Repair of distal biceps tendon ruptures using a combined anatomic interference screw and cortical button

Techniques in Shoulder and Elbow Surgery 01/2005; 6:108-115. DOI: 10.1097/01.bte.0000160547.61893.79

ABSTRACT n HISTORICAL PERSPECTIVE Complete and partial ruptures of the distal biceps tendon seem to be occurring with an increased frequency. This trend is probably the result of increased demands placed on the upper extremities, as well as increased activity in the middle-aged population. Treatment options have ex-panded in an effort to use modern fixation methods to return patients to work or athletics more quickly. Originally, a single extensile anterior exposure was used to reinsert the avulsed tendon. Boyd and Anderson subsequently described a 2-incision technique designed to minimize anterior exposure and limit the risk to neuro-vascular structures in proximity to the tuberosity. 1 Their 2-incision technique introduced the potential for hetero-topic ossification and proximal radio-ulnar synostosis as new complications. In 1985, Morrey and colleagues mod-ified Boyd's original approach by splitting the supinator and avoiding subperiosteal dissection. 2 These modifica-tions led to a decrease in the rate of heterotopic bone for-mation and synostosis. Modifications in the method of fixation have also been proposed. Single incision techniques have been revived with the advent of suture anchors. These procedures use a Henry exposure and secure the tendon to the cortical sur-face of the tuberosity and not into a tunnel or trough. Ben-efits of the single incision technique include decreased morbidity, as well as technical ease in use of the suture anchors. Biomechanical studies have shown that the su-ture anchor techniques are not as stiff or strong when com-pared with fixation over a bone bridge. 3 However, in cyclic loading, the suture anchors have performed ade-quately to allow early passive range of motion. 4 In an attempt to combine both a single incision and the use of a tunnel to place the tendon into, Bain has de-scribed a technique using the Endobutton (Smith and Nephew, Andover, MA). 5 Studies evaluating its stiffness and strength are ongoing, but the Endobutton has per-formed well in other applications. However, potential com-plications in passing a Beath pin through the radius, approximating the length of the suture loop, and ''flip-ping'' of the device on the posterior cortex can make it a challenging technical procedure. Furthermore, cyclic loading early on might lead to pistoning of the tendon in the tunnel and impaired healing. Bioabsorbable interference screw fixation is a popular and reproducible method of fixation. Multiple studies have routinely shown that the constructs fail by graft slip-page past the screws but at a level equal to or greater than other fixation methods. 6–8 In cyclical loading models, the screws have performed favorably as well. On a histologic level, direct tendon healing to bone has been observed with interference screw fixation. 6,7 A mature fibrocartilage intratunnel, direct ligamentous insertion can be found at 9 to 12 weeks. 9 When indirect methods of tendon fixation are used, healing progresses via a zone of vascular, highly cellular fibrous tissue that matures through orientation of collagen fibers over a period of 12 to 26 weeks. 10,11 With the development of new equipment, a bioab-sorbable screw can be delivered into a prepared socket Arthrex Inc, Naples, FL, provided the funding for this research.

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    ABSTRACT: Tension slide repair maintains the strength of the standard cortical button repair but reduces gap formation at the repair. Distal biceps tendon repair with a suspensory cortical button has yielded the strongest published repair, despite observed gap formation and tendon pistoning. The tension slide technique (TST) was described to reduce gap formation while maintaining the strength of cortical button repair. This study evaluates the biomechanics of the TST compared with previously described EndoButton (Smith & Nephew, Memphis, TN) repair and the TST with and without an interference screw. The study used 20 matched specimens: 5 had a standard cortical button repair, and 5 had biceps repair with the TST. An additional 10 specimens underwent a TST, 5 with an interference screw and 5 without. All were cyclically loaded for 3600 cycles. Gap formation and load to failure were measured. The mean (SD) load to failure for standard technique was at 389 (148) N vs 432 (66) N for the TST (P = .28). The mean (SD) gap formation was 2.79 (1.43) mm with the standard repair and 1.26 (0.61) mm with the TST (P = .03). The mean (SD) load to failure with TST repair was 436 (103) N without the interference screw and 439 (94) N (P = 0.48) with the screw. The mean gap formation was 1.63 (1.09) mm without the screw and 1.45 (0.67) mm with the screw (P = .38.) This TST maintains the strength of the standard cortical button repair, but significantly reduces gap formation and motion at the repair site. Basic science study.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 07/2009; 19(1):53-7. · 1.93 Impact Factor
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    ABSTRACT: There are many techniques described to repair acute distal biceps tendon ruptures. The authors' objective is to report the results of a single-incision technique using a combination of a soft tissue button and biotenodesis interference screw with accelerated rehabilitation. Dual fixation of a distal biceps rupture will allow for early return to function. Case series; Level of evidence, 4. From February 2004 to July 2007, 41 elbows in 40 patients had repair of an acute distal biceps tendon rupture (<6 weeks) through an anterior incision using a soft tissue button and interference screw combined technique. The patients were evaluated pre- and postoperatively with a physical examination, radiographs, and the Andrews-Carson elbow score. Nine patients were unavailable for follow-up. The remaining 31 patients (32 elbows) were contacted for a telephone interview at an average of 24 months postoperatively. The preoperative Andrews-Carson score averaged 168 and the postoperative Andrews-Carson score averaged 196 points at final clinical follow-up. There was a statistically significant difference between the pre- and postoperative Andrews-Carson scores (P < .001). One patient had heterotopic ossification associated with decreased pronation and supination. Two superficial radial nerve palsies completely resolved by final follow-up. The average postoperative time to resume normal activities or return to work was 6.5 weeks. Repair of acute distal biceps tendon ruptures using a soft tissue button and interference screw technique through a limited anterior incision can allow for accelerated rehabilitation and early return to function.
    The American journal of sports medicine 04/2009; 37(5):989-94. · 3.61 Impact Factor
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    ABSTRACT: Treatment options for distal biceps tendon ruptures are vast, including conservative treatment and many techniques for surgical repair. Surgical repair of distal biceps ruptures is indicated in patients wanting to restore supination strength and endurance. In most cases, direct anatomic repair is indicated, with the two-incision technique modified by Morrey considered the standard. Superior outcomes of surgical repair compared with conservative treatment have been well established. Most contemporary techniques focus on the single-incision approach with types of fixation including suture anchors, cortical buttons and interference screws. Recent literature has focused on descriptions of new techniques along with biomechanical comparisons of these options. Of the one-incision approaches, it is not yet clear which technique is superior. This review provides a discussion of all the most recent data and gives our algorithm for treatment of this injury.
    Current Orthopaedic Practice 07/2009; 20(4):374–381.

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