Musculoskelet Surg DOI 10.1007/s12306-014-0314-3
ORIGINAL ARTICLE
Repair of distal biceps tendon acute ruptures with two suture anchors and anterior mini-open single incision technique: clinical follow-up and isokinetic evaluation A. Gasparella • D. Katusic • A. Perissinotto A. Miti
•
Received: 2 December 2013 / Accepted: 28 January 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Background All the techniques described in literature for treatment of acute distal biceps tendon ruptures provide good functional outcomes. The purpose of this study is to report the results of a single limited-incision technique for repair of acute distal biceps ruptures using two suture anchors. Materials and methods Fourteen patients, all man, were treated consecutively from one author between January 2009 and December 2011 and evaluated at a mean followup of 26 months. All patients were evaluated clinically, through DASH and MEPS score questionnaires, and with isokinetic biomechanical tests. Results All patients achieved complete elbow flexion and extension. Deficit for supination of the forearm was found in only two patients (7° and 13°). Mean DASH score was 4.7 points, and mean MEPS was excellent (96.8 points). There was no nervous complication involving posterior interosseous nerve (PIN) and no case of failure of the sutures. The isokinetic evaluation detected an average flexion strength increase by 10.2 % compared to the opposite arm not operated.
A. Gasparella (&) Department of Orthopaedic and Trauma Surgery, University of Padua, Padua, Italy e-mail: [email protected] D. Katusic A. Miti U.O.C. Orthopaedic Trauma Center, Ospedale dell’Angelo, Venice, Italy A. Perissinotto U.O. Biomechanics Center, Ospedale dell’Angelo, Venice, Italy
Conclusion Our study shows that mini-open access and fixation with two suture anchors achieved in medium-term excellent functional and cosmetic results needed short rehabilitation times and is minimally invasive. Keywords Distal biceps tendon Repair Suture anchor Mini-open technique
Background Distal biceps tendon is the strongest of human body and the most important flexion-supinator muscle of the forearm. Avulsion of distal tendon from the radial tuberosity is a rare event, with an annually incidence of 1.2 per 100.000, and account for a 10 % of total lesions of brachialis biceps muscle. Partial avulsion in most cases remains without surgical treatment [1]. It occurs most commonly in men participating in sports or hard-working activities, and middleaged from 40 to 60 years [2]. In women, the injury occurs later in life, and it is most often partial [3]. It happens following indirect trauma, and the most common mechanism of injury remains a forceful eccentric contraction of the muscle with extended forearm and flexed-supinated elbow (for example trying to stop unexpected weight force). The aetiology is most likely multifactorial, involving mainly mechanical (repeated forces in completed pronosupination) and hypo vascular factors, which lead to the tendon degeneration [2]. Predisposing factors have been shown to be associated with less favourable outcome following repair including age, rheumatologic pathology (AR, LES, gotta), history of smoking and the use of anabolic steroids for long time [4],
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which also appear to influence functional recovery after surgery [5]. Diagnosis of a biceps tendon rupture is based mainly on clinical examination: acute pain (severe at first) in antecubital fossa and twisting the forearm in supination, visual and palpatory deformity (Popeye sign, hook test) [6] and sometimes brushing and functional impotence. Also the squeeze test, similar to the Thompson sign for the Achilles tendon rupture, has proven to be highly effective in the diagnosis of distal biceps tendon rupture [7]. Morrey has codified the three absolute diagnostic criteria of complete rupture of the distal head of the biceps brachii: report of a traumatic event, gross and palpable signs of retraction proximally of the distal head, partial loss of strength in flexion and supination of the forearm [38]. In a recent article [40], there was evidence that application in sequence of the hook test, the passive forearm pronation (PFP) test and the biceps crease interval (BCI) test results in 100 % sensitivity and specificity when the outcomes on all three special tests are in agreement; diagnosis was subsequently confirmed with high-quality soft tissue imaging (MRI or ultrasound). The imaging is not essential, but gold-standard instrumental examination is US, while MRI is reserved for cases of partial tears or doubful diagnosis [8]. Stark first described distal biceps tendon rupture in 1843. Since 1940, conservative treatment was the primary choice even in young patients, with the inability of the tendon to reintegrate spontaneously in anatomical side: conservative management compared to operative treatment showed a decrease in flexion strength (88 % respect 97 %) and supination strength (74 % respect 101 %) of forearm compared with the normal contralateral side [9–11]. The choice between conservative or surgical treatment depends on the type of injury (acute or chronic, partial or total), the patient’s age and functional demands [12]. Without surgery, there is a good chance that the patient will notice weakness, during activities requiring forceful supination (e.g., using a screwdriver). Surgery aims to achieve a ‘‘restitutio ad integrum’’ of injured anatomical structures and should be practised as soon as possible for smaller tendon retraction [27]. Surgical approach takes place mainly in two techniques: single incision Henry approach or classic Boyd Anderson’s two-incision technique with later changes [13]. There is no consensus regarding the surgical approach or the best method of fixation [14, 15], the choice depends on the experience and preferences of surgeon. Fixation can occur with various procedures: bone tunnel (310 N), endobutton (439 N) [16] and suture anchor (381 N) [17].
