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Distal Biceps Brachii Tendon Repairs: A Single-Incision Technique Using a Cortical Button With Interference Screw Versus a Double-Incision Technique Using Suture Fixation Through Bone Tunnels Edward Shields, Joshua R. Olsen, Richard B. Williams, Lucien Rouse, Michael Maloney and Ilya Voloshin Am J Sports Med published online February 19, 2015 DOI: 10.1177/0363546515570465 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/02/19/0363546515570465
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Distal Biceps Brachii Tendon Repairs A Single-Incision Technique Using a Cortical Button With Interference Screw Versus a Double-Incision Technique Using Suture Fixation Through Bone Tunnels Edward Shields,* MD, Joshua R. Olsen,* MD, Richard B. Williams,* MD, Lucien Rouse,* MD, Michael Maloney,* MD, and Ilya Voloshin,*y MD Investigation performed at the University of Rochester, Rochester, New York, USA Background: Distal biceps brachii tendon repairs performed with a tension slide technique using a cortical button (CB) and interference screw are stronger than those based on suture fixation through bone tunnels (BTs) in biomechanical studies. However, clinical comparison of these 2 techniques is lacking in the literature. Purpose: To perform a clinical comparison of the single-incision CB and double-incision BT techniques. Study Design: Cohort study; Level of evidence, 3. Methods: Distal biceps tendon ruptures repaired through either the single-incision CB or double-incision BT technique were retrospectively identified at a single institution. Patients .1 year out from surgery were assessed for range of motion, strength, and complications, and they completed a DASH questionnaire (Disabilities of the Arm, Shoulder, and Hand). Results: Patients in the CB group (n = 20) were older (52 6 9.5 vs 43.7 6 8.7 years; P = .008), had a shorter interval from surgery to evaluation (17.7 6 5 vs 30.8 6 16.5 months; P = .001), and were less likely to smoke (0% vs 28.5%; P = .02) compared with the BT patients (n = 21). DASH scores were similar between groups (4.46 6 4.4 [CB] vs 5.7 6 7.5 [BT]; P = .65). Multivariate analysis revealed no differences in range of motion or strength between groups. More CB patients (30%; n = 6) experienced a complication compared with those in the BT group (4.8%; n = 1) (P = .04), and these complications were predominantly paresthesias of the superficial radial nerve that did not resolve. There were no reoperations or repair failures in either group. Conclusion: Both the single-incision CB and double-incision BT techniques provided excellent clinical results. Complications were more common in the single-incision CB group and most commonly involved paresthesias of the superficial radial nerve. Keywords: distal biceps brachii tendon repair; single incision; double incision; cortical button; suture anchor; interference screw
Multiple surgical techniques have been described for distal biceps brachii tendon repairs. These include doubleincision techniques using suture fixation through bone tunnels (BTs) and single-incision techniques using suture anchors, intraosseous screws, or cortical buttons (CBs). The original 2-incision technique was described by Boyd and Anderson.3 However, concerns regarding heterotopic ossification (HO), postoperative stiffness, and weakness
compared with the uninjured extremity have led to an increase in the popularity of single-incision techniques.4,6,9,12 Clinical studies have yet to demonstrate a clinical advantage of single-incision techniques to doubleincision techniques using suture fixation through BTs.5,7,20 Recently, a ‘‘tension slide technique’’ utilizing a CB has been described.18 This technique has been demonstrated in biomechanical studies to have similar strength to the traditional CB technique; however, it results in less gap formation after cyclical loading.17 Biomechanically, the CB appears to have the highest load to failure of all current repair methods.4,10 The addition of the interference screw does not improve strength of fixation but provides a more anatomic reconstruction, which may provide better clinical outcomes.16 The clinical results of patients treated with CB repairs have not been compared with BT repairs. In this study, we compare single-incision CB and double-incision BT techniques in patients with distal biceps brachii tendon
y Address correspondence to Ilya Voloshin, MD, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14625, USA (email: [email protected]). *Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, New York, USA. One or more of the authors has declared the following potential conflict of interest or source of funding: I.V. is a paid consultant for Arthrex, Zimmer, Arthrosurface, and Acumed.
The American Journal of Sports Medicine, Vol. XX, No. X DOI: 10.1177/0363546515570465 Ó 2015 The Author(s)
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repairs. We hypothesized that there would be no meaningful clinical differences between the repair techniques.
MATERIALS AND METHODS After institutional review board approval, patients who underwent operative fixation of distal bicep tendon tears were identified from billing records during 2 periods. Patients repaired with the BT technique were identified from 1997 to 2003, and patients repaired with the CB technique were identified from 2008 to 2012. Data collection began in 2003 centering on results after BT technique repairs. The study protocol was modified to include patients with CB fixation in 2012. In an attempt to keep time from surgery to study evaluation similar between groups, a 4year span was selected to recruit CB technique patients, creating a gap in recruitment periods. Basic chart review was performed to identify patients meeting the following inclusion criteria: age .18 years, at least 1 year out from surgery, and surgical fixation with CB or BT technique. The surgical procedures were performed by 1 of the 4 authors at a single institution. Two of these surgeons performed exclusively BT repairs in this study; 1 contributed patients to the BT and CB groups after changing techniques; and 1 performed exclusively CB repairs. The repair technique chosen for each patient was based on surgeon preference at the time of surgery. The CB technique was performed through a single incision and utilized the BicepsButton and Bio-interference screw (Arthrex) as previously described.18 The BT technique was performed through 2 incisions and utilized No. 5 Ethibond sutures and BTs in the bicipital tuberosity (Ethicon) as previously described.7 Costs of the implant materials for each technique were obtained from the institutional financial office and company representatives. Exclusion criteria were chronic bicep tendon ruptures requiring allograft tendon reconstruction and any preexisting shoulder or elbow conditions. A total of 54 patients who underwent CB fixation and 25 patients after BT fixation were eligible for the study. Patients from these pools were invited back to the clinic to undergo physical examination and completion of functional outcome measures. Twenty patients were successfully recruited in the CB group and 21 in the BT group. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was administered to all participating subjects. Range of motion (ROM; flexion, extension, pronation, and supination) and strength measurements (flexion, supination) in the operated and nonoperated extremities were recorded with the use of a dynamometer (BTE PrimusRS) and a standard goniometer, respectively. Patients rated their current pain with daily activities on a visual analog scale at the time of follow-up. Basic demographic information, time from injury to surgery, workers’ compensation status, comorbidities, complications, and patient satisfaction measures were obtained from chart review and patient inquiry at time of study examination. Chart review of the 34 CB patients who were unable to be reached or unwilling/unable to participate in the study was also performed to evaluate for early postoperative complications.
