Musculoskelet Surg DOI 10.1007/s12306-015-0360-5
ORIGINAL ARTICLE
Treatment of distal biceps tendon rupture: why, when, how? Analysis of literature and our experience F. Giacalone1 • E. Dutto1 • M. Ferrero1 • M. Bertolini1 • A. Sard1 • I. Pontini1
Received: 21 August 2014 / Accepted: 11 March 2015 Ó Istituto Ortopedico Rizzoli 2015
Abstract Introduction The rupture of the distal biceps tendon is a relatively uncommon lesion. Even if conservative treatment may be an option in low demanding patients, young and active subjects may benefit from an early surgical reinsertion. Many techniques and fixation devices have been described, but in the literature, there are no clinical evidences that show the superiority of any of these. In this article, we report an analysis of the ‘‘state of the art’’ and our case series of surgical reinsertion with the double approach transosseous technique. Materials and methods Between 2003 and 2013, 26 patients underwent surgical reinsertion, either for acute or for chronic lesions of distal biceps tendon. We evaluated 21 acute cases treated with double approach using DASH and SECEC Elbow Scores. The mean follow-up was 22 months. Range of motion, supination and flexion strength were also recorded. Results Mean final ROM was 6–132° in F/E and 89–0– 87° in P/S; flexion and supination strength were 96 and 88 % compared to the opposite side. The main complications were two cases of heterotopic ossifications: one asymptomatic fracture of the proximal radius and one temporary neurapraxia of the radial nerve. Conclusions Analysing the literature and our outcomes, we underline the importance of timing for surgery, in
& F. Giacalone [email protected] & E. Dutto [email protected] 1
Department of Hand Surgery, CTO A.O. Citta` della Salute e della Scienza, Ospedale CTO, Via Zuretti 29, 10126 Turin, Italy
young and compliant patients, with a valid rehabilitation protocol for excellent results. The choice of surgical technique remains controversial, and we believe that the double approach transosseous reinsertion is a safe, costless and relatively non-invasive technique, offering satisfactory results when performed early. Keywords Distal biceps tendon Distal biceps tendon rupture Elbow Elbow double approach Tendon injury
Introduction The rupture of the distal biceps brachii tendon is a relatively rare event, with an incidence of 1.2/100,000 inhabitants per year [1]. It represents 3 % of all lesions of the biceps, and in relation to all, the subcutaneous tendon ruptures are estimated at 1.5 % [2]. The lesion is more frequent in male subjects, with a mean age between 40 and 60 years, in subjects employed in manual labour or engaged in strenuous sports. It mainly affects the dominant side (86 %). Predisposing factors are tendinosis, prolonged steroid therapy [3], hyperparathyroidism [4, 5], metabolic acidosis [6], smoking and chronic inflammatory diseases (rheumatoid arthritis) [7]. The diagnosis of acute avulsion of the distal head of the biceps is essentially based on accurate medical history and clinical examination. The rupture is associated with an onset of acute sharp pain in the antecubital region, sometimes accompanied by ecchymotic swelling. A biceps profile asymmetry between the healthy and affected side is often evident, due to the proximal retraction of the injured biceps muscular fibres. The squeeze test [8] and the hook test [9] are also indicative diagnostic manoeuvers.
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Morrey defined three major diagnostic criteria: history of a single traumatic event, signs of palpable proximal retraction of the long head of biceps and partial loss of flexion and supination strength of the forearm, compared to the contralateral side. The imaging examinations are mainly helpful to confirm a lesion already diagnosed clinically or to differentiate and quantify the severity of partial injuries, in order to establish the modality and timing of any conservative treatment. The first-level examination is ultrasonography that helps identifying the type of injury, the degeneration and possible retraction of the tendon. Recent studies show that this method has a 95 % sensitivity, 71 % specificity and 91 % accuracy in the differential diagnosis between complete and partial lesions [10]. Magnetic resonance imaging (MRI) is considered the gold standard. This is the most suitable instrumental examination for the differential diagnosis of partial and complete tears and to determinate the degree of retraction and degeneration of the tendon, especially in older lesions, thus guiding the surgeon to the most appropriate treatment [11]. Sometimes, traditional X-rays may be useful to identify possible bone abnormalities of the radial tuberosity [12] or calcifications that may be the expression of a chronic inflammation. It is extremely uncommon to detect an avulsion fracture of the tuberosity, detached with the biceps tendon. Starks originally described this lesion in 1843; since then, several authors reported numerous cases. Until 1940, the treatment of choice was conservative. However, subsequent studies [13] showed the tendon inability to reintegrate spontaneously to the radius or to closer teno-muscular structures with a sufficient tension to perform, at least in part, its function. It was documented, through isokinetic tests [14], a loss of 40–50 % of supination strength. The loss of flexion strength is about 15–20 %, but tends to improve over time. The most significant data are the decrease of over 60 % of the endurance at prolonged flexion. A chronic pain may also persist at the site of injury, exacerbated by physical effort, and a weakness in grip strength could remain. Currently, conservative treatment is still widely used, especially in elderly (over 50) and low functional demanding patients, as there are other muscles that can supply, at least partially, the action of flexion and supination of the biceps. However, considering that the typical patient is young and high functionally demanding, the surgical treatment is usually indicated, except in case of general contraindications. The surgical options are basically two: the biceps tenodesis to the brachialis muscle (not anatomic
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reconstruction) and the anatomic reattachment of the biceps tendon to the tuberosity of the radius. The first one is the faster and easier technique; it consists in tethering the biceps tendon at the underlying brachialis muscle, using a single access to the anterior region of the elbow. This allows restoring a variable degree of strength in elbow flexion, but not in supination [15]. The literature is unanimous in reserving such treatment to rare circumstances, such as the failure of a tendon reattachment or chronic lesions. In such cases, the conditions of the tendon (retraction, scarring, degeneration) may not allow to relocate it into its right insertional site, so the treatment should only be limited to a simple tenodesis, if it is not possible or suitable to use grafts. Looking at the most recent literature, three questions concerning the treatment still have to be defined: why, when and how surgery should be performed? The gold standard certainly is the anatomic reattachment of the tendon, and the timing for surgery seems to be crucial as well [16]. Analysing the outcomes of our case series, we tried to deepen these open issues.
