Musculoskelet Surg (2014) 98 (Suppl 1):S71–S76 DOI 10.1007/s12306-014-0318-z
ORIGINAL ARTICLE
Anatomic reinsertion of the distal biceps tendon rupture through a single anterior approach: extensile or mini-invasive approach? A retrospective study at mean 45-month follow-up L. Murena • G. Canton • E. Camana E. Vulcano • P. Cherubino
•
Received: 17 January 2014 / Accepted: 22 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Purpose To evaluate and compare clinical results and complication rate of a standard and mini-invasive reconstruction technique for distal biceps tendon rupture. Methods Twenty-eight cases of biceps tendon rupture were evaluated at mean 45-month follow-up. A standard anterior approach was used in 19 cases, and a less invasive anterior approach was used in nine cases. Suture anchors were used for tendon reconstruction in all cases. Elbow range of motion (ROM), subjective strength recovery, time to return to work and sports activities, and complications were recorded. Disability of the Arm, Shoulder and Hand Score (DASH) the Oxford Elbow Score (OES), and the Mayo Elbow Performance Score (MEPS) were obtained for all patients. Results Mean ROM recovery was almost complete. Mean subjective strength recovery allowed full return to sports and work in 93 % of cases, within mean 3-month postoperative. Mean DASH, OES, and MEPS scores were good. The clinically relevant complications rate was 17.8 %, all associated with the standard extensile approach group (Group A). Asymptomatic heterotopic ossifications were detected in four cases (14.3 %), not affecting functional recovery. Conclusions Clinical results and complications rate of anatomical reconstruction of the distal biceps tendon rupture were comparable to the literature. Comparison between Group A and B showed no significant differences in terms of ROM, and OES and MEPS scores. Strength
recovery, time to return to sports and work, and DASH score showed a positive trend in Group B. The clinically relevant complications rate was 0 % in Group B and 26 % in Group A. Keywords Biceps tendon Biceps rupture Biceps repair Mini-invasive Suture anchors Anterior approach
Introduction The rupture of the distal tendon of the biceps brachii is infrequent. It typically occurs in males aged 30–50 years with high functional demands of the upper limbs [1]. Several studies have shown better clinical results with the surgical treatment of the lesion as opposed to conservative management [2, 3]. The surgical treatment aims at recovering painless forearm flexion and supination strength [4]. Biomechanical studies demonstrated that such result is best achieved if the distal biceps tendon is reinserted at its footprint on the radial tuberosity [5]. Despite being the preferred method of treatment, the latter technique presents controversies. Method of fixation of the tendon, surgical approach, and complications rate are the most debated issues [6–8]. The aim of the present study is to assess clinical outcome and complication rate of a less invasive anterior approach, compared with the more extended standard anterior approach.
Materials and methods L. Murena G. Canton (&) E. Camana E. Vulcano P. Cherubino Department of Orthopaedics and Traumatology, University of Insubria, Ospedale di Circolo, Viale Borri 57, Varese, Italy e-mail: [email protected]
Thirty-eight patients, between June 2003 and August 2012, presenting with the acute rupture of the distal biceps tendon were surgically treated at our department. Two of these
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patients were affected by bilateral lesions, for a total of 40 tendon ruptures. The following surgical approaches were used to treat the lesions: anterior extensile approach to the elbow according to Henry [9]; mini-invasive anterior approach centred on the radial tuberosity; and mini-invasive combined anterior and posterior approach according to Morrey [10]. All tendon repairs were performed using two suture anchors, with the exception of the patients treated with a combined anterior-posterior approach. In the latter cases, the tendon was reinserted with transosseous stitches. In the present study, only patients treated with either the extensile or the less invasive anterior approach were included. Hence, 35 ruptured tendons were surgically treated in 33 patients. The extensile approach and the minimally invasive approach were used in 26 and 9 cases, respectively. The extensile anterior approach [9] is performed through an incision starting proximally at the radial aspect of the biceps, crosses the cubital fold in a transverse fashion, and ends at the ulnar margin of the brachioradialis muscle. Deep dissection allows for identification of the biceps tendon from its musculo-tendinous junction to its distal extremity, and for exposure of the radial tuberosity through Henry’s interval. The radial nerve is identified under the brachioradialis muscle proximally to Frohse’s arcade. The less invasive approach is a modified extensile approach relying on the most distal part of the latter. A 4-cm skin incision (longitudinal, transverse, or oblique) is centred over the radial tuberosity. The authors prefer the oblique incision as it is more easily centred over the radial tuberosity, it results in an aesthetically acceptable scar (Fig. 1), and it can be combined with a more proximal incision in cases where wider exposure of the cubital fossa is needed. Prior to the exposure of the radial tuberosity through Henry’s interval, the lateral cutaneous antebrachial nerve (LCABN) with its satellite vein must be identified and protected. Further, the collateral branches of the radial artery are identified and ligated in most cases to allow for a more distal deep dissection and adequate visualisation of the radial tuberosity. In acute cases, the tendon can often be easily recovered with either a blunt instrument or a finger. Regardless of the type of anterior approach, the forearm must be kept in supination to keep the posterior interosseous nerve away from the surgical field. The authors would like to stress certain technical aspects when using the mini-invasive technique. Firstly, no Hohmann retractor should ever be used around the radius to prevent nerve damage. Secondly, the forearm should be kept in maximum supination during suture anchor insertion—which should be performed in medial to lateral direction. This allows to correctly expose the footprint and to precisely implant the anchors to achieve anatomical reinsertion. Cruentation of the footprint by means of a motorised burr prior to anchor insertion should be performed without removing all
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Fig. 1 Mini-invasive anterior approach for distal biceps anatomic reconstruction: surgical scar at 5-month postoperative
