Distal Biceps Tendon Injuries Research Articles

Which risk factors are involved in a distal biceps tendon injury? A systematic review.

Distal biceps tendon rupture is a rare injury predominately occurring in middle-aged men. This study aimed to collect relevant risk factors associated with distal biceps tendon rupture from the published literature. This systematic review aimed to collect and tabulate the risk factors for distal biceps tendon rupture. Studies published in English were searched concerning risk factors for distal biceps tendon ruptures until July 2022; cohort studies, case series and randomized controlled trials were subjected to analysis. Case studies, cadaveric studies and reviews in any form were excluded. The studies were quantitatively and qualitatively reviewed. One hundred twenty-one articles presenting risk factors for distal biceps tendon ruptures were identified, recruiting a total of 7,484-7,576 patients. The average age of the individuals was 46.8 years, with 96.7% being males and 94.7% having affinity for sports activities. In 56.7% of the cases, the dominant arm was involved, and in 54.6%, the right arm was affected. The use of tobacco was found in 20.8% of cases and of anabolic steroids in 2.5% of cases. On average, 55.8% of distal biceps tendon rupture patients had a physical occupation and the most common mechanism of the injury was related to heavy weight lifting observed in 53.2% of subjects. The most common and outstanding reported risk factors for distal biceps tendon ruptures were age, sex and sports activity, i.e., middle-aged males being still physically active and practicing sports. Steroid usage does not seem to increase significantly the risk of the distal biceps tendon rupture.

Distal biceps tendon injuries treatment: A survey of orthopaedic surgeons' current practice and preferences.

Distal biceps tendon (DBT) injuries are relatively uncommon. Controversies exist regarding the best approach, leading to variations in treatment. This study aims to understand the preferences and practices of orthopedic surgeons regarding management of DBT injuries, as well as assess the feasibility of a future pilot randomized controlled trial (RCT) to evaluate the impact of various surgical factors on patient outcomes. A cross-sectional international survey was conducted amongst surgeons treating patients with DBT injuries. The survey included questions about treatment preferences, surgical techniques, case volumes, and interest in participating in a future RCT. Responses from 491 orthopedic surgeons from 26 countries/territories were obtained. Most surgeons had limited exposure to DBT ruptures. Variations were observed in the work-up process, with some relying solely on clinical examinations while others used diagnostic imaging. A single incision approach was the most common surgical technique, and tendon fixation with suspensory cortical buttons was frequently preferred. Most surgeons did not explore or repair the bicipital aponeurosis. Interest in participating in a future RCT varied for different surgical controversies. This survey provides valuable insights into surgeons' preferences and practices for DBT injury management. The study highlights the need for standardization in the work-up process and the use of evidence-based guidelines. Current practices may be influenced by factors such as training, implant availability, and costs. The survey also identified surgeons and centers interested in collaboration for future multicenter trials, allowing for equitable access to surgical collaboration opportunities and addressing the lack of evidence in DBT rupture treatment. Level V, expert-opinion.

Single-Incision Distal Biceps Tendon Repair With Bicortical Tensionable Locking Button Fixation

Single-Incision Distal Biceps Tendon Repair With Bicortical Tensionable Locking Button Fixation

The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair.

In the United States, the use of testosterone therapy has increased over recent years. Anabolic steroid use has been associated with tendon rupture, although there is a paucity of evidence evaluating the risk of biceps tendon injury (BTI) with testosterone therapy. The aim of this study was to quantify the risk of BTI after the initiation of testosterone therapy. This was a retrospective cohort study using the PearlDiver database. Records between 2011 and 2018 were queried to identify patients aged 35-75 years who filled a testosterone prescription for a minimum of 3 months. A control group was created, comprising patients aged 35-75 years who had never filled a prescription for exogenous testosterone. International Classification of Diseases, Ninth Revision, International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes were used to identify patients with distal biceps injuries and those undergoing surgical repair. Three matching processes were completed: one for the overall cohort, one for the cohort comprising only male patients, and one for the cohort comprising only female patients. Each cohort was matched to its control on age, sex, Charlson Comorbidity Index, diabetes, tobacco use, and osteoporosis. Multivariate logistic regression was used to compare rates of distal BTI and subsequent surgical repair in the testosterone groups with their control groups. A total of 776,974 patients had filled a prescription for testosterone for a minimum of 3 consecutive months. In the overall matched analysis between the testosterone and control groups (n=291,610 in both), the mean age of the patients was 53.9 years and 23.1% were women. Within 1 year of filling exogenous testosterone prescriptions for a minimum of 3 consecutive months, 650 patients experienced a distal BTI compared with 159 patients in the control group (odds ratio [OR],4.10; 95% confidence interval [CI], 3.45-4.89; P<.001). At any time after testosterone therapy, patients with testosterone use were more than twice as likely to experience a distal BTI as their matched controls (OR,2.07; 95% CI, 1.94-2.38). Patients who filled prescriptions for testosterone were more likely to undergo surgical repair within a year of the injury compared with the control group. A similar trend was seen in the cohort comprising male patients (OR,1.63; 95% CI, 1.29-2.07). Patients with prior prescription testosterone exposure have an increased rate of BTI and biceps tendon repair compared with patients without such exposure. This finding provides insight into the risk profile of testosterone therapy, and doctors should consider counseling patients about this risk, particularly male patients.

