Single Versus Double-Incision Technique for the Repair of Acute Distal Biceps Tendon Ruptures A Randomized Clinical Trial

Article (PDF Available)inThe Journal of Bone and Joint Surgery 94(13):1166-74 · July 2012with87 Reads
DOI: 10.2106/JBJS.K.00436 · Source: PubMed
Abstract
This clinical trial was done to evaluate outcomes of the single and double-incision techniques for acute distal biceps tendon repair. We hypothesized that there would be fewer complications and less short-term pain and disability in the two-incision group, with no measureable differences in outcome at a minimum of one year postoperatively. Patients with an acute distal biceps rupture were randomized to either a single-incision repair with use of two suture anchors (n = 47) or a double-incision repair with use of transosseous drill holes (n = 44). Patients were followed at three, six, twelve, and twenty-four months postoperatively. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) elbow score. Secondary outcomes included muscle strength, complication rates, and Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Elbow Evaluation (PREE) scores. All patients were male, with no significant differences in the mean age, percentages of dominant hands affected, or Workers' Compensation cases between groups. There were also no differences in the final outcomes (at two years) between the two groups (p = 0.4 for ASES pain score, p = 0.10 for ASES function score, p = 0.3 for DASH score, and p = 0.4 for PREE score). In addition, there were no differences in isometric extension, pronation, or supination strength at more than one year. A 10% advantage in final isometric flexion strength was seen in the patients treated with the double-incision technique (104% versus 94% in the single-incision group; p = 0.01). There were no differences in the rate of strength recovery. The single-incision technique was associated with more early transient neurapraxias of the lateral antebrachial cutaneous nerve (nineteen of forty-seven versus three of forty-three in the double-incision group, p < 0.001). There were four reruptures, all of which were related to patient noncompliance or reinjury during the early postoperative period and appeared to be unrelated to the fixation technique (p = 0.3). There were no significant differences in outcomes between the single and double-incision distal biceps repair techniques other than a 10% advantage in final flexion strength with the latter. Most complications were minor, with a significantly greater prevalence in the single-incision group.

Figures

Sing le Versus Double-Incision Technique for the
Repair of Acute Distal Biceps Tendon Ruptures
A Randomized Clinical Trial
Ruby Grewal, MD, MSc, FRCSC, George S. Athwal, MD, FRCSC, Joy C. MacDermid, BScPT, MSc, PhD,
Kenneth J. Faber, MD, MHPE, FRCSC, Darren S. Drosdowech, MD, FRCSC,
Ron El-Hawary, MD, MSc, FRCSC, and Graham J.W. King, MD, MSc, FRCSC
Investigation performed at the Hand and Upper Limb Center, St. Josephs Health Center, Division of Orthopaedic Surgery,
University of Western Ontario, London, Ontario, Canada
Background: This clinical trial was done to evaluate outcomes of the single and double-incision techniques for acute
distal biceps tendon repair. We hypothesized that there would be fewer complications and less short-term pain and
disability in the two-incision group, with no measureable differences in outcome at a minimum of one year postoperatively.
Methods: Patients with an acute distal biceps rupture were randomized to either a single-incision repair with use of two
suture anchors (n = 47) or a double-incision repair with use of transosseous drill holes (n = 44). Patients were followed at
three, six, twelve, and twenty-four months postoperatively. The primary outcome was the American Shoulder and Elbow
Surgeons (ASES) elbow score. Secondary outcomes included muscle strength, complication rates, and Disabilities of the
Arm, Shoulder and Hand (DASH) and Patient-Rated Elbow Evaluation (PREE) scores.
Results: All patients were male, with no significant differences in the mean age, percentages of dominant hands
affected, or Workers’ Compensation cases between groups. There were also no differences in the final outcomes (at two
years) between the two groups (p = 0.4 for ASES pain score, p = 0.10 for ASES function score, p = 0.3 for DASH score, and
p = 0.4 for PREE score). In addition, there were no differences in isometric extension, pronation, or supination strength at
more than one year. A 10% advantage in final isometric flexion strength was seen in the patients treated with the double-
incision technique (104% versus 94% in the single-incision group; p = 0.01). There were no differences in the rate of
strength recovery. The single-incision technique was associated with more early transient neurapraxias of the lateral
antebrachial cutaneous nerve (nineteen of forty-seven versus three of forty-three in the double-incision group, p < 0.001).