cortical bone. This will facilitate tendon-to-bone healing while minimising the risk of anchors mobilisation. Lastly, the tendon should be repaired directly to the bone with optimal suture tension, to ensure the loop security of the reconstruction. The surgical steps for anterior mini-invasive reinsertion of the distal biceps tendon are shown in detail in Fig. 2. At follow-up, seven patients were lost. Therefore, 26 patients (28 tendons) were clinically assessed at mean 45-month follow-up (range 5–115 months). Mean age at the time of trauma was 49.5 years (range 26–66 years). The standard extensile and the less invasive anterior approach were used in 19 and 9 cases, respectively. Mean time from trauma to surgery was 4 days (range 0–12 days). At clinical and radiographic follow-up, the following were assessed: length of incision; active and passive, injured and uninjured elbow range of motion (flexion, extension, supination, pronation); subjective flexion and supination strength recovery; subjective and objective elbow function using the Disability of the Arm, Shoulder and Hand Score (DASH) (including Work and Sports/ Performing arts modules), the Oxford Elbow Score (OES), and the Mayo Elbow Performance Score (MEPS); time and modality to return to work and sports activities; postoperative complications such as neuro-vascular lesions, failed tendon repair, antecubital pain, and heterotopic ossifications. The latter were considered clinically relevant only in cases where they affected functional results in terms of
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Fig. 2 Minimally invasive technique for biceps tendon anatomical reconstruction: a anterior oblique skin incision centred over the radial tuberosity; b identification and protection of the lateral cutaneous nerve of the forearm; c isolation and ligation of recurrent radial vessels; d radial tuberosity exposure, biceps bursa removal, and footprint identification; e cruentation of the footprint, taking care not
to remove all cortical bone; f insertion of two suture anchors in medial to lateral direction with the forearm in extreme supination; g recovery of the tendon; h provisional reinsertion with two mattress sutures, respecting the insertions of the long and short head of the biceps; i completion of the suture with a Krackow technique; j result in supination; k result in pronation
ROM, strength recovery, pain, and/or objective outcome measurement. The patients were divided into two groups based on the type of anterior approach used. Group A included the 19 cases treated with an extensile, more aggressive approach. Group B included nine patients treated with the less invasive approach. Demographic characteristics and results from both groups were compared and, wherever possible, Fisher’s exact test and Wilcoxon–Mann–Whitney test were used for statistical analysis.
in flexion, 1° in extension, 8° in pronation, and 3° in supination. Eighty-six per cent of patients reported full subjective recovery of flexion and supination strength. In 93 % of cases, strength recovery allowed for full return to work and sports, which occurred at mean 3.7 months (range 1–12 months) after surgery. Table 1 reports the differences between Group A and B in terms of ROM, strength recovery, and return to work and sports. Mean DASH score was 2.88 (range 0–18.1), with 18 patients (64 %) scoring 0. The OES was above 40 in 96 % of patients with a mean score of 46.3 (range 36–48). Mean MEPS was 98.2 (range 60–100), with 25 cases (89 %) scoring 100. DASH, OES, and MEPS scores results for Group A and B are shown in Table 2. Nine cases (32.1 %) reported postoperative complications, five of which (17.8 %) were clinically relevant. One patient (3.6 %) was affected by neuropraxia of the LCABN, causing persistent paresthesias at the forearm. In one case (3.6 %), the patient complained of antecubital pain during weight lifting and upper extremity working activities. There was one case (3.6 %) of posterior interosseus nerve (PIN) paralysis that completely resolved after neurolysis. There were six cases (21.4 %) of heterotopic ossification, compromising pronation and supination ROM and affecting subjective strength recovery in two cases (7.1 %), both observed in Group A (Fig. 3). The remaining
Results The groups were comparable in terms of sex, age, functional demand, surgical approach (anterior), and fixation method (anchors). Group A and B differed in terms of length of the surgical incision (13.2 cm, range 16–10 cm; and 4.9 cm, range 4–6.5 cm, respectively) as per the different surgical technique. In terms of elbow range of motion, mean flexion was 147° (range, 130° to 160°), and mean extension was -1° (range 0° to -10°). Specifically, three patients had a 5° extension deficit and one patient had a 10° extension deficit, all in the extensile approach group (Group A). Mean pronation was 76° (range 40° to 85°), and mean supination was 86° (range 60° to 90°). Comparison of the operated elbow to the uninjured elbow showed a mean deficit of 5°
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Table 1 Mean postoperative range of motion, percentage of patients with full flexion/ supination strength recovery, and percentage of patients returning to pre-injury level work and sports activities: Group A versus Group B
Postoperative results
Group A: extended approach
Group B: mini-invasive
Incision length
13.2 cm (range 10/16 cm)
4.9 cm (range 4.5/6 cm)
Flexion
145° (range 130°/160°)
150° (range 140°/160°)
Extension
-1.5° (range -10°/0°)
0°
Pronation
70° (range 40°/90°)
82° (range 80°/90°)
Supination
84° (range 60°/90°)
87° (range 80°/90°)
Full flexion and supination strength recovery
85 %
89 %
Return to pre-injury level work and sports
90 %
100 %
Table 2 Mean DASH (Disability of Arm, Soulder and Hand), OES (Oxford Elbow Score), and MEPS (Mayo Performance Elbow Score) scores: Group A versus Group B
Table 3 Clinically relevant complications: Group A versus Group B Complications
Group A: extended approach
Group B: mini-invasive
LCABN neuropraxia
1
0
Score
Group A: extended approach
Group B: mini-invasive
DASH
4.11 (range 0/18.1)
0.1 (range 0/0.8)
Antecubital pain
1
0
OES
45.6 (range 36/48)
47.7 (range 46/48)
PIN paralysis
1
0
MEPS
97.6 (range 60/100)
99.4 (range 95/100)
HO causing ROM deficit
2
0
Asymptomatic HO
3
1
Radiographic complications are reported in italics
Fig. 3 Heterotopic ossification limiting maximal pronation at 40° and causing supination strength impairment
four cases (14.3 %) were minor ossifications not affecting functional recovery, all but one detected in Group A. These four cases were considered only radiographic complications. There were no tendon re-ruptures and no vascular lesions (Table 3).
