J Shoulder Elbow Surg (2014) 23, 1532-1536
www.elsevier.com/locate/ymse
Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw Michael C. Cusick, MDa, Benjamin J. Cottrell, BSb, Richard A. Cain, MDc, Mark A. Mighell, MDa,* a
Florida Orthopaedic Institute, Tampa, FL, USA Foundation for Orthopaedic Research and Education, Tampa, FL, USA c University of South Florida, Tampa, FL, USA b
Background: The use of cortical suspensory fixation in conjunction with an interference screw to treat distal biceps ruptures has yielded favorable results. However, literature examining the incidence of fixation failure in a large consecutive series of patients treated with this technique is lacking. Methods: A retrospective review of electronic medical records identified 170 distal biceps ruptures in 168 consecutive patients (164 men and 4 women) treated using a cortical button in conjunction with an interference screw. The study group was an average age of 48 years (range, 20-71 years). Records were reviewed from the time of the initial clinic visit to the most recent follow-up. Early failures were defined as those that occurred within 12 weeks of the index procedure. Failed repair was defined as tendon defect, deformity, or significant weakness in supination. Results: The early incidence of failure was 1.2%, with 2 of the fixations meeting the criteria for failure. One patient had significant brachial artery thrombosis. Other complications included posterior interosseous nerve palsy, lateral antebrachial cutaneous nerve-related complication, and numbness about the radial nerve. Conclusion: The use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Distal biceps repair; cortical button; cortical suspensory fixation; interference screw; complication rate; combined technique
Rupture of the distal biceps tendon typically occurs with a forced eccentric contraction, often in a middle-aged patient. Anatomic repair offers the potential for improved This study was determined to be exempt from review by the Western Institutional Review Board (WIRB). *Reprint requests: Mark A. Mighell, MD, Florida Orthopaedic Institute, 13020 N Telecom Pkwy, Tampa, FL 33637. E-mail address: [email protected] (M.A. Mighell).
strength, function, and cosmetic appearance. In 1985, Morrey et al22 demonstrated a 40% loss of supination strength and 30% loss of flexion strength in a cohort of patients treated nonoperatively and that strength was significantly improved by repair. Further studies have confirmed increased strength and endurance in patients after distal biceps repair.3,17,25 There are multiple methods for fixation of the distal biceps tendon, including suture through bone tunnels,
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.04.013
Rerupture in cortical button with screw suture anchors, interference screw fixation, and cortical suspensory fixation. Bain et al1 first described the use of a cortical button in 2000. Multiple biomechanical studies have shown that cortical fixation has a higher load to failure than other methods of fixation.15,20,33 In 2005, Mazzocca et al19 described a technique using a cortical suspensory device in conjunction with an interference screw. Biomechanical studies have shown that suspensory cortical button fixation exhibits maximum peak load to failure. In addition, Sethi et al30 demonstrated that the use of an interference screw significantly reduces gap formation at the repair site. Heinzelmann et al13 were the first to report tendon failure with the use of this technique. In a consecutive series of 41 patients, they reported no failures of fixation, fractures, or reruptures. The purpose of this study was to determine the early incidence of tendon rerupture after distal biceps repair using a cortical button and interference screw in a large consecutive series.