There were four reruptures, all of which were related to patient noncompliance or reinjury during the early postoperative
period and appeared to be unrelated to the fixation technique (p = 0.3).
Conclusions: There were no significant differences in outcomes between the single and double-incision distal biceps
repair techniques other than a 10% advantage in final flexion strength with the latter. Most complications were minor, with
a significantly greater prevalence in the single-incision group.
Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
R
upture of the distal biceps tendon occurs most fre-
quently in middle-aged men, and usually in the dom-
inant arm. Typically, the injury results when the biceps
undergoes a forceful eccentric contraction. Without operative
repair, a significant reduction in endurance and in supination
(40%) and flexion (30%) strength can be expected
1
. Early
operative intervention is generally indicated in younger active
patients as the repair provides consistently good results, with
restoration of elbow strength and end urance to nearly normal
levels
2
. Both single and double-incision techniques have been
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activi ties, that could be perceived to influence or have the pote ntial to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided wi th the online version of the
article.
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described for the repair of distal biceps tendon ruptures. The
selection of the surgical technique remains controversial, and
currently there is no good scientific evidence to support the use
of one technique over the other. The single-incision, anterior
approach was historically associated with an increased preva-
lence of nerve injury
3,4
, probably as the result of the larger
anterior exposure and the need for deep retractors to visualize
the tendon and attach it to its insertion on the radial tuber-
osity
4
. To avoid the complications associated with an anterior
exposure, Boyd and Anderson developed a two-incision tech-
nique to limit the amount of anterior dissection required
3
. The
safety of the two-incision technique was also questioned as a
result of proximal radioulnar synostosis and posterior inter-
osseous nerve injury
5,6
.
In an attempt to reduce the complications associated
with each approach, newer techniques have been developed
over time. The two-incision approach was modified by Morrey
et al.
1
, who employed a posterior muscle-splitting approach to
reduce the likelihood of radioulnar synostosis by avoiding
subperiosteal exposure of the ulna. With this modification,
the tendon is sutured to the bicipital tuberosity through
transo sseous drill holes. Improvements of th e one-incision
technique have also been made and are as sociated w ith the
development of newer fixation systems (i.e., suture anchors
7
,
interference screws
8,9
, or the EndoButton
10,11
), which limit
the anter ior exposure necessary to secure the tendon to the
bone. The purpose of this study was to compare the outcomes
of the sing le-incision technique using an anterior approach
and suture anchors with those of a double-incision technique
using an additional posterior approach and transosseous
tunnels for distal biceps tend on repair in a prospective ran-
domized clin ical trial. The results were assessed with use of
standardized, validated, patient-rated outcome instruments.
Materials and Methods
T
his study was approved by our institutions research and ethics board. It was
designed as a nonblinded prospective randomized trial. Patients with an
acute distal biceps rupture (with acute defined as less than four weeks post-
injury) were recruited from the clinical practices of five upper-extremity sub-
specialty orthopaedic surgeons in a tertiary referral center between May 2001
and 2008. The clinical trial was registered at ClinicalTrials.gov (NCT01322828).
Patients with medical comorbidities precluding operative intervention and
those with a chronic biceps tear were excluded. A computer-generated sequence
was used to select treatment allocations, which were concealed in opaque en-
velopes. Once patients consented to be enrolled in the trial, allocations were
provided to the surgeon.
Patients were assessed by one of two research assistants at baseline and
at postoperative intervals of three, six, twelve, and twenty-four months. The
primary outcome measure was the American Shoulder and Elbow Surgeons
(ASES) elbow score
12
, which includes a 10-point v isual analog pain scale and a
functional component (Likert format) based on activities of daily living
(maximum score, 36). Secondary outcomes included complication rates, elbow
range of motion
13
, elbow strength (isometric and isokinetic)
14
, Patient-Rated
Elbow Evaluation (PREE) scores
15
, and Disabilities of the Arm, Shoulder and
Hand (DASH) scores
16
. Isometric elbow flexion and supination strength were
assessed with the subject sitting with the arm in neutral shoulder flexion/
abduction/rotation and the elbow in 90° of flexion and neutral rotation. Sub-
jects were instructed on how to perform the movement and had a single
practice trial. Then three maximal contractions were recorded. The average
peak torque from the three repetitions was recorded as the criterion score.
