Distal Biceps Tendon Ruptures Research Articles

Bilateral simultaneous distal biceps tendon rupture repair with both cortical button and interference screw

Bilateral simultaneous distal biceps tendon rupture repair with both cortical button and interference screw

PoCUS identification of distal biceps tendon rupture: a case report

BackgroundIn the Emergency Department (ED), patients may present with various injuries that damage muscles, tendons, ligaments, and bony structures. Fractures, joint dislocations, strains, and sprains are prevalent among them. However, distal biceps tendon ruptures are uncommon.Case ReportHere, we report a case of a young man presented to the ED with a complaint of left arm pain following a martial arts activity. The diagnosis of distal biceps tendon rupture was made using a point-of-care ultrasound (PoCUS), and an early referral to the orthopedic service was provided.ConclusionThis case highlights the utility of point-of-care ultrasound in assessing musculoskeletal injuries in the ED. Early incorporation of PoCUS into routine clinical practice can potentially improve the overall care of musculoskeletal injuries.

Clinical case of the surgical treatment of complete rupture of distal biceps tendon using two cortical buttons

Clinical case of the surgical treatment of complete rupture of distal biceps tendon using two cortical buttons

Prevalence and clinical implications of heterotopic ossification after distal biceps tendon repair.

Complete distal biceps tendon ruptures are relatively uncommon. Conservative treatment may result in persistent pain and weakness. Therefore, surgical repair is usually indicated in order to restore strength. Different surgical techniques and fixation methods have been described. The most reported complications after surgery are iatrogenic nerve damage, heterotopic ossification (HO) and re-rupture. Heterotopic ossification can be variable in size. Significant HO can limit range of motion while minor HO often remains asymptomatic. The overall presence of HO is likely underreported in literature, as imaging is reserved for symptomatic patients. The purpose of this study is to report the prevalence and clinical implications of heterotopic ossification after surgical repair of the distal biceps tendon. This retrospective study assessed the prevalence and clinical relevance of postoperative HO after distal biceps tendon repair. CT-scans were used to evaluate size and location of the HO. VAS scores, DASH scores, MEPI, and range of motion (ROM) were assessed to evaluate pain, patient satisfaction and elbow function. HO was observed on CT images of 19 out of 35 patients (54%). The use of interference screws, timing of surgery after rupture and timing of radiographic assessment postoperatively did not influence the prevalence of HO. The presence of HO had no statistically significant impact on the VAS scores, ROM measurements and MEPI and DASH scores. According to our findings, the overall incidence of HO is higher than previously reported but there are no differences in clinical outcomes when compared to patients without HO.

Is the Complication Rate in the Surgical Repair of the Distal Biceps Tendon Rupture Influenced by the Timing, Type of Incision and Method of Fixation?

Distal biceps tears are uncommon injuries, typically leading to significant loss of elbow flexion and supination strength; surgical repairs restore muscular strength and endurance. The aim of this study was to compare the complication rate of early (< 21 days) vs delayed (> 21 days) repair and the effect of types of incision and fixation methods used in the repair. A total of 86 cases were retrospectively reviewed, and 66 cases were included in the study after exclusion. Different preoperative and intraoperative variables and postoperative outcome measures were recorded. We analysed the effects of early and delayed repair, types of incision and fixation methods on the complications. 31 had an early, and 35 had delayed distal biceps repair. The mean follow-up was 14.92 weeks. 13.6% had major, and 40.9% had minor complications. No significant difference was noted in complications between the two groups (54.8% vs 54.3%). Higher complications were observed when surgery was done using a single anterior incision compared to 2 anterior incisions (68.8% vs 16.7%, p=0.0002). Overall, higher (76.3% vs 25.9%, p=0.0001) complications were noted in patients where fixation was done using a cortical button & interference screw in comparison to the cortical button alone. No significant difference in complication was noted between early and delayed repair. However, more complications were noted in the single anterior incision compared to the two anterior incision technique. Higher complications were also observed with the cortical button and interference screw fixation method compared to the cortical button alone.

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

Purpose 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. Methods 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. Results 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. Conclusion 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 of Evidence Level V, expert-opinion.