Materials and methods A consecutive series of elbows that underwent primary distal biceps repair by 6 fellowship-trained physicians between October 2006 and February 2013 were retrospectively identified. Clinical and operative notes were retrospectively reviewed by 2 staff members (R.A.C. and B.J.C.), not directly involved in patient care, to isolate distal biceps repairs and to determine the technique used. Inclusion criteria included any patient aged older than 18 years in which the technique described by Mazzocca et al19 was performed. A single vertical incision is placed 2 to 3 cm distal to the elbow flexion crease. In all cases, the lateral antebrachial cutaneous nerve is identified and protected. Tenotomy scissors are used to complete the dissection and to identify the biceps tendon. The tendon is retrieved with an Allis clamp, and a heavy whipstitch is placed within the substance of the tendon. The tendon end is bulletized to facilitate docking into the radial tunnel. The forearm is then maximally supinated to facilitate exposure of the radial tuberosity and prevent injury to the posterior interosseous nerve. Angled retractors are placed to expose the tuberosity. All traversing vessels are ligated with a bipolar cautery. We strongly discourage the use of a levered retractor radially to avoid traction injury to the posterior interosseous nerve. A 2.9-mm guide pin in placed centrally in the radial tuberosity, and the near cortex is opened with a 7.5-mm reamer. The tendon is repaired using a cortical button and tension-slide technique with the addition of a 7 10-mm interference screw (Arthrex, Naples, FL, USA; Fig. 1). Patients are immobilized in a splint for approximately 1 week, followed by 1 month of application of a range of motion brace to prevent terminal extension (locked from 30 -130 ). After 1 month, patients begin range of motion exercises as tolerated but are instructed to avoid lifting. Patients are permitted to do light lifting after 3 months. Our follow-up protocol involves a wound check visit at 7 to 10 days, and follow-up visits at 6 weeks, 3 months, and 6 months, at which time patients are told to follow-up as needed. The 3-month follow-up was required to evaluate for failed repair of the distal biceps in the early postoperative period. Elbow radiographs were performed in all patients at the 3-month follow-up
1533
Figure 1 Illustration shows the placement and orientation of the cortical button and interference screw implanted in the radial tuberosity. visit and reviewed by 3 independent reviewers for button placement, evidence of screw cut-out or fracture, osteolysis around the screw, and the presence of heterotopic bone. Heterotopic ossification (HO) was graded according to the classification of Graham and Hastings.12 This classification system divides HO into 3 groups, with class I representing subclinical lesions, class II representing bone formation that limits functional motion in any plane, and class III lesions representing complete ankylosis of the elbow.12 Exclusion criteria included repairs that required the use of allograft material and revision biceps repairs. Clinical and operative notes were reviewed for complications. The focus of the study was on acute failure of fixation and immediate perioperative complications; however, all complications observed to date are reported. Failed repair was defined as the clinical findings of a tendon defect, recurrence of deformity, or significant weakness of supination when compared with the contralateral side using the Medical Research Council grading system (0 to 5). Advanced imaging was only used in 1 patient with suspected failure to confirm the diagnosis.
Results This study identified 202 consecutive distal biceps repairs using the cortical button and interference screw. Of these, 170 repairs performed in 168 patients (164 men and 4 women) met the inclusion criteria. The average age at time of surgery was 48 years (range, 20-71 years). The average length of follow-up was 8 months (range, 3-61 months). Any complications that occurred outside of the minimum period of 3 months were also reported. The analysis excluded 32 patients (15.8%) whose follow-up was less than 3 months. According to the classification of Kelly et al,14 there were 41 acute repairs, 47 subacute repairs, and 82 delayed repairs. Evaluation of 3-month radiographs revealed subclinical grade I HO only. Two of the 170 elbows had an early failure of the repair for an incidence of 1.2%. There were no instances of early device failure in this study. In 1 patient, improper placement of the implant into the radial head resulted in
1534 Table I
M.C. Cusick et al. Studies in the literature with a patient population greater than 50 that documented the incidence of rerupture
First author (year)
Location
No.
Technique
Rate of rerupture % (No.)
Cain6 (2012) Grewal11 (2012) McKee24 (2005) Kelly14 (2000)
Tampa, FL, USA London, ON, Canada Toronto, ON, Canada Rochester, MN, USA
198 91 53 78
Various Suture anchor/transosseous drill holes Suture anchor Various
2.0 4.4 0.0 1.3
subsequent rerupture and revision surgery. In the second case, the patient had an injury while moving furniture and was felt to have failed fixation when examined in the clinic. Plain film radiographs showed that the button had not migrated. However, magnetic resonance imaging confirmed failure at the myotendinous junction proximal to the weaved suture. This was a failure of tendon biology in an elderly man, who opted for nonsurgical management. The only major intraoperative complication was a brachial artery thrombosis that required a thrombectomy. This was identified immediately after tourniquet deflation. The artery was traced distally and was patent. Intraoperative Doppler could not identify a radial pulse. A vascular surgery consultation was obtained emergently, and a thrombectomy was performed. No further intervention was required, and the patient recovered uneventfully. The etiology of the thrombosis remains unclear; however, it could have been due to traction or compression resulting in an intimal tear. Three patients (2.3%) developed postoperative posterior interosseous nerve (PIN) palsy. In each patient, spontaneous recovery was observed without further surgical intervention. No proximal radial fractures occurred intraoperatively or in the early postoperative period. Minor complications were observed in 12.9% of patients. There were 22 superficial neuropathies associated with surgery. These included numbness about the lateral antebrachial cutaneous nerve (LABCN) in 17 of 170 repairs (10%), 2 patients (1.5%) with radial nerve numbness (superficial sensory branch), and 3 patients (2.3%) with unspecified numbness around the surgical site. Spontaneous recovery was observed in all patients without further intervention.