Scores were related to the average peak torque on the unaffected side.
Patients who were unable to return for a final clinical assessment were
asked to complete the outcome s questionnaires either by telephone or mail.
Final radiographs were reviewed by the treating orthopaedic sur geon to de-
termine if there was any implant failure or evidence of he terotopic ossifica-
tion. The seve rity of heterotopic ossification was graded w ith use of the
classification sys tem described by Hastings and Graham
17
. Complications
were tracked prospectively and entered at each follow-up visit. At the com-
pletion of the trial, medical records were audit ed to ensure no adverse events
were excluded.
Surgical Techniques
Patients were placed supine on the operating room table, and a sterile tour-
niquet was used for both techniques. Prophylactic antibiotics were given
preoperatively.
Single-Incision Technique
For the single-incision technique, a longitudinal incision was made extending
distally from the antecubital fossa. The basilic vein and lateral antebrachial
cutaneous nerve were identified and protected. The biceps tendon was iden-
tified, and the distal degenerated portion was debrided. The brachioradialis
was retracted laterally, and the pronator teres was retracted medially. The re-
current leash of Henry was ligated and divided to expose the bicipital tuberosity.
After scraping of the tuberosity with a curet, two suture anchors (Mitek G4
Super Anchor; Mitek Surgical Products, Norwood, Massachusetts), each loaded
with a single suture (number-2 Ethibond; Ethicon, Somerville, New Jersey),
were placed 1 cm apart into the ulnar aspect of the bicipital tuberosity. A
sliding stitch was placed into the distal limb of the biceps tendon, allowing
the tendon to be pulled onto the tuberosity, and the sutures were tied with the
elbow in 60° of flexion and full supination. The repair was reinforced with
the ends of these sutures by using a locking Krackow technique above the
sliding suture
18
.
Double-Incision Technique
The double-incision technique
18
utilized a t ransverse incision in the ante-
cubital crease. The biceps tendon was identified, and the distal degenerated
portion of the tendon was resected. Two sutures (number-2 Ethibond) we re
passed through the distal part of the tendon with use of the locking Krackow
technique. The biceps tuberosity was palpated wi th an index finger, and a
curved clamp was passed just ulnar to the bicipital tuberosity and directed
through the interosseous space. The forceps was then palpated on the dorsal
aspect of the proximal part of the forearm, and a second longitudinal incision
was made over it. The tuberosity was exposed with a mus cle-splitting tech-
nique with t he forearm maximally prona ted
1,18
. The ulna w as not exposed. A
burr was used to create a longitudinal trough in t he ulnar aspect of the
bicipital tuberosity that communicated with the intramedullary cavit y. Th ree
2.0-mm drill holes were placed 8 mm apart through the dors al cortical
margin of the tuberosity. The tendon sut ures were passed through these
hol es, two in the middle hole and one in e ach of the proximal and distal holes.
With the elbow in 90° of fle xion and the forearm in pronation, the biceps
tendon was pulled into the bicipital tuberosity and the sutures were tensioned
and tied.
Postoperative Protocol
The postoperative protocol was identical for both groups. Unless contra-
indicated, indomethacin (25 mg three times daily for three weeks) was pre-
scribed as prophylaxis against heterotopic ossification. The elbow was
immobilized in 90° of flexion with the forearm in supination. Active elbow
extension exercises, passive flexion exercises with the forearm in full supination,
and active pronation and passive supination exercises were initiated within the
first few days postoperatively. A resting splint at 90° with the forearm main-
tained in supination was worn between exercises for six weeks. Depending on
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the degree of intraoperative tension at the tendon repair, extension was limited
initially, and increased by 10° per week until full extension was achieved. Active
motion was permitted after six weeks, and strengthening was permitted after
three months.