Discussion The surgical treatment of the ruptured distal biceps tendon aims at recovering forearm flexion and supination strength, along with good and painless elbow range of motion. This allows for return to high demanding activities of the upper
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limb, especially work and sport related [4]. Clinical and biomechanical studies have shown that such functional results are only achievable if anatomical reconstruction (i.e. reinsertion of the tendon at its radial tuberosity footprint) is obtained. [1, 6–8]. Other surgical techniques like the nonanatomical reinsertion or the tenodesis to the brachioradialis do not yield these results. Rantanen and Orava [2] showed that at mean 3 years of follow-up, 14, 60, and 90 % of cases achieved good functional results after conservative treatment, non-anatomical reconstruction, and anatomical reconstruction, respectively. In terms of strength recovery, Klonz et al. [3] reported comparable flexion (96 vs. 96 %) and a significantly superior supination strength recovery (91 vs. 42–56 %) when anatomical versus non-anatomical reconstruction was performed. The results in the present study confirm the superiority of anatomical reconstruction, compared with data reported in literature for other techniques, in terms of ROM, subjective flexion and supination strength recovery, and return to high demanding activities. Specifically, 86 % of patients fully recovered subjective flexion and supination strength, and 93 % of patients were able to return to work and sports activities at pre-injury level. The authors considered the subjective strength recovery as a satisfactory end-point because of two reasons. Firstly, the objective measurement of supination strength could only be performed with a dedicated dynamometer that is not available at the authors department. Secondly, because the aim of surgical intervention is to allow for return to normal work and sport activities and high demanding upper limb activities. Standardised objective scales, such as the DASH, OES, and MEPS, also supported
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the subjective evaluation. The highly satisfactory scores were all in line with the literature. The identification of the footprint is paramount to obtain an anatomical reconstruction of the biceps tendon, crucial to achieve optimal results. Anatomical studies have clearly shown that the footprint is localised at the ulnar aspect of the radial tuberosity [11–13]. Such studies have also demonstrated that the tuberosity presents an inclination of 30° anteriorly, with significant variability among individuals (16°–68°). Further, the two heads of the biceps muscle have two distinct insertions on the tuberosity. The short head attaches more distal and anterior; the long head attaches more proximal and posterior [12, 13]. Hence, the supination of the forearm is strongly dependent on the medial insertion of the tendon, which results in the correct rotation of the radius along its axis [12, 13]. Several surgical techniques are available to obtain an anatomical repair of the ruptured biceps tendon. The two most important variables to consider are the surgical approach and the fixation method [1, 6–8]. Fixation of the distal biceps tendon can be achieved with transosseous sutures, anchors, interference screws, and endobuttons. Although each technique presents its own specific advantages and disadvantages, the literature has not yet demonstrated the clear superiority of one technique over the other [4, 8, 14, 15]. Despite significant differences shown in biomechanical studies between the several fixation methods [11], clinical in vivo studies have not confirmed such results. Therefore, as long as anatomical reconstruction is achieved, the fixation method mostly relies on the surgical approach chosen by the surgeon. Indeed, endobuttons and suture anchors are typically used through the anterior approach, while transosseous sutures are preferred when a combined anterior and posterior approach is chosen. Interference screws may be used in both surgical approaches [1]. In the present study, it was not possible to compare different fixation devices as all cases were treated with suture anchors. Henry et al. [16] support the use of two suture anchors to achieve the best possible anatomical reconstruction. This technique aims at maximising the area of tendon-to-bone repair on the footprint respecting the two heads different insertions. The anchors must be inserted in medial to lateral direction while keeping the forearm in extreme supination to best visualise the postero-medial aspect of the tuberosity (i.e. the footprint) [16]. In the past, the most commonly used surgical approaches were the anterior extensile approach according to Henry, and the Boyd–Anderson combined approach [1, 4, 6]. With these techniques a high incidence of complications, particularly antecubital pain, failure of the reconstruction, neuro-vascular lesions, and heterotopic ossifications is reported. The anterior approach is mostly associated with lesions of the LCABN and the PIN. Heterotopic ossifications are more