Materials and methods Between 2003 and 2013, 33 patients affected by a distal biceps tendon tear were treated in our Hand Surgery Department. All subjects were male, with a mean age at surgery of 45 years (range 30–56). We performed a retrospective evaluation of the results. In acute lesions (diagnosis within 3 weeks), the average time between trauma and surgery was 6 days (range 1–19). In chronic lesions (diagnosed over 3 weeks after trauma), the time between diagnosis and treatment was much more variable. The dominant side was involved in 85 % patients. We used ultrasound examination in all patients to confirm diagnosis. In some cases, we also performed an AP X-ray of the elbow (with forearm supinated) and a lateral radiograph (compared to the contralateral elbow) to provide information regarding the anatomy of the radial tuberosity. In selected cases (chronic lesions and partial tears), we also performed an MRI: this is helpful especially to differentiate complete tears from partial tears or when the lacertus fibrosus is intact and the typical retraction deformity is not present (Fig. 1). Out of the 33 patients treated surgically, 30 had a complete rupture of the tendon and 3 had a partial tear. The three partial tears were treated only with strengthening sutures, and therefore, they were excluded from the study. Of the remaining 30 patients, in 25 cases (83.3 %), the injury was acute or subacute and it was treated by anatomic reinsertion of the biceps tendon to the radial tuberosity (23 cases) or simple tenodesis (two cases).
Musculoskelet Surg
Fig. 1 Elbow’s RMN. The yellow arrow shows the distal biceps lesion (color figure online)
In five cases (16.6 %), the lesion was chronic and it was treated by tenodesis (two patients) or delayed reconstruction with autografts (three patients). Three different grafts were used: (1) the fascia lata, (2) the palmaris longus tendon and (3) the accessory abductor pollicis longus tendon. The accessory abductor pollicis longus was used in one case, given the absence of palmaris longus. Autografts were never used for the repair of acute tears. The four patients who underwent tenodesis were excluded from the study, as well as the three patients with partial tears. The number of chronic lesions treated with autografts was also too small to offer significant results; therefore, other three patients were excluded. Out of the 23 acute lesions treated with reinsertion to the radial tuberosity, 21 were performed using the two-incision technique (91 %), and only in two patients, a single anterior approach was performed (9 %). These were the two oldest cases, and they have been excluded from the study. The surgical approach is made by an anterior limited transversal incision to the elbow, while a ‘‘squeezing’’ arm manoeuver is usually helpful to recognize the tendon stump proximally. If a deeper dissection is required to reach the retracted tendon, we generally extend the initial incision in an ‘‘S-shaped’’ form in order to decrease soft tissues stress and to avoid both transient paresthesias in the lateral antebrachial cutaneous nerve distribution and PIN palsy. After identifying the radial tuberosity, a pair of curved forceps (Kelly) is placed in the interosseous radioulnar space (Fig. 2). This manoeuver has to be done very carefully, close to the bone, to avoid any damage to soft tissues or to the ulnar cortex, causing subchondral exposure that may produce radioulnar heterotopic ossifications or synostosis. We suggest to place the forearm in a complete pronation, in order to eliminate the conflict between the radial tuberosity and the forceps itself. The second incision
Fig. 2 Boyd–Anderson double-incision technique, modified by Morrey, with a short dorsal incision focused on bicipital tuberosity
Fig. 3 Three holes for transosseous reinsertion on the crest of bicipital tuberosity
is made after identifying the forceps tip under the stretched skin on the dorsal aspect of the proximal forearm. We suggest to pull back with the same forceps a #0 wire (Vicryl) in order to maintain a guide in the soft tissue tunnel. After a delicate split of the epicondylar muscles, we expose the radial tuberosity. A burr is used to ream through the anterior cortex, to create a slot of 1.5 cm of length and 1 cm of depth in the centre of the tuberosity. After that, three holes (of 2–2, 5–2 mm) are drilled in the anterior wall of the slot (Fig. 3). A #2 polyester suture (Ticron suture by Covidien) is used to harness 3 cm of the distal tendon stump, with a
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locking loop technique. We prefer the Orthocord Braided Composite two colors Suture (DePuy Mitek): with the blue wires, we perform a 3-cm Bunnell suture of the tendon stump, and with the violet wires, a Kessler suture 1.5 cm on the top of it. Then, the tendon is pulled until it reaches the slot and the wires are passed through the holes of the tuberosity: one violet and one blue wire go into the central hole, and a violet and a blue ones are passed into each lateral hole. To facilitate the passage of the wires, we use a Chia Percpasser (DePuy Mitek). Once in position, with the elbow flexed at 90° and the forearm in mild supination, the knots have to be tightened. The post-operative protocol included the use of an articulated splint locked at 90° flexion for 3 weeks and a subsequent gradual increase in flexion and extension until the ninth week. No heavy weight lifting was allowed for at least 3 months. The 21 patients treated by reattachment to the radial tuberosity were evaluated by the same examiner at a mean follow-up of 22 months (range 6 months–9 years). No patients were lost at follow-up. The elbow final ROM was measured with a goniometer, evaluating the degrees of flexion–extension and pronation– supination. We also measured, with a dynamometer, the force of flexion and supination of the forearm, expressing the results in terms of percentage compared to the contralateral unaffected side. All patients underwent two questionnaires for the subjective evaluation of the results: the DASH (Disabilities of Arm, Shoulder and Hand) and the SECEC Elbow Score. Additionally, we analysed the complications of the surgical treatment and the need for additional surgical procedures. We performed X-ray or MRI during the follow-up only in cases of delayed functional recovery or chronic pain.