Discussion Multiple series have reported good clinical results with the use of a cortical button device to fix distal biceps injuries.1,5,7,9,11,18,25,27,32,33 In contrast, relatively few series have reported the clinical results using a button type device in conjunction with an interference screw.13,19,23 The rationale for using this method of fixation rather than a cortical suspensory device alone is to decrease the cyclical motion at the tendon-to-bone interface.19 Biomechanical analysis has shown that interference fixation has the least motion with cyclical loading, whereas the cortical button has the highest load to failure (440 N).20 The potential advantages afforded by the addition of the interference screw may impart
(4) (4) (0) (1)
increased stability and reduce gap formation in the immediate postoperative period. However, we note that this advantage is theoretical. Another potential benefit is to position the tendon ulnarly within the tunnel with placement of the interference screw. This may provide a mechanical advantage for supination strength by approximating the native footprint of the biceps tendon. Obtaining secure fixation of the tendon is critical to allow early rehabilitation and provide adequate strength to avoid rerupture. Most distal biceps case series are relatively small, with fewer than 50 patients and sparse reports of rerupture.2-5,7,8,11,13-18,25,27,31 Larger studies, between 50 and 200 cases of biceps repair, reported a rerupture rate between 0% and 4%.6,10,14,21 (Table I) The rerupture rate of 1.2% in the early postoperative period in the current study was comparable with other large series. Kelly et al14 defined 3 time periods between biceps tear and biceps repair: acute, with less than 10 days to repair, subacute, with between 10 and 21 days to repair, and delayed, with greater than 21 days to repair. The study reported increased complications in patients treated in a delayed period compared with the acute and subacute repairs.14 In our series, a complication occurred in 7.3% (3 of 41) of acute repairs, in 13% (6 of 47) of subacute repairs, and in 20% (16 of 82) of delayed repairs. The 2 patients who reruptured and the patient with brachial artery thrombosis were delayed repairs. A technical complication reported in this study was the incorrect placement of the implant in the radial head instead of the radial tuberosity. This malposition resulted in early failure of the repair, necessitating revision surgery. This mistake can be made despite surgeon experience and stresses the importance of C-arm fluoroscopy during the case to confirm correct placement of the cortical suspensory fixation and interference screw. The relative size of the interference screw compared to the radius has led some to express concern about the potential for fracture of the proximal radius. A case series by Potapov et al26 discussed the rates of osteolysis in patients whose biceps tear was treated with an interference screw. The study concluded that there is a significant chance of osteolysis in the proximal radius after interference screw fixation. Because osteolysis reduces bone volume, the study surmised that this reduced bone volume could lead to fracture.26 However, their study found no significant functional or clinical differences in patient outcomes. The Potapov et al26 study also evaluated osteolysis rates using poly-L-lactide interference screws. Polyether ether ketone
Rerupture in cortical button with screw interference screws were used in our study, and no reports investigating rates of polyether ether ketone osteolysis in vivo are available in the literature. In our current series of 170 patients, no acute fractures of the proximal radius were identified radiographically at the 3-month follow-up visit. Further radiographs were not routinely taken, but we are not aware of any fractures to date. Several reports have tracked the rates of minor complications, such as occurred in our study, for patients treated with different repair techniques. The most common complication in this study was numbness about the LABCN, with an early rate of 10%. This is comparable to the literature for biceps repair in general, which has reported LABCN-related complications in 3% to 26% of patients.4,6,10,14,21,29 Other specific cases of nerve injury included PIN palsy, which developed in 2.3% of the study population. These are also comparable to the literature, which report PIN-related complications between 1% and 9%.6,14,21,24 One criticism of this study is that we lack information on the functional results of this repair method. Specifically, we cannot clearly state that this fixation technique provides long-term clinical benefit compared with other types of repair. The theoretical improvement provided by this method is reduced rehabilitation time and earlier active motion postoperatively. A dynamometer was not used to measure supination strength postoperatively; rather, the patients were clinically tested using the Medical Research Council grading system (0 to 5), and results were compared with the unaffected side. Another weakness was a relatively short length of follow-up. The short-term complication rate may not be a complete representation of the long-term rate. Our rationale for selecting a 3-month follow-up time to determine tendon healing was based on animal studies of tendon healing in a bone tunnel by Rodeo et al.28 Their study reported that most tendon strength was gained in the first 12 weeks after transplantation. In addition, they found that the tendon strength to failure did not significantly improve (P ¼ .28) between 12 and 26 weeks after transplantation.28 It should be noted that all complications outside of the 3-month window have been reported for completeness of this study.