Smaller radioulnar window is associated with a distal biceps tendon rupture in patients with limited forearm rotation: a 3-dimensional computed tomography comparison study of proximal impingement caused by radial tuberosity hypertrophy—a single-center case series

It has been suggested that hypertrophy of the radial tuberosity may result in impingements leading to either lesion of the distal biceps tendon or rotational impairment. The two studies on hypertrophy of the radial tuberosity had contradictory results and did not study the distance between the radius and ulna: the radioulnar window. Therefore, this comparative cohort study aims to investigate the radioulnar window in healthy subjects and compare them with subjects suffering from either non-traumatic onset rotational impairment of the forearm or non-traumatic onset distal biceps tendon ruptures with a rotational impairment of the forearm using dynamic 3D CT measurements in order to attain a comprehensive understanding of the underlying etiology of distal biceps tendon ruptures. We hypothesize that a smaller radioulnar window increases the risk of having a non-traumatic onset distal biceps tendon rupture and/or a rotational impairment compared to healthy individuals. This study measured the distance between the radius and ulna at the level of the radial tuberosity using entire forearm computed tomography (CT) scans of fifteen patients in the Amphia Hospital between 2019 and 2022. Measurements of healthy subjects were compared to subjects with non-traumatic onset rotational impairment of the forearm and subjects with a non-traumatic onset distal biceps tendon rupture with a rotational impairment of the forearm. The Wilcoxon signed-rank test was used for individual comparisons, and the Mann-Whitney U test was used for group comparisons. A significant difference was found between the radioulnar window in the forearms of the subjects with a distal biceps tendon rupture (mean: 1.4, SD 0.4 mm) compared to the radioulnar window in forearms of the healthy subjects (mean: 4.8, SD 1.4 mm, p = 0.018). A trend towards smaller radioulnar windows in the rotational impairment groups was also observed, although it was not significant (p > 0.05). The radioulnar window in the forearms of the subjects with a distal biceps tendon rupture with a rotational impairment was significantly smaller than in the forearms of the healthy subjects. Therefore, patients with a smaller radioulnar window have a higher risk of rupturing their distal biceps tendon. Non-traumatic onset rotational impairments of the forearm may also be caused by a similar mechanism. Future studies are needed to back this finding further.

Comparative Analysis of Surgical Approaches for Distal Biceps Tendon Rupture: Single-Incision Technique versus Double-Incision Technique.

Background: This study aimed to compare the outcomes of the single-incision technique with a distal biceps repair system versus the modified double-incision technique, specifically the Morrey-modified approach, Krackow sutures, and drill holes, for the management of acute and chronic distal biceps tendon rupture. The study was conducted at the Orthopedic-Traumatology Clinic II of SCJUPBT Timisoara, Romania, between 2014 and 2022. Methods: A total of sixty-nine patients with acute distal biceps tendon rupture and five patients with chronic distal tendon rupture were included in the study. Forty-eight cases underwent the single-incision technique with the distal biceps repair system, while twenty-four patients were treated with the modified double-incision technique. Results: Both surgical techniques demonstrated favorable outcomes in terms of successful tendon repair and functional restoration. However, the single-incision technique exhibited slightly superior results in terms of patient satisfaction, range of motion, and postoperative rehabilitation. The modified double-incision technique showed comparable outcomes but had a higher incidence of complications, particularly related to wound healing. Conclusion: The single-incision technique with the distal biceps repair system and the modified double-incision technique, including the Morrey-modified approach, Krackow sutures, and drill holes, are effective surgical approaches for the management of distal biceps tendon rupture. The single-incision technique yielded better functional outcomes and patient satisfaction, while the modified double-incision technique had a higher risk of complications. Further research with larger sample sizes and longer follow-up periods is necessary to validate these findings and determine the most appropriate surgical approach for distal biceps tendon rupture.

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

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.

Retrospective Study on the Risk of Nerve Injury After Distal Biceps Tendon Repair Using Cortical Button.