Results Both subjective and objective outcomes after surgical reinsertion of the biceps tendon were satisfying. In all but two patients, the recovery of elbow ROM was almost complete, with an average 6–132° flexion–extension and 89–0–87° pronation–supination. The maximum extension restriction was approximately 10°. Flexion and supination strength were recovered to near normality, reaching 96 and 88 %, respectively, compared to the contralateral side. Three months after surgery, pain was reported by only two patients: one patient who complained of persistent pain in the antecubital region, improved only after 1 year of medical and physical therapy, and another patient who reported persistent pain during extreme supination.
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All patients resumed daily activities in 2 months and returned to previous work within 3 months after operation, depending on the task being performed. No one had to change his previous work after surgery. The average final DASH score was 8/100 (0 excellent result, 100 bad), and the SECEC Elbow Score was 91/100 (100 excellent result, 0 bad). Two patients (9 %) developed heterotopic ossifications with a mean 30° loss of supination. In one case, one year after surgery, a surgical excision and arthrolysis were performed, with the restoration of complete ROM. One patient suffered an asymptomatic proximal radius fracture probably due to an overtightened tendon reinsertion. One patient reported a transient radial nerve neurapraxia, completely resolved in 4 months with steroid therapy and no need for additional surgical treatment. No lesions of sensitive radial branch or lateral antebrachial cutaneous nerve were reported. One patient had a contralateral distal biceps tendon rupture after one year but he refused the surgical treatment, and at 5-year follow-up, he showed a complete restore of movement and flexion and supination strength.
Discussion and literature analysis The results of this study confirm the outcomes found in the literature and are comparable to other case series in terms of number of patients and scores evaluation [17]. We used the Boyd and Anderson’s two-incision technique [18], modified by Morrey [19], with transosseous reinsertion. In the authors’ opinion, this surgical technique grants a stable and strong reinsertion and allows an early and rapid mobilization, following a strict rehabilitative protocol that is necessary to enhance the final outcomes. The clinical objective and subjective results reported in this paper, as well as the complications rate (two cases of heterotopic ossification, one proximal radius fracture and one transient radial neurapraxia, out of 21 patients), are satisfying and comparable to literature [20]. As shown by other authors [21], early surgery is fundamental for a better and faster functional elbow recovery and an early return to working activities. In case of chronic lesions and in lesions treated using grafts for tendon reconstruction, the outcomes are worse, because the tendon degeneration and retraction jeopardize the possibility of a complete recovery. All the data regarding the post-operative timing for recovery in chronic lesions seem to confirm this trend. In these cases, the decision whether to perform surgery or not must be carefully planned with the patient, considering his functional demands. There are two main issues that are still debated: the choice of surgical approach and the reinsertion technique.
Musculoskelet Surg
It is difficult to find a definitive answer to these open questions, because in the literature, there are no clinical evidences supporting any of these treatments over the others. Karunakar et al. [22] in 1999 reported the results of 21 distal biceps ruptures in 20 patients treated with doubleincision technique with transosseous fixation, with 44 months of follow-up. Isokinetic testing revealed 48 % elbow weakness in supination versus 14 % in flexion and loss of endurance in 38 % elbows in supination and 33 % in flexion. Heterotopic ossification was the most common complication (15 %), and one patient also had a synostosis. Despite diminished strength and endurance and a high rate of complications, patient satisfaction was excellent (100 %) and functional outcome was good. In 2000, Sotereanos [23] presented a simplified method for the repair of distal biceps tendon ruptures through a single anterior incision with minimal volar dissection, using suture anchors. He reported excellent functional results with no failures and no complications of radioulnar synostosis or posterior interosseous nerve palsy. Few years later, in a prospective study, Balabaud et al. [24] reported a case series of eight patients with nine ruptures of the distal biceps tendon that underwent repair through a single incision. All patients were satisfied with their clinical results and had full ranges of elbow and forearm motion. There were no radial nerve injuries and no radioulnar synostosis. In 2005, McKee reported the outcomes of 53 patients who underwent repair of a complete rupture of the distal biceps tendon via a single anterior incision technique with suture anchors [25]. The mean DASH score was 8.2. Compared to the opposite side, the flexion strength recovery was 96 % and supination 93 %. There were no reruptures or synostosis. Another study in 2014 [26] evaluated the functional results of 49 distal biceps tendon repairs using suture anchors via a single-incision approach. Eighty-six per cent of patients were satisfied with their outcome. Compared to contralateral, the active ROM of elbow flexion, extension and pronation was not affected; however, supination was decreased by 3° (P \ 0.001). The isometric maximum strengths showed significant deficits. Heterotopic ossifications (HO) were found in 39 % of patients, and four anchor failures were detected. Bain et al. [27] in 2000 described a technique with a single anterior incision and fixation with a suspension device, the EndobuttonÒ. It was used in 12 patients who were allowed early active mobilization. All patients were satisfied, and all patients returned to activities and regained grade 5 strength. More recently, in 2013, the outcomes of EndobuttonÒ fixation were analysed by Kodde, who treated 24 traumatic