Conclusions The early incidence of distal biceps reruptures using a cortical button in conjunction with an interference screw is 1.2% in this study. The etiology of the rerupture was not device related in either patient. This is the first large consecutive series of distal biceps repairs using cortical suspensory fixation in conjunction with an interference screw. We recommend this technique as a safe option for distal biceps fixation with a comparable early postoperative rerupture rate compared with other reported techniques.
1535
Disclaimer Mark A. Mighell receives royalties from UPex (Newclip Technics). He also received consulting fees or honoraria for conducting teaching sessions and is a paid consultant for Biomet. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D. Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Shoulder Elbow Surg 2000;9:120-6. 2. Behounek J, Hrubina M, Skotak M, Krumpl O, Zahalka M, Dvorak J, et al. [Evaluation of surgical repair of distal biceps tendon ruptures]. Acta Chir Orthop Traumatol Cech 2009;76:47-53. 3. Bell RH, Wiley WB, Noble JS, Kuczynski DJ. Repair of distal biceps brachii tendon ruptures. J Shoulder Elbow Surg 2000;9: 223-6. 4. 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, http://dx.doi. org/10.1016/j.jse.2007.04.008 5. Bosman HA, Fincher M, Saw N. Anatomic direct repair of chronic distal biceps brachii tendon rupture without interposition graft. J Shoulder Elbow Surg 2012;21:1342-7, http://dx.doi.org/10.1016/j.jse. 2012.01.012 6. Cain RA, Nydick JA, Stein MI, Williams BD, Polikandriotis JA, Hess AV. Complications following distal biceps repair. J Hand Surg Am 2012;37:2112-7, http://dx.doi.org/10.1016/j.jhsa.2012.06.022 7. Dillon MT, Bollier MJ, King JC. Repair of acute and chronic distal biceps tendon ruptures using the EndoButton. Hand (N Y) 2011;6:3946, http://dx.doi.org/10.1007/s11552-010-9286-4 8. Duffiet P, Fontes D. [Endoscopic repair of distal biceps brachii tendon avulsion: a new technique. Report of 25 cases]. Chir Main 2009;28: 146-52, http://dx.doi.org/10.1016/j.main.2009.03.003 9. Greenberg JA, Fernandez JJ, Wang T, Turner C. EndoButton-assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 2003; 12:484-90, http://dx.doi.org/10.1016/S1058-2746(03)00173-3 10. Grewal R, Athwal GS, MacDermid JC, Faber KJ, Drosdowech DS, El-Hawary R, et al. Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am 2012;94:1166-74, http://dx.doi.org/10. 2106/JBJS.K.00436 11. Gupta RK, Bither N, Singh H, Kapoor S, Chhabra A, Garg S. Repair of the torn distal biceps tendon by endobutton fixation. Indian J Orthop 2012;46:71-6, http://dx.doi.org/10.4103/0019-5413.91638 12. Hastings H 2nd, Graham TJ. The classification and treatment of heterotopic ossification about the elbow and forearm. Hand Clin 1994;10: 417-37. 13. Heinzelmann AD, Savoie FH 3rd, Ramsey JR, Field LD, Mazzocca AD. A combined technique for distal biceps repair using a soft tissue button and biotenodesis interference screw. Am J Sports Med 2009;37:989-94, http://dx.doi.org/10.1177/0363546508330130 14. 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-A:1575-81.
