Management of Distal Biceps Tendon Ruptures: A Survey of Fellowship-Trained Subspecialist Elbow Surgeons.

Abstract

There are several approaches to the management of distal biceps tendon ruptures, with no consensus on what constitutes best practice. An online survey queried the perceptions and management of distal biceps tendon ruptures amongst fellowship-trained subspecialist elbow surgeons, which primarily comprised of members of the Shoulder and Elbow Society of Australia, the national subspecialist interest group of the Australian Orthopaedic Association and the Mayo Clinic Elbow Club (Rochester, MN). One hundred surgeons responded. The median (IQR) experience as orthopedic surgeons amongst respondents was 17 (10-23) years. 78% of respondents saw >10 cases of distal biceps tendon ruptures annually. 95% of respondents would recommend surgery for symptomatic radiologically-confirmed partial tears, the most common indications being pain (83%), weakness (60%), and tear size (48%). 43% of respondents would have grafts available for tears older than 6 weeks. The one-incision approach (70%) was preferred over two-incisions (30%). 78% of one-incision users believed that their repair location was anatomic, compared to 100% of two-incision users. One-incision users were more likely to have encountered lateral antebrachial cutaneous nerve (78% vs 46%) and superficial radial nerve palsies (28% vs 11%). Two-incision users were more likely to have encountered posterior interosseus nerve palsy (21% v 15%), heterotopic ossification (54% vs 42%), and synostosis (14% vs 0%). Re-ruptures were the most common cause of reoperation. The more conservative a respondent's postoperative immobilization was, the less likely they were to have ever encountered re-rupture (14% amongst cast users, 29% amongst splint/brace users, 49% amongst sling users, 100% amongst non-immobilizers). 30% of respondents who placed elbow strength restrictions for 6 months postoperatively encountered re-rupture, compared to 40% amongst those who restricted for 6-12 weeks postoperatively. The operation rate for repair of distal biceps tendon ruptures amongst subspecialist elbow surgeons is high, as seen in our cohort. However, there is a large variation in the approach toward its management. One-incision (anterior) was preferred over two-incisions (posterior). Complications from repair of distal biceps tendon ruptures can be expected even amongst subspecialists, and are associated with surgical approach. The responses imply that more conservative postoperative rehabilitation may be associated with a lower risk of re-rupture.