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common in the Boyd–Anderson approach, including radioulnar synostosis [1, 4, 6]. In recent years, both anterior and combined less invasive approaches have been described [1, 4, 6]. The mini-invasive anterior approach takes advantage of the most proximal part of Henry’s approach, thus avoiding dissection at the cubital fossa [17–20]. The anterior-posterior combined approach differs from the Boyd– Anderson approach as it exposes the tuberosity by splitting the extensor digitorum longus and supinator fibres. By doing so, it avoids the exposure and deperiostization of the ulna following the detachment of the anconeus muscle [21]. To the best of our knowledge in the literature, there is no study that specifically compares traditional versus miniinvasive techniques. However, reviews suggest differences between the traditional and the minimally invasive approaches, regardless of the fixation method. In fact, the tissue-sparing approaches seem to have better results and fewer complications [6–8, 22]. Nonetheless, these studies do not suggest significant differences between the anterior and combined approach, regardless of the fixation method, as long as it is mini-invasive [6–8, 22]. In the present study, we compared results from two similar groups of patients which differed only in the type of approach used: extensile (Group A) or less invasive (Group B). The incision length was obviously different given the different surgical techniques, with mean 13.2 cm in Group A and 4.9 cm in Group B. Conversely, ROM was comparable (Table 1). The subjective flexion and supination strength recovery, and the return to work and sports activities were almost comparable between the two study groups, yet with a positive trend in Group B (Table 1). The objective functional evaluation assessed with the DASH score showed worse results in the traditional approach group versus the less invasive group, especially if patients suffered complications (Table 2). Nevertheless, comparable results were obtained with OES and MEPS scores (Table 2). This data supports the better results reported in the literature with the tissue-sparing approaches, albeit to date no study has directly compared less invasive to traditional techniques [1, 6–8, 22]. The reported incidence of postoperative complications following the anatomical reconstruction of the distal biceps tendon ranges from 8 to 44 % [4]. The highest complications are observed with the extensile anterior approach (neurological complications) and the combined Boyd– Anderson approach (heterotopic ossifications) [1, 6–8, 22]. As suggested by other authors [14, 23], it is likely that less invasive procedures on soft tissues may lower postoperative complication rates, despite the current lack of studies directly comparing the two types of techniques. The incidence of clinically relevant complications in the present study (17.8 %) is comparable to the literature. In particular, Cain et al. [24] recently reported an incidence of
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0–11 % of LCABN paresthesias (3.6 % in the present study), 1–4 % of PIN palsy (3.6 % in the present study), and an extremely variable incidence of HO, from 1 to 6 % (clinically relevant) to 36 % when considering minor asymptomatic HO (7.1 % of symptomatic HO and 21.4 % total in the present study). In the present study, the incidence of clinically relevant complications in Group A (26 %) was substantially higher than Group B (0 %). Although the difference was not significant, probably due to the small sample size, the presented data seem to support the aforementioned speculations by directly comparing the traditional technique with the mini-invasive one. The presence of minor, asintomatic HO without any influence on functional result has not been considered a clinically relevant complication, as already suggested by other authors [24]. The incidence of complications (including the 11.1 % of clinically irrelevant minor HO’s) in the miniinvasive group of the present study is comparable to the mean rate reported in the literature (16–18 %) for either the anterior or combined approaches when tissue sparing [22]. The limits of this study are its retrospective nature, the small population sample for inferential statistics and the lack of objective muscle strength evaluation with a dynamometer. On this note, however, several authors suggest that the subjective recovery of the patient and the return to high demand activities of the upper limb represent the most significant parameters to assess the success of the treatment [4]. In conclusion, the anterior approach for distal biceps tendon repair is a reliable technique that provides highly satisfying clinical results with an acceptable complications rate, particularly when a mini-invasive technique is used. Conflict of interest Luigi Murena, Gianluca Canton, Eleonora Camana, Ettore Vulcano, Paolo Cherubino declare that they have no conflict of interest. Informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification.
References 1. Miyamoto RG, Elser F, Millet PJ (2010) Distal biceps tendon injuries. JBJS Am 92:2128–2138 2. Rantanen J, Orava S (1999) Rupture of the distal biceps tendon. A report of 19 patients treated with anatomic reinsertion, and a meta-analysis of 147 cases found in the literature. Am J Sports Med 27:128–132 3. Klonz A, Loitz D, Wo¨hler P, Reilmann H (2003) Rupture of the distal biceps brachii tendon: isokinetic power analysis and complications after anatomic reinsertion compared with fixation to the brachialis muscle. J Shoulder Elbow Surg 12:607–611