Statistical Methods
A sample size calculation indicated that twenty-seven patients were needed per
group to ensure 80% power based on a variance of 20 and a 15-point minimal
clinically important difference between groups for the primary outcome
measure (ASES elbow score). In the absence of any information regarding the
minimal clinically important difference for the ASES elbow score, 15 was an
estimate based on the clinically important difference of other, similar upper-
extremity self-reported questionnaires and the literature on the ASES shoulder
score
19,20
. Data were inspected for normality, and outliers were verified for data
accuracy. Analysis of functional outcome was conducted by comparing the
ASES, PREE, and DASH scores between the two treatment groups. To account
for the repeated measures of outcomes across time, we used generalized linear
modeling (controlling for age and delay in surgery as potential covariates).
Post-hoc testing (Student-Newman-Keuls) was used where main effects were
significant (a = 0.05). A Student t test was used to compare final outcome
scores, range of motion, and strength measures between the two groups, and
complication rates were compared by using a chi-square test. We used survival
analysis to compare the time needed to regain normal strength between groups,
with the time to event defined as achievement of 90% of the strength of the
contralateral arm. No correction was made for hand dominance
21
. It should be
noted that strength, range of motion, and complications were secondary out-
comes and that the study was not powered to detect such differences in these
outcomes. We defined a poor outcome as an ASES pain score of >20 and
evaluated the subjects with poor outcomes separately.
Source of Funding
No external funding sources were utilized for this study.
Fig. 1
Flow diagram for enrollment and analysis.
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Results
N
inety-one patients were recruited and randomized (forty-
seven in the single-incision group and forty-four into the
double-incision group). One patient (in the double-incision
group) did not undergo surgery, and seven were lost to follow-
up after six months (on e patient died). Seventy-two (79%) of
the ninety-one patients were followed for a minimum of one
year, with completion of both outcome questionnaires and
clinical assessments for range of motion and strength. An
additional eleven patients could not return for clinical as-
sessment because of their geog raphical distance from our
clinic, but they completed outcome questionnaires by tele-
phone at two years. In total, eighty-three patients (91%) of the
ninety-one patients completed outcome questionnaires at two
years (Fig. 1). All patients were male, and there were no signif-
icant differences between the mean ages, percentages of domi-
nant hands affected, or Workers’ Compensation cases between
groups ( Table I).
Outcomes Assessment
Therewasnodifferenceinmeanoutcomescores,eithershort
term (at three to six months) or long term (at twelve to
twenty-four months), between th e two groups (Figs. 2 and 3).
The nal two-year outco me scores were comparable between
the two groups, with mean ASES pain scores (and standard
deviation) of 4.6 ± 8.0 and 4.4 ± 8.5 for the single and double-
Fig. 2-A
Fig. 2-B
TABLE I Patient Characteristics
Single Incision
(n = 47)
Double Incision
(n = 44)
% male 100 100
Mean age
(and stand. dev.) (yr)
45.3 ± 7.4 44.9 ± 9.3
Dominant arm involved 68% (n = 32) 59% (n = 26)
Workers’ Compensation
claim
32% (n = 15) 23% (n = 10)
Time between injury
and surgery
0 to 13 days 29 32
14 to 30 days 18 11
No surgery performed 1
Figs. 2-A and 2-B Mean ASES elbow scores over
time for the two groups. Fig. 2-A Pain subscale
(p = 0.89). Fig. 2-B Function subscale (p = 0.46).
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incision groups, respectively (p = 0.4); mean ASES function
scores of 32.6 ± 5.2 and 34.6 ± 3.7 points, respectively (p =
0.10); mean DASH scores of 7.8 ± 12.9 and 5.5 ± 11.8 (p =
0.3); and mean PREE scores of 6.1 ± 14.6 and 4.9 ± 13.0
(p = 0.4).
Comparison of isometric strength regained at one year
or later, expressed as a percentage of the strength of the un-
affected arm, revealed no overall differences between groups
with regard to elbow extension strength (104% and 106%
in the single and double-incision groups, respe ctively; p =
0.6), forearm pronation strength (99% and 103%, respec-
tively; p = 0.6), or forearm supination strength (98% and
92%, respectively ; p = 0.4). Comparison of mean isometric
flexion strength with that of the contralateral normal arm
showed that the double-incision group re gained 10% more
strengt h than did the single- incision group (104% versus
94%; p = 0.01). There were no differences in the n umber of
months needed to achieve full flexion (Fig. 4-A) or supination
(Fig. 4-B) strength.