Patient demographic and magnetic resonance imaging evaluation of isolated posterolateral corner knee injuries.

Posterolateral stability of the knee is maintained by capsular, ligamentous and tendinous structures, which collectively are known as the posterolateral corner (PLC). Injuries to the PLC of the knee rarely occur without associated anterior (ACL) or posterior cruciate (PCL) ligament tears. The main objectives of our study were to report patient demographics and magnetic resonance imaging (MRI) findings of patients with isolated PLC injuries. This study consists of a retrospective analysis of knee MRI from January 2011 to June 2016, in two hospitals in São Paulo, Brazil, where PLC injuries without associated ACL and PCL injuries were identified in MRI by two radiologists specialized in musculoskeletal injuries. Relative and absolute frequencies were used to describe the injuries of each of the PLC structures in the study cases. A total of 23 cases of PLC injuries without associated cruciate ligament injuries were identified. The mean age of patients was 32.0±8.1 years and 91% patients were male. The main sport associated with isolated PLC injury was Brazilian Jiu-Jitsu (48%), followed by soccer (35%). MRI evaluations of the knees showed lateral collateral ligament (LCL) injuries in 70% of cases, popliteus tendon injuries in 26% of cases and distal biceps tendon injuries in 30% of cases. The popliteofibular ligament (PFL) was damaged in 83% of cases. An associated ALL injury was observed in 43% of cases. Isolated PLC injuries occurred mainly in young men when practicing Brazilian Jiu-Jitsu and soccer. The LCL was the most frequently injured larger structure in association, and the capsuloligamentous structures (PFL) were the most frequently injured structures overall. ALL injuries occurred in approximately half of the cases, most often concomitantly with LCL injuries.

Trends and complications of distal biceps tendon repair among American Board of Orthopaedic Surgery part II oral examination candidates

Surgical fixation of distal biceps tendon ruptures can restore supination strength and minimize biceps fatigue, resulting in high patient satisfaction rates. Surgical approaches can vary (single incision vs. double incision), and the number of fixation techniques has increased in recent years. The reported rate of postoperative complications after surgical repair of distal biceps tendon injuries is high, ranging from 15% to 35%. The purpose of this study was to assess the trends and postoperative complication profile among newly trained surgeons who performed distal biceps tendon repairs utilizing the American Board of Orthopaedic Surgery database. The American Board of Orthopaedic Surgery database was retrospectively queried for patients treated with distal biceps tendon repair by part II examination candidates between 2017 and 2020. Distal biceps tendon repairs were isolated using the Current Procedural Terminology code 24,342. Distal triceps tendon injuries were excluded with International Classification of Diseases code S46.3∗∗. Patient demographics, intraoperative data, and surgeon fellowship training were collected. Surgeon-reported postoperative 90-day complications, including general anesthetic, medical, and surgical complications, rates of readmission, and rates of reoperation were recorded. Comparisons of rates among patient groups organized by surgeon fellowship training were performed using the chi-squared test. A total of 2089 distal biceps tendon repairs were included in the analysis. The average patient age was 47.5yr, and 97.3% of patients were men. The majority of cases was performed by surgeons with fellowship training in sports medicine, hand/upper extremity, and shoulder and elbow, with 867 (41.5%) cases performed by sports medicine-trained surgeons, 740 (35.4%) by hand/upper extremity-trained surgeons, and 313 (15.0%) by shoulder and elbow-trained surgeons. In total, 608 (29.1%) patients experienced an anesthetic (0.2%), medical (1.1%), or surgical (28.2%) complication. The most common surgical complications were nerve injury (20.6%), failure of tendon repair or fixation (2.4%), and infection (1.7%). The overall reoperation rate was 2.4%. There were no significant differences in complication or reoperation rates among subspecialty training received. Among newly trained surgeons, those with fellowship training in sports medicine, hand/upper extremity, and shoulder and elbow performed the most distal biceps tendon repairs, and there was no difference in complication rates among subspecialty training received. Complication rates after distal biceps tendon repair performed by newly trained surgeons were similar to those previously reported in large cohort studies, with nerve injury as the most common complication.