Distal biceps tendon ruptures are relatively rare injuries that typically require surgical intervention to restore flexion and supination strength. Concerns have been raised regarding the risk of nerve injuries, particularly the posterior interosseous nerve (PIN), associated with the use of cortical buttons in distal biceps repair. This study aimed to estimate the incidence of PIN injury as well as injuries to the lateral cutaneous nerve of the forearm and superficial branch of the radial nerve following distal biceps repair using cortical buttons. A retrospective review was conducted on all patients who underwent distal biceps repair with cortical buttons at a district general hospital between January 2014 and May 2022. Patient data, including age, gender, time from injury to surgery, type of procedure, and postoperative nerve injuries, were collected. The incidence of nerve injuries was analyzed, and the outcomes were assessed during postoperative follow-up visits. Ninety-six male patients were included in the study, with an average age of 45.6 years. The average time from injury to surgery was 22.6 days. All patients underwent primary repairexcept for two patients who underwent reconstruction with hamstring grafts. None of the patients experienced a PIN injury. However, 16 patients (16.7%) developed lateral cutaneous nerve injuries of the forearm, and three patients (3.1%) had superficial radial nerve injuries. Our study, encompassing a large cohort of patients over an eight-year period, demonstrates the safety of distal biceps repair using cortical buttons with regard to PIN nerve injury. However, there were incidences of lateral cutaneous nerve of the forearm and superficial radial nerve injuries, consistent with previous studies.

Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures

Although the initial description of the distal biceps tendon (DBT) hook test (HT) reported 100% sensitivity (Sn) and specificity (Sp), subsequent retrospective series have demonstrated imperfect validity. The purpose of this investigation was to prospectively assess the validity and reliability of the HT for complete DBT ruptures. We aimed to determine the Sn/Sp and interrater reliability for the HT. A consecutive series of adult patients presenting to our outpatient clinics with an elbow complaint was prospectively examined. Patients were included if they had undergone advanced imaging (magnetic resonance imaging or ultrasound) that imaged the DBT and underwent DBT repair. There were four participating surgeons, all of whom were blinded to magnetic resonance imaging/ultrasound prior to performing the HT. To determine the Sn/Sp of the HT and advanced imaging, intraoperative findings served as the primary reference standard. The interrater reliability of the HT was calculated for cases in which a primary examiner (surgeon) and secondary examiner (physician assistant or resident) performed the HT. Of 64 patients who had undergone advanced imaging, 28 (44%) underwent DBT surgery and were included in the assessment of Sn/Sp. The mean age was 49 years, and all patients were men. The Sn and Sp of the HT were 96% and 67%, respectively. Advanced imaging demonstrated 100% Sn and Sp. Twenty-five patients were evaluated by a primary and secondary examiner. The interrater reliability was substantial (Cohen kappa, 0.71). The Sn and Sp of the HT were 96% and 67%, respectively, when assessed prospectively. Advanced imaging findings (magnetic resonance imaging/ultrasound) demonstrated 100% Sn and Sp. The HT can be performed reliably by examiners with varying experience levels. Considering the imperfect validity of the HT, we caution against the use of this examination alone to diagnose DBT ruptures. Diagnostic II.

Distal biceps tendon ruptures: clinical features, diagnostic strategy and treatment options

Relevance. This paper reviews the latest evidence concerning distal biceps tendon repair, particularly aspects such as tear type, patient demographics, diagnostic clues, surgical indications, the anatomy of distal tendon insertion, radial tuberosity, single- vs double-incision reconstruction, fixation techniques (bone tunnels, distal biceps button, interference screw, button plus screw) and postoperative outcomes.Material and methods. The MEDLINE, Cochrane, Web of Science, Scopus and Elibrary online databases were searched using the keywords ‘distal biceps tendon’, ‘elbow’, ‘intramedullary’, ‘partial’. ‘complete’, ‘review’ and ‘rupture’. Sixty publications on distal biceps tendon rupture treatment were identified that appeared over 60 years, between 1951 and October 2021.Results and discussion. The review has demonstrated that complete deltoid ligament (DBT) tears are predominantly diagnosed clinically, while medical imaging has proven to be a valuable adjunct for diagnosing partial tears. Advances in clinical and medical imaging of partial tears have the potential to expedite the diagnostic process and guide treatment strategies. Primary repair is commonly employed for complete tears, utilizing either a single-incision or double-incision approach, resulting in favorable clinical outcomes. However, the double-incision technique carries a higher risk of heterotopic ossification, whereas the single-incision approach presents a greater risk of nerve-related complications. To mitigate the risk of posterior interosseous nerve lesions in single-incision repairs, intramedullary fixation may serve as a viable solution. Additionally, DBT endoscopy holds promise for the treatment of low-grade partial tears and tendinosis.

