Article

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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