distal biceps tendon ruptures [28]. The results after distal biceps tendon fixation with a cortical button were good according to ROM recovery, strength, MEPI and DASH scores. However, this procedure showed a high incidence of complications; in particular, the formation of heterotopic ossifications was frequently seen, though clinically relevant in only one patient. Few studies in the literature directly compared the clinical outcomes of different approaches and techniques. In 2003, El-Hawary et al. [29] analysed the outcomes of two different distal biceps tendon reattachment techniques, comparing the results obtained in nine cases treated with single anterior incision and anchors to ten cases with twoincision technique and transosseous fixation. At 1-year follow-up, the single-incision group regained more flexion than the two-incision group. There was no difference between groups in the range of motion, supination or flexion strength and in SF-36 scores. Complications were encountered in 44 % of cases treated with a one-incision technique and in 10 % of cases treated with the two-incision technique, most of which were minor transient paresthesias. In 2012, Grewal et al. [30] presented the results of a randomized clinical trial evaluating two different surgical approaches and demonstrated that there were no significant differences in outcomes between the single- and doubleincision groups, other than a 10 % advantage in final flexion strength with the latter. The single-incision technique was associated with more early transient neurapraxias of the lateral antebrachial cutaneous nerve. In 2015, Shields et al. [31] compared distal biceps tendon repairs performed with a tension slide technique using a cortical button (CB) and interference screw with suture fixation through bone tunnels (BT). Both the single-incision CB and double-incision BT techniques provided excellent clinical results, with no differences in the range of motion or strength between groups. Complications were more common in the single-incision CB group and most commonly involved paresthesias of the superficial radial nerve. The data in the literature regarding biomechanical tests showed discording results [32]. The first seemed to demonstrate that transosseous reinsertion had greater strength compared to reinsertion through suture anchors [33]. More recently, some authors, on the opposite, showed that suture anchors are biomechanically more resistant [34]. The latest studies show that the EndobuttonÒ (Smith & Nephew, London, UK) has the highest load resistance [35], even if this superiority does not lead to better clinical results. In 2003, Greenberg et al. [36] compared three different techniques in a cadaveric study. EndobuttonÒ showed a traction resistance three times higher than the transosseous
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reinsertion, two times higher than fixation with an interference screw and one time higher than suture anchors. The clinical results seen in 14 patients treated with EndobuttonÒ were good, with a 97 % recovery of flexion and 82 % of supination strength compared to the opposite arm at 20 months. However, there was no case-control to show that this technique leads to better clinical results compared to others. In the present paper, we could not compare different approaches or techniques. Nevertheless, we observed that the double-incision transosseous reinsertion is a safe (less risks of radial nerve lesions, the worse complication), costless (because there is no need of fixation devices such as suture anchors, EndobuttonÒ or interference screws) and relatively non-invasive technique (because it is performed through two mini-incisions). This study has several drawbacks. First of all, it is retrospective, as most of the others in the literature. Then, this paper did not compare the outcomes of reinsertion and tenodesis, neither compared the outcomes of conservative vs surgical treatment. Furthermore, the sample of patients treated with single access and suture anchors or those treated with allografts for chronic lesions treated was too small to be significantly included in the study. The interventions were not performed by the same surgeon, even if the technique used has always been the same. Finally, concerning the clinical evaluation, there is a lack of measurement of the flexion and supination endurance, a parameter that is more affected than strength after such injury.
Conclusions Distal biceps tendon ruptures are relatively uncommon lesions and require a specialized treatment. When? Analysing the literature and the result of this case series, it is clear that the timing of surgery is a key element for good results; delayed treatment is influenced by the tendon retraction, degeneration and soft tissue scarring that do not permit an anatomic restoration. Surgery is indicated in young and active patients that should be correctly informed about results and alternatives because compliance is necessary for an early and correct rehabilitation. Some authors recommend to identify potentially uncompliant patients, or those at risk of additional injury, in order to have better outcomes. Why? Conservative treatment is indicated only in elderly low demanding patients, because of significant loss of supination and flexion strength. Surgical treatment, instead, restores the strength and the endurance of biceps muscle, while retaining a functional range of movement.
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How? Both single- and double-incision techniques have reported good subjective and objectives results. The selection of the surgical technique remains controversial, and currently, there is no clear evidence to support the use of one technique over the other. EndobuttonÒ stabilization shows a stronger biomechanical fixation, but not superior clinical or functional results have been reported yet. Literature evidences suggest that surgeons can choose the operative approach that is most suitable to their personal experience.
Conflict of interest of interest.
The authors declare that they have no conflict
Human and animal rights This article does not contain any studies with human or animal subjects performed by any of the authors.