Rehabilitation All patients underwent a similar rehabilitation protocol at our institution. Patients were placed into a splint after surgery, which was removed to begin active ROM at 5 to 7 days postoperatively. After 6 weeks of nonweightbearing, patients were advanced to a 10-lb lifting restriction, and at 12 weeks they begin progressive resistance exercises as tolerated. No bracing was used, and all patients attended formal physical therapy.
Statistical Analysis Univariate analyses were performed using 2-sample t tests to compare the outcomes between the 2 groups. After this, multivariate regression models were created, employing a backward stepwise selection procedure and adjusting for time between injury and surgery, time between surgery and evaluation, existence of complications, smoker or not, workers’ compensation, and whether the operation was performed on the dominant side. In this selection method, after the full model is fitted, the variables with least association with the outcome are removed (excluding group indicators). This continues until the variables already in the model are determined to be significantly associated with the outcome. All analyses used R 2.15.2 software (The R Foundation for Statistical Computing) on a Mac OS platform. Statistical significance was set at P \ .05. Power analysis (P = .80) suggested that 13 patients in each group would be sufficient to detect a clinically meaningful difference in DASH scores, based on data published previously by Grewal et al,7 with a minimally clinical important difference of 10.2.14 The operated extremity was compared with the nonoperated side to obtain differential strength and active ROM measurements, which were used for comparing surgical techniques. The operated-minus-nonoperated extremity values yielded the differential measurements. This was done for flexion strength and supination strength, with higher or more positive values favoring the operated extremity (except for extension, which is opposite). Differential ROM was also calculated (operated-minus-nonoperated extremity values) and was done for flexion, extension, supination, and pronation. Raw motion values for flexion, extension, supination, and pronation are also presented but not included in multivariate analysis. Basic demographic information and subjective patient outcomes were analyzed with MannWhitney U and chi-square/Fisher exact tests as appropriate. All data are presented as mean 6 standard deviation.
RESULTS Patients in the CB group were significantly older (52 6 9.5 vs 43.7 6 8.7; P = .008), had a shorter interval from surgery to study evaluation in months (17.7 6 5 vs 30.8 6 16.5; P = .001), and were less likely to smoke (0% vs 28.5%; P = .02) compared with those in the BT group (Table 1).
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TABLE 1 Participant Demographicsa Groups Single-Incision CB (n = 20) General Age, y Male sex Time from injury to surgery, d Time from surgery to evaluation, mo Smoker Dominant extremity affected Workers’ compensation patient Outcome measures DASH score Perceived weakness in operated extremity Differential measures relative to nonoperated extremityc Strength, lb Flexion Supination Range of motion, deg Flexion Extension Supination Pronation Range of motion in operated extremity, deg Flexion Extension Supination Pronation
52 6 9.5 (32-66) 20 (100) 15.6 6 16 (0-60) 17.7 6 5 (12-25) 0 (0) 6 (30) 4 (20)
P Value
Double-Incision BT (n = 21)
43.7 21 10.4 30.8 6 8 7
4.46 6 4.4 4 (20)
6 8.7 (31-61) (100) 6 7.1 (1-27) 6 16.5 (12-76) (28.5) (38) (33)
5.7 6 7.5 7 (33)
1.8 6 0.6 26.8 6 11.0
21.96 6 11.6 211.2 6 17.7
23.4 0.5 27.4 20.44
6 6 6 6
4.8 1.5 11.8 5.0
21.8 0.53 210.8 211.3
6 6 6 6
5 0.0 17.5 15
139 7.4 71.9 78.6
6 6 6 6
6.2 5.1 9.5 6.8
131.9 7.6 67.1 71.4
6 6 6 6
5.4 (120-140) 6.8 (0-20) 20 (–5 to 85) 15.6 (15-90)
(120-148) (0-18) (55-90) (65-90)
Univariate
Multivariate
.008b ..99 .21 .001b .02b .74 .48
NA NA NA NA NA NA NA
.65 .48
.25 NA
.29 .45
.45 .47
.34 .98 .52 .01b
.29 .48 .82 .15
\.001b .92 .36 .07
NA NA NA NA
a Data are reported as mean 6 SD (range) or No. (%). BT, bone tunnel; CB, cortical button; DASH, Disabilities of the Arm, Shoulder, and Hand; NA, not applicable/tested. b Statistically significant between-group difference (P \ .05). c Operated-minus-nonoperated extremity values yielded differential measurements in each category, which were used to compare the 2 groups. Higher or less negative values indicate more function relative to the contralateral extremity, except for measures of extension. Positive values for the differential measures indicate the operative extremity tested better than the nonoperated side, while negative values indicate that the nonoperative side had better results.