1536 15. Kettler M, Lunger J, Kuhn V, Mutschler W, Tingart MJ. Failure strengths in distal biceps tendon repair. Am J Sports Med 2007;35: 1544-8, http://dx.doi.org/10.1177/0363546507300690 16. Khan AD, Penna S, Yin Q, Sinopidis C, Brownson P, Frostick SP. Repair of distal biceps tendon ruptures using suture anchors through a single anterior incision. Arthroscopy 2008;24:39-45, http://dx.doi.org/ 10.1016/j.arthro.2007.06.019 17. Klonz A, Loitz D, Wohler P, Reilmann H. 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 2003;12:607-11. http://dx.doi.org/10.1016/ S1058-2746(03)00212-X 18. Kodde IF, van den Bekerom MP, Eygendaal D. Reconstruction of distal biceps tendon ruptures with a cortical button. Knee Surg Sports Traumatol Arthrosc, 2013, http://dx.doi.org/10.1007/s00167-013-2571-3 19. Mazzocca AD, Bicos J, Arciero RA, Romeo AA, Cohen MS, Nicholson G. Repair of distal biceps tendon ruptures using a combined anatomic interference screw and cortical button. Tech Shoulder Elbow Surg 2005;6:108-15, http://dx.doi.org/10.1097/01.bte.0000160547. 61893.79 20. 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;35:252-8, http://dx.doi. org/10.1177/0363546506294854 21. 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; 14:302-6, http://dx.doi.org/10.1177/0363546506294854 22. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63: 872-7. 23. Naidu SH. Interference screw failure in distal biceps endobutton repair: case report. J Hand Surg Am 2010;35:1510-2, http://dx.doi.org/ 10.1016/j.jhsa.2010.06.016
M.C. Cusick et al. 24. Nigro PT, Cain R, Mighell MA. Prognosis for recovery of posterior interosseous nerve palsy after distal biceps repair. J Shoulder Elbow Surg 2013;22:70-3, http://dx.doi.org/10.1016/j.jse. 2012.08.001 25. Peeters T, Ching-Soon NG, Jansen N, Sneyers C, Declercq G, Verstreken F. Functional outcome after repair of distal biceps tendon ruptures using the endobutton technique. J Shoulder Elbow Surg 2009; 18:283-7, http://dx.doi.org/10.1016/j.jse.2008.10.004 26. Potapov A, Laflamme YG, Gagnon S, Canet F, Rouleau DM. Progressive osteolysis of the radius after distal biceps tendon repair with the bioabsorbable screw. J Shoulder Elbow Surg 2011;20:819-26, http://dx.doi.org/10.1016/j.jse.2011.02.021 27. Ranelle RG. Use of the Endobutton in repair of the distal biceps brachii tendon. Proc (Bayl Univ Med Cent) 2007;20:235-6. 28. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF. Tendonhealing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am 1993;75:1795-803. 29. Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N. Distal biceps tendon rupture: current concepts. Injury 2013;44:417-20, http://dx.doi.org/10.1016/j.injury.2012.10.029 30. 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;19:53-7, http://dx.doi.org/10.1016/j.jse.2009.05.007 31. Sharma DK, Goswami V, Wood J. Surgical repair of chronic rupture of the distal end of the biceps brachii. A modified anterior surgical repair technique. Acta Orthop Belg 2004;70:268-72. 32. Sharma S, MacKay G. Endoscopic repair of distal biceps tendon using an EndoButton. Arthroscopy 2005;21:897, http://dx.doi.org/10.1016/j. arthro.2005.04.001 33. Spang JT, Weinhold PS, Karas SG. A biomechanical comparison of EndoButton versus suture anchor repair of distal biceps tendon injuries. J Shoulder Elbow Surg 2006;15:509-14, http://dx.doi.org/10. 1016/j.jse.2005.09.020
www.elsevier.com/locate/ymse
Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw Michael C. Cusick, MDa, Benjamin J. Cottrell, BSb, Richard A. Cain, MDc, Mark A. Mighell, MDa,* a
Florida Orthopaedic Institute, Tampa, FL, USA Foundation for Orthopaedic Research and Education, Tampa, FL, USA c University of South Florida, Tampa, FL, USA b
Background: The use of cortical suspensory fixation in conjunction with an interference screw to treat distal biceps ruptures has yielded favorable results. However, literature examining the incidence of fixation failure in a large consecutive series of patients treated with this technique is lacking. Methods: A retrospective review of electronic medical records identified 170 distal biceps ruptures in 168 consecutive patients (164 men and 4 women) treated using a cortical button in conjunction with an interference screw. The study group was an average age of 48 years (range, 20-71 years). Records were reviewed from the time of the initial clinic visit to the most recent follow-up. Early failures were defined as those that occurred within 12 weeks of the index procedure. Failed repair was defined as tendon defect, deformity, or significant weakness in supination. Results: The early incidence of failure was 1.2%, with 2 of the fixations meeting the criteria for failure. One patient had significant brachial artery thrombosis. Other complications included posterior interosseous nerve palsy, lateral antebrachial cutaneous nerve-related complication, and numbness about the radial nerve. Conclusion: The use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Distal biceps repair; cortical button; cortical suspensory fixation; interference screw; complication rate; combined technique
Rupture of the distal biceps tendon typically occurs with a forced eccentric contraction, often in a middle-aged patient. Anatomic repair offers the potential for improved This study was determined to be exempt from review by the Western Institutional Review Board (WIRB). *Reprint requests: Mark A. Mighell, MD, Florida Orthopaedic Institute, 13020 N Telecom Pkwy, Tampa, FL 33637. E-mail address: [email protected] (M.A. Mighell).