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27. Bain GI et al (2000) Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Shoulder Elbow Surg 9(2):120–126 28. Kodde IF, van den Bekerom MP, Eygendaal D (2015) Reconstruction of distal biceps tendon ruptures with a cortical button. Knee Surg Sports Traumatol Arthrosc 23(3):919–925 29. El-Hawary R, Macdermid JC, Faber KJ, Patterson SD, King GJ (2003) Distal biceps tendon repair: comparison of surgical techniques. J Hand Surg Am 28:496–502 30. Grewal R et al (2012) Single versus double-incision technique for the repair of acute distal biceps tendon ruptures. A randomized clinical trial. J Bone Joint Surg Am 3(94):1166–1174 31. Shields E, Olsen JR, Williams RB, Rouse L, Maloney M, Voloshin I (2015) Distal biceps brachii tendon repairs: a singleincision technique using a cortical button with interference screw versus a double-incision technique using suture fixation through bone tunnels. Am J Sports Med [Epub ahead of print] 32. 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 33. Berlet GC, Johnson JA, Milne AD, Patterson SD, King GJ (1998) Distal biceps brachii tendon repair: an in vitro biomechanical study of tendon reattachment. Am J Sports Med 26:428–432 34. Lemos SE, Ebramzedeh E, Kvitne RS (2004) A new technique: in vitro suture anchor fixation has superior yield strength than bone tunnel fixation for distal biceps tendon repair. Am J Sports Med 32:406–410 35. Quach T (2010) Distal biceps tendon injuries—current treatment options. Bull NYU Hosp Joint Dis 68(2):103–111 36. Greenberg JA, Fernandez JJ, Wang T, Turner C (2003) Endobutton—assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 12:484–490
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ORIGINAL ARTICLE
Treatment of distal biceps tendon rupture: why, when, how? Analysis of literature and our experience F. Giacalone1 • E. Dutto1 • M. Ferrero1 • M. Bertolini1 • A. Sard1 • I. Pontini1
Received: 21 August 2014 / Accepted: 11 March 2015 Ó Istituto Ortopedico Rizzoli 2015
Abstract Introduction The rupture of the distal biceps tendon is a relatively uncommon lesion. Even if conservative treatment may be an option in low demanding patients, young and active subjects may benefit from an early surgical reinsertion. Many techniques and fixation devices have been described, but in the literature, there are no clinical evidences that show the superiority of any of these. In this article, we report an analysis of the ‘‘state of the art’’ and our case series of surgical reinsertion with the double approach transosseous technique. Materials and methods Between 2003 and 2013, 26 patients underwent surgical reinsertion, either for acute or for chronic lesions of distal biceps tendon. We evaluated 21 acute cases treated with double approach using DASH and SECEC Elbow Scores. The mean follow-up was 22 months. Range of motion, supination and flexion strength were also recorded. Results Mean final ROM was 6–132° in F/E and 89–0– 87° in P/S; flexion and supination strength were 96 and 88 % compared to the opposite side. The main complications were two cases of heterotopic ossifications: one asymptomatic fracture of the proximal radius and one temporary neurapraxia of the radial nerve. Conclusions Analysing the literature and our outcomes, we underline the importance of timing for surgery, in
& F. Giacalone [email protected] & E. Dutto [email protected] 1
Department of Hand Surgery, CTO A.O. Citta` della Salute e della Scienza, Ospedale CTO, Via Zuretti 29, 10126 Turin, Italy
young and compliant patients, with a valid rehabilitation protocol for excellent results. The choice of surgical technique remains controversial, and we believe that the double approach transosseous reinsertion is a safe, costless and relatively non-invasive technique, offering satisfactory results when performed early. Keywords Distal biceps tendon Distal biceps tendon rupture Elbow Elbow double approach Tendon injury
Introduction The rupture of the distal biceps brachii tendon is a relatively rare event, with an incidence of 1.2/100,000 inhabitants per year [1]. It represents 3 % of all lesions of the biceps, and in relation to all, the subcutaneous tendon ruptures are estimated at 1.5 % [2]. The lesion is more frequent in male subjects, with a mean age between 40 and 60 years, in subjects employed in manual labour or engaged in strenuous sports. It mainly affects the dominant side (86 %). Predisposing factors are tendinosis, prolonged steroid therapy [3], hyperparathyroidism [4, 5], metabolic acidosis [6], smoking and chronic inflammatory diseases (rheumatoid arthritis) [7]. The diagnosis of acute avulsion of the distal head of the biceps is essentially based on accurate medical history and clinical examination. The rupture is associated with an onset of acute sharp pain in the antecubital region, sometimes accompanied by ecchymotic swelling. A biceps profile asymmetry between the healthy and affected side is often evident, due to the proximal retraction of the injured biceps muscular fibres. The squeeze test [8] and the hook test [9] are also indicative diagnostic manoeuvers.
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Morrey defined three major diagnostic criteria: history of a single traumatic event, signs of palpable proximal retraction of the long head of biceps and partial loss of flexion and supination strength of the forearm, compared to the contralateral side. The imaging examinations are mainly helpful to confirm a lesion already diagnosed clinically or to differentiate and quantify the severity of partial injuries, in order to establish the modality and timing of any conservative treatment. The first-level examination is ultrasonography that helps identifying the type of injury, the degeneration and possible retraction of the tendon. Recent studies show that this method has a 95 % sensitivity, 71 % specificity and 91 % accuracy in the differential diagnosis between complete and partial lesions [10]. Magnetic resonance imaging (MRI) is considered the gold standard. This is the most suitable instrumental examination for the differential diagnosis of partial and complete tears and to determinate the degree of retraction and degeneration of the tendon, especially in older lesions, thus guiding the surgeon to the most appropriate treatment [11]. Sometimes, traditional X-rays may be useful to identify possible bone abnormalities of the radial tuberosity [12] or calcifications that may be the expression of a chronic inflammation. It is extremely uncommon to detect an avulsion fracture of the tuberosity, detached with the biceps tendon. Starks originally described this lesion in 1843; since then, several authors reported numerous cases. Until 1940, the treatment of choice was conservative. However, subsequent studies [13] showed the tendon inability to reintegrate spontaneously to the radius or to closer teno-muscular structures with a sufficient tension to perform, at least in part, its function. It was documented, through isokinetic tests [14], a loss of 40–50 % of supination strength. The loss of flexion strength is about 15–20 %, but tends to improve over time. The most significant data are the decrease of over 60 % of the endurance at prolonged flexion. A chronic pain may also persist at the site of injury, exacerbated by physical effort, and a weakness in grip strength could remain. Currently, conservative treatment is still widely used, especially in elderly (over 50) and low functional demanding patients, as there are other muscles that can supply, at least partially, the action of flexion and supination of the biceps. However, considering that the typical patient is young and high functionally demanding, the surgical treatment is usually indicated, except in case of general contraindications. The surgical options are basically two: the biceps tenodesis to the brachialis muscle (not anatomic
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reconstruction) and the anatomic reattachment of the biceps tendon to the tuberosity of the radius. The first one is the faster and easier technique; it consists in tethering the biceps tendon at the underlying brachialis muscle, using a single access to the anterior region of the elbow. This allows restoring a variable degree of strength in elbow flexion, but not in supination [15]. The literature is unanimous in reserving such treatment to rare circumstances, such as the failure of a tendon reattachment or chronic lesions. In such cases, the conditions of the tendon (retraction, scarring, degeneration) may not allow to relocate it into its right insertional site, so the treatment should only be limited to a simple tenodesis, if it is not possible or suitable to use grafts. Looking at the most recent literature, three questions concerning the treatment still have to be defined: why, when and how surgery should be performed? The gold standard certainly is the anatomic reattachment of the tendon, and the timing for surgery seems to be crucial as well [16]. Analysing the outcomes of our case series, we tried to deepen these open issues.
Materials and methods Between 2003 and 2013, 33 patients affected by a distal biceps tendon tear were treated in our Hand Surgery Department. All subjects were male, with a mean age at surgery of 45 years (range 30–56). We performed a retrospective evaluation of the results. In acute lesions (diagnosis within 3 weeks), the average time between trauma and surgery was 6 days (range 1–19). In chronic lesions (diagnosed over 3 weeks after trauma), the time between diagnosis and treatment was much more variable. The dominant side was involved in 85 % patients. We used ultrasound examination in all patients to confirm diagnosis. In some cases, we also performed an AP X-ray of the elbow (with forearm supinated) and a lateral radiograph (compared to the contralateral elbow) to provide information regarding the anatomy of the radial tuberosity. In selected cases (chronic lesions and partial tears), we also performed an MRI: this is helpful especially to differentiate complete tears from partial tears or when the lacertus fibrosus is intact and the typical retraction deformity is not present (Fig. 1). Out of the 33 patients treated surgically, 30 had a complete rupture of the tendon and 3 had a partial tear. The three partial tears were treated only with strengthening sutures, and therefore, they were excluded from the study. Of the remaining 30 patients, in 25 cases (83.3 %), the injury was acute or subacute and it was treated by anatomic reinsertion of the biceps tendon to the radial tuberosity (23 cases) or simple tenodesis (two cases).
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Fig. 1 Elbow’s RMN. The yellow arrow shows the distal biceps lesion (color figure online)
In five cases (16.6 %), the lesion was chronic and it was treated by tenodesis (two patients) or delayed reconstruction with autografts (three patients). Three different grafts were used: (1) the fascia lata, (2) the palmaris longus tendon and (3) the accessory abductor pollicis longus tendon. The accessory abductor pollicis longus was used in one case, given the absence of palmaris longus. Autografts were never used for the repair of acute tears. The four patients who underwent tenodesis were excluded from the study, as well as the three patients with partial tears. The number of chronic lesions treated with autografts was also too small to offer significant results; therefore, other three patients were excluded. Out of the 23 acute lesions treated with reinsertion to the radial tuberosity, 21 were performed using the two-incision technique (91 %), and only in two patients, a single anterior approach was performed (9 %). These were the two oldest cases, and they have been excluded from the study. The surgical approach is made by an anterior limited transversal incision to the elbow, while a ‘‘squeezing’’ arm manoeuver is usually helpful to recognize the tendon stump proximally. If a deeper dissection is required to reach the retracted tendon, we generally extend the initial incision in an ‘‘S-shaped’’ form in order to decrease soft tissues stress and to avoid both transient paresthesias in the lateral antebrachial cutaneous nerve distribution and PIN palsy. After identifying the radial tuberosity, a pair of curved forceps (Kelly) is placed in the interosseous radioulnar space (Fig. 2). This manoeuver has to be done very carefully, close to the bone, to avoid any damage to soft tissues or to the ulnar cortex, causing subchondral exposure that may produce radioulnar heterotopic ossifications or synostosis. We suggest to place the forearm in a complete pronation, in order to eliminate the conflict between the radial tuberosity and the forceps itself. The second incision
Fig. 2 Boyd–Anderson double-incision technique, modified by Morrey, with a short dorsal incision focused on bicipital tuberosity
Fig. 3 Three holes for transosseous reinsertion on the crest of bicipital tuberosity
is made after identifying the forceps tip under the stretched skin on the dorsal aspect of the proximal forearm. We suggest to pull back with the same forceps a #0 wire (Vicryl) in order to maintain a guide in the soft tissue tunnel. After a delicate split of the epicondylar muscles, we expose the radial tuberosity. A burr is used to ream through the anterior cortex, to create a slot of 1.5 cm of length and 1 cm of depth in the centre of the tuberosity. After that, three holes (of 2–2, 5–2 mm) are drilled in the anterior wall of the slot (Fig. 3). A #2 polyester suture (Ticron suture by Covidien) is used to harness 3 cm of the distal tendon stump, with a
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locking loop technique. We prefer the Orthocord Braided Composite two colors Suture (DePuy Mitek): with the blue wires, we perform a 3-cm Bunnell suture of the tendon stump, and with the violet wires, a Kessler suture 1.5 cm on the top of it. Then, the tendon is pulled until it reaches the slot and the wires are passed through the holes of the tuberosity: one violet and one blue wire go into the central hole, and a violet and a blue ones are passed into each lateral hole. To facilitate the passage of the wires, we use a Chia Percpasser (DePuy Mitek). Once in position, with the elbow flexed at 90° and the forearm in mild supination, the knots have to be tightened. The post-operative protocol included the use of an articulated splint locked at 90° flexion for 3 weeks and a subsequent gradual increase in flexion and extension until the ninth week. No heavy weight lifting was allowed for at least 3 months. The 21 patients treated by reattachment to the radial tuberosity were evaluated by the same examiner at a mean follow-up of 22 months (range 6 months–9 years). No patients were lost at follow-up. The elbow final ROM was measured with a goniometer, evaluating the degrees of flexion–extension and pronation– supination. We also measured, with a dynamometer, the force of flexion and supination of the forearm, expressing the results in terms of percentage compared to the contralateral unaffected side. All patients underwent two questionnaires for the subjective evaluation of the results: the DASH (Disabilities of Arm, Shoulder and Hand) and the SECEC Elbow Score. Additionally, we analysed the complications of the surgical treatment and the need for additional surgical procedures. We performed X-ray or MRI during the follow-up only in cases of delayed functional recovery or chronic pain.