Distal biceps tendon ruptures: more efficient diagnostics for a better outcome.

Distal biceps tendon ruptures are a rare pathology, but can have significant functional repercussions. Rapid, accurate diagnosis and treatment are essential for a favorable prognosis. During the diagnostic process of distal biceps tendon ruptures, several problems can emerge. An answer to the following clinical questions is given based on an extensive literature review. - Which clinical tests are the most sensitive/ specific for clinical examination? - Can ultrasound evaluation of the distal biceps tendon be optimized? - Is ultrasound an equivalent alternative to MRI in the diagnosis of distal biceps tendon injuries? An extensive literature search was conducted through Pubmed and Embase. The search strategy was developed systematically in the Medline data- base (PubMed interface), using medical subject headings as well as free text words. A standardized clinical examination of the distal biceps tendon consisting of the Hook test, the Passive Forearm Pronation Test and the Biceps Crease Interval test has a high accuracy for correct diagnosis of full-thickness ruptures. Furthermore, Cobra sign, Supinator view and Pronator view give an additional value to the standard ultrasound examination of the distal biceps tendon. Finally, ultrasound can be considered a trustworthy and cost-effective alternative to MRI in evaluation of distal biceps tendon ruptures.

Role of dynamic ultrasound in assessment of the snapping elbow and distal biceps tendon injury.

Ultrasound is useful in assessing patients with snapping syndromes around the elbow joint. The dynamic nature of the examination allows for direct visualisation of the underlying causative factor.Topic description: We discuss the role of dynamic ultrasound in assessing various snapping syndromes around the elbow, such as ulnar nerve instability, snapping triceps and less commonly, snapping brachialis. Ultrasound is also useful in evaluating the distal biceps tendon, particularly in differentiating partial from complete tendon injury. Ulnar nerve instability and snapping triceps can be assessed via a medial approach with the transducer placed transversely between the medial epicondyle and the olecranon. In ulnar nerve instability, the nerve can be seen crossing over the medial epicondyle on elbow flexion. In snapping triceps syndrome, both the ulnar nerve and the distal triceps can be seen dislocating over the medial epicondyle. Dynamic assessment of the distal biceps tendon using a lateral approach minimises anisotropy artefact often seen on the anterior approach. Passive pronation and supination of the forearm will reveal little or no movement in a completely torn tendon whereas moving tendon fibres will be appreciated in partial tears. In a snapping brachialis, the medial portion of brachialis will be seen abnormally translocating anterolateral to the medial border of the trochlea during elbow flexion and snapping back into its normal position on elbow extension. Dynamic ultrasound of the elbow is valuable in diagnosing patients with snapping sensations around the joint and in evaluating the integrity of the distal biceps tendon.

The Role of Deadlifts in Distal Biceps Brachii Tendon Ruptures: An Alternative Mechanism Described With YouTube Videos.