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Suture anchor compared to others facilitates anatomical fixation and reduces bone exposure, the incidence of ossification and injuries to the posterior interosseous nerve [18, 19, 41].
Materials and methods Between January 2009 and December 2011, we treated 18 consecutive patients with acute rupture of distal biceps tendon. All the patients were men, and their average age at injury was 44.6 (range 25–66) years. The mean follow-up time was 26 months. The average time interval from injury to surgery was 5 ± 3 (range 1–11) days. All patients underwent primary anatomical reattachment of the biceps tendon onto the radial tuberosity using a single mini-open anterior approach and fixation with two suture anchors. The patients with partial tendon injury treated conservatively were excluded from the study. Fourteen of all patients operated accepted to participate to the study. The lesion involved for 85 % of the non-dominant extremity. At admission and discharge from hospital, radiographic examination was performed (AP, LL and oblique projections) to assess whether bone lesions were present. In all patients, a direct reinsertion, without the use of allograft or augmentation, was performed. All patients were evaluated clinically using the MEPS (Mayo Elbow Performance Score) and the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire, with additional modules for work and sport, universally regarded as valid and effective test for specific pathology of the upper limb [23], both with a score from 0 to 100. We assessed the range of motion (ROM) of the elbow with the patient erected for flexion–extension measures and sat with his elbow on a rigid table, holding a pencil with his hand, for the prono-supination; measurements were performed with a goniometer. Surgical technique The mean operative time was 63 ± 26 min. After plexus anaesthesia (axillary or supraclavicular block), the patient was placed in the supine position with the elbow extended and the forearm supinated on an arm board. All operations were performed by the senior surgeon (A.M.). We gave short-term antibiotic prophylaxis (Cefazolin 2 g IV as a single dose). A pneumatic tourniquet is applied on the proximal arm and inflated. We have used a mini-open anterior approach to radius [20], and a transverse 4 cm skin incision is then made
Musculoskelet Surg
Fig. 2 Proper placemen of spreaders
Fig. 1 Short skin incision and mini-open anterior access
slightly laterally in the antecubital area (about 3.5–4 cm or two transverse fingers distal to the flexion crease), slightly proximal to the skin projection of the bicipital tuberosity of the radius. Antecubital veins and the lateral antecubital cutaneous nerve are encountered while approaching, and they are all protected (Fig. 1). Although a longitudinal incision is better for exposure, a transverse incision is advisable from a cosmetic point of view and does not compromise exposure in acute cases. The tendon stump has always been found through a simple operation of ‘‘squeezing’’ of the front face of the arm in proximal–distal direction. Normally (in all cases operated by us), the tendon stump is found at the proximal margin of the surgical wound superficial to the brachialis fascia. We have always cut it. By blunt retraces, the space left empty by the tendon and is identified by palpation with the finger the radial tuberosity keeping the forearm in maximally forced supination. We placed 4 mini-Hohmann retractors on the medial and lateral side of radial tuberosity in addition to a spreader useful to expose the distal margin at the time of insertion of the anchors. Carefully give attention not to over-drag the soft tissue with the spreader as an exhibition too distal of tuberosity endangers the interosseous posterior nerve (Fig. 2). Then, we fit two anchors armed with non-resorbable wire (3.5 or 4 mm according to the size of the radio) perpendicular to the cortical and spaced about 1 cm, one in the distal part for the component of the short head and the other in the proximal part for the long head [21, 22] (Figs. 3, 4).
Figs. 3–4 Radiographs in two projections show the proper positioning of anchors
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Before isokinetic muscle testing, all patients warmed up with an arm-cycloergometer for 4 submaximal repetitions and then perform the true test for other 4 repetitions, all at each different angular velocity. Both arms were tested, the uninvolved side first, to asses the function of the involved side as percentage of the normal side.
Postoperative rehabilitation
Fig. 5 Krachow suture for each tendon bundles
We sketched the two proximal and distal tendon bundles with a wire each one originating from a single still and with Krachow suture (Fig. 5). The sutures are progressively made to slide through the eyelet of the anchor distal first, then proximal. The elbow should be flexed about 45°–60°. Of fundamental importance is to ensure that there is an optimal flow of sutures, paying maximum attention to that there are no obstacles to it and the tendon can slide freely in its proper position or direction. We performed abundant washing with saline solution to prevent heterotopic ossification and release the torniquet, and performed adequate hemostasis before the skin suture, to minimize the postoperative edema. Muscle strength assessment Isokinetic muscle testing was performed using the Cybex 350 dynamometer and its accompanying software for data analysis. The patient was supine, with free shoulder and arm placed on fixed stand; tests were performed at 90°/s in all subjects, at velocity of 60°/s and 105°/s in some subjects of interest, corresponding to the normal activity and work in general (for example: normal adjustment position and gestures, maintaining prolonged neck position—shoulder—hand). The conformation of the curve, that describes the movement, was evaluated using the interpolation of performed repetitions, for both the healthy side that for one operated.
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We followed our rehabilitation protocol consisting of 7-day immobilization in posterior elbow splint of FractomedÒ which held elbow flexed to 90° and the forearm supinated. At 7 days, the splint was removed; we apply a bag sling and start gradual mobilization, for two–three times a week, with passive flexion and active-assisted extension of the elbow under the supervision of a rehabilitation therapist. At the same time, we also used a passive mobilizer twice a day for 20 min each session and for about 20 days. During the 2 weeks postoperative, until removal of skin sutures, extension of elbow is limited in 30°. From 5th week, the bag sling is removed and muscle reinforcement is started in flexion/supination with maximum weight force of 2–2.5 kg. From 10th week, muscle reinforcement increased progressively with greater loads. Strengthening exercises and full activities are permitted 3 months after surgery.
Results The mean DASH score was 4.7 ± 6.3 points (range 0–20), in line with the average score in the control population (6.2 points), but better than other studies in the literature [24, 25]: the best result has been obtained in patients with heavy work. All patients were satisfied with the postoperative result, have returned to normal daily activities and/or work (the Work Module mean DASH score was 2.7 ± 5.9 points); 20 % complained of mild discomfort during sports activities (the DASH Sports/Performing Arts Module mean score was 14.7 ± 2.9 points, worse in patients who practise tennis or gym). Mean Mayo elbow performance score (MEPS) was excellent, resulting in 96.8 points. No patient had an appreciable loss of flexion/extension of the elbow. The prono-supination of the forearm is complete in all patients, except in two patients where we found a deficit in supination (7° and 13°) and in a patient with a deficit of pronation (20°). There was no clinical evidence of pain, stiffness, or heterotopic ossification (HO), neither of re-ruptures of the tendon.
Musculoskelet Surg
From the results of biomechanical tests, we detected a proper kinematic with conformation of the curve that describes the movement not substantially altered (no alteration of the sequence and execution of the movement and in particular without the presence of significant flexibility and\or alterations of the succession of peaks). Such uniformity is present in all repetitions and it is also evident in the tests performed at 105°/s in the speed movement performed and in the tests at 60°/s under stress, establishing itself as a matter of course significantly. It is an indication of the absence of pain, good coordination of gesture and a well-performed rehabilitation. No patients detected any deficit of the PMF (maximum peak flexion torque) and of the LER (work undertaken by repetition), both under intense or coordinated effort.
Discussion In our series, compared with data from the literature, we found in two patients (14 %) long-term paraesthesia in the distribution of the lateral antebrachial cutaneous nerve (from 7 to 25 % of cases in the literature) [25, 26], but no damage to the posterior interosseous nerve (5 % of cases in the literature) [24] nor the superficial radial nerve. The dominant side was involved in only 15 % of examined patients, this differs from literature by Safran and Graham [2], which showed an involvement of the dominant side in 86 % of cases: most recent data, however, a predominance of the non-dominant side [27]. Morrey et al. [28] compared the repair of the tendon within 10 days (acute), between 10 and 21 days (subacute) and after 22 days (late chronic) and observed that the more you delay the repair tendon, the greater is the risk of complications. In our series, the patient operated after 11 days from trauma got the worst result in test scores. An early repair of the tendon is technically easier and it also provide a better wound healing, according to recent studies of MRI [29]. There has been no failure of the sutures, that is a rare complication, but at greater risk in the fixation with anchors [25, 27]. It was not necessary to release the ‘‘lacertus fibrosus’’ to release the tendon (increased risk of injury of the radial artery). We did not find any complication with the use of Torniquet nor we had to run detensioning sutures with the brachialis muscle [31]. The results of biomechanics tests are indicative of a correct and stable position of the anchors that generates a continuous curve without significant flexibility in the first 15° of flexion. The correct insertion of the anchors is
Fig. 6 Clear anatomical distinction of tendon bundles: the long head, fusiform, and the short head, widest and thinner
important in inducing proper parallelism and synergistic action of the flexor forces; otherwise, it alters the direction and generates an effect of tension/rotation not physiological. It should be noted that a positioning problem (which alters the direction of the vector component of contractile muscle) would have shown an alteration of the curve due to an adjustment muscle/tendon junctional character, with the appearance of foci by scrolling between several bundle components. The goal of surgical fixation with suture anchor is that it is the only technique to obtain a true anatomical repair of the injured tendon [20, 21, 42], with one anchor for each end of the tendon, both short and long head (Fig. 6), and well-proportioned to the right size of the radial tuberosity [32]. The short head in neutral position and pronation is an important flexor of the elbow, while the long head at 60° of supination of the forearm has a greater moment of force [33]. The strain of the two heads must be optimal: when we operated a partial tear of the tendon with separation, [50 % is appropriate to completely disconnect the tendon before its reinsertion [34]. The position of the anchor is important for best results, as much as possible an anatomical collocation does not alter the lever arm and forearm rotation [35]. In the majority of patients (64 %), we used 3,5 mm anchors. Also in cadaver studies, the use of two anchors guarantees a greater resistance to stress [16], shown to be higher than transosseous bone tunnel [36], reducing the risks of possible failures [37] during postoperative rehabilitation terapies, when the applied forces are greater [38].
