Abstract
Our aim was to evaluate the outcome of our surgical technique for the repair of complete distal biceps tendon rupture in nonprofessional athletes. We examined the effect of our surgical technique in restoring the functionality of 11 injured limbs by correlating the total functional outcome of the repaired limb with their contralateral side.
Introduction
The purpose of this study was to evaluate the outcomes of our surgical technique in repairing complete distal biceps tendon ruptures in nonprofessional athletes involved in competitive sports. We treated 11 patients (weight lifters and bodybuilders) surgically, all of them practicing sports from an early age, and we correlated the total functional outcome of their repaired limb with their contralateral side.
Although complete distal biceps tendon rupture is a relatively rare injury, there is an increase in the incidence of this type of injury over the past decades, probably due to the rise in the percentage of people involving in sports.
Distal biceps tendon rupture was first described in early 20th century, actually in 1898, in a paper written by Aquaviva. 1 Until today, the best method of surgical intervention for distal biceps tendon rupture remains a challenge. Early references suggest that this type of injury accounts for 3% of all injuries involving biceps muscles, whereas more recent studies state that 1.2 patients per 100,000 sustain this kind of injury. The dominant limb is injured in 86% more often than the contralateral, with the mean age varying between 47 and 50 years. 2
There is a statistically significant increase in the incidence of this kind of injury in smokers and a clinical correlation between these types of ruptures and the use of anabolic substances. 2 Some local factors such as an osteophyte in the area of insertion or an ischemic local area of tendon near this area can lead to an increased possibility of rupture. 3,4,5
The most common pattern of injury in distal biceps tendon rupture is the complete detachment of the tendon from its insertional footprint at radial tuberosity, and it usually happens when a sudden force is applied to a flexed elbow at 90°. 2,3,6,7 Most commonly, this type of injury is common in athletes involving in contact and competitive sports such as football, weight lifting, rugby, or judo.
Materials and methods
A retrospective case–control study was conducted between 2001 and 2013. The study consisted of 11 male patients (weight lifters and bodybuilders) aged between 22 and 35 years, who presented with functional disability associated with a complete distal biceps tendon rupture and were treated with our surgical technique (distal biceps tendon repair using both an anchor and a bone tunnel) by two surgeons. According to their personal statement, all patients practiced sports from an early age and none of them have ever used anabolic substances. All of them were nonsmokers, and none underwent any surgical intervention at this site in the past.
The diagnosis of the distal biceps tendon rupture was made according to the clinical findings (palpation, hook test, Popeye sign) along with the Magnetic Resonance Imaging (MRI) findings in all patients who met the inclusion criteria (hematoma, complete detachment of the insertional tendon, retraction of the proximal stump). 8 –19 All ruptures were acute at the time of surgical intervention—3 weeks at maximum—and they all involved the dominant upper limb. All patients returned for clinical examination, radiographic evaluation, and functional measurements using Cybex ergometer (http://www.cybexintl.com/company/overview/heritage.aspx). We measured Range Of Motion (ROM) of elbow flexion–extension and pronation–supination per kilogram of body weight as well as the peak and mean (three cycles) torque during the aforementioned movements and compared these findings with the contralateral side, respectively. We introduced a control group with the same characteristics of our study group (gender, age, mass) to eliminate the statistical error caused by the nondominant deficit of the study group. We also used the Disabilities of the Arm, Shoulder and Hand (DASH) 9 and visual analog scale (VAS) scores. Statistical analysis was made using the SPSS for windows (version 17; SPSS, Chicago, IL, USA).
Surgical technique
A curved incision was made over the anterior aspect of the elbow (antecubital fossa), starting approximately 3 cm above the flexion crease on the medial side of the biceps. The incision curved over the front of the elbow, ending on the medial border of the brachioradialis muscle, 3 cm under the flexion crease (Figure 1(a) and (b)). After subcutaneous dissection—avoiding injury to the lateral antebrachial cutaneous nerve—lacertus fibrosus and other surrounding tissues had to be divided (dissected) in order to mobilize the ruptured distal biceps tendon. Most of the tributaries of the basilic and cephalic veins were electrocauterized. The radial recurrent branch of the radial artery was ligated with a 3-0 vicryl free suture. The exposure of the bicipital tuberosity of the radius led to the reflection of the supinator muscle, at the same time protecting posterior interosseous nerve (PIN). To achieve this, an assistant held the forearm supinated throughout the whole operation (Figures 2 and 3).
(a) Incision mark. (b) Incision mark.
Biceps tendon (proximal stump), Anterior Interosseous Nerve (AIN) tagged.
Biceps tendon’s proximal stump debrided.
In most of the cases, due to the fact that the injuries were acute, a pseudosheath from the distal end of the ruptured tendon was used (making it easier for the radial tuberosity to be traced). Once the tuberosity was identified, all soft tissues were retracted and a high-speed cutting burr was used to roughen the surface. Then, two holes were drilled through both cortices, 5–6 mm apart, on the proximal part of the bicipital tuberosity using a 3.5-mm drill (Figure 4). By doing so, we created the transosseous tunnels for a pullout technique. Next, a hole was drilled 1 cm distal to the bone tunnels for the insertion of a 3.5-mm anchor with a 3.5-mm drill (Figure 5). The whole area of the bicipital tuberosity was irrigated in a meticulous manner in order to avoid any postoperative heterotopic ossification.
Two holes drilled through both cortices, 5–6 mm apart, on the proximal part of the bicipital tuberosity using a 3.5-mm drill.
Insertion of a 3.5-mm anchor.
The end of the biceps tendon stump was proximally retracted in most of the cases. Once it was identified, all damaged and degenerative tissues were debrided. Then an Ethibond N5 suture was passed through the tendon using the Krakow technique (and exiting through the proximal part of the stump). Likewise, the anchor’s sutures were passed through the tendon’s stump using the Krakow technique (and exiting through the distal part of the stump).
With the elbow joint at 90° of flexion and the forearm fully supinated, the biceps tendon stump was approximated to the radial tuberosity (Figure 6). The anchor’s sutures were secured first, on the distal part of the radial tuberosity. Next, both the free ends of the Ethibond N5 suture were passed through the transosseous tunnels and secured on the dorsal muscular surface over the drilled site, through a small 2 mm (stab) incision made at the dorsolateral side of the forearm (Figure 7). In this way, both edges of the tendon’s stump were consolidated on the radial tuberosity from distal to proximal, increasing the footprint of the tendon, distributing the loads exercised on the stump more evenly, and consequently increasing the security level of the suture (Figure 8). Figure 9 demonstrates an x-ray of the repair site showing the direction of the anchor placement.
Biceps tendon stump approximated to the radial tuberosity.
Small stab incision (2 mm) for the pullout technique.
Both edges of the tendon’s stump consolidated on the radial tuberosity.
X-ray demonstrating the anchor placement.
The wound was then closed with a 3.0 vicryl and 3.0 nylon sutures or staples. Finally, the arm was placed in a posterior splint with the elbow flexed at 90° and the forearm fully supinated.
Postoperative management
The upper extremity was immobilized at 90° of flexion in a sling overnight. When wound healing was ensured and controlled motion was permitted, the patient was encouraged to use the arm for basic activities of daily living followed by gentle, gravity-assisted elbow motion, depending on the level of patient comfort as well as the security of the fixation. No patients were left immobilized for more than 14 days. For a period of 4 weeks, the patients were encouraged to mobilize within a flexion arc from 60° to 120°. This was followed by assisted movement for another 2 weeks. In the next 6 weeks, the patient started moving the arm actively in full ROM and then gradual loading was applied to the arm until the 20th week from the time of surgical intervention. All athletes of our study returned to full sports activity schedule in a total time of 40 weeks postop.
Evaluation
Each patient was evaluated at a final follow-up. Physical examination consisted of elbow and forearm motion and torque evaluation and comparison with the contralateral side. Pain was documented with a VAS from 0 to 10 in terms of pain evaluation. Statistical analysis was performed with SPSS for Windows. T tests were used to evaluate the preoperative and postoperative differences. The level of significance was set at p < 0.05. A two-tailed test was used in all cases. The limitations of our study were the small sample of participants, the fact that they were athletes, and the rare type of injury we focused on.