The DASH scores at the time of study evaluation did not differ between the CB group (4.46 6 4.4) and the BT group (5.7 6 7.5; P = .65). In univariate analysis, the CB group had nearly 11° more pronation, relative to the contralateral extremity, compared with BT patients (P = .01). In the multivariate model, no differences were found between the CB and BT techniques (Table 1). Raw motion measures for the operated extremities in both groups are presented in Table 1. Flexion was significantly greater in the CB group (P \ .001), without taking into account motion in the contralateral extremity. There were no significant differences between the 2 groups for extension, supination, and pronation ROM. Patient-perceived weakness was present in 4 patients (20%) from the CB group and 7 patients (33%) from the BT group (P = .48). All patients in each group could continue working, and no patients had to change jobs after surgery. Visual analog pain score during activity was 0.79 6 1.9 for the single-incision group and 1.6 6 2.1 for the double group (P = .22). Standard surgical implants for each patient in the CB group cost our institution roughly $775. The implant costs
for the BT group, consisting of No. 5 Ethibond suture, was roughly $15. After surgery, 30% (n = 6) of CB patients experienced a complication, compared with 4.8% (n = 1) of the patients in the BT group (P = .04) (Table 2). Four patients in the CB group had numbness/paresthesias in the superficial radial nerve distribution, while only 1 patient had decreased sensation over the superficial radial nerve distribution in the BT group (P = .18) (Table 2). None of these sensory deficits had completely resolved at the time of study evaluation in either group. Two patients in the CB group were treated with 7 days of Keflex for a superficial erythema and suspected cellulitis or stitch abscess around the incision. Both resolved without any additional intervention, and the rehabilitation protocol was not affected in either case. There were no reoperations or repair failures in either group. No patients had evidence of HO on plain films in the CB group, and 2 patients had evidence in the BT group. The HO was mild and did not affect function in these 2 patients. There were 34 patients that underwent CB repair who were eligible but did not participate in the study. Chart review was performed to identify early postoperative
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TABLE 2 Complications by Treatment Groupa Complication Superficial infection Superficial radial nerve paresthesias All
Single-Incision CB (n = 20)
Double-Incision BT (n = 21)
P Value
2 (10) 4 (20) 6 (30)
0 (0) 1 (4.8) 1 (4.8)
.23 .18 .04b
a
Data are reported as No. (%). BT, bone tunnel; CB, cortical button. Statistically significant between-group difference (P \ .05).
b
complications. These patients were predominantly male (32 male, 2 female) with an average age of 46.8 6 7 years. The average time from surgery to last clinic note was 4.9 6 3 months. Based on clinical note review alone, 32% (n = 11) experienced 1 of the following complications: 4 had superficial radial nerve numbness or paresthesias (2 unresolved at last follow-up); 3 had lateral antebrachial cutaneous nerve numbness or paresthesias (none resolved at time of last follow-up); 1 had ulnar nerve paresthesias (resolved at last follow-up); and 3 patients had superficial cellulitis or stitch abscesses treated with 7 days of Keflex and no additional intervention. One patient from this group had mild HO on radiographs, which was asymptomatic. If these patients are included into the complication analysis, the complication rate in patients undergoing CB repair was 31% (n = 17 of 54) compared with 4.8% (n = 1 of 21) in the BT group (P = .01). Patients undergoing CB repair experienced 12 neuropraxias (22%; 12 of 54 patients: 8 superficial radial nerve; 3 lateral antebrachial cutaneous nerve; 1 ulnar nerve) compared with 1 patient (4.8%; 1 of 21 patients: superficial radial nerve) in the BT group (P = .09).
DISCUSSION Previous studies comparing clinical outcomes of single- versus double-incision techniques have largely reported on single-incision suture anchor repairs.5,7 This study is the first to report a comparison between a tension slide CB technique via a single incision and a BT technique through 2 incisions. These results are consistent with previous publications suggesting that there is no significant difference in functional outcomes after single- versus double-incision surgery for repair of distal biceps tendon rupture.5,7,20 Similar results were also found by Grewal et al,7 who reported a trend toward increased pronation in the single-incision group but otherwise no differences in DASH or elbow ROM. Although the tension slide CB technique has been shown to have the highest load to failure and least gap formation,4,10,17 this does not appear to translate into clinical superiority. Previous reports have documented decreases in forearm motion from 2 incision techniques.11 We did see 2 patients in our study in the 2-incision technique group with \50° of supination/pronation, which is similar to previous studies.4 All other double-incision patients and all single-incision patients had a clinically acceptable ROM.13 The DASH scores in our cohorts were similar to previous publications1,11,15,19 and were near or below the
average US normative DASH score of 10.1.8 This suggests that with either technique, patients will recover to a level of function that is at least similar to the average US citizen. Nerve paresthesias were the most common complication in this study, which is consistent with previous reports.2,7,11 There were more nerve complications in the CB group versus the BT group, but this difference did not meet statistical significance. This trend has been reported.7 The majority of patients in our study with numbness or paresthesias had not recovered at the time of follow-up, which differs from earlier reports of transient nerve complications.7,11 Supplemental chart review of 34 eligible patients who did not formally participate in the study from the CB cohort suggests that the complication frequency observed in the 20 study participants is representative of the group as a whole, although this extrapolation should be interpreted with caution. Although not all statistically significant, several differences between the groups warrant further discussion. Asymptomatic HO was present in 2 patients that underwent BT repair, compared with none undergoing CB repair. Since these patients with HO were asymptomatic, we did not consider this a complication; however, a larger cohort may have found patients with HO that was symptomatic. The majority of complications in the CB group were superficial radial nerve palsies (4 in CB group [20%] vs 1 in BT group [4.8%]), and this frequency of neurapraxias (not all superficial radial nerve) was maintained in the CB group when the 34 CB patients who did not formally participate in the study were included (n = 12 of 54 [22%]). In general, we believe that more retraction is needed during acorn reaming for the CB to ensure that no cortical blowout occurs. This could explain more superficial radial nerve complications. No Hohman retractors were used radial to the tuberosity in either group. Although patients in the CB group had more flexion in the operated extremity compared with the BT group, this difference was not significant when ROM was controlled for in the contralateral extremity. The higher biomechanical strength of the CB repair comes with a price, as the implant cost for the CB repair is roughly $760 more than a BT repair at our institution. However, it is possible that the CB repair may take less time with only a single incision, compared with the BT repair, which requires 2 skin incisions. We were unfortunately unable to compare operation times between the 2 groups, due to the retrospective nature of this study.