Background:The classic injury mechanism of a distal biceps brachii tendon rupture (DBBTR) is eccentric loading to the flexed elbow when the forearm is supinated.Purpose:To determine alternative mechanisms of a DBBTR in powerlifting sports, particularly in deadlift competitions, with the use of YouTube videos.Study Design:Descriptive epidemiology study.Methods:A search on YouTube was performed using the search terms “distal biceps tendon rupture” and “distal biceps tendon injury” combined with “competition,” “deadlift,” and “powerlifting.” The videos underwent an evaluation for accuracy by 3 surgeons according to predetermined criteria. Type of sports activity, participant sex, side of the injury, and arm positions at the time of the injury were recorded.Results:Among the videos reviewed, 35 injuries were found appropriate for an evaluation. All participants were male. The majority of the injuries (n = 25) were observed during the deadlift. Only in 1 deadlift injury were both forearms in supination. In the remaining deadlift injuries (n = 24), all elbows were in extension, with 1 forearm in supination and the other in pronation. Among the deadlift injuries in the mixed-grip position, all ruptures occurred in a supinated extremity: 25% (n = 6) of ruptures occurred on the right side, and 75% (n = 18) of ruptures occurred on the left side; this was a significant difference (P = .014).Conclusion:We described an alternative mechanism for a DBBTR, namely, eccentric loading to an extended elbow when the forearm is supinated during the deadlift. As all the ruptures occurred in a supinated extremity, holding the bar with both forearms in pronation may prevent or decrease the risk of ruptures during the deadlift.

Is the flexion-abduction-supination magnetic resonance imaging view more accurate than standard magnetic resonance imaging in detecting distal biceps pathology?

Partial biceps tendon pathology is difficult to diagnose. The flexion-abduction-supination (FABS) magnetic resonance imaging (MRI) view has been advocated to improve the accuracy of MRI investigation. The purpose of this study was to evaluate the accuracy of the FABS view MRI in the diagnosis of distal biceps tendon pathology. The study included 50 patients with surgically confirmed distal biceps tendon pathology and 50 patients with other elbow disorders. In both groups, standard elbow MRI (retrospective review of previously obtained MRI data) was performed in half of the patients whereas FABS views MRI were obtained in the other half. These were evaluated by 2 independent musculoskeletal radiologists. The sensitivity and specificity of both MRI views were determined. Tendinosis and grade of rupture were reported from MRI and then compared with surgical findings. There were no significant differences in sensitivity and specificity in detecting partial distal biceps injuries when the FABS view MRI (sensitivity, 84%; specificity, 86%) and standard MRI (sensitivity, 76%; specificity, 98%) were compared. The interobserver reliability was 92% for the FABS view MRI with biceps pathology and 68% for standard MRI. In the control group, the interobserver reliability was 88% for the FABS view MRI and 96% for standard MRI. FABS MRI was significantly better regarding grade of injury. No significant differences in sensitivity and specificity were found between the FABS view and standard elbow MRI in the diagnosis of partial distal biceps tendon injuries, with high sensitivity and specificity for both views. Inter-rater reliability was better for FABS views, and FABS views were significantly more accurate than surgical findings in grading the extent of pathology.

Distal biceps tendon rupture: diagnostic strength of ultrasonography and magnetic resonance

Abstract Objective the main purpose of this study is to determine the agreement between two radiological tests, ultrasonography and magnetic resonance, in the diagnosis of distal brachial biceps tendon injury. Material and method A retrospective study was made of patients over 3 years who underwent distal brachial biceps tendon reattachment open surgery, and whose preoperative diagnosis was complemented either by ultrasonography, by magnetic resonance or both. The agreement was calculated by Cohen’s kappa coefficient (k). Results information of 79 patients was analyzed. The concordance was excellent between resonance and surgical findings (k = .950), and a good Cohen´s kappa coefficient was also achieved between both ultrasonography and surgery (k = .706) and between information of sonography and magnetic resonance (k = 0.667). Conclusions Resonance and ultrasonography could be considered reliable diagnostic tests to determine the acute rupture of the distal brachial biceps tendon in patients with consistent aetiology and physical examination.