Results Both subjective and objective outcomes after surgical reinsertion of the biceps tendon were satisfying. In all but two patients, the recovery of elbow ROM was almost complete, with an average 6–132° flexion–extension and 89–0–87° pronation–supination. The maximum extension restriction was approximately 10°. Flexion and supination strength were recovered to near normality, reaching 96 and 88 %, respectively, compared to the contralateral side. Three months after surgery, pain was reported by only two patients: one patient who complained of persistent pain in the antecubital region, improved only after 1 year of medical and physical therapy, and another patient who reported persistent pain during extreme supination.
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All patients resumed daily activities in 2 months and returned to previous work within 3 months after operation, depending on the task being performed. No one had to change his previous work after surgery. The average final DASH score was 8/100 (0 excellent result, 100 bad), and the SECEC Elbow Score was 91/100 (100 excellent result, 0 bad). Two patients (9 %) developed heterotopic ossifications with a mean 30° loss of supination. In one case, one year after surgery, a surgical excision and arthrolysis were performed, with the restoration of complete ROM. One patient suffered an asymptomatic proximal radius fracture probably due to an overtightened tendon reinsertion. One patient reported a transient radial nerve neurapraxia, completely resolved in 4 months with steroid therapy and no need for additional surgical treatment. No lesions of sensitive radial branch or lateral antebrachial cutaneous nerve were reported. One patient had a contralateral distal biceps tendon rupture after one year but he refused the surgical treatment, and at 5-year follow-up, he showed a complete restore of movement and flexion and supination strength.
Discussion and literature analysis The results of this study confirm the outcomes found in the literature and are comparable to other case series in terms of number of patients and scores evaluation [17]. We used the Boyd and Anderson’s two-incision technique [18], modified by Morrey [19], with transosseous reinsertion. In the authors’ opinion, this surgical technique grants a stable and strong reinsertion and allows an early and rapid mobilization, following a strict rehabilitative protocol that is necessary to enhance the final outcomes. The clinical objective and subjective results reported in this paper, as well as the complications rate (two cases of heterotopic ossification, one proximal radius fracture and one transient radial neurapraxia, out of 21 patients), are satisfying and comparable to literature [20]. As shown by other authors [21], early surgery is fundamental for a better and faster functional elbow recovery and an early return to working activities. In case of chronic lesions and in lesions treated using grafts for tendon reconstruction, the outcomes are worse, because the tendon degeneration and retraction jeopardize the possibility of a complete recovery. All the data regarding the post-operative timing for recovery in chronic lesions seem to confirm this trend. In these cases, the decision whether to perform surgery or not must be carefully planned with the patient, considering his functional demands. There are two main issues that are still debated: the choice of surgical approach and the reinsertion technique.
