 kg for 3 weeks and then increased the weights to come to full strength with no restrictions on activity. The postoperative protocol was identical for both groups.
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Statistical methods The distribution of continuous data is described as means and standard deviations. We analyzed continuous data using the Wilcoxon rank sum test, a nonparametric test. For categorical data, possible differences between groups were analyzed use of the Fisher exact test. RESULTS Patient demographics There were 15 cases (14 patients: 11 men and 3 women) in the partial tear group (group 1). Seventeen cases involving complete distal biceps tears (16 patients, all men) were reviewed as a matched control cohort (group 2). The mean age at the time of surgery was 55 years (range, 38e75 y) in group 1 and 48 years (range, 25e69 y) in group 2. Although the partial rupture group was slightly older, the age difference was not statistically significant (P ¼ .120). In this series, all patients with complete ruptures recalled a specific incident associated with the tendon rupture. Although the exact activity leading to rupture was variable, almost all acute injuries occurred during resisted elbow flexion. In the partial rupture group, 13 of the 15 patients described a repetitive activity that was subjectively thought to have led to the injury. In group 1, surgery was performed at an average of 10 months after the onset of symptoms (range, 9 d to 3.4 y; SD, 0.9 y), usually after a lengthy period of nonsurgical treatment including physical therapy. The nonsurgical treatment regimen for partial tears was highly variable because patients were often treated elsewhere or misdiagnosed before referral. In general, all patients were treated with activity modification and nonsteroidal anti-inflammatory medications before presenting to our clinic. After our assessment, all patients with chronic injuries were sent to physical therapy for a minimum of 4 to 6 weeks. Surgery was performed an average of 19 days (range, 5e44 d; SD, 13 d) after the acute rupture in group 2 patients. Anatomical findings In 14 cases involving partial tendon rupture, intraoperative evaluation of the biceps insertion demonstrated disruption of the lateral fibers. In all partial rupture cases, the medial fibers remained intact. In 1 of the cases, the fibers of the short head of the distal biceps tendon were disrupted whereas the more proximal fibers of the long head of the biceps remained intact (Fig. 1). Intratendinous ganglions at
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In 3 group 1 patients, PIN palsy was identified after surgery. Fortunately, full motor recovery returned at an average of 5 months postoperatively (range, 4e7 mo). No patients with complete ruptures developed PIN palsy. This finding approached statistical significance (P ¼ .090). Whereas the mean time from symptoms to surgery for the partial tear group was 10 months, the mean time to surgery for patients who experienced LABCN irritation was 16 months, and was 25 months for those who experienced PIN palsy; this suggests a higher risk of postoperative nerve injury with longer time to surgery. One patient with complete distal biceps rupture with a history of chronic steroid use and smoking developed superficial wound dehiscence, which healed by secondary intention with wound care alone. No other surgical site complications were identified. No differences in outcome or complications were observed in the 3 patients who underwent EndoButton fixation compared with suture anchors, although this study was not designed to investigate such differences.
FIGURE 1: Intraoperative photograph showing the torn, more distal short head biceps tendon fibers in the vessel loop. The arrow points to the intact long head of the distal biceps tendon.
DISCUSSION Acute, complete rupture of the distal biceps tendon is associated with disability and is often treated with acute surgical repair.4 Morrey et al17 reported 97% flexion strength and 95% supination strength compared with the uninvolved extremity after surgical repair. The operative indications for partial ruptures are not as well defined; in general, an initial nonsurgical approach is recommended. Because partial rupture of the distal biceps tendon occurs in about 3% of all biceps tendon injuries, the diagnosis is often unrecognized or an accurate diagnosis may be delayed.8 Historically, partial tears of the distal biceps tendon were thought to be insidious, associated with chronic tendinopathy.2,10 In this series, however, 13 of 15 patients with partial ruptures recalled a specific activity, although chronic tendinopathy could have been associated with progressive insertional site strength and insufficiency. Similarly, Dellaero and Mallon8 reported that 5 of 7 patients recalled a specific traumatic event. Based on the variability in patient histories and symptoms and in intraoperative findings, the mechanical failure of the partial distal biceps tendon injury is likely multifactorial in nature.18 For partial distal biceps tendon ruptures, we consistently observed that the remaining intact fibers of the distal tendon were of the medial border of the tendon and connected to fibers of the lacertus fibrosus
FIGURE 2: An extensive scar, cyst formation, and adhesions are seen in the case of a delayed surgical repair of a partial biceps tendon tear.
the detachment of the distal tendon were observed in 5 cases of partial tendon rupture (Fig. 2). In addition, the degenerative changes noted in group 1 patients included a patulous, amorphous appearance to the collagen of the tendon with a grossly visible loss of collagen macrostructure. This finding was not seen in any case of complete biceps tear. This was a significant difference between the 2 groups (P ¼ .015). Complications We observed transient irritation of the LABCN in 8 group 1 patients (57%) and 6 group 2 patients (38%). This difference did not reach statistical significance (P ¼ .480). The dysesthesia resolved in all patients an average of 4 months (range, 2e10 mo). J Hand Surg Am.