Complications After Distal Biceps Tendon Repair: A Systematic Review

Background: Distal biceps tendon injuries typically occur in the dominant arm of men in their fourth decade of life. Surgical repair restores flexion and supination strength, resulting in good functional outcome. The complication profile of each surgical approach and fixation technique has not been widely studied in the literature. Purpose: To report the rate of complications after repair of complete distal biceps ruptures, to classify them according to surgical approach and fixation technique, and to analyze risk factors and outcomes of the individual complications. Study Design: Systematic review. Methods: Studies published in English on primary repair of the distal biceps between January 1998 and January 2019 were identified. Data on complications were extracted and classified as major and minor for analysis. A quantitative synthesis of data was done to compare the complication rates between (1) limited anterior incision, extensile anterior incision, and double incision and (2) 4 fixation methods. Results: Seventy-two articles including 3091 primary distal biceps repairs were identified. The overall complication rate was 25% (n = 774). The major complication rate was 4.6% (n = 144) and included a 1.6% (n = 51) rate of posterior interosseous nerve injury; 0.3% (n = 10), median nerve injury; 1.4% (n = 43), rerupture; and a 0.1% (n = 4), synostosis. Brachial artery injury, ulnar nerve injury, compartment syndrome, proximal radius fracture, and chronic regional pain syndrome occurred at a rate of <0.1% each. The majority of nerve injuries resolved with an expectant approach. The minor complication rate was 20.4% (n = 630). The most common complication was lateral cutaneous nerve injury (9.2%, n = 283). An extensile single incision was associated with a higher rate of superficial radial nerve injury when compared to limited single incision(6% vs 2.1%, P = .002). Limited anterior single incision technique had a higher rate of lateral antebrachial cutaneous nerve injury compared to extensile single incision. (9.7% vs 5.2%, P = .03). Synostosis occurred only with double incision. Fixation technique had no significant effect on rerupture rate and posterior interosseous nerve injury rate. Conclusion: This is the largest analysis of complications after distal biceps repair, indicating a major complication rate of 4.6%. This study provides valuable data with regard to the choice of technique, surgical approach, and rate of complications, which is essential for surgical planning and patient consent. Registration: CRD42017074066 (PROSPERO).

Rotura del tendón distal del bíceps: potencia diagnóstica de la ecografía y la resonancia magnética

The main purpose of this study is to determine the agreement between two radiological tests, ultrasonography and magnetic resonance, in the diagnosis of distal brachial biceps tendon injury. A retrospective study was made of patients over 3 years who underwent distal brachial biceps tendon reattachment open surgery, and whose preoperative diagnosis was complemented either by ultrasonography, by magnetic resonance or both. The agreement was calculated by Cohen's kappa coefficient (k). Information of 79 patients was analyzed. The concordance was excellent between resonance and surgical findings (k=.950), and a good Cohen's kappa coefficient was also achieved between both ultrasonography and surgery (k=.706) and between information of sonography and magnetic resonance (k=.667). Resonance and ultrasonography could be considered reliable diagnostic tests to determine the acute rupture of the distal brachial biceps tendon in patients with consistent aetiology and physical examination.

Diagnostic des ruptures distales du tendon Biceps brachial : imagerie en résonance magnétique versus échographie

Abstract Introduction The severity of distal biceps tendon (DBT) injuries ranges from partial to complete tears leading to various clinical manifestation. Accuracy of early diagnosis and selection of treatment are critical to long-term recovery outcomes. Magnetic resonance imaging (MRI) or ultrasonography (US) are two commonly modalities for pre-operative diagnosis. The objective of this study was to determine the efficiency of MRI and ultrasonography US in the diagnosis of DBT rupture confirmed by operative findings. Hypothesis MRI and US are equally effective in terms of accuracy, sensitivity and specificity. Material and methods A total of 31 patients with DBT avulsion and surgical treatment were recruited for this retrospective study. All these patients received both US and MRI examinations prior to surgery. DBT avulsion was classified into partial tear and complete tear. Diagnosis outcomes by MRI and US were analyzed and compared statistically for the accuracy, sensitivity, and specificity in discriminating partial and complete DBT tears. Results The accuracy of MRI and US was 86.4% and 45.5% in diagnosis of complete DBT rupture, respectively. Accuracy rate of MRI (66.7%) was the same as US in diagnosis of partial tear. Overall accuracy rate of MRI (80.6%) was higher than US (51.6%) in diagnosis all DBT avulsion with an odds ratio of 3.9. Sensitivity and specificity of MRI were 76.0% and 50.0%, while that of ultrasonography were 62.5% and 20.0%. Conclusions The findings of this study suggest that MRI is a more accurate imaging modality at correctly identifying the type of DBT tear although US is more cost-effective. Level of evidence III, Cohort study, Diagnosis study.

An intact lacertus fibrosus improves strength after reinsertion of the distal biceps tendon.