The range of motion was comparable between the two
groups at all time points, with no significant differences seen
after one year; however, there was slightly greater pronation in
the single-incision group (76.7° versus 72.4° in the double-
incision group; p = 0.08) (Table II).
Complications
The single-incision technique resulted in a significantly higher
overall complication rate, primarily due to a high number
of early transient neurapraxias involving the lateral ante-
brachial cutaneous nerve (nineteen of fo rty-seven versus three
of forty-three in the double-incision group; p < 0.001) (Table
III). Two patients in the double-incision group had numbness
in the distribution of the lateral antebrachial cutaneous nerve,
and one had numbness around the antecubital skin incision
only. Most neurapraxias in the single-incision group resolved,
although three patients remained symptomatic beyond six
months, and two of these continued to have numbness and
tingling at the time of final follow-up. Four tendon reruptures
Fig. 3-A
Fig. 3-B
Figs. 3-A and 3-B Patient-reported pain and disability over time for the two groups. Fig. 3-A Mean DASH score (p = 0.89). Fig. 3-B Mean PREE Score
(p = 0.73).
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were obser ved (three in the sing le-incision group and one
in the double-incision g roup), and all were related to non-
compliance or reinjury during the early postoperative period
and appeared to be unrelated to the fixation technique (p =
0.3).
Prophylaxis against heterotopic ossification was initiated
in sixty-one patients (thirty in the single-incision group and
thirty-one in the double-incision group). We were unable to
verify that an indomethacin prescription was provided to nine
patients (five in the single-incision group and four in the
double-incision group), and we confirmed that it was medi-
cally contraindicated in the twenty-one patients (twelve in the
single-incision group and nine in the double-incision group)
who did not receive any prophylaxis. Two patients developed
very mild heterotopic ossification, with only scant areas of
calcification evident in the soft tissues and no resultant loss of
elbow or forearm motion (Grade 1)
17
. Of the two patients who
developed heterotopic ossification, one (in the double-incision
group) had received prophylaxis and the other (in the single-
incision group) had not because of a history of gastroesopha-
geal reflux. There was one superficial wound infection (in the
single-incision group) and no cases of synostosis or suture
anchor migration. No relationship was observed between the
time to surge ry and the complication rate (p = 0.6) when we
compared the patients who had been treated within two weeks
after the in jury (n = 57) and those who had been treated two
weeks or more after the injury (n = 27; mean, 17 ± 4.9 days;
range, fourteen to thirty days).
TABLE II Final Mean Elbow and Forearm Range of Motion at a Minimum of One Year
Single Incision* (deg) Double Incision* (deg) P Value
Flexion 134.5 ± 6.9 131.8 ± 9.1 0.16
Extension 3.0 ± 4.3 1.9 ± 4.6 0.29
Pronation 76.7 ± 8.2 72.4 ± 12.6 0.08
Supination 63.9 ± 12.5 59.5 ± 11.5 0.13
*The values are given as the mean and standard deviation.
TABLE III Complications
Single Incision
(N = 47)
Double Incision
(N = 43) P Value
Neurapraxias <0.001
Any symptoms 19 3
Symptoms >6 mo 3 0
Tendon rerupture 3 1 0.3
Grade-1 heterotopic ossification 1 (did not receive prophylaxis) 1 (received prophylaxis) 0.7
Fig. 4-A Fig. 4-B
Figs. 4-A and 4-B Number of months needed to achieve normal strength (90% of that of the contralateral arm). Fig. 4-A Supination strength. Fig. 4-B
Flexion strength.
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Discussion
T
o our knowledge, this is the first prospective randomized
clinical trial comparing the outcomes of single and double-
incision techniques for the repair of dis tal biceps tendon
ruptures. The results of this trial indicated no significant dif-
ferences in outcomes (ASES, DASH, or PREE scores) between
the single-incision technique utilizing suture anchors and the
double-incision technique utilizing transosseous tunnels. Both
groups achieved favorable outcomes and reported minimal
pain and disability, suggesting that surgeons can select the
operative approach that is most suited to their personal expe-
rience. Overall, we found minimal differences in pain and
disability scores between these techniques across our primary
outcome (ASES score) and secondary outcomes of pain and
disability (DASH and PREE). Physical impairments (in range
of motion and in strength) were minimal after one year. Su-
pination, pronation, and elbow extension strength was similar
between groups. Isometric flexion strength (as evaluated in a
comparison with the contralateral arm) was slightly greater
after the double-incision technique. The magnitude of this dif-
ference was small (10%) and its clinical relevance is unknown.