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Musculoskelet Surg (2014) 98 (Suppl 1):S71–S76 4. Baratz M, King GJV, Steinmann S (2012) Repair of distal biceps ruptures. J Hand Surg 37(A):1462–1466 5. Mazzocca AD, Cohen M, Berkson E, Nicholson G, Carofino BC, Arciero R, Romeo AA (2007) The anatomy of the bicipital tuberosity and distal biceps tendon. J Shoulder Elbow Surg 16:122–127 6. Keener JD (2011) Controversies in the surgical treatment of distal biceps tendon ruptures: single versus double-incision repairs. J Shoulder Elbow Surg 220:S113–S125 7. Widmer BJ, Tashjian RZ (2010) Treatment of distal biceps tendon ruptures. Am J Orthop 39(6):288–296 8. Sarda P, Qaddori A, Nauschutz F, Boulton F, Nanda R, Bayliss N (2013) Distal biceps tendon rupture: current concepts. Injury 44(4):417–420 9. Carita` E, Cassini M, Ricci M, Corain M, Donadelli A, Cugola L (2009) Reinsertion of the distal head of the biceps using minianchors and the anterior access: a retrospective study. Musculoskelet Surg 93:21–25 10. Morrey BF (2007) Distal biceps tendon injury. In: Morrey BF (ed) The Elbow: Master Techniques in Orthopaedic Surgery, 3rd edn. Lippincott Williams & Wilkins, Philadelphia 11. Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA, Arciero RA (2007) Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med 35(2):252–258 12. Cho CH, Song KS, Choi IJ, Kim DK, Lee JH, Kim HT, Moon YS (2011) Insertional anatomy and clinical relevance of the distal biceps tendon. Knee Surg Sports Traumatol Arthrosc 19:1930–1935 13. Athwal GS, Steinmann SP, Rispoli DM (2007) The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg 32:8 14. Jobin CM, Kippe MA, Gardner TR, Levine WN, Ahmad CS (2009) Distal biceps tendon repair: a cadaveric analysis of suture anchor and interference screw restoration of the anatomic footprint. Am J Sports Med 37:2214 15. Spang JT, Weinhold PS, Karas SG (2006) A biomechanical comparison of EndoButton versus suture anchor repair of distal biceps tendon injuries. J Shoulder Elbow Surg 15:509–514 16. Henry J, Feinblatt J, Kaeding CC, Latshaw J, Litsky A, Sibel R, Stephens JA, Jones GL (2007) Biomechanical analysis of distal biceps tendon repair methods. Am J Sports Med 35:11. doi:10. 1177/0363546507305009 17. Woods DA, Hoyb G, Shimmin A (1999) A safe technique for distal biceps repair using a suture anchor and a limited anterior approach. Injury. Int J Care Inj 30:233–237 18. Mazzocca AD, Alerta FG, Elattrache NS, Romeo AA (2003) Single incision technique using an interference screw for the repair of distal biceps tendon ruptures. Oper Tech Sports Med 11(1):36–41 19. Sethi PM, Tibone JE (2008) Distal biceps repair using cortical button fixation. Sports Med Arthrosc Rev 16:130–135 20. Eardley WGP, Odak S, Adesina TS, Jeavons RP, McVie JL (2010) Bioabsorbable interference screw fixation of distal biceps ruptures through a single anterior incision: a single-surgeon case series and review of the literature. Arch Orthop Trauma Surg 130:875–881 21. Kelly EW, Morrey BF, O’Driscoll SW (2000) Complications of repair of the distal biceps tendon with the modified two-incision technique. JBJS 82(11A):1575–1581 22. Chavan PR, Thomas RD, Bisson LJ (2008) Repair of the ruptured distal biceps tendon. A systematic review. Am J Sports Med 36(8):1618–1624 23. Cohen MS, Katolic L (2003) Complications of distal biceps tendon repairs. Oper Tech Sports Med 11(1):60–66 24. Cain RA, Nydick JA, Stein MI, Williams BD, Polikandriotis JA, Hess AV (2012) Complications following distal biceps repair. J Hand Surg 37A:2112–2117
ORIGINAL ARTICLE
Anatomic reinsertion of the distal biceps tendon rupture through a single anterior approach: extensile or mini-invasive approach? A retrospective study at mean 45-month follow-up L. Murena • G. Canton • E. Camana E. Vulcano • P. Cherubino
•
Received: 17 January 2014 / Accepted: 22 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Purpose To evaluate and compare clinical results and complication rate of a standard and mini-invasive reconstruction technique for distal biceps tendon rupture. Methods Twenty-eight cases of biceps tendon rupture were evaluated at mean 45-month follow-up. A standard anterior approach was used in 19 cases, and a less invasive anterior approach was used in nine cases. Suture anchors were used for tendon reconstruction in all cases. Elbow range of motion (ROM), subjective strength recovery, time to return to work and sports activities, and complications were recorded. Disability of the Arm, Shoulder and Hand Score (DASH) the Oxford Elbow Score (OES), and the Mayo Elbow Performance Score (MEPS) were obtained for all patients. Results Mean ROM recovery was almost complete. Mean subjective strength recovery allowed full return to sports and work in 93 % of cases, within mean 3-month postoperative. Mean DASH, OES, and MEPS scores were good. The clinically relevant complications rate was 17.8 %, all associated with the standard extensile approach group (Group A). Asymptomatic heterotopic ossifications were detected in four cases (14.3 %), not affecting functional recovery. Conclusions Clinical results and complications rate of anatomical reconstruction of the distal biceps tendon rupture were comparable to the literature. Comparison between Group A and B showed no significant differences in terms of ROM, and OES and MEPS scores. Strength
recovery, time to return to sports and work, and DASH score showed a positive trend in Group B. The clinically relevant complications rate was 0 % in Group B and 26 % in Group A. Keywords Biceps tendon Biceps rupture Biceps repair Mini-invasive Suture anchors Anterior approach
Introduction The rupture of the distal tendon of the biceps brachii is infrequent. It typically occurs in males aged 30–50 years with high functional demands of the upper limbs [1]. Several studies have shown better clinical results with the surgical treatment of the lesion as opposed to conservative management [2, 3]. The surgical treatment aims at recovering painless forearm flexion and supination strength [4]. Biomechanical studies demonstrated that such result is best achieved if the distal biceps tendon is reinserted at its footprint on the radial tuberosity [5]. Despite being the preferred method of treatment, the latter technique presents controversies. Method of fixation of the tendon, surgical approach, and complications rate are the most debated issues [6–8]. The aim of the present study is to assess clinical outcome and complication rate of a less invasive anterior approach, compared with the more extended standard anterior approach.