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It is difficult to find a definitive answer to these open questions, because in the literature, there are no clinical evidences supporting any of these treatments over the others. Karunakar et al. [22] in 1999 reported the results of 21 distal biceps ruptures in 20 patients treated with doubleincision technique with transosseous fixation, with 44 months of follow-up. Isokinetic testing revealed 48 % elbow weakness in supination versus 14 % in flexion and loss of endurance in 38 % elbows in supination and 33 % in flexion. Heterotopic ossification was the most common complication (15 %), and one patient also had a synostosis. Despite diminished strength and endurance and a high rate of complications, patient satisfaction was excellent (100 %) and functional outcome was good. In 2000, Sotereanos [23] presented a simplified method for the repair of distal biceps tendon ruptures through a single anterior incision with minimal volar dissection, using suture anchors. He reported excellent functional results with no failures and no complications of radioulnar synostosis or posterior interosseous nerve palsy. Few years later, in a prospective study, Balabaud et al. [24] reported a case series of eight patients with nine ruptures of the distal biceps tendon that underwent repair through a single incision. All patients were satisfied with their clinical results and had full ranges of elbow and forearm motion. There were no radial nerve injuries and no radioulnar synostosis. In 2005, McKee reported the outcomes of 53 patients who underwent repair of a complete rupture of the distal biceps tendon via a single anterior incision technique with suture anchors [25]. The mean DASH score was 8.2. Compared to the opposite side, the flexion strength recovery was 96 % and supination 93 %. There were no reruptures or synostosis. Another study in 2014 [26] evaluated the functional results of 49 distal biceps tendon repairs using suture anchors via a single-incision approach. Eighty-six per cent of patients were satisfied with their outcome. Compared to contralateral, the active ROM of elbow flexion, extension and pronation was not affected; however, supination was decreased by 3° (P \ 0.001). The isometric maximum strengths showed significant deficits. Heterotopic ossifications (HO) were found in 39 % of patients, and four anchor failures were detected. Bain et al. [27] in 2000 described a technique with a single anterior incision and fixation with a suspension device, the EndobuttonÒ. It was used in 12 patients who were allowed early active mobilization. All patients were satisfied, and all patients returned to activities and regained grade 5 strength. More recently, in 2013, the outcomes of EndobuttonÒ fixation were analysed by Kodde, who treated 24 traumatic
distal biceps tendon ruptures [28]. The results after distal biceps tendon fixation with a cortical button were good according to ROM recovery, strength, MEPI and DASH scores. However, this procedure showed a high incidence of complications; in particular, the formation of heterotopic ossifications was frequently seen, though clinically relevant in only one patient. Few studies in the literature directly compared the clinical outcomes of different approaches and techniques. In 2003, El-Hawary et al. [29] analysed the outcomes of two different distal biceps tendon reattachment techniques, comparing the results obtained in nine cases treated with single anterior incision and anchors to ten cases with twoincision technique and transosseous fixation. At 1-year follow-up, the single-incision group regained more flexion than the two-incision group. There was no difference between groups in the range of motion, supination or flexion strength and in SF-36 scores. Complications were encountered in 44 % of cases treated with a one-incision technique and in 10 % of cases treated with the two-incision technique, most of which were minor transient paresthesias. In 2012, Grewal et al. [30] presented the results of a randomized clinical trial evaluating two different surgical approaches and demonstrated that there were no significant differences in outcomes between the single- and doubleincision groups, other than a 10 % advantage in final flexion strength with the latter. The single-incision technique was associated with more early transient neurapraxias of the lateral antebrachial cutaneous nerve. In 2015, Shields et al. [31] compared distal biceps tendon repairs performed with a tension slide technique using a cortical button (CB) and interference screw with suture fixation through bone tunnels (BT). Both the single-incision CB and double-incision BT techniques provided excellent clinical results, with no differences in the range of motion or strength between groups. Complications were more common in the single-incision CB group and most commonly involved paresthesias of the superficial radial nerve. The data in the literature regarding biomechanical tests showed discording results [32]. The first seemed to demonstrate that transosseous reinsertion had greater strength compared to reinsertion through suture anchors [33]. More recently, some authors, on the opposite, showed that suture anchors are biomechanically more resistant [34]. The latest studies show that the EndobuttonÒ (Smith & Nephew, London, UK) has the highest load resistance [35], even if this superiority does not lead to better clinical results. In 2003, Greenberg et al. [36] compared three different techniques in a cadaveric study. EndobuttonÒ showed a traction resistance three times higher than the transosseous
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reinsertion, two times higher than fixation with an interference screw and one time higher than suture anchors. The clinical results seen in 14 patients treated with EndobuttonÒ were good, with a 97 % recovery of flexion and 82 % of supination strength compared to the opposite arm at 20 months. However, there was no case-control to show that this technique leads to better clinical results compared to others. In the present paper, we could not compare different approaches or techniques. Nevertheless, we observed that the double-incision transosseous reinsertion is a safe (less risks of radial nerve lesions, the worse complication), costless (because there is no need of fixation devices such as suture anchors, EndobuttonÒ or interference screws) and relatively non-invasive technique (because it is performed through two mini-incisions). This study has several drawbacks. First of all, it is retrospective, as most of the others in the literature. Then, this paper did not compare the outcomes of reinsertion and tenodesis, neither compared the outcomes of conservative vs surgical treatment. Furthermore, the sample of patients treated with single access and suture anchors or those treated with allografts for chronic lesions treated was too small to be significantly included in the study. The interventions were not performed by the same surgeon, even if the technique used has always been the same. Finally, concerning the clinical evaluation, there is a lack of measurement of the flexion and supination endurance, a parameter that is more affected than strength after such injury.
Conclusions Distal biceps tendon ruptures are relatively uncommon lesions and require a specialized treatment. When? Analysing the literature and the result of this case series, it is clear that the timing of surgery is a key element for good results; delayed treatment is influenced by the tendon retraction, degeneration and soft tissue scarring that do not permit an anatomic restoration. Surgery is indicated in young and active patients that should be correctly informed about results and alternatives because compliance is necessary for an early and correct rehabilitation. Some authors recommend to identify potentially uncompliant patients, or those at risk of additional injury, in order to have better outcomes. Why? Conservative treatment is indicated only in elderly low demanding patients, because of significant loss of supination and flexion strength. Surgical treatment, instead, restores the strength and the endurance of biceps muscle, while retaining a functional range of movement.
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How? Both single- and double-incision techniques have reported good subjective and objectives results. The selection of the surgical technique remains controversial, and currently, there is no clear evidence to support the use of one technique over the other. EndobuttonÒ stabilization shows a stronger biomechanical fixation, but not superior clinical or functional results have been reported yet. Literature evidences suggest that surgeons can choose the operative approach that is most suitable to their personal experience.
Conflict of interest of interest.
The authors declare that they have no conflict
Human and animal rights This article does not contain any studies with human or animal subjects performed by any of the authors.
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![[Distal biceps tendon injuries -- injuries of the distal biceps tendon].](/assets/img/hold.png)