Results
All patients performed a full arc of elbow motion after the end of the physical therapy program. None of the patients had any symptoms or signs of elbow pain at the end of the physical therapy protocol, and they all had great feeling of their upper extremity and returned to their previous activity level.
The final evaluation of all 11 patients was performed at a mean of 2 years (range, 12–36 months) postoperatively. After the rehabilitation–strengthening program, all patients performed a full arc of elbow motion. No patients reported symptoms or signs of elbow pain at the end of the physical therapy protocol. One patient experienced some discomfort after practicing sports for 2 or more hours continuously but with no strength deficit. The discomfort resolved in the first hour of resting after the workout. Patient satisfaction averaged 9/10 on the VAS.
At the end of the rehabilitation–strengthening protocol, all patients were evaluated with regard to their functionality status, according to the DASH score. The mean DASH score was 0.98181. Ten patients scored 1 and one patient scored 0.8 (mild difficulty at carrying a heavy object; see http://www.orthopaedicscore.com/scorepages/disabilities_of_arm_shoulder_hand_score_dash.html).
All patients were evaluated with the Cybex ergometer in terms of elbow flexion–extension and supination–pronation in both upper extremities for one and three repetitions, respectively. No statistically important differences were observed in the above measurements.
Discussion
Distal biceps tendon rupture is a relatively rare in the general population, with a small increase in people with athletic interference. Regarding the etiology of the rupture, some authors state that this is due to a spur at the insertion of the muscle or even attributed to an anatomic abnormality or synovitis, leading to erosion and eventually tearing of the insertional tendon. 3,4 Some other authors attribute the rupture to low arterial flow at the tendon near its insertion into the radial groove. 4 There has been research regarding the operative treatment of the biceps rupture such as the use of one or two incisions, with two incisions being more unsatisfactory due to loss of forearm rotation, 10 –12 anatomic or nonanatomic restoration of the ruptured tendon, 13 and lastly the kind of materials (osseous sutures, anchors, or Endobutton) that should be used for the restoration of the ruptured tendon to its previous condition. 11,13 –16 In general, fixation through bone tunnels is thought to provide repair strength approximately equal—if not greater—to that of the native biceps’ attachment. While in some studies Endobutton-type devices seem to provide stronger initial repair, 10 suture anchor techniques—in most studies—present inferior biomechanical properties. 13,14 On the other hand, interference screws alone seem to be weaker than other techniques but, apparently, they recreate native load and stiffness. 15,17
More recently, the use of hybrid fixation, such as the fixation with both a button-type device and an interference screw, has given some promising results regarding the initial fixation strength and the gap formation. 18 Toward this direction, we tested a new hybrid fixation technique using a suture anchor and a bone tunnel (pullout technique) simultaneously.
There is a number of studies that favor the one or the other technique. The vast majority of them is being held in cadavers and uses the load to failure either by loading the upper extremity to fail or by testing failure with cyclic loading. The different part in our study is the fact that is being held in living humans, so it was not possible to measure the failure limit. That’s the purpose of introducing additional measurements to evaluate the total functionality of the repaired upper limb. All of our participants returned to full duty, as they were preinjured, and they experienced great self-confidence in training and practicing sports.
Conclusion
Distal biceps tendon rupture is a rare injury, with an increased incidence reported among people practicing sports. According to some authors, there is usually an anatomic predisposition in some people leading to the development of distal biceps tendon rupture. Research are being performed, with a focus on achieving an optimal treatment of distal biceps tendon rupture. Studies have been conducted regarding the best treatment of distal biceps tendon rupture, such as the use of one or two incisions, 4 anatomic or nonanatomic restoration of the ruptured tendon, and the kind of materials that should be used. 11,13 –16 Research is focused on measuring parameters in cadavers, usually the load to failure. Our study was conducted in humans, making it impossible to measure the load to failure. Apart from that, we believe that our study is closer to in vivo simulation of reality. All our participants returned to full duty, as they were before the injury, and experienced great self-confidence in training and practicing sports.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.