Materials and methods L. Murena G. Canton (&) E. Camana E. Vulcano P. Cherubino Department of Orthopaedics and Traumatology, University of Insubria, Ospedale di Circolo, Viale Borri 57, Varese, Italy e-mail: [email protected]
Thirty-eight patients, between June 2003 and August 2012, presenting with the acute rupture of the distal biceps tendon were surgically treated at our department. Two of these
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patients were affected by bilateral lesions, for a total of 40 tendon ruptures. The following surgical approaches were used to treat the lesions: anterior extensile approach to the elbow according to Henry [9]; mini-invasive anterior approach centred on the radial tuberosity; and mini-invasive combined anterior and posterior approach according to Morrey [10]. All tendon repairs were performed using two suture anchors, with the exception of the patients treated with a combined anterior-posterior approach. In the latter cases, the tendon was reinserted with transosseous stitches. In the present study, only patients treated with either the extensile or the less invasive anterior approach were included. Hence, 35 ruptured tendons were surgically treated in 33 patients. The extensile approach and the minimally invasive approach were used in 26 and 9 cases, respectively. The extensile anterior approach [9] is performed through an incision starting proximally at the radial aspect of the biceps, crosses the cubital fold in a transverse fashion, and ends at the ulnar margin of the brachioradialis muscle. Deep dissection allows for identification of the biceps tendon from its musculo-tendinous junction to its distal extremity, and for exposure of the radial tuberosity through Henry’s interval. The radial nerve is identified under the brachioradialis muscle proximally to Frohse’s arcade. The less invasive approach is a modified extensile approach relying on the most distal part of the latter. A 4-cm skin incision (longitudinal, transverse, or oblique) is centred over the radial tuberosity. The authors prefer the oblique incision as it is more easily centred over the radial tuberosity, it results in an aesthetically acceptable scar (Fig. 1), and it can be combined with a more proximal incision in cases where wider exposure of the cubital fossa is needed. Prior to the exposure of the radial tuberosity through Henry’s interval, the lateral cutaneous antebrachial nerve (LCABN) with its satellite vein must be identified and protected. Further, the collateral branches of the radial artery are identified and ligated in most cases to allow for a more distal deep dissection and adequate visualisation of the radial tuberosity. In acute cases, the tendon can often be easily recovered with either a blunt instrument or a finger. Regardless of the type of anterior approach, the forearm must be kept in supination to keep the posterior interosseous nerve away from the surgical field. The authors would like to stress certain technical aspects when using the mini-invasive technique. Firstly, no Hohmann retractor should ever be used around the radius to prevent nerve damage. Secondly, the forearm should be kept in maximum supination during suture anchor insertion—which should be performed in medial to lateral direction. This allows to correctly expose the footprint and to precisely implant the anchors to achieve anatomical reinsertion. Cruentation of the footprint by means of a motorised burr prior to anchor insertion should be performed without removing all
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Fig. 1 Mini-invasive anterior approach for distal biceps anatomic reconstruction: surgical scar at 5-month postoperative
cortical bone. This will facilitate tendon-to-bone healing while minimising the risk of anchors mobilisation. Lastly, the tendon should be repaired directly to the bone with optimal suture tension, to ensure the loop security of the reconstruction. The surgical steps for anterior mini-invasive reinsertion of the distal biceps tendon are shown in detail in Fig. 2. At follow-up, seven patients were lost. Therefore, 26 patients (28 tendons) were clinically assessed at mean 45-month follow-up (range 5–115 months). Mean age at the time of trauma was 49.5 years (range 26–66 years). The standard extensile and the less invasive anterior approach were used in 19 and 9 cases, respectively. Mean time from trauma to surgery was 4 days (range 0–12 days). At clinical and radiographic follow-up, the following were assessed: length of incision; active and passive, injured and uninjured elbow range of motion (flexion, extension, supination, pronation); subjective flexion and supination strength recovery; subjective and objective elbow function using the Disability of the Arm, Shoulder and Hand Score (DASH) (including Work and Sports/ Performing arts modules), the Oxford Elbow Score (OES), and the Mayo Elbow Performance Score (MEPS); time and modality to return to work and sports activities; postoperative complications such as neuro-vascular lesions, failed tendon repair, antecubital pain, and heterotopic ossifications. The latter were considered clinically relevant only in cases where they affected functional results in terms of
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Fig. 2 Minimally invasive technique for biceps tendon anatomical reconstruction: a anterior oblique skin incision centred over the radial tuberosity; b identification and protection of the lateral cutaneous nerve of the forearm; c isolation and ligation of recurrent radial vessels; d radial tuberosity exposure, biceps bursa removal, and footprint identification; e cruentation of the footprint, taking care not
to remove all cortical bone; f insertion of two suture anchors in medial to lateral direction with the forearm in extreme supination; g recovery of the tendon; h provisional reinsertion with two mattress sutures, respecting the insertions of the long and short head of the biceps; i completion of the suture with a Krackow technique; j result in supination; k result in pronation
ROM, strength recovery, pain, and/or objective outcome measurement. The patients were divided into two groups based on the type of anterior approach used. Group A included the 19 cases treated with an extensile, more aggressive approach. Group B included nine patients treated with the less invasive approach. Demographic characteristics and results from both groups were compared and, wherever possible, Fisher’s exact test and Wilcoxon–Mann–Whitney test were used for statistical analysis.
in flexion, 1° in extension, 8° in pronation, and 3° in supination. Eighty-six per cent of patients reported full subjective recovery of flexion and supination strength. In 93 % of cases, strength recovery allowed for full return to work and sports, which occurred at mean 3.7 months (range 1–12 months) after surgery. Table 1 reports the differences between Group A and B in terms of ROM, strength recovery, and return to work and sports. Mean DASH score was 2.88 (range 0–18.1), with 18 patients (64 %) scoring 0. The OES was above 40 in 96 % of patients with a mean score of 46.3 (range 36–48). Mean MEPS was 98.2 (range 60–100), with 25 cases (89 %) scoring 100. DASH, OES, and MEPS scores results for Group A and B are shown in Table 2. Nine cases (32.1 %) reported postoperative complications, five of which (17.8 %) were clinically relevant. One patient (3.6 %) was affected by neuropraxia of the LCABN, causing persistent paresthesias at the forearm. In one case (3.6 %), the patient complained of antecubital pain during weight lifting and upper extremity working activities. There was one case (3.6 %) of posterior interosseus nerve (PIN) paralysis that completely resolved after neurolysis. There were six cases (21.4 %) of heterotopic ossification, compromising pronation and supination ROM and affecting subjective strength recovery in two cases (7.1 %), both observed in Group A (Fig. 3). The remaining
Results The groups were comparable in terms of sex, age, functional demand, surgical approach (anterior), and fixation method (anchors). Group A and B differed in terms of length of the surgical incision (13.2 cm, range 16–10 cm; and 4.9 cm, range 4–6.5 cm, respectively) as per the different surgical technique. In terms of elbow range of motion, mean flexion was 147° (range, 130° to 160°), and mean extension was -1° (range 0° to -10°). Specifically, three patients had a 5° extension deficit and one patient had a 10° extension deficit, all in the extensile approach group (Group A). Mean pronation was 76° (range 40° to 85°), and mean supination was 86° (range 60° to 90°). Comparison of the operated elbow to the uninjured elbow showed a mean deficit of 5°
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Table 1 Mean postoperative range of motion, percentage of patients with full flexion/ supination strength recovery, and percentage of patients returning to pre-injury level work and sports activities: Group A versus Group B
Postoperative results
Group A: extended approach
Group B: mini-invasive
Incision length
13.2 cm (range 10/16 cm)
4.9 cm (range 4.5/6 cm)
Flexion
145° (range 130°/160°)
150° (range 140°/160°)
Extension
-1.5° (range -10°/0°)
0°
Pronation
70° (range 40°/90°)
82° (range 80°/90°)
Supination
84° (range 60°/90°)
87° (range 80°/90°)
Full flexion and supination strength recovery
85 %
89 %
Return to pre-injury level work and sports
90 %
100 %
Table 2 Mean DASH (Disability of Arm, Soulder and Hand), OES (Oxford Elbow Score), and MEPS (Mayo Performance Elbow Score) scores: Group A versus Group B
Table 3 Clinically relevant complications: Group A versus Group B Complications
Group A: extended approach
Group B: mini-invasive
LCABN neuropraxia
1
0
Score
Group A: extended approach
Group B: mini-invasive
DASH
4.11 (range 0/18.1)
0.1 (range 0/0.8)
Antecubital pain
1
0
OES
45.6 (range 36/48)
47.7 (range 46/48)
PIN paralysis
1
0
MEPS
97.6 (range 60/100)
99.4 (range 95/100)
HO causing ROM deficit
2
0
Asymptomatic HO
3
1
Radiographic complications are reported in italics
Fig. 3 Heterotopic ossification limiting maximal pronation at 40° and causing supination strength impairment
four cases (14.3 %) were minor ossifications not affecting functional recovery, all but one detected in Group A. These four cases were considered only radiographic complications. There were no tendon re-ruptures and no vascular lesions (Table 3).
Discussion The surgical treatment of the ruptured distal biceps tendon aims at recovering forearm flexion and supination strength, along with good and painless elbow range of motion. This allows for return to high demanding activities of the upper
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limb, especially work and sport related [4]. Clinical and biomechanical studies have shown that such functional results are only achievable if anatomical reconstruction (i.e. reinsertion of the tendon at its radial tuberosity footprint) is obtained. [1, 6–8]. Other surgical techniques like the nonanatomical reinsertion or the tenodesis to the brachioradialis do not yield these results. Rantanen and Orava [2] showed that at mean 3 years of follow-up, 14, 60, and 90 % of cases achieved good functional results after conservative treatment, non-anatomical reconstruction, and anatomical reconstruction, respectively. In terms of strength recovery, Klonz et al. [3] reported comparable flexion (96 vs. 96 %) and a significantly superior supination strength recovery (91 vs. 42–56 %) when anatomical versus non-anatomical reconstruction was performed. The results in the present study confirm the superiority of anatomical reconstruction, compared with data reported in literature for other techniques, in terms of ROM, subjective flexion and supination strength recovery, and return to high demanding activities. Specifically, 86 % of patients fully recovered subjective flexion and supination strength, and 93 % of patients were able to return to work and sports activities at pre-injury level. The authors considered the subjective strength recovery as a satisfactory end-point because of two reasons. Firstly, the objective measurement of supination strength could only be performed with a dedicated dynamometer that is not available at the authors department. Secondly, because the aim of surgical intervention is to allow for return to normal work and sport activities and high demanding upper limb activities. Standardised objective scales, such as the DASH, OES, and MEPS, also supported
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the subjective evaluation. The highly satisfactory scores were all in line with the literature. The identification of the footprint is paramount to obtain an anatomical reconstruction of the biceps tendon, crucial to achieve optimal results. Anatomical studies have clearly shown that the footprint is localised at the ulnar aspect of the radial tuberosity [11–13]. Such studies have also demonstrated that the tuberosity presents an inclination of 30° anteriorly, with significant variability among individuals (16°–68°). Further, the two heads of the biceps muscle have two distinct insertions on the tuberosity. The short head attaches more distal and anterior; the long head attaches more proximal and posterior [12, 13]. Hence, the supination of the forearm is strongly dependent on the medial insertion of the tendon, which results in the correct rotation of the radius along its axis [12, 13]. Several surgical techniques are available to obtain an anatomical repair of the ruptured biceps tendon. The two most important variables to consider are the surgical