Our results confirm the findings of other studies that have
demonstrated favorable results with both techniques
7,22-28
.
There were six patients (four in the single and two in the
double-incision group) with poor outcomes (an ASES pain
score of >20). Five of these patients were involved in a Workers’
Compensation claim, and the other had persistent numbness
in the lateral antebrachial cutaneous ner ve until one year
postoperatively. An additi onal three pat ients, in the single-
incision group, sustained new, unrelated injuries between their
one and two-year follow-up appointments, which also ad-
versely affected their outcomes. Within two to three months
before their two-year testing dat e, one of these three patients
sustained a wrist fracture, another sustained a shoulder injury,
and the third had a recent appendectomy and tibial osteotomy.
Another analysis was conducted with exclusion of the two-year
scores of these patients, and there was no influence on the final
results.
Although this study was not powered to detect differ-
ences in co mplication rates, the only significant diff erence
observed between groups was the greater prevalence of tran-
sient neurapraxias of the lateral antebrachial cutaneous nerve
after the single-incision technique. The issue of nerve injury
relates to the retraction required during preparation of the
bicipital tuberosity. In the single-incision technique, the lateral
antebrachial cutaneous nerve must be retracted during expo-
sure and preparation of the bicipital tuberosity. In contrast,
with the two-incision technique, retraction is required for only
a brief time during tendon retrieval. It is not know n whether
an alternative incision would reduce the prevalence of nerve
injury. The senior authors (G.J.W.K., K.J.F., and J.C.M.) pre-
viously reported a similar incidence of lateral antebrachial
cutaneous nerve injuries when using an L-shaped incision
24
.It
is our experience that it is the length of the incision and the size
of the patient, not the orientation of the incision, that influence
the amount of retraction required to visualize the tuberosity
adequately. The reported prevalence of neurapraxias in this
trial is comparable with that reported in our previous study
24
,
although it is higher than those reported in other series treated
with single-incision repairs
7,22,26
. One reason for this difference
may be related to the larger size of our sample in comparison
with previous studies (n = 17
7
and n = 12
22
). Another reason
for the higher repor ted nerve complication rate is that, in our
prospective study, we may have more rigorously collected and
tracked minor or transient neurapraxias, which are likely un-
derreported in retrospective studies. For example, only sub-
stantial nerve deficits, such as the observation of wrist drop,
was reported in another series
26
. All neurapraxias in our trial
involved sensory impairments only, and there were only three
cases with symptoms reported beyond six months. Unlike
the findings reported by Kelly et al.
27
and Bisson et al.
23
,our
complication rate was not related to a delay in surgical
treatment.
Unlike other published series, in which the prevalence of
heterotopic ossification has been reported to be between 5% to
10%
23,24,27
, our series had a prevalence of 2% (one of fort y-seven
in the single-incision group and one of forty-three in the
double-incision group). The heterotopic ossification was mi-
nor in both cases, with minimal calcification in the soft tissues
and no resultant loss of elbow or forearm motion (Grade 1
according to the system described by Hastings and Graham
17
).
One possible explanation for our low prevalence of heterotopic
ossification may be the postoperative use of indomethacin,
which was prescribed for sixty-one of the ninet y patients.
Therateofcompliancewiththistreatmentwasnotdocu-
mented. The role of routine heterotopic ossification pro-
phylaxis w ith either of the two techniques wi ll require further
study, with use of a much larger sample size to provide ac-
curate estimates since the prevalence of heterotopic ossification
is so low.
In this study, all instances of reruptures or failures were
believed to be related to noncompliance or falls in the early
postoperative period and not to the fixation technique. All
single-incision repairs failed with suture pull-out from the
tendon. We cannot determine whether stronger suture mate rial
would have affected the mode of failure.
Fixation methods have been studied in several biome-
chanical studies. In a cadaveric study, Lemos et al.