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Fig. 7 Flexion strenght of operated side compared to the normal opposite arm after physiotherapy
Conclusion Distal biceps tendon repair with anchors associated with single mini-open access [30] is an excellent solution for treatment of these lesions. We believe that mini-open anterior access gives enough surgery vision, is less invasive, requires minimal dissection of the soft tissues and is subject to fewer complications [13]. The tests measured the flexion strength that was on average 10.2 % higher than in the unoperated side, a result comparable with P. Sarda et al. [39] who measured flexion strength of 19.8 %, when compared to the normal opposite arm (Fig. 7). Of course, this can be interpreted as dependent on muscle strengthening in the course of rehabilitation, but it is also a true indicator of a good surgical outcome. The procedure is minimally invasive, and we achieved in medium-term excellent functional and cosmetic results and short rehabilitation times. Conflict of interest All authors hereby declare they have no financial or personal relationship with other peolpe or organisations that could inappropriately influence (bias) their work.
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5. Pagonis T, Givissis P, Ditsios K (2011) The effect of steroidabuse on anatomic reinsertion of ruptured distal biceps brachii tendon. Injury 42(11):1307–1312 6. O’Driscoll SW, Goncalves LB, Dietz P (2007) The hook test for distal biceps tendon avulsion. Am J Sports Med 35(11): 1865–1869 7. Ruland RT, Dunbar RP (2005) Bowen JD the biceps squeeze test for diagnosis of distal biceps tendon ruptures. Clin Orthop Relat Res 437:128–131 8. Weiss C, Mittelmeier M, Gruber G (2000) Do we need MR images for diagnosing tendon ruptures of the distal biceps brachii? The value of ultrasonography imaging. Ultraschall Med 21(6):284–286 9. Freeman CR, McCormick KR, Mahoney D, Baratz M, Lubahn J (2009) Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. J Bone Jt Surg Am 91:2329–2334 10. Chillemi C, Marinelli M, De Cupis V (2007) Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertion–clinical and radiological evaluation after 2 years. Arch Orthop Trauma Surg 127(8):705–708 Epub 2007 Apr 28 11. Klonz A, Loitz D, Reilmann H (2003) Proximal and distal ruptures of the biceps brachii tendon. Unfallchirurg 106:755–763 12. Freeman CR, McCormick K, Mahoney D, Baratz M, Lubahn J (2009) Nonoperative treatment of distal Biceps tendon ruptures compared with a historical control group. J Bone Jt Surg 91:2329–2334 13. Boyd MM, Anderson LD (1961) A method for reinsertion of the distal biceps brachii tendon. J Bone Jt Surg 43A:1041–1043 14. Keener JD (2011) Controversies in the surgical treatment of distal biceps tendon rupture: single versus double incision repairs. J Shoulder Elbow Surg 20(2Suppl):S113–S125 15. Grewal R, Athwal GS, Macdermid IC, Faber KJ, King GJ (2012) Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Jt Surg Am 94(13):1166–1174 16. Greenberg JA, Fernandez JJ, Wang T, Turner C (2003) Endobutton assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 12:484–490 17. Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA, Arciero RA (2007) Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med 35(2): 252–258 18. Rampoldi M, Cammarano G, De Peppo M, Piccioli A, Gentilucci F (2001) Rottura del tendine distale del bicipite brachiale: riparazione con ancorette in titanio, Riv Chir Mano, vol. 38(3) 19. Morrison KD (2002) Hunt TR comparing and contrasting methods for tenodesis of the ruptured distal biceps tendon. Hand Clin 18(1):169–178 20. Klonz A, Loitz D, Reilmann H (2002) Technique of distal biceps tendon repair using a limited anterior approach. Unfallchirurg 105(9):837–842 21. Eames MH, Bain GI, Fogg QA, van Riet RP (2007) Distal biceps tendon anatomy: a cadaveric study. J Bone Jt Surg Am 89(5): 1044–1049 22. Cho CH, Song KS, Choi IJ, Kim DK, Lee JH, Kim HT, Moon YS (2011) Insertional anatomy and clinical relevance of the distal biceps tendon. Knee Surg Sports Traumatol Arthrosc 19(11): 1930–1935 23. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C (2001) Measuring the whole or the parts? Validity, reliability, and responsiveness of the disabilities of the arm, shoulder and hand outcome measure in different regions of the upper extremity. J Hand Ther 14(2):128–146 24. McKee MD, Hirji R, Schemitsch EH, Wild LM, Waddell JP (2005) Patient-oriented functional outcome after repair of distal
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35. Schmidt CC, Weir DM, Wong AS, Howard M, Miller MC (2010) The effect of biceps reattachment site. J Shoulder Elbow Surg 19(8):1157–1165 36. Lemos SE, Ebramzedeh E, Kvitne RS (2004) A new technique: in vitro suture anchor fixation ha superior yield strength to bone tunnel fixation for distal biceps tendon repair. Am J Sports Med 32:406–410 37. Weber O, Pagenstern G, Wirtz DC, Burger C, Wimmer M, Pennekamp PH, Gravius S, Muller M (2011) Refixation of distal biceps tendon rupture using 2 anchor sutures-sports ability after 1 year follow-up and operative technique. Sportverletz Sportschaden 25(2):97–192 38. Shukla DR, Morrey BF, Thoreson AR, An KN, O’Driscoll SW. Distal biceps tendon rupture: an in vitro study.Clin Biomech (Bristol, Avon). 2012 Mar;27(3):263-7. Epub 2011 Oct 24 39. Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N (2013) Distal biceps tendon rupture: current concepts. Injury 44(4):417–420 40. Moira W Devereaux, Amr W ElMaraghy (2013) Improving the rapid and reliable diagnosis of complete distal biceps tendon rupture: a nuanced approach to the clinical examination. Am J Sports Med 41(9) 41. Banerjee M, Shafizadeh S, Bouillon B, Tjardes T, Wafaisade A, Balke M (2013) High complication rate following distal biceps refixation with cortical button. Arch Orthop Trauma Surg 133(10):1361–1366 42. Carita` E, Cassini M, Ricci M, Corain M, Donatelli A, Cugola L (2009) Reinsertion of the distal head of the biceps using minianchors and the anterior access: a retrospective study. Musculoskelet Surg 93:21–25
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ORIGINAL ARTICLE
Repair of distal biceps tendon acute ruptures with two suture anchors and anterior mini-open single incision technique: clinical follow-up and isokinetic evaluation A. Gasparella • D. Katusic • A. Perissinotto A. Miti
•
Received: 2 December 2013 / Accepted: 28 January 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Background All the techniques described in literature for treatment of acute distal biceps tendon ruptures provide good functional outcomes. The purpose of this study is to report the results of a single limited-incision technique for repair of acute distal biceps ruptures using two suture anchors. Materials and methods Fourteen patients, all man, were treated consecutively from one author between January 2009 and December 2011 and evaluated at a mean followup of 26 months. All patients were evaluated clinically, through DASH and MEPS score questionnaires, and with isokinetic biomechanical tests. Results All patients achieved complete elbow flexion and extension. Deficit for supination of the forearm was found in only two patients (7° and 13°). Mean DASH score was 4.7 points, and mean MEPS was excellent (96.8 points). There was no nervous complication involving posterior interosseous nerve (PIN) and no case of failure of the sutures. The isokinetic evaluation detected an average flexion strength increase by 10.2 % compared to the opposite arm not operated.