approach and the fixation method [1, 6–8]. Fixation of the distal biceps tendon can be achieved with transosseous sutures, anchors, interference screws, and endobuttons. Although each technique presents its own specific advantages and disadvantages, the literature has not yet demonstrated the clear superiority of one technique over the other [4, 8, 14, 15]. Despite significant differences shown in biomechanical studies between the several fixation methods [11], clinical in vivo studies have not confirmed such results. Therefore, as long as anatomical reconstruction is achieved, the fixation method mostly relies on the surgical approach chosen by the surgeon. Indeed, endobuttons and suture anchors are typically used through the anterior approach, while transosseous sutures are preferred when a combined anterior and posterior approach is chosen. Interference screws may be used in both surgical approaches [1]. In the present study, it was not possible to compare different fixation devices as all cases were treated with suture anchors. Henry et al. [16] support the use of two suture anchors to achieve the best possible anatomical reconstruction. This technique aims at maximising the area of tendon-to-bone repair on the footprint respecting the two heads different insertions. The anchors must be inserted in medial to lateral direction while keeping the forearm in extreme supination to best visualise the postero-medial aspect of the tuberosity (i.e. the footprint) [16]. In the past, the most commonly used surgical approaches were the anterior extensile approach according to Henry, and the Boyd–Anderson combined approach [1, 4, 6]. With these techniques a high incidence of complications, particularly antecubital pain, failure of the reconstruction, neuro-vascular lesions, and heterotopic ossifications is reported. The anterior approach is mostly associated with lesions of the LCABN and the PIN. Heterotopic ossifications are more
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common in the Boyd–Anderson approach, including radioulnar synostosis [1, 4, 6]. In recent years, both anterior and combined less invasive approaches have been described [1, 4, 6]. The mini-invasive anterior approach takes advantage of the most proximal part of Henry’s approach, thus avoiding dissection at the cubital fossa [17–20]. The anterior-posterior combined approach differs from the Boyd– Anderson approach as it exposes the tuberosity by splitting the extensor digitorum longus and supinator fibres. By doing so, it avoids the exposure and deperiostization of the ulna following the detachment of the anconeus muscle [21]. To the best of our knowledge in the literature, there is no study that specifically compares traditional versus miniinvasive techniques. However, reviews suggest differences between the traditional and the minimally invasive approaches, regardless of the fixation method. In fact, the tissue-sparing approaches seem to have better results and fewer complications [6–8, 22]. Nonetheless, these studies do not suggest significant differences between the anterior and combined approach, regardless of the fixation method, as long as it is mini-invasive [6–8, 22]. In the present study, we compared results from two similar groups of patients which differed only in the type of approach used: extensile (Group A) or less invasive (Group B). The incision length was obviously different given the different surgical techniques, with mean 13.2 cm in Group A and 4.9 cm in Group B. Conversely, ROM was comparable (Table 1). The subjective flexion and supination strength recovery, and the return to work and sports activities were almost comparable between the two study groups, yet with a positive trend in Group B (Table 1). The objective functional evaluation assessed with the DASH score showed worse results in the traditional approach group versus the less invasive group, especially if patients suffered complications (Table 2). Nevertheless, comparable results were obtained with OES and MEPS scores (Table 2). This data supports the better results reported in the literature with the tissue-sparing approaches, albeit to date no study has directly compared less invasive to traditional techniques [1, 6–8, 22]. The reported incidence of postoperative complications following the anatomical reconstruction of the distal biceps tendon ranges from 8 to 44 % [4]. The highest complications are observed with the extensile anterior approach (neurological complications) and the combined Boyd– Anderson approach (heterotopic ossifications) [1, 6–8, 22]. As suggested by other authors [14, 23], it is likely that less invasive procedures on soft tissues may lower postoperative complication rates, despite the current lack of studies directly comparing the two types of techniques. The incidence of clinically relevant complications in the present study (17.8 %) is comparable to the literature. In particular, Cain et al. [24] recently reported an incidence of
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0–11 % of LCABN paresthesias (3.6 % in the present study), 1–4 % of PIN palsy (3.6 % in the present study), and an extremely variable incidence of HO, from 1 to 6 % (clinically relevant) to 36 % when considering minor asymptomatic HO (7.1 % of symptomatic HO and 21.4 % total in the present study). In the present study, the incidence of clinically relevant complications in Group A (26 %) was substantially higher than Group B (0 %). Although the difference was not significant, probably due to the small sample size, the presented data seem to support the aforementioned speculations by directly comparing the traditional technique with the mini-invasive one. The presence of minor, asintomatic HO without any influence on functional result has not been considered a clinically relevant complication, as already suggested by other authors [24]. The incidence of complications (including the 11.1 % of clinically irrelevant minor HO’s) in the miniinvasive group of the present study is comparable to the mean rate reported in the literature (16–18 %) for either the anterior or combined approaches when tissue sparing [22]. The limits of this study are its retrospective nature, the small population sample for inferential statistics and the lack of objective muscle strength evaluation with a dynamometer. On this note, however, several authors suggest that the subjective recovery of the patient and the return to high demand activities of the upper limb represent the most significant parameters to assess the success of the treatment [4]. In conclusion, the anterior approach for distal biceps tendon repair is a reliable technique that provides highly satisfying clinical results with an acceptable complications rate, particularly when a mini-invasive technique is used. Conflict of interest Luigi Murena, Gianluca Canton, Eleonora Camana, Ettore Vulcano, Paolo Cherubino declare that they have no conflict of interest. Informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification.
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