29
demon-
strated superior yield strength of suture anchors (single incision)
compared with osseous tunnels (double incision); however, the
average age of the donors of the specimens was 74.7 years at
the time of death, fixation strength testing was evaluated only
at time zero, and the clinical relevance of the difference is
unknown. Conversely, Berlet et al. found that transo sseo us
sutures tolerated a significantly greater load to failure than
suture anchors on biomechanical testing in cadaveric speci-
mens from elderly donors
30
. Pereira et al. also reported sig-
nificantly greater tensile strength with bone tunnel repair
compared with suture anchor repair in non-oste oporotic el-
bows
31
. Recent studies have shown superior pull- out strength
of cortical buttons compared with transosseous tunnels,
suture anchors, and interference screws
32,33
,withonereport
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demonstrating that the pull-out strength of cortical fixation
buttons was three times greater than that with transosseous
tunnels and two times greater than that of suture anchors
34
.
Given that the overall success of both techniques was excellent,
and the surgical failures were all assumed to be related to
noncompliance, it may be more important to identify poten-
tially noncompliant patients or those at risk of additional injury
to have the greatest impact on outcomes. In a recent biome-
chanical study, Schmidt et al. reported differences in peak
torque generation at four different tendon attachment loca-
tions
35
. They observed that a more anterior reattachment site
generated less forearm supination torque than did the ana-
tomical attachment site. The diminished torque was attributed
to an inability to fully exploit the windlass and cam effect that is
observed in the anatomical attachment site. We did not identify
a difference in supination strength between the groups as
predicted by Schmidt et al., but we acknowledge that our study
was not powered to detect such strength differences.
On the basis of our study, there does not appear to be an
important clinical differenc e with respect to clinical outcomes,
strength recove ry , or failure rates between the single-incision
technique (with suture anchors) and the double-incision tech-
nique (with transosseous tunnels). The impro ved flexion strength
with the double-incision method may not be noted by patients.
This study does have several limitations. Althoug h
eighty-three (91%) of ninety-one patients completed outcome
questionnaires at two years, eleven of them completed them by
telephone. The validity of the questionnaires completed by
telephone is not known. In addition, only seventy-two (79%)
of the patients return ed for strength and range-of-motion
testing. Five of the seventy-two returned at one year only, and
the other sixty-seven returned at two years. Traditionally, the
concern about a high dropout rate is that the treatment effect
may be overestimatedthat is, the patients lost to follow-up
may have had poor outcomes that are not being captured. Of
the nineteen patients who did not return for range-of-motion
or strength testing after six months, thirteen had completed
subjective questionnaires, with all reporting minim al pain and
disability based on the ASES, DASH, and PREE scores at both
six months and one year. Another weakness of our study is the
analysis of prophylaxis against heterotopic ossification. Indo-
methacin was not routinely prescribed and information iden-
tifying heterotopic ossification was obtained by a chart audit
and not assessed prospectively. While the prevalence of hetero-
topic ossification was very low, the question about whether
prophylaxis is beneficial in this patient population remains
unanswered. Another limitation is that the study was powered
for the primary outcome (ASES scores), and probably for the
DASH and PREE scores, but lacked sufficient power to detect
group differences for all other secondary outcomes (strength,
range of motion, and complications).
Surgeon bias for one technique over the other has had
little underlying scientific basis. The only current evidence is
based on several case series
7,22-28
and biomechanical cad averic
studies
29-35
. The present study is, to our knowledge, the first
prospective randomized trial to evaluate the functional and
clinical outcomes of the single and double-incision repair
techniques for distal biceps tendon ruptures. The clinical and
functional outcomes of the single-incision technique using
suture anchors were comparable with those of the double-
incision technique using bone tunnels; however, there was a
higher rate of transient neurapraxias after the single-incision
technique. Neither technique was associated with clinically
relevant heterotopic ossification. Our data suggest that both
techniques described in this study are highly effective and the
decision as to which to use clinically can be at the discretion of
the surgeon and patient. n
Ruby Grewal, MD, MSc, FRCSC
George S. Athwal, MD, FRCSC
Joy C. MacDermid, BScPT, MSc, PhD
Kenneth J. Faber, MD, MHPE, FRCSC
Darren S. Drosdowech, MD, FRCSC
Graham J.W. King, MD, MSc, FRCSC
Hand and Upper Limb Center, St. Josephs Health Care,
Division of Orthopaedic Surgery, University of Western Ontario,
268 Grosvenor Street, London, ON N6A 4L6, Canada.
E-mail address for R. Grewal: rgrewa@uwo.ca.