A. Gasparella (&) Department of Orthopaedic and Trauma Surgery, University of Padua, Padua, Italy e-mail: [email protected] D. Katusic A. Miti U.O.C. Orthopaedic Trauma Center, Ospedale dell’Angelo, Venice, Italy A. Perissinotto U.O. Biomechanics Center, Ospedale dell’Angelo, Venice, Italy
Conclusion Our study shows that mini-open access and fixation with two suture anchors achieved in medium-term excellent functional and cosmetic results needed short rehabilitation times and is minimally invasive. Keywords Distal biceps tendon Repair Suture anchor Mini-open technique
Background Distal biceps tendon is the strongest of human body and the most important flexion-supinator muscle of the forearm. Avulsion of distal tendon from the radial tuberosity is a rare event, with an annually incidence of 1.2 per 100.000, and account for a 10 % of total lesions of brachialis biceps muscle. Partial avulsion in most cases remains without surgical treatment [1]. It occurs most commonly in men participating in sports or hard-working activities, and middleaged from 40 to 60 years [2]. In women, the injury occurs later in life, and it is most often partial [3]. It happens following indirect trauma, and the most common mechanism of injury remains a forceful eccentric contraction of the muscle with extended forearm and flexed-supinated elbow (for example trying to stop unexpected weight force). The aetiology is most likely multifactorial, involving mainly mechanical (repeated forces in completed pronosupination) and hypo vascular factors, which lead to the tendon degeneration [2]. Predisposing factors have been shown to be associated with less favourable outcome following repair including age, rheumatologic pathology (AR, LES, gotta), history of smoking and the use of anabolic steroids for long time [4],
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which also appear to influence functional recovery after surgery [5]. Diagnosis of a biceps tendon rupture is based mainly on clinical examination: acute pain (severe at first) in antecubital fossa and twisting the forearm in supination, visual and palpatory deformity (Popeye sign, hook test) [6] and sometimes brushing and functional impotence. Also the squeeze test, similar to the Thompson sign for the Achilles tendon rupture, has proven to be highly effective in the diagnosis of distal biceps tendon rupture [7]. Morrey has codified the three absolute diagnostic criteria of complete rupture of the distal head of the biceps brachii: report of a traumatic event, gross and palpable signs of retraction proximally of the distal head, partial loss of strength in flexion and supination of the forearm [38]. In a recent article [40], there was evidence that application in sequence of the hook test, the passive forearm pronation (PFP) test and the biceps crease interval (BCI) test results in 100 % sensitivity and specificity when the outcomes on all three special tests are in agreement; diagnosis was subsequently confirmed with high-quality soft tissue imaging (MRI or ultrasound). The imaging is not essential, but gold-standard instrumental examination is US, while MRI is reserved for cases of partial tears or doubful diagnosis [8]. Stark first described distal biceps tendon rupture in 1843. Since 1940, conservative treatment was the primary choice even in young patients, with the inability of the tendon to reintegrate spontaneously in anatomical side: conservative management compared to operative treatment showed a decrease in flexion strength (88 % respect 97 %) and supination strength (74 % respect 101 %) of forearm compared with the normal contralateral side [9–11]. The choice between conservative or surgical treatment depends on the type of injury (acute or chronic, partial or total), the patient’s age and functional demands [12]. Without surgery, there is a good chance that the patient will notice weakness, during activities requiring forceful supination (e.g., using a screwdriver). Surgery aims to achieve a ‘‘restitutio ad integrum’’ of injured anatomical structures and should be practised as soon as possible for smaller tendon retraction [27]. Surgical approach takes place mainly in two techniques: single incision Henry approach or classic Boyd Anderson’s two-incision technique with later changes [13]. There is no consensus regarding the surgical approach or the best method of fixation [14, 15], the choice depends on the experience and preferences of surgeon. Fixation can occur with various procedures: bone tunnel (310 N), endobutton (439 N) [16] and suture anchor (381 N) [17].
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Suture anchor compared to others facilitates anatomical fixation and reduces bone exposure, the incidence of ossification and injuries to the posterior interosseous nerve [18, 19, 41].
Materials and methods Between January 2009 and December 2011, we treated 18 consecutive patients with acute rupture of distal biceps tendon. All the patients were men, and their average age at injury was 44.6 (range 25–66) years. The mean follow-up time was 26 months. The average time interval from injury to surgery was 5 ± 3 (range 1–11) days. All patients underwent primary anatomical reattachment of the biceps tendon onto the radial tuberosity using a single mini-open anterior approach and fixation with two suture anchors. The patients with partial tendon injury treated conservatively were excluded from the study. Fourteen of all patients operated accepted to participate to the study. The lesion involved for 85 % of the non-dominant extremity. At admission and discharge from hospital, radiographic examination was performed (AP, LL and oblique projections) to assess whether bone lesions were present. In all patients, a direct reinsertion, without the use of allograft or augmentation, was performed. All patients were evaluated clinically using the MEPS (Mayo Elbow Performance Score) and the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire, with additional modules for work and sport, universally regarded as valid and effective test for specific pathology of the upper limb [23], both with a score from 0 to 100. We assessed the range of motion (ROM) of the elbow with the patient erected for flexion–extension measures and sat with his elbow on a rigid table, holding a pencil with his hand, for the prono-supination; measurements were performed with a goniometer. Surgical technique The mean operative time was 63 ± 26 min. After plexus anaesthesia (axillary or supraclavicular block), the patient was placed in the supine position with the elbow extended and the forearm supinated on an arm board. All operations were performed by the senior surgeon (A.M.). We gave short-term antibiotic prophylaxis (Cefazolin 2 g IV as a single dose). A pneumatic tourniquet is applied on the proximal arm and inflated. We have used a mini-open anterior approach to radius [20], and a transverse 4 cm skin incision is then made