strength, function, and cosmetic appearance. In 1985, Morrey et al22 demonstrated a 40% loss of supination strength and 30% loss of flexion strength in a cohort of patients treated nonoperatively and that strength was significantly improved by repair. Further studies have confirmed increased strength and endurance in patients after distal biceps repair.3,17,25 There are multiple methods for fixation of the distal biceps tendon, including suture through bone tunnels,
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.04.013
Rerupture in cortical button with screw suture anchors, interference screw fixation, and cortical suspensory fixation. Bain et al1 first described the use of a cortical button in 2000. Multiple biomechanical studies have shown that cortical fixation has a higher load to failure than other methods of fixation.15,20,33 In 2005, Mazzocca et al19 described a technique using a cortical suspensory device in conjunction with an interference screw. Biomechanical studies have shown that suspensory cortical button fixation exhibits maximum peak load to failure. In addition, Sethi et al30 demonstrated that the use of an interference screw significantly reduces gap formation at the repair site. Heinzelmann et al13 were the first to report tendon failure with the use of this technique. In a consecutive series of 41 patients, they reported no failures of fixation, fractures, or reruptures. The purpose of this study was to determine the early incidence of tendon rerupture after distal biceps repair using a cortical button and interference screw in a large consecutive series.
Materials and methods A consecutive series of elbows that underwent primary distal biceps repair by 6 fellowship-trained physicians between October 2006 and February 2013 were retrospectively identified. Clinical and operative notes were retrospectively reviewed by 2 staff members (R.A.C. and B.J.C.), not directly involved in patient care, to isolate distal biceps repairs and to determine the technique used. Inclusion criteria included any patient aged older than 18 years in which the technique described by Mazzocca et al19 was performed. A single vertical incision is placed 2 to 3 cm distal to the elbow flexion crease. In all cases, the lateral antebrachial cutaneous nerve is identified and protected. Tenotomy scissors are used to complete the dissection and to identify the biceps tendon. The tendon is retrieved with an Allis clamp, and a heavy whipstitch is placed within the substance of the tendon. The tendon end is bulletized to facilitate docking into the radial tunnel. The forearm is then maximally supinated to facilitate exposure of the radial tuberosity and prevent injury to the posterior interosseous nerve. Angled retractors are placed to expose the tuberosity. All traversing vessels are ligated with a bipolar cautery. We strongly discourage the use of a levered retractor radially to avoid traction injury to the posterior interosseous nerve. A 2.9-mm guide pin in placed centrally in the radial tuberosity, and the near cortex is opened with a 7.5-mm reamer. The tendon is repaired using a cortical button and tension-slide technique with the addition of a 7 10-mm interference screw (Arthrex, Naples, FL, USA; Fig. 1). Patients are immobilized in a splint for approximately 1 week, followed by 1 month of application of a range of motion brace to prevent terminal extension (locked from 30 -130 ). After 1 month, patients begin range of motion exercises as tolerated but are instructed to avoid lifting. Patients are permitted to do light lifting after 3 months. Our follow-up protocol involves a wound check visit at 7 to 10 days, and follow-up visits at 6 weeks, 3 months, and 6 months, at which time patients are told to follow-up as needed. The 3-month follow-up was required to evaluate for failed repair of the distal biceps in the early postoperative period. Elbow radiographs were performed in all patients at the 3-month follow-up
1533
Figure 1 Illustration shows the placement and orientation of the cortical button and interference screw implanted in the radial tuberosity. visit and reviewed by 3 independent reviewers for button placement, evidence of screw cut-out or fracture, osteolysis around the screw, and the presence of heterotopic bone. Heterotopic ossification (HO) was graded according to the classification of Graham and Hastings.12 This classification system divides HO into 3 groups, with class I representing subclinical lesions, class II representing bone formation that limits functional motion in any plane, and class III lesions representing complete ankylosis of the elbow.12 Exclusion criteria included repairs that required the use of allograft material and revision biceps repairs. Clinical and operative notes were reviewed for complications. The focus of the study was on acute failure of fixation and immediate perioperative complications; however, all complications observed to date are reported. Failed repair was defined as the clinical findings of a tendon defect, recurrence of deformity, or significant weakness of supination when compared with the contralateral side using the Medical Research Council grading system (0 to 5). Advanced imaging was only used in 1 patient with suspected failure to confirm the diagnosis.