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or Sharpey fibers on the medial side of the radial tuberosity, preventing retraction of the tendon proximally. Morphologically, the biceps tendon is composed of 2 portions. There is a traction-type portion on the medial aspect of the tendon and a gliding portion on the radial side, which abuts the bursa.19,20 Chronic inflammation of the bursa may predispose this lateral portion of the tendon to rupture.18 Also, Mazzocca et al18 demonstrated that the shape of the bicipital tuberosity may act in a knifelike fashion to cause erosion of the overlying biceps tendon. This theory may explain the pathoanatomy observed at the time of surgery in this series, in which bursal inflammation may have resulted in tearing of the lateral fibers while leaving the tractiontype medial fibers intact. There are several limitations to this study. With the retrospective nature of the study and the limited number of patients evaluated for this uncommon condition, the findings would be strengthened by greater numbers or prospective investigation. Although this study was observational in nature and did not focus on treatment outcomes, it may be useful to incorporate surgeries performed through a 2-incision or posterior technique to be able to draw more defined conclusions. However, the results of this study provide insight regarding anatomical findings and complication risks that can be anticipated in patients with partial tear repairs. In the treatment of complete distal biceps tears, some authors noted that complications increase as the time interval between injury and surgery increases.1e6 In this series there were more cases of both sensory and motor nerve complications postoperatively in patients with partial ruptures, who were treated in a delayed fashion compared with those with complete ruptures. Although more cases of LABCN irritation and postoperative PIN palsy were observed in the partial rupture group, neither met statistical significance. The number of postoperative nerve complications described in this study is relatively high, but the state of altered anatomy in partial ruptures, especially those that undergo late operative treatment, requires a more tedious dissection and may warrant a slightly larger exposure than usual to identify and protect the structures at risk. One weakness of this study was the small number of partial rupture cases for comparison with a matched cohort of acute ruptures. If sample sizes were larger, perhaps these differences would become more apparent and meaningful. Our surgical technique included formal dissection of the LABCN, which may be considered controversial. It is our opinion that this technique allows for the safest management of this nerve throughout the procedure. The reported incidence of postoperative J Hand Surg Am.
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LABCN complications in this series was relatively high, but our definition of LABCN irritation was liberal so as not to miss any instances. All patients were specifically examined for nerve irritation and any mention of dysesthesia, regardless of severity or duration, was recorded as a complication. Other authors may not use such liberal criteria, which explains the difference between our report and prior ones. All surgeries in this series were performed through a single anterior incision. Using this technique, some authors have noted high rates of radial nerve palsy, although in most reports this deficit resolved.21,22 A 2-incision technique can be used, although historically there have been reported complications of proximal radioulnar synostosis that may stem from subperiosteal ulna dissection.17,23 Three patients with partial ruptures in this series developed PIN palsy after surgery, which may be related to delay in surgical treatment. For complete biceps tears that are more than 4 weeks old, surgical dissection may be difficult because of extensive scarring of the biceps tendon to the brachialis muscle.4 Similarly, we often found extensive scar tissue at the site of injury. In 5 cases, we encountered intratendinous ganglions and extensive degenerative changes with gross friability of the tendon. One of these cases was complicated by a postoperative PIN palsy. Perhaps more retraction and dissection than was required in that particular case that led to a traction injury of the nerve. For this reason, we avoid using deep self-retaining retractors during this procedure and also the use of Hohmann retractors because of the risk of levering the nerve against the proximal radius. Our preference is to use deep handheld retractors when feasible. Our opinion is that the nerve injuries observed in this series nonetheless likely resulted from excessive retraction in trying to free the residual tendon, made difficult by scarring. We now believe this complication can be avoiding by not dissecting the residual tendon, and instead transecting it where it is visible, because the unhealthy end of the tendon is debrided anyway. This is now our preferred technique. We did not observe elbow stiffness in these patients despite our postoperative protocol including 6 weeks of immobilization. We are now using more toggle button fixations for these injuries and have accelerated the rehabilitation protocol. We believe that this fixation modality is stronger and safer for early motion, although this is relatively new and would not affect most patients in this cohort. It has been our experience with tendon injuries about the elbow (unlike fractures) that stiffness is uncommon. These are extra-articular injuries, and the elbow seems r
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to be tolerant of brief immobilization in these cases compared with intra-articular injuries. Our consistent observations of the pathologic alterations in the distal biceps tendon insertion associated with partial distal biceps injury in this case series support the anatomical reports in the literature: specifically, that partial ruptures have disruption of the tendinous fibers on the lateral side of the insertion or are isolated to the small head insertion. We also identified the common finding of intratendinous ganglion cysts, most likely associated with degenerative, tendinosis-related changes in the tendon, probably a factor in insufficiency of the tendonebone junction. Technically, the study findings point out the relatively high incidence of transient nerve injury, particularly involving the LABCN and postoperative PIN palsy. This observation highlights the importance of a preoperative informed consent that reviews these risks with the patient and suggests careful reevaluation of surgical technique to minimize traction on the nerves during surgical exposure and soft tissue retraction. These findings can help the surgeon better understand the intraoperative pathology from an anatomical perspective and educate patients about potential risks of surgery in the course of shared decision making.
5. Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis of distal biceps tendon ruptures. Clin Orthop Relat Res. 2005;(437):128e131. 6. Aldridge JW, Bruno RJ, Strauch RJ, et al. Management of acute and chronic biceps tendon ruptures. Hand Clin. 2000;16(3):497e503. 7. Cain RA, Nydick JA, Stein MI. Complications following distal biceps repair. J Hand Surg Am. 2012;37(10):2112e2117. 8. Dellaero DT, Mallon WJ. Surgical treatment of partial biceps tendon ruptures at the elbow. J Shoulder Elbow Surg. 2006;15(2):215e217. 9. Rokito AS, McLaughlin JA, Gallagher MA, et al. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg. 1996;5(1):73e75. 10. Vardakas DG, Musgrave DS, Varitimidis SE, et al. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg. 2001;10(4): 377e379. 11. Karanjia ND, Stiles PJ. Cubital bursitis. J Bone Joint Surg Br. 1988;70(5):832e833. 12. Davis WM, Yassine Z. An etiological factor in tear of the distal tendon of the biceps brachii; report of two cases. J Bone Joint Surg Am. 1956;38(6):1365e1368. 13. Kelly EW, Steinmann S, O’Driscoll SW. Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision. J Shoulder Elbow Surg. 2003;12(5):456e461. 14. Sieler JG III, Parker LM, Chamberland PD, et al. The distal biceps tendon: two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg. 1995;4(3):149e156. 15. Koulouris G, Malone W, Omar IM, et al. Bifid insertion of the distal biceps brachii tendon with isolated rupture: magnetic resonance findings. J Shoulder Elbow Surg. 2009;18(6):e22ee25. 16. Durr HR, Stabler A, Pfahler M, et al. Partial rupture of the distal biceps tendon. Clin Orthop Relat Res. 2000;(374):195e200. 17. Morrey BF, Askew LJ, An KN, et al. Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg Am. 1985;67(3):418e421. 18. Mazzocca AD, Cohen M, Berkson E, et al. The anatomy of the bicipital tuberosity and distal biceps tendon. J Shoulder Elbow Surg. 2007;16(1):122e127. 19. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg Am. 1991;73(10):1507e1525. 20. Koch S, Tillmann B. The distal tendon of the biceps brachii: structures and clinical correlations. Ann Anat. 1995;177(5):467e474. 21. Boucher PR, Morton KS. Rupture of the distal biceps brachii tendon. J Trauma. 1967;7(5):626e632. 22. Friedmann E. Rupture of the distal biceps brachii tendon: report on 13 cases. JAMA. 1963;184:60e63. 23. Dobbie RP. Avulsion of the lower biceps brachii tendon: analysis of fifty-one previously unreported cases. Am J Surg. 1941;51:662e683.
REFERENCES 1. O’Driscoll S, Goncalves L, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med. 2007;35(11):1865e1869. 2. Kelly E, Morrey D, O’Driscoll S. Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am. 2000;82(11):1575e1581. 3. Levy HJ, Mashoof AA, Morgan D. Repair of chronic ruptures of the distal biceps tendon using flexor carpi radialis tendon graft. Am J Sports Med. 2000;28(4):538e540. 4. Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg. 1999;7(3):199e207.
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