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Fig. 2 Proper placemen of spreaders
Fig. 1 Short skin incision and mini-open anterior access
slightly laterally in the antecubital area (about 3.5–4 cm or two transverse fingers distal to the flexion crease), slightly proximal to the skin projection of the bicipital tuberosity of the radius. Antecubital veins and the lateral antecubital cutaneous nerve are encountered while approaching, and they are all protected (Fig. 1). Although a longitudinal incision is better for exposure, a transverse incision is advisable from a cosmetic point of view and does not compromise exposure in acute cases. The tendon stump has always been found through a simple operation of ‘‘squeezing’’ of the front face of the arm in proximal–distal direction. Normally (in all cases operated by us), the tendon stump is found at the proximal margin of the surgical wound superficial to the brachialis fascia. We have always cut it. By blunt retraces, the space left empty by the tendon and is identified by palpation with the finger the radial tuberosity keeping the forearm in maximally forced supination. We placed 4 mini-Hohmann retractors on the medial and lateral side of radial tuberosity in addition to a spreader useful to expose the distal margin at the time of insertion of the anchors. Carefully give attention not to over-drag the soft tissue with the spreader as an exhibition too distal of tuberosity endangers the interosseous posterior nerve (Fig. 2). Then, we fit two anchors armed with non-resorbable wire (3.5 or 4 mm according to the size of the radio) perpendicular to the cortical and spaced about 1 cm, one in the distal part for the component of the short head and the other in the proximal part for the long head [21, 22] (Figs. 3, 4).
Figs. 3–4 Radiographs in two projections show the proper positioning of anchors
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Before isokinetic muscle testing, all patients warmed up with an arm-cycloergometer for 4 submaximal repetitions and then perform the true test for other 4 repetitions, all at each different angular velocity. Both arms were tested, the uninvolved side first, to asses the function of the involved side as percentage of the normal side.
Postoperative rehabilitation
Fig. 5 Krachow suture for each tendon bundles
We sketched the two proximal and distal tendon bundles with a wire each one originating from a single still and with Krachow suture (Fig. 5). The sutures are progressively made to slide through the eyelet of the anchor distal first, then proximal. The elbow should be flexed about 45°–60°. Of fundamental importance is to ensure that there is an optimal flow of sutures, paying maximum attention to that there are no obstacles to it and the tendon can slide freely in its proper position or direction. We performed abundant washing with saline solution to prevent heterotopic ossification and release the torniquet, and performed adequate hemostasis before the skin suture, to minimize the postoperative edema. Muscle strength assessment Isokinetic muscle testing was performed using the Cybex 350 dynamometer and its accompanying software for data analysis. The patient was supine, with free shoulder and arm placed on fixed stand; tests were performed at 90°/s in all subjects, at velocity of 60°/s and 105°/s in some subjects of interest, corresponding to the normal activity and work in general (for example: normal adjustment position and gestures, maintaining prolonged neck position—shoulder—hand). The conformation of the curve, that describes the movement, was evaluated using the interpolation of performed repetitions, for both the healthy side that for one operated.
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We followed our rehabilitation protocol consisting of 7-day immobilization in posterior elbow splint of FractomedÒ which held elbow flexed to 90° and the forearm supinated. At 7 days, the splint was removed; we apply a bag sling and start gradual mobilization, for two–three times a week, with passive flexion and active-assisted extension of the elbow under the supervision of a rehabilitation therapist. At the same time, we also used a passive mobilizer twice a day for 20 min each session and for about 20 days. During the 2 weeks postoperative, until removal of skin sutures, extension of elbow is limited in 30°. From 5th week, the bag sling is removed and muscle reinforcement is started in flexion/supination with maximum weight force of 2–2.5 kg. From 10th week, muscle reinforcement increased progressively with greater loads. Strengthening exercises and full activities are permitted 3 months after surgery.
Results The mean DASH score was 4.7 ± 6.3 points (range 0–20), in line with the average score in the control population (6.2 points), but better than other studies in the literature [24, 25]: the best result has been obtained in patients with heavy work. All patients were satisfied with the postoperative result, have returned to normal daily activities and/or work (the Work Module mean DASH score was 2.7 ± 5.9 points); 20 % complained of mild discomfort during sports activities (the DASH Sports/Performing Arts Module mean score was 14.7 ± 2.9 points, worse in patients who practise tennis or gym). Mean Mayo elbow performance score (MEPS) was excellent, resulting in 96.8 points. No patient had an appreciable loss of flexion/extension of the elbow. The prono-supination of the forearm is complete in all patients, except in two patients where we found a deficit in supination (7° and 13°) and in a patient with a deficit of pronation (20°). There was no clinical evidence of pain, stiffness, or heterotopic ossification (HO), neither of re-ruptures of the tendon.