Results This study identified 202 consecutive distal biceps repairs using the cortical button and interference screw. Of these, 170 repairs performed in 168 patients (164 men and 4 women) met the inclusion criteria. The average age at time of surgery was 48 years (range, 20-71 years). The average length of follow-up was 8 months (range, 3-61 months). Any complications that occurred outside of the minimum period of 3 months were also reported. The analysis excluded 32 patients (15.8%) whose follow-up was less than 3 months. According to the classification of Kelly et al,14 there were 41 acute repairs, 47 subacute repairs, and 82 delayed repairs. Evaluation of 3-month radiographs revealed subclinical grade I HO only. Two of the 170 elbows had an early failure of the repair for an incidence of 1.2%. There were no instances of early device failure in this study. In 1 patient, improper placement of the implant into the radial head resulted in
1534 Table I
M.C. Cusick et al. Studies in the literature with a patient population greater than 50 that documented the incidence of rerupture
First author (year)
Location
No.
Technique
Rate of rerupture % (No.)
Cain6 (2012) Grewal11 (2012) McKee24 (2005) Kelly14 (2000)
Tampa, FL, USA London, ON, Canada Toronto, ON, Canada Rochester, MN, USA
198 91 53 78
Various Suture anchor/transosseous drill holes Suture anchor Various
2.0 4.4 0.0 1.3
subsequent rerupture and revision surgery. In the second case, the patient had an injury while moving furniture and was felt to have failed fixation when examined in the clinic. Plain film radiographs showed that the button had not migrated. However, magnetic resonance imaging confirmed failure at the myotendinous junction proximal to the weaved suture. This was a failure of tendon biology in an elderly man, who opted for nonsurgical management. The only major intraoperative complication was a brachial artery thrombosis that required a thrombectomy. This was identified immediately after tourniquet deflation. The artery was traced distally and was patent. Intraoperative Doppler could not identify a radial pulse. A vascular surgery consultation was obtained emergently, and a thrombectomy was performed. No further intervention was required, and the patient recovered uneventfully. The etiology of the thrombosis remains unclear; however, it could have been due to traction or compression resulting in an intimal tear. Three patients (2.3%) developed postoperative posterior interosseous nerve (PIN) palsy. In each patient, spontaneous recovery was observed without further surgical intervention. No proximal radial fractures occurred intraoperatively or in the early postoperative period. Minor complications were observed in 12.9% of patients. There were 22 superficial neuropathies associated with surgery. These included numbness about the lateral antebrachial cutaneous nerve (LABCN) in 17 of 170 repairs (10%), 2 patients (1.5%) with radial nerve numbness (superficial sensory branch), and 3 patients (2.3%) with unspecified numbness around the surgical site. Spontaneous recovery was observed in all patients without further intervention.