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Previous reports are written by authors who have many years of experience with the particular technique under scrutiny.1,4,11,15 Perhaps patient outcomes are linked with the experience and comfort level of the surgeon, as opposed to the actual repair technique performed. Our study is retrospective; however, it allows for a meaningful comparison between these 2 repair options, and it adds to the argument that the repair technique may not have a strong influence on patient outcomes with distal biceps injuries. Perhaps, surgeon experience with a certain technique is what most strongly influences outcomes. Weaknesses of this retrospective study include potential patient selection bias, demographic differences between the groups, and the number of surgeons involved with the study. The study was appropriately powered to assess for differences in DASH scores, and multivariate analysis was utilized in an attempt to reduce potential confounders, such as the unequal time from surgery to study evaluation between groups. As to the number of surgeons, it may improve the generalizability of this study to the general orthopaedic community. The follow-up for patients in the CB group was low and may bias the results. Additional chart review performed on the CB patients lost to follow-up should be interpreted with caution, as they were not questioned or examined per study protocol. This supplementary chart review of patients lost to follow-up was performed to ensure that the complications seen in the patients participating in this study from the CB group were representative of the entire group eligible for participation. A performance bias may also be present in our results, as only 1 surgeon contributed patients to both study groups, while 2 performed only BT repairs and 1 only CB repairs. We were also unable to compare the operation times between groups. Furthermore, patients with good overall outcomes may be more willing to participate, which could further bias the overall results.
CONCLUSION Repair of distal biceps tendon ruptures by CB utilizing the tension slide technique with an interference screw through a single incision did not result in any clinical advantage when compared with the double-incision technique with BTs in this small study. The single-incision CB group had a higher complication rate, which predominantly involved paresthesias of the superficial radial nerve. REFERENCES 1. Balabaud L, Ruiz C, Nonnenmacher J, Seynaeve P, Kehr P, Rapp E. Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach. J Hand Surg Br. 2004;29:178-182.
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2. Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal biceps rupture using the modified two-incision technique. J Shoulder Elbow Surg. 2008;17:67S-71S. 3. Boyd H, Anderson L. A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am. 1961;43:1041-1043. 4. Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: a systematic review. Am J Sports Med. 2008;36:1618-1624. 5. Citak M, Backhaus M, Seybold D, Suero EM, Schildhauer TA, Roetman B. Surgical repair of the distal biceps brachii tendon: a comparative study of three surgical fixation techniques. Knee Surg Sports Traumatol Arthrosc. 2011;19:1936-1941. 6. Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD. Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: report of four cases. Clin Orthop Relat Res. 1990;253:133-136. 7. Grewal R, Athwal GS, MacDermid JC, et al. Single versus doubleincision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am. 2012;94:1166-1174. 8. Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002;84:208-215. 9. Kelly EW, Morrey BF, O’Driscoll SW. Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am. 2000;82:1575-1581. 10. Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA, Arciero RA. Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med. 2007;35:252-258. 11. McKee MD, Hirji R, Schemitsch EH, Wild LM, Waddell JP. Patientoriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique. J Shoulder Elbow Surg. 2005;14:302-306. 12. Moosmayer S, Odinsson A, Holm I. Distal biceps tendon rupture operated on with the Boyd-Anderson technique: follow-up of 9 patients with isokinetic examination after 1 year. Acta Orthop Scand. 2000;71:399-402. 13. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63:872-877. 14. Roy J-S, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61:623-632. 15. Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N. Distal biceps tendon rupture: current concepts. Injury. 2013; 44:417-420. 16. Schmidt CC, Diaz VA, Weir DM, Latona CR, Miller MC. Repaired distal biceps magnetic resonance imaging anatomy compared with outcome. J Shoulder Elbow Surg. 2012;21:1623-1631. 17. Sethi P, Obopilwe E, Rincon L, Miller S, Mazzocca A. Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation. J Shoulder Elbow Surg. 2010;19: 53-57. 18. Sethi PM, Tibone JE. Distal biceps repair using cortical button fixation. Sports Med Arthrosc. 2008;16:130-135. 19. Silva J, Eskander MS, Lareau C, DeAngelis NA. Treatment of distal biceps tendon ruptures using a single-incision technique and a Bio-Tenodesis screw. Orthopedics. 2010;33:477. 20. Widmer BJ, Tashjian RZ. Treatment of distal biceps tendon ruptures. Am J Orthop (Belle Mead NJ). 2010;39:288-296.