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From the results of biomechanical tests, we detected a proper kinematic with conformation of the curve that describes the movement not substantially altered (no alteration of the sequence and execution of the movement and in particular without the presence of significant flexibility and\or alterations of the succession of peaks). Such uniformity is present in all repetitions and it is also evident in the tests performed at 105°/s in the speed movement performed and in the tests at 60°/s under stress, establishing itself as a matter of course significantly. It is an indication of the absence of pain, good coordination of gesture and a well-performed rehabilitation. No patients detected any deficit of the PMF (maximum peak flexion torque) and of the LER (work undertaken by repetition), both under intense or coordinated effort.
Discussion In our series, compared with data from the literature, we found in two patients (14 %) long-term paraesthesia in the distribution of the lateral antebrachial cutaneous nerve (from 7 to 25 % of cases in the literature) [25, 26], but no damage to the posterior interosseous nerve (5 % of cases in the literature) [24] nor the superficial radial nerve. The dominant side was involved in only 15 % of examined patients, this differs from literature by Safran and Graham [2], which showed an involvement of the dominant side in 86 % of cases: most recent data, however, a predominance of the non-dominant side [27]. Morrey et al. [28] compared the repair of the tendon within 10 days (acute), between 10 and 21 days (subacute) and after 22 days (late chronic) and observed that the more you delay the repair tendon, the greater is the risk of complications. In our series, the patient operated after 11 days from trauma got the worst result in test scores. An early repair of the tendon is technically easier and it also provide a better wound healing, according to recent studies of MRI [29]. There has been no failure of the sutures, that is a rare complication, but at greater risk in the fixation with anchors [25, 27]. It was not necessary to release the ‘‘lacertus fibrosus’’ to release the tendon (increased risk of injury of the radial artery). We did not find any complication with the use of Torniquet nor we had to run detensioning sutures with the brachialis muscle [31]. The results of biomechanics tests are indicative of a correct and stable position of the anchors that generates a continuous curve without significant flexibility in the first 15° of flexion. The correct insertion of the anchors is
Fig. 6 Clear anatomical distinction of tendon bundles: the long head, fusiform, and the short head, widest and thinner
important in inducing proper parallelism and synergistic action of the flexor forces; otherwise, it alters the direction and generates an effect of tension/rotation not physiological. It should be noted that a positioning problem (which alters the direction of the vector component of contractile muscle) would have shown an alteration of the curve due to an adjustment muscle/tendon junctional character, with the appearance of foci by scrolling between several bundle components. The goal of surgical fixation with suture anchor is that it is the only technique to obtain a true anatomical repair of the injured tendon [20, 21, 42], with one anchor for each end of the tendon, both short and long head (Fig. 6), and well-proportioned to the right size of the radial tuberosity [32]. The short head in neutral position and pronation is an important flexor of the elbow, while the long head at 60° of supination of the forearm has a greater moment of force [33]. The strain of the two heads must be optimal: when we operated a partial tear of the tendon with separation, [50 % is appropriate to completely disconnect the tendon before its reinsertion [34]. The position of the anchor is important for best results, as much as possible an anatomical collocation does not alter the lever arm and forearm rotation [35]. In the majority of patients (64 %), we used 3,5 mm anchors. Also in cadaver studies, the use of two anchors guarantees a greater resistance to stress [16], shown to be higher than transosseous bone tunnel [36], reducing the risks of possible failures [37] during postoperative rehabilitation terapies, when the applied forces are greater [38].
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Fig. 7 Flexion strenght of operated side compared to the normal opposite arm after physiotherapy
Conclusion Distal biceps tendon repair with anchors associated with single mini-open access [30] is an excellent solution for treatment of these lesions. We believe that mini-open anterior access gives enough surgery vision, is less invasive, requires minimal dissection of the soft tissues and is subject to fewer complications [13]. The tests measured the flexion strength that was on average 10.2 % higher than in the unoperated side, a result comparable with P. Sarda et al. [39] who measured flexion strength of 19.8 %, when compared to the normal opposite arm (Fig. 7). Of course, this can be interpreted as dependent on muscle strengthening in the course of rehabilitation, but it is also a true indicator of a good surgical outcome. The procedure is minimally invasive, and we achieved in medium-term excellent functional and cosmetic results and short rehabilitation times. Conflict of interest All authors hereby declare they have no financial or personal relationship with other peolpe or organisations that could inappropriately influence (bias) their work.
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