Corrigendum to Biomechanical analysis of single-incision anatomic repair technique for distal biceps tendon rupture using tunneling device

Corrigendum to Biomechanical analysis of single-incision anatomic repair technique for distal biceps tendon rupture using tunneling device

Distal Biceps Tendon Reconstruction with Achilles Tendon Allograft: A Case-Series

Background: Chronic, complete ruptures of the distal biceps tendon are often difficult to surgically repair due to significant fibrosis and retraction. The use of a graft is recommended, with recent literature suggesting that an Achilles tendon allograft leads to superior clinical outcomes. The purpose of this study is to present the surgical technique and retrospectively review the clinical outcomes of a distal biceps reconstruction technique that utilizes an Achilles tendon allograft with an Endobutton bicortical fixation system through a single S-shaped incision. Methods: Seven male patients and eight cases of distal biceps reconstruction with Achilles tendon allograft were identified between January 2017 and March 2022. The mean age was 48.3 ± 8.9 years with a mean time from initial injury to surgery of 6.1 ± 3.8 months. Charts were retrospectively reviewed for patient demographics, procedural technique, preoperative and postoperative evaluation, and complications. Results: The cohort had a mean follow-up of 4.6 ± 2.0 months (range, 1.4-8.2). At the final office visit, full range of motion had returned for all patients except one, who had a persistent 10° extension deficit. Flexion strength had returned to equal preoperative and preinjury gross strength out of 5 (4.7 ± 0.5 preoperatively vs. 4.4 ± 0.5 postoperatively) and supination improved from preoperative strength (2.2 ± 1.1 preoperatively vs. 3.6 ± 1.2 postoperatively). Four out of eight cases resulted in a new neuropraxia identified in postoperative care: two lateral antebrachial cutaneous nerves, one superficial branch of radial nerve, and one ulnar nerve, with insufficient follow-up duration to determine resolution. One patient reported excessive scar formation; otherwise, there were no major complications. Conclusion: Reconstruction of the distal biceps tendon using an Achilles tendon allograft is a technically challenging, yet effective approach for the treatment of complete distal biceps tendon ruptures that are chronic in nature, resulting in an improvement in preoperative disability with few postoperative complications.

Stromal-vascular fraction of adipose tissue using in the repair of distal biceps tendon tears

Distal biceps tendon rupture is most commonly found in working-age men, making the treatment terms and functional recovery level of significant socio-economic importance. Modern scientific research aims to minimize the number of complications, particularly recurrent ruptures. Attention is drawn to modern technologies aimed at stimulating regenerative processes, including the use of the stromal vascular fraction (SVF) of abdominal adipose tissue. The article presents the results of the practical application of SVF in the surgical restoration of the distal biceps tendon of the shoulder. The aim of the study: to improve the results of surgical treatment of distal biceps tendon rupture, shorten recovery times and reduce the incidence of complications using stromal vascular fraction obtained from adipose tissue. Materials and methods. The study was carried out by evaluating the results of surgical restoration of the distal biceps tendon in 34 patients who were divided into 2 groups – with intraoperative introduction of SVF at the reattachment site (n = 14) and without it (n = 20). At follow-up examinations after 3 days, 2 weeks, 6 weeks, and 3 months, the results of the patients were evaluated using the VASH, DASH scales and the range of motion in the affected elbow joint was measured. In addition, a general blood analysis and quantitative determination of C-reactive protein were performed before the operation and at follow-up visits. Results. There was no difference in the level of C-reactive protein and the general blood analysis score between patients in both groups at all study time points. It was found that after 2 weeks, the VAS score was significantly lower in the study group. The DASH score on follow-up examinations after 2 and 6 weeks was significantly better in the study group. Also, at follow-up examinations after 2 and 6 weeks, a greater volume of supination movements was observed in the study group. Conclusions. The using of SVF did not lead to the development of postoperative complications. The using of SVF allowed the reduction of the recovery time and decreased in the incidence of complications, as well as improved functional outcomes.