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Distal Biceps Brachii Tendon Repairs: A Single-Incision Technique Using a Cortical Button With Interference Screw Versus a Double-Incision Technique Using Suture Fixation Through Bone Tunnels Edward Shields, Joshua R. Olsen, Richard B. Williams, Lucien Rouse, Michael Maloney and Ilya Voloshin Am J Sports Med published online February 19, 2015 DOI: 10.1177/0363546515570465 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/02/19/0363546515570465
Published by: http://www.sagepublications.com
On behalf of: American Orthopaedic Society for Sports Medicine
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Distal Biceps Brachii Tendon Repairs A Single-Incision Technique Using a Cortical Button With Interference Screw Versus a Double-Incision Technique Using Suture Fixation Through Bone Tunnels Edward Shields,* MD, Joshua R. Olsen,* MD, Richard B. Williams,* MD, Lucien Rouse,* MD, Michael Maloney,* MD, and Ilya Voloshin,*y MD Investigation performed at the University of Rochester, Rochester, New York, USA Background: Distal biceps brachii tendon repairs performed with a tension slide technique using a cortical button (CB) and interference screw are stronger than those based on suture fixation through bone tunnels (BTs) in biomechanical studies. However, clinical comparison of these 2 techniques is lacking in the literature. Purpose: To perform a clinical comparison of the single-incision CB and double-incision BT techniques. Study Design: Cohort study; Level of evidence, 3. Methods: Distal biceps tendon ruptures repaired through either the single-incision CB or double-incision BT technique were retrospectively identified at a single institution. Patients .1 year out from surgery were assessed for range of motion, strength, and complications, and they completed a DASH questionnaire (Disabilities of the Arm, Shoulder, and Hand). Results: Patients in the CB group (n = 20) were older (52 6 9.5 vs 43.7 6 8.7 years; P = .008), had a shorter interval from surgery to evaluation (17.7 6 5 vs 30.8 6 16.5 months; P = .001), and were less likely to smoke (0% vs 28.5%; P = .02) compared with the BT patients (n = 21). DASH scores were similar between groups (4.46 6 4.4 [CB] vs 5.7 6 7.5 [BT]; P = .65). Multivariate analysis revealed no differences in range of motion or strength between groups. More CB patients (30%; n = 6) experienced a complication compared with those in the BT group (4.8%; n = 1) (P = .04), and these complications were predominantly paresthesias of the superficial radial nerve that did not resolve. There were no reoperations or repair failures in either group. Conclusion: Both the single-incision CB and double-incision BT techniques provided excellent clinical results. Complications were more common in the single-incision CB group and most commonly involved paresthesias of the superficial radial nerve. Keywords: distal biceps brachii tendon repair; single incision; double incision; cortical button; suture anchor; interference screw
Multiple surgical techniques have been described for distal biceps brachii tendon repairs. These include doubleincision techniques using suture fixation through bone tunnels (BTs) and single-incision techniques using suture anchors, intraosseous screws, or cortical buttons (CBs). The original 2-incision technique was described by Boyd and Anderson.3 However, concerns regarding heterotopic ossification (HO), postoperative stiffness, and weakness
compared with the uninjured extremity have led to an increase in the popularity of single-incision techniques.4,6,9,12 Clinical studies have yet to demonstrate a clinical advantage of single-incision techniques to doubleincision techniques using suture fixation through BTs.5,7,20 Recently, a ‘‘tension slide technique’’ utilizing a CB has been described.18 This technique has been demonstrated in biomechanical studies to have similar strength to the traditional CB technique; however, it results in less gap formation after cyclical loading.17 Biomechanically, the CB appears to have the highest load to failure of all current repair methods.4,10 The addition of the interference screw does not improve strength of fixation but provides a more anatomic reconstruction, which may provide better clinical outcomes.16 The clinical results of patients treated with CB repairs have not been compared with BT repairs. In this study, we compare single-incision CB and double-incision BT techniques in patients with distal biceps brachii tendon
y Address correspondence to Ilya Voloshin, MD, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14625, USA (email: [email protected]). *Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, New York, USA. One or more of the authors has declared the following potential conflict of interest or source of funding: I.V. is a paid consultant for Arthrex, Zimmer, Arthrosurface, and Acumed.
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repairs. We hypothesized that there would be no meaningful clinical differences between the repair techniques.
MATERIALS AND METHODS After institutional review board approval, patients who underwent operative fixation of distal bicep tendon tears were identified from billing records during 2 periods. Patients repaired with the BT technique were identified from 1997 to 2003, and patients repaired with the CB technique were identified from 2008 to 2012. Data collection began in 2003 centering on results after BT technique repairs. The study protocol was modified to include patients with CB fixation in 2012. In an attempt to keep time from surgery to study evaluation similar between groups, a 4year span was selected to recruit CB technique patients, creating a gap in recruitment periods. Basic chart review was performed to identify patients meeting the following inclusion criteria: age .18 years, at least 1 year out from surgery, and surgical fixation with CB or BT technique. The surgical procedures were performed by 1 of the 4 authors at a single institution. Two of these surgeons performed exclusively BT repairs in this study; 1 contributed patients to the BT and CB groups after changing techniques; and 1 performed exclusively CB repairs. The repair technique chosen for each patient was based on surgeon preference at the time of surgery. The CB technique was performed through a single incision and utilized the BicepsButton and Bio-interference screw (Arthrex) as previously described.18 The BT technique was performed through 2 incisions and utilized No. 5 Ethibond sutures and BTs in the bicipital tuberosity (Ethicon) as previously described.7 Costs of the implant materials for each technique were obtained from the institutional financial office and company representatives. Exclusion criteria were chronic bicep tendon ruptures requiring allograft tendon reconstruction and any preexisting shoulder or elbow conditions. A total of 54 patients who underwent CB fixation and 25 patients after BT fixation were eligible for the study. Patients from these pools were invited back to the clinic to undergo physical examination and completion of functional outcome measures. Twenty patients were successfully recruited in the CB group and 21 in the BT group. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was administered to all participating subjects. Range of motion (ROM; flexion, extension, pronation, and supination) and strength measurements (flexion, supination) in the operated and nonoperated extremities were recorded with the use of a dynamometer (BTE PrimusRS) and a standard goniometer, respectively. Patients rated their current pain with daily activities on a visual analog scale at the time of follow-up. Basic demographic information, time from injury to surgery, workers’ compensation status, comorbidities, complications, and patient satisfaction measures were obtained from chart review and patient inquiry at time of study examination. Chart review of the 34 CB patients who were unable to be reached or unwilling/unable to participate in the study was also performed to evaluate for early postoperative complications.