Discussion Multiple series have reported good clinical results with the use of a cortical button device to fix distal biceps injuries.1,5,7,9,11,18,25,27,32,33 In contrast, relatively few series have reported the clinical results using a button type device in conjunction with an interference screw.13,19,23 The rationale for using this method of fixation rather than a cortical suspensory device alone is to decrease the cyclical motion at the tendon-to-bone interface.19 Biomechanical analysis has shown that interference fixation has the least motion with cyclical loading, whereas the cortical button has the highest load to failure (440 N).20 The potential advantages afforded by the addition of the interference screw may impart
(4) (4) (0) (1)
increased stability and reduce gap formation in the immediate postoperative period. However, we note that this advantage is theoretical. Another potential benefit is to position the tendon ulnarly within the tunnel with placement of the interference screw. This may provide a mechanical advantage for supination strength by approximating the native footprint of the biceps tendon. Obtaining secure fixation of the tendon is critical to allow early rehabilitation and provide adequate strength to avoid rerupture. Most distal biceps case series are relatively small, with fewer than 50 patients and sparse reports of rerupture.2-5,7,8,11,13-18,25,27,31 Larger studies, between 50 and 200 cases of biceps repair, reported a rerupture rate between 0% and 4%.6,10,14,21 (Table I) The rerupture rate of 1.2% in the early postoperative period in the current study was comparable with other large series. Kelly et al14 defined 3 time periods between biceps tear and biceps repair: acute, with less than 10 days to repair, subacute, with between 10 and 21 days to repair, and delayed, with greater than 21 days to repair. The study reported increased complications in patients treated in a delayed period compared with the acute and subacute repairs.14 In our series, a complication occurred in 7.3% (3 of 41) of acute repairs, in 13% (6 of 47) of subacute repairs, and in 20% (16 of 82) of delayed repairs. The 2 patients who reruptured and the patient with brachial artery thrombosis were delayed repairs. A technical complication reported in this study was the incorrect placement of the implant in the radial head instead of the radial tuberosity. This malposition resulted in early failure of the repair, necessitating revision surgery. This mistake can be made despite surgeon experience and stresses the importance of C-arm fluoroscopy during the case to confirm correct placement of the cortical suspensory fixation and interference screw. The relative size of the interference screw compared to the radius has led some to express concern about the potential for fracture of the proximal radius. A case series by Potapov et al26 discussed the rates of osteolysis in patients whose biceps tear was treated with an interference screw. The study concluded that there is a significant chance of osteolysis in the proximal radius after interference screw fixation. Because osteolysis reduces bone volume, the study surmised that this reduced bone volume could lead to fracture.26 However, their study found no significant functional or clinical differences in patient outcomes. The Potapov et al26 study also evaluated osteolysis rates using poly-L-lactide interference screws. Polyether ether ketone
Rerupture in cortical button with screw interference screws were used in our study, and no reports investigating rates of polyether ether ketone osteolysis in vivo are available in the literature. In our current series of 170 patients, no acute fractures of the proximal radius were identified radiographically at the 3-month follow-up visit. Further radiographs were not routinely taken, but we are not aware of any fractures to date. Several reports have tracked the rates of minor complications, such as occurred in our study, for patients treated with different repair techniques. The most common complication in this study was numbness about the LABCN, with an early rate of 10%. This is comparable to the literature for biceps repair in general, which has reported LABCN-related complications in 3% to 26% of patients.4,6,10,14,21,29 Other specific cases of nerve injury included PIN palsy, which developed in 2.3% of the study population. These are also comparable to the literature, which report PIN-related complications between 1% and 9%.6,14,21,24 One criticism of this study is that we lack information on the functional results of this repair method. Specifically, we cannot clearly state that this fixation technique provides long-term clinical benefit compared with other types of repair. The theoretical improvement provided by this method is reduced rehabilitation time and earlier active motion postoperatively. A dynamometer was not used to measure supination strength postoperatively; rather, the patients were clinically tested using the Medical Research Council grading system (0 to 5), and results were compared with the unaffected side. Another weakness was a relatively short length of follow-up. The short-term complication rate may not be a complete representation of the long-term rate. Our rationale for selecting a 3-month follow-up time to determine tendon healing was based on animal studies of tendon healing in a bone tunnel by Rodeo et al.28 Their study reported that most tendon strength was gained in the first 12 weeks after transplantation. In addition, they found that the tendon strength to failure did not significantly improve (P ¼ .28) between 12 and 26 weeks after transplantation.28 It should be noted that all complications outside of the 3-month window have been reported for completeness of this study.
Conclusions The early incidence of distal biceps reruptures using a cortical button in conjunction with an interference screw is 1.2% in this study. The etiology of the rerupture was not device related in either patient. This is the first large consecutive series of distal biceps repairs using cortical suspensory fixation in conjunction with an interference screw. We recommend this technique as a safe option for distal biceps fixation with a comparable early postoperative rerupture rate compared with other reported techniques.
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Disclaimer Mark A. Mighell receives royalties from UPex (Newclip Technics). He also received consulting fees or honoraria for conducting teaching sessions and is a paid consultant for Biomet. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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