Return to sports following distal biceps tendon repair: A current concepts review

Distal biceps tendon ruptures are relatively rare injuries but tend to occur in active and athletic populations, especially in weightlifting and contact sports. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow, thus an injury to this ligament can be invalidating for athletes. The aim of this review was to determine the ability and the time to return to sports following distal biceps tendon repair in athletes and the level of performance. The literature is scarce about the return to sports among athletes. Most studies include athletes are National Football League (NFL) players, others are weightlifters and a few recreational athletes. The return to play rate after distal biceps tendon repair is high. The performances of the returned players were similar to matched players and most players returned to the same level. Most players—depending on the sport—were not able to return to competition within the same season. In order to manage expectations, it should be discussed preoperatively with the athlete (and their coach) that the return to sports rate is high, but the return will probably be the following season.

A Novel Distal Biceps Rupture Repair Technique Utilizing a Biocomposite Scaffold.

Distal biceps tendon ruptures are uncommon injuries that have a re-rupture rate of 1.2% - 6%. In severe traumatic injuries or chronic injuries, a distal biceps tendon repair may require augmentation due to insufficient tissue quality. Unsuccessful treatment of these injuries can result in the loss of approximately 40% of supination strength and 30% of elbow flexion strength. There has been a growing interest in biologic augmentation in orthopedic surgery, and its incorporation into distal biceps tendon repairs has increased as well. Established bio-inductive implants and dermal allografts have been shown to be of benefit; however, these biologics have drawbacks such as failure to incorporate at time of implantation, lack of structural strength, and technical difficulty of implantation. The BioBrace® (ConMed, New Haven, CT) is a bio-inductive, biocomposite scaffold that is composed of highly porous type I collagen and bio-resorbable poly (L-Lactide) (PLLA) microfilaments. It can be used in conjunction with distal biceps tendon repair or reconstruction. It has the advantage of providing strength to the augmented repair at time zero of implantation, while also demonstrating the ability to induce new organized tissue growth throughout its resorptive phase. We describe a technique to successfully augment a distal biceps tendon repair using the BioBrace®.

What's New in Sports Medicine.

What's New in Sports Medicine.

Krackow Stitch and Whipstitch Use in Distal Biceps Tendon Rupture Repair: A Porcine Composite Bone Biomechanical Study.

The suture combination of a Krackow stitch plus a whipstitch can be used to strengthen a tendon rupture repair. We compared biomechanical outcomes of suture repair techniques for distal biceps tendon ruptures using a single Krackow stitch with and without a whipstitch and a whip-stitch alone. Data were obtained from 36 thawed porcine flexor profundus tendons. A cortical button was secured to fourth-generation composite bone using No. 2 FiberWire (Arthrex) and No. 2 FiberLoop (Arthrex). The primary outcome was maximum load to failure. Secondary outcomes were displacement at the bone-tendon interface, total construct elongation, and stiffness. The Krackow plus whipstitch group (mean, 493.82 N; SD, 209.44 N) had a greater maximum load to failure as compared with the single Krackow group (mean, 333.71 N; SD, 172.32 N) (P=.01) and single whipstitch group (mean, 207.27 N; SD, 66.42 N) (P<.001). The single Krackow group (mean, 1.67 mm; SD, 0.89 mm) had a greater bone-tendon interface displacement (P=.01) after preloading and before cyclic loading than the single whipstitch group (mean, 0.83 mm; SD, 0.58 mm). There were no other secondary outcome differences between groups. A repair using Krackow plus whipstitch is biomechanically stronger with no difference in bone-tendon interface displacement, total construct elongation, or stiffness when compared with a single Krackow or single whipstitch. We recommend this repair technique for distal biceps tendon rupture repair, which may accelerate rehabilitation and decrease re-rupture rate. [Orthopedics. 2023;46(4):224-229.].

Shoulder &amp; Elbow

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