Repair of Distal Biceps Tendon Ruptures Using a Combined Anatomic Interference Screw and Cortical Button

Techniques in Shoulder and Elbow Surgery 06/2005; 6(2):108-115. DOI: 10.1097/01.bte.0000160547.61893.79


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: The anatomy of the distal biceps tendon and bicipital tuberosity (BT) is important in the pathophysiology of tendon rupture, as well as surgical repair. Understanding the dimensions of the BT and its angular relationship to the radial head and radial styloid will facilitate surgical procedures such as reconstruction of the distal biceps tendon, radial head prosthesis implantation, and reconstruction of proximal radius trauma. We examined 178 dried cadaveric radii, and the following measurements were collected: radial length, length and width of the BT, diameter of the radius just distal to the BT, distance from the radial head to the BT, radial head diameter, width of the radius at the BT, radial neck-shaft angle, and styloid angle. Furthermore, the morphology of the BT ridge was defined as smooth (absent), small, medium, large, or bifid. Of the specimens, 48 were further analyzed with a computed tomography scanner at the level of the BT to determine the distance to traverse both the anterior and posterior cortex and the anterior cortex alone. Eighteen fresh-frozen cadaveric elbows were dissected, and the insertion footprint of the distal biceps tendon was defined. The BT has a mean length of 22 +/- 3 mm and a mean width of 15 +/- 2 mm. The tendon insertion footprint is a ribbon-shaped configuration on the most ulnar aspect of the BT, and it occupies 63% of the length and 13% of the width of the BT. The BT ridge is absent in 6% of specimens and bifid in 6%, and the remaining 88% of specimens have a single ridge that may be classified as small, medium, or large. The mean diameter of the radial head is 22 +/- 3 mm. The mean radial neck-shaft angle is 7 degrees +/- 3 degrees , and the mean BT-radial styloid angle is 123 degrees +/- 10 degrees . None of the measurements correlated with patient age, sex, or race. We concluded that the morphology of the BT ridge is variable. The insertion footprint of the distal biceps tendon is on the ulnar aspect of the BT ridge. The dimensions of the radius and BT are applicable to several surgical procedures about the elbow.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 01/2007; 16(1):122-7. DOI:10.1016/j.jse.2006.04.012 · 2.29 Impact Factor
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    ABSTRACT: Recognition and treatment of distal biceps tendon ruptures is increasing, likely because of greater clinical awareness and the greater activity and demands of the middle-aged population. This article focuses on the proper evaluation and treatment of distal biceps tendon ruptures with special attention focused on recently developed techniques. A review of the recent clinical literature will accompany an overview of pertinent biomechanical studies and an explanation of the risks and benefits of the most popular surgical techniques for distal biceps repair.
    Orthopedic Clinics of North America 05/2008; 39(2):237-49, vii. DOI:10.1016/j.ocl.2008.01.001 · 1.25 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. DOI:10.1177/0363546508330130 · 4.36 Impact Factor
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