The importance of an intact lacertus fibrosus in distal biceps tendon injury is uncertain. This study aimed to assess long-term outcome following distal biceps tendon repair with focus on the significance of the lacertus fibrosus. Thirty-six patients surgically treated for primary distal biceps tendon rupture were identified. Medical records were reviewed for patient demographics in addition to surgery-related data. All patients underwent a targeted clinical examination to assess elbow function and they completed a patient reported questionnaire. Radiographs were obtained at time of follow-up and evaluated for the presence of osteoarthritis (OA) and heterotopic ossification (HO). All patients were male. Median age at injury was 48years (34-69) and median time of follow-up of was 71months (23-165). All patients presented functional range of motion in the elbow. Median flexion strength was 76Nm (45-135) (median 99% of uninjured side; range 66-128) with intact lacertus fibrosus and 70Nm (43-124) (88%, 62-114) with torn lacertus fibrosus. Median supination strength was 6Nm (3-11) (86%, range 36-144) with intact lacertus fibrosus and 8Nm (3-17) (67%, 28-118) with torn lacertus fibrosus. No signs of OA were revealed, but three patients had major HO of which one patient had minor limitations in range of elbow motion. An intact lacertus fibrosus contributes to elbow strength and should be preserved in distal biceps tendon repair. III.

Magnetic resonance imaging versus ultrasound in diagnosis of distal biceps tendon avulsion

The severity of distal biceps tendon (DBT) injuries ranges from partial to complete tears leading to various clinical manifestation. Accuracy of early diagnosis and selection of treatment are critical to long-term recovery outcomes. Magnetic resonance imaging (MRI) or ultrasonography (US) are two commonly modalities for pre-operative diagnosis. The objective of this study was to determine the efficiency of MRI and ultrasonography US in the diagnosis of DBT rupture confirmed by operative findings. MRI and US are equally effective in terms of accuracy, sensitivity and specificity. A total of 31 patients with DBT avulsion and surgical treatment were recruited for this retrospective study. All these patients received both US and MRI examinations prior to surgery. DBT avulsion was classified into partial tear and complete tear. Diagnosis outcomes by MRI and US were analyzed and compared statistically for the accuracy, sensitivity, and specificity in discriminating partial and complete DBT tears. The accuracy of MRI and US was 86.4% and 45.5% in diagnosis of complete DBT rupture, respectively. Accuracy rate of MRI (66.7%) was the same as US in diagnosis of partial tear. Overall accuracy rate of MRI (80.6%) was higher than US (51.6%) in diagnosis all DBT avulsion with an odds ratio of 3.9. Sensitivity and specificity of MRI were 76.0% and 50.0%, while that of ultrasonography were 62.5% and 20.0%. The findings of this study suggest that MRI is a more accurate imaging modality at correctly identifying the type of DBT tear although US is more cost-effective. III, Cohort study, Diagnosis study.

REHABILITATION FOLLOWING DISTAL BICEPS REPAIR

Distal biceps rupture is less common than injury to the proximal biceps; however, injury distally has profound functional implications on activities which rely on power during elbow flexion and forearm supination. The majority of distal biceps ruptures can be treated with surgical repair of the distal biceps utilizing either a single or two-incision technique; both of which achieve comparable improved outcomes and reported minimal pain and disability at two years. Safe and effective rehabilitation following distal biceps repair is accomplished through a phased progression, with avoidance of premature stress to the healing soft tissue repair.The purpose of this clinical commentary is to provide a concise review of distal biceps tendon injury, including relevant anatomy, etiology, diagnosis, and operative intervention as well as post-operative factors influencing the pursuit of a criterion based, progressive rehabilitation program after distal biceps tendon repair. This commentary seeks to provide an update on current treatment strategies used in distal biceps rehabilitation with accompanying scientific rationale. 5.

Treatment of Distal Biceps Tendon Injuries with Particular Emphasis on Postoperative Physiotherapy.

Distal biceps tendon injuries are relatively rare. Standard treatment of complete tears and significant partial tears involves surgical anatomical reinsertion of the tendon at the radial tuberosity. Chronic injuries are usually managed with surgical tendon reconstruction using autografts or allografts. Conservative treatment is mostly limited to the elderly, individuals with a very low level of physical activity, patients with evident contraindications to surgical treat-ment, and cases of mild partial tendon tears. The selection of an optimum surgical technique and method of fixation remains controversial. The aim of this paper is to characterize distal biceps tendon injuries, discuss methods of their surgical treatment, and analyze postoperative physiotherapy regimens described in the literature. A literature review did not reveal any relationship between the surgical method and type of fixation used on the one hand and the period of immobilization, type of immobilization, or the postoperative physiotherapy regimen on the other.

All-Endoscopic Distal Biceps Repair: Cadaveric Portal Safety Analysis and Technical Feasibility Using 2 Fixation Techniques

The 2-part cadaveric study evaluated portal placement sites for distal biceps endoscopic repair. Technical feasibility and safety of an all-endoscopic repair using 2 fixation techniques (4 devices) was assessed. The study demonstrates the cadaveric anatomy-at-risk and presents guidelines for safe endoscopy in the cubital fossa and upper forearm region. Distal biceps tendon (DBT) injuries often require surgical intervention. Current treatment strategies use open surgical approaches to debride and repair the tendon. Endoscopic techniques have been suggested, however, the safety and feasibility of performing an endoscopic procedure in the upper forearm has not been evaluated. The purpose of this study was (1) to determine safe portal placement sites for endoscopy in the upper forearm, and (2) to analyze the feasibility and safety of performing an all-endoscopic repair of the ruptured distal biceps tendon using 2 fixation techniques (Button, suture anchors). The hypothesis of this study was that all-endoscopic DBT repair was possible without injury to neurovascular structures. 35 fresh frozen cadavers were used in 2 groups. In the first part of the study, 10 fresh frozen cadavers were used to analyze 5 possible portal sites (Parabiceps portal, two distal anterior portals [DAP 1 and DAP 2], tuberosity portal, and distal posterior portal) for distal biceps endoscopy. Nine neurovascular structures (cephalic vein; lateral cutaneous nerve; leash of vessels; radial nerve; superficial radial nerve; posterior interosseous nerve; radial artery; brachial artery; median nerve) were dissected, and their distances from portal sites were measured. In the second part, 25 fresh frozen cadaveric elbows were used. An endoscopic technique was used to explore the normal distal biceps and cubital fossa. The DBT was sectioned at the radial tuberosity. The tendon was then endoscopically reattached to the tuberosity using (1) button technique, with and without interference screw (15 cadaveric elbows), and (2) dual suture-anchor technique with 2 anchor types (10 cadaveric elbows). At the end of the procedure, each cadaver was dissected and nine neurovascular structures were assessed for injury. In addition, analysis of footprint of repaired DBT was performed, and placement site of fixation devices was evaluated. Compartmental pressures were obtained before and after procedure. In the first part (10 cadavers): parabiceps and distal posterior portals were safe. Radial artery was significantly ‘‘at risk’’ of injury from tuberosity portal. Similarly, superficial radial nerve (SRN) was ‘‘at risk’’ from the distal anterior portal 2, and the posterior interosseous nerve (PIN) was ‘‘at risk’’ from distal anterior portal (DAP 1). Overall, RA, SRN, and PIN were found to be significantly'' at risk'' (p<0.05). In the second part (25 cadavers): The normal and sectioned tendons, and the anterior and medial aspects of the tuberosity were clearly visualized via the parabiceps portal. Endoscopic repair was possible using all fixation devices. Neurovascular structures were at low risk for injury. A small rise in compartment pressures was noted before and after the procedure. Gapping and contact area varied between the different fixation devices. Endoscopic reattachment of the sectioned DBT was safe and feasible using all fixation devices. Parabiceps and distal posterior portals were safe, However, other 3 anterior portals were significantly closer to neurovascular structures, and open dissection is recommended if these portals are used. RA, SRN, and PIN were significantly ‘‘at risk’’ as compared to other structures amongst the portals studied.

Distal Biceps Tendon Injuries: Treatment of Partial and Complete Tears

Distal biceps ruptures predominantly affect males in their third to fifth decade of life who are involved in heavy lifting or manual labor activities. This includes athletes from those in the professional ranks to weekend warriors. They commonly describe a tearing event with the elbow in flexion and undergoing an eccentric load. The hook test is highly sensitive and specific in diagnosis. In the setting of partial-thickness tears, the hook test can be negative but can elicit pain. Magnetic resonance imaging is the imaging modality of choice to determine partial vs full-thickness tears and the degree of proximal migration of the tendon stump. Operative intervention is recommended for most athletes and people in need of elbow flexion and supination strength and endurance. Operative repair techniques have improved and now allow early range of motion and strengthening for return of patients to their sports or activities of choice with good clinical outcomes reported using multiple techniques. The authors preferred technique is the use of a suture button and interference screw construct that has been validated in both biomechanical testing and clinical outcomes studies.