Rehabilitation All patients underwent a similar rehabilitation protocol at our institution. Patients were placed into a splint after surgery, which was removed to begin active ROM at 5 to 7 days postoperatively. After 6 weeks of nonweightbearing, patients were advanced to a 10-lb lifting restriction, and at 12 weeks they begin progressive resistance exercises as tolerated. No bracing was used, and all patients attended formal physical therapy.
Statistical Analysis Univariate analyses were performed using 2-sample t tests to compare the outcomes between the 2 groups. After this, multivariate regression models were created, employing a backward stepwise selection procedure and adjusting for time between injury and surgery, time between surgery and evaluation, existence of complications, smoker or not, workers’ compensation, and whether the operation was performed on the dominant side. In this selection method, after the full model is fitted, the variables with least association with the outcome are removed (excluding group indicators). This continues until the variables already in the model are determined to be significantly associated with the outcome. All analyses used R 2.15.2 software (The R Foundation for Statistical Computing) on a Mac OS platform. Statistical significance was set at P \ .05. Power analysis (P = .80) suggested that 13 patients in each group would be sufficient to detect a clinically meaningful difference in DASH scores, based on data published previously by Grewal et al,7 with a minimally clinical important difference of 10.2.14 The operated extremity was compared with the nonoperated side to obtain differential strength and active ROM measurements, which were used for comparing surgical techniques. The operated-minus-nonoperated extremity values yielded the differential measurements. This was done for flexion strength and supination strength, with higher or more positive values favoring the operated extremity (except for extension, which is opposite). Differential ROM was also calculated (operated-minus-nonoperated extremity values) and was done for flexion, extension, supination, and pronation. Raw motion values for flexion, extension, supination, and pronation are also presented but not included in multivariate analysis. Basic demographic information and subjective patient outcomes were analyzed with MannWhitney U and chi-square/Fisher exact tests as appropriate. All data are presented as mean 6 standard deviation.
RESULTS Patients in the CB group were significantly older (52 6 9.5 vs 43.7 6 8.7; P = .008), had a shorter interval from surgery to study evaluation in months (17.7 6 5 vs 30.8 6 16.5; P = .001), and were less likely to smoke (0% vs 28.5%; P = .02) compared with those in the BT group (Table 1).
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TABLE 1 Participant Demographicsa Groups Single-Incision CB (n = 20) General Age, y Male sex Time from injury to surgery, d Time from surgery to evaluation, mo Smoker Dominant extremity affected Workers’ compensation patient Outcome measures DASH score Perceived weakness in operated extremity Differential measures relative to nonoperated extremityc Strength, lb Flexion Supination Range of motion, deg Flexion Extension Supination Pronation Range of motion in operated extremity, deg Flexion Extension Supination Pronation
52 6 9.5 (32-66) 20 (100) 15.6 6 16 (0-60) 17.7 6 5 (12-25) 0 (0) 6 (30) 4 (20)
P Value
Double-Incision BT (n = 21)
43.7 21 10.4 30.8 6 8 7
4.46 6 4.4 4 (20)
6 8.7 (31-61) (100) 6 7.1 (1-27) 6 16.5 (12-76) (28.5) (38) (33)
5.7 6 7.5 7 (33)
1.8 6 0.6 26.8 6 11.0
21.96 6 11.6 211.2 6 17.7
23.4 0.5 27.4 20.44
6 6 6 6
4.8 1.5 11.8 5.0
21.8 0.53 210.8 211.3
6 6 6 6
5 0.0 17.5 15
139 7.4 71.9 78.6
6 6 6 6
6.2 5.1 9.5 6.8
131.9 7.6 67.1 71.4
6 6 6 6
5.4 (120-140) 6.8 (0-20) 20 (–5 to 85) 15.6 (15-90)
(120-148) (0-18) (55-90) (65-90)
Univariate
Multivariate
.008b ..99 .21 .001b .02b .74 .48
NA NA NA NA NA NA NA
.65 .48
.25 NA
.29 .45
.45 .47
.34 .98 .52 .01b
.29 .48 .82 .15
\.001b .92 .36 .07
NA NA NA NA
a Data are reported as mean 6 SD (range) or No. (%). BT, bone tunnel; CB, cortical button; DASH, Disabilities of the Arm, Shoulder, and Hand; NA, not applicable/tested. b Statistically significant between-group difference (P \ .05). c Operated-minus-nonoperated extremity values yielded differential measurements in each category, which were used to compare the 2 groups. Higher or less negative values indicate more function relative to the contralateral extremity, except for measures of extension. Positive values for the differential measures indicate the operative extremity tested better than the nonoperated side, while negative values indicate that the nonoperative side had better results.
The DASH scores at the time of study evaluation did not differ between the CB group (4.46 6 4.4) and the BT group (5.7 6 7.5; P = .65). In univariate analysis, the CB group had nearly 11° more pronation, relative to the contralateral extremity, compared with BT patients (P = .01). In the multivariate model, no differences were found between the CB and BT techniques (Table 1). Raw motion measures for the operated extremities in both groups are presented in Table 1. Flexion was significantly greater in the CB group (P \ .001), without taking into account motion in the contralateral extremity. There were no significant differences between the 2 groups for extension, supination, and pronation ROM. Patient-perceived weakness was present in 4 patients (20%) from the CB group and 7 patients (33%) from the BT group (P = .48). All patients in each group could continue working, and no patients had to change jobs after surgery. Visual analog pain score during activity was 0.79 6 1.9 for the single-incision group and 1.6 6 2.1 for the double group (P = .22). Standard surgical implants for each patient in the CB group cost our institution roughly $775. The implant costs
for the BT group, consisting of No. 5 Ethibond suture, was roughly $15. After surgery, 30% (n = 6) of CB patients experienced a complication, compared with 4.8% (n = 1) of the patients in the BT group (P = .04) (Table 2). Four patients in the CB group had numbness/paresthesias in the superficial radial nerve distribution, while only 1 patient had decreased sensation over the superficial radial nerve distribution in the BT group (P = .18) (Table 2). None of these sensory deficits had completely resolved at the time of study evaluation in either group. Two patients in the CB group were treated with 7 days of Keflex for a superficial erythema and suspected cellulitis or stitch abscess around the incision. Both resolved without any additional intervention, and the rehabilitation protocol was not affected in either case. There were no reoperations or repair failures in either group. No patients had evidence of HO on plain films in the CB group, and 2 patients had evidence in the BT group. The HO was mild and did not affect function in these 2 patients. There were 34 patients that underwent CB repair who were eligible but did not participate in the study. Chart review was performed to identify early postoperative
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Shields et al
The American Journal of Sports Medicine
TABLE 2 Complications by Treatment Groupa Complication Superficial infection Superficial radial nerve paresthesias All
Single-Incision CB (n = 20)
Double-Incision BT (n = 21)
P Value
2 (10) 4 (20) 6 (30)
0 (0) 1 (4.8) 1 (4.8)
.23 .18 .04b
a
Data are reported as No. (%). BT, bone tunnel; CB, cortical button. Statistically significant between-group difference (P \ .05).
b
complications. These patients were predominantly male (32 male, 2 female) with an average age of 46.8 6 7 years. The average time from surgery to last clinic note was 4.9 6 3 months. Based on clinical note review alone, 32% (n = 11) experienced 1 of the following complications: 4 had superficial radial nerve numbness or paresthesias (2 unresolved at last follow-up); 3 had lateral antebrachial cutaneous nerve numbness or paresthesias (none resolved at time of last follow-up); 1 had ulnar nerve paresthesias (resolved at last follow-up); and 3 patients had superficial cellulitis or stitch abscesses treated with 7 days of Keflex and no additional intervention. One patient from this group had mild HO on radiographs, which was asymptomatic. If these patients are included into the complication analysis, the complication rate in patients undergoing CB repair was 31% (n = 17 of 54) compared with 4.8% (n = 1 of 21) in the BT group (P = .01). Patients undergoing CB repair experienced 12 neuropraxias (22%; 12 of 54 patients: 8 superficial radial nerve; 3 lateral antebrachial cutaneous nerve; 1 ulnar nerve) compared with 1 patient (4.8%; 1 of 21 patients: superficial radial nerve) in the BT group (P = .09).
DISCUSSION Previous studies comparing clinical outcomes of single- versus double-incision techniques have largely reported on single-incision suture anchor repairs.5,7 This study is the first to report a comparison between a tension slide CB technique via a single incision and a BT technique through 2 incisions. These results are consistent with previous publications suggesting that there is no significant difference in functional outcomes after single- versus double-incision surgery for repair of distal biceps tendon rupture.5,7,20 Similar results were also found by Grewal et al,7 who reported a trend toward increased pronation in the single-incision group but otherwise no differences in DASH or elbow ROM. Although the tension slide CB technique has been shown to have the highest load to failure and least gap formation,4,10,17 this does not appear to translate into clinical superiority. Previous reports have documented decreases in forearm motion from 2 incision techniques.11 We did see 2 patients in our study in the 2-incision technique group with \50° of supination/pronation, which is similar to previous studies.4 All other double-incision patients and all single-incision patients had a clinically acceptable ROM.13 The DASH scores in our cohorts were similar to previous publications1,11,15,19 and were near or below the
average US normative DASH score of 10.1.8 This suggests that with either technique, patients will recover to a level of function that is at least similar to the average US citizen. Nerve paresthesias were the most common complication in this study, which is consistent with previous reports.2,7,11 There were more nerve complications in the CB group versus the BT group, but this difference did not meet statistical significance. This trend has been reported.7 The majority of patients in our study with numbness or paresthesias had not recovered at the time of follow-up, which differs from earlier reports of transient nerve complications.7,11 Supplemental chart review of 34 eligible patients who did not formally participate in the study from the CB cohort suggests that the complication frequency observed in the 20 study participants is representative of the group as a whole, although this extrapolation should be interpreted with caution. Although not all statistically significant, several differences between the groups warrant further discussion. Asymptomatic HO was present in 2 patients that underwent BT repair, compared with none undergoing CB repair. Since these patients with HO were asymptomatic, we did not consider this a complication; however, a larger cohort may have found patients with HO that was symptomatic. The majority of complications in the CB group were superficial radial nerve palsies (4 in CB group [20%] vs 1 in BT group [4.8%]), and this frequency of neurapraxias (not all superficial radial nerve) was maintained in the CB group when the 34 CB patients who did not formally participate in the study were included (n = 12 of 54 [22%]). In general, we believe that more retraction is needed during acorn reaming for the CB to ensure that no cortical blowout occurs. This could explain more superficial radial nerve complications. No Hohman retractors were used radial to the tuberosity in either group. Although patients in the CB group had more flexion in the operated extremity compared with the BT group, this difference was not significant when ROM was controlled for in the contralateral extremity. The higher biomechanical strength of the CB repair comes with a price, as the implant cost for the CB repair is roughly $760 more than a BT repair at our institution. However, it is possible that the CB repair may take less time with only a single incision, compared with the BT repair, which requires 2 skin incisions. We were unfortunately unable to compare operation times between the 2 groups, due to the retrospective nature of this study.
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Previous reports are written by authors who have many years of experience with the particular technique under scrutiny.1,4,11,15 Perhaps patient outcomes are linked with the experience and comfort level of the surgeon, as opposed to the actual repair technique performed. Our study is retrospective; however, it allows for a meaningful comparison between these 2 repair options, and it adds to the argument that the repair technique may not have a strong influence on patient outcomes with distal biceps injuries. Perhaps, surgeon experience with a certain technique is what most strongly influences outcomes. Weaknesses of this retrospective study include potential patient selection bias, demographic differences between the groups, and the number of surgeons involved with the study. The study was appropriately powered to assess for differences in DASH scores, and multivariate analysis was utilized in an attempt to reduce potential confounders, such as the unequal time from surgery to study evaluation between groups. As to the number of surgeons, it may improve the generalizability of this study to the general orthopaedic community. The follow-up for patients in the CB group was low and may bias the results. Additional chart review performed on the CB patients lost to follow-up should be interpreted with caution, as they were not questioned or examined per study protocol. This supplementary chart review of patients lost to follow-up was performed to ensure that the complications seen in the patients participating in this study from the CB group were representative of the entire group eligible for participation. A performance bias may also be present in our results, as only 1 surgeon contributed patients to both study groups, while 2 performed only BT repairs and 1 only CB repairs. We were also unable to compare the operation times between groups. Furthermore, patients with good overall outcomes may be more willing to participate, which could further bias the overall results.
CONCLUSION Repair of distal biceps tendon ruptures by CB utilizing the tension slide technique with an interference screw through a single incision did not result in any clinical advantage when compared with the double-incision technique with BTs in this small study. The single-incision CB group had a higher complication rate, which predominantly involved paresthesias of the superficial radial nerve. REFERENCES 1. Balabaud L, Ruiz C, Nonnenmacher J, Seynaeve P, Kehr P, Rapp E. Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach. J Hand Surg Br. 2004;29:178-182.
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2. Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal biceps rupture using the modified two-incision technique. J Shoulder Elbow Surg. 2008;17:67S-71S. 3. Boyd H, Anderson L. A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am. 1961;43:1041-1043. 4. Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: a systematic review. Am J Sports Med. 2008;36:1618-1624. 5. Citak M, Backhaus M, Seybold D, Suero EM, Schildhauer TA, Roetman B. Surgical repair of the distal biceps brachii tendon: a comparative study of three surgical fixation techniques. Knee Surg Sports Traumatol Arthrosc. 2011;19:1936-1941. 6. Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD. Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: report of four cases. Clin Orthop Relat Res. 1990;253:133-136. 7. Grewal R, Athwal GS, MacDermid JC, et al. Single versus doubleincision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am. 2012;94:1166-1174. 8. Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002;84:208-215. 9. Kelly EW, Morrey BF, O’Driscoll SW. Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am. 2000;82:1575-1581. 10. Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA, Arciero RA. Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med. 2007;35:252-258. 11. McKee MD, Hirji R, Schemitsch EH, Wild LM, Waddell JP. Patientoriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique. J Shoulder Elbow Surg. 2005;14:302-306. 12. Moosmayer S, Odinsson A, Holm I. Distal biceps tendon rupture operated on with the Boyd-Anderson technique: follow-up of 9 patients with isokinetic examination after 1 year. Acta Orthop Scand. 2000;71:399-402. 13. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63:872-877. 14. Roy J-S, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61:623-632. 15. Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N. Distal biceps tendon rupture: current concepts. Injury. 2013; 44:417-420. 16. Schmidt CC, Diaz VA, Weir DM, Latona CR, Miller MC. Repaired distal biceps magnetic resonance imaging anatomy compared with outcome. J Shoulder Elbow Surg. 2012;21:1623-1631. 17. Sethi P, Obopilwe E, Rincon L, Miller S, Mazzocca A. Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation. J Shoulder Elbow Surg. 2010;19: 53-57. 18. Sethi PM, Tibone JE. Distal biceps repair using cortical button fixation. Sports Med Arthrosc. 2008;16:130-135. 19. Silva J, Eskander MS, Lareau C, DeAngelis NA. Treatment of distal biceps tendon ruptures using a single-incision technique and a Bio-Tenodesis screw. Orthopedics. 2010;33:477. 20. Widmer BJ, Tashjian RZ. Treatment of distal biceps tendon ruptures. Am J Orthop (Belle Mead NJ). 2010;39:288-296.
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