E-mail address for G.S. Athwal: gathwal@uwo.ca.
E-mail address for J.C. MacDermid: joy.macdermid@sjhc.london.on.ca.
E-mail address for K.J. Faber: kjfaber@uwo.ca.
E-mail address for D.S. Drosdowech: ddros@mac.com.
E-mail address for G.J.W. King: gking@uwo.ca
Ron El-Hawary, MD, MSc, FRCSC
IWK Health Centre, P.O. Box 9700, 5850 University Avenue,
Halifax, NS B3K 6R8, Canada.
E-mail address: ron.el-hawary@iwk.nshealth.ca
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    • "Both at short-term and long-term follow up, there was no difference in mean outcome scores. However, there were significantly more (minor) complications seen in the single-incision group, predominately because of transient neurapraxias of the lateral antebrachial cutaneous nerve in this group [14]. A major drawback of this study is that besides the difference in approach, there was also a difference in fixation technique used between both groups [19] . "
    [Show abstract] [Hide abstract] ABSTRACT: Purpose: The aim of this review was to present an overview, based on a literature search, of surgical anatomy for distal biceps tendon repairs, based on the current literature. Methods: A narrative review was performed using Pubmed/Medline using key words: Search terms were distal biceps, insertional, and anatomy. Results: Last decade, the interest in both reconstruction techniques, as well as surgical anatomy of the distal biceps tendon, has increased. The insights into various aspects of distal biceps tendon anatomy (two tendons, bicipital tuberosity, lacertus fibrosis, bicipital-radial bursa, posterior interosseous nerve, and lateral antebrachial cutaneous nerve) have evolved significantly in the last years. Conclusion: Thorough knowledge of the anatomy is essential for the surgeon in order to understand the biomechanics of rupture and reconstruction of the distal biceps tendon and to avoid injuries of the nerves. Some tips and tricks are provided, and some pitfalls were described to avoid complications and optimize surgical outcome. LEVEL OF EVIDENCE: IV.
    Full-text · Article · Sep 2014
    • "The prevalence of HO was similar in both groups. They recommended further research on the use of indomethacin on HO formation following distal biceps tendon surgery [17]. Peeters et al. [29] reported 8.7 % HO after a retrospective mean follow-up of 16 months. "
    [Show abstract] [Hide abstract] ABSTRACT: Reconstruction of the ruptured distal biceps tendon is best done with a cortical button technique according to recent biomechanical studies. However, clinical outcome studies that evaluate the cortical button reconstruction technique are scarce. The purpose of this study was to evaluate the results of a cortical button reconstruction technique in patients with a traumatic distal biceps tendon rupture. Twenty-two patients with 24 traumatic distal biceps tendon ruptures underwent surgical treatment. Reconstructions were done using the Endobutton or Toggle Loc. Postoperative evaluation consisted of ROM, strength, stability, neurological status and standard radiographs in AP view and lateral direction. The Mayo Elbow Performance Index (MEPI) and quick Disabilities of Arm, Shoulder and Hand (qDASH) questionnaires were also obtained. At a median follow-up of 22 months, the mean strength for flexion was 100 % (SD 21.3) and for supination 97 % (SD 7.8), compared to the contralateral side. There were complications in 8 patients (36 %), and heterotopic ossifications were seen on radiographs in 23 % of patients. Heterotopic ossifications were symptomatic in one patient. The results after distal biceps tendon refixation with a cortical button were good according to ROM, MEPI and qDASH scores and strength. However, this procedure was accompanied with complications; in particular, the formation of heterotopic ossifications was frequently seen, though clinically relevant in only one patient. Case series, Level IV.
    Full-text · Article · Jun 2013
  • [Show abstract] [Hide abstract] ABSTRACT: Distal biceps tendon ruptures continue to be an important injury seen and treated by upper extremity surgeons. Since the mid-1980s, the emphasis has been placed on techniques that limit complications or improve initial tendon-to-bone fixation strength. Recently, basic science research has expanded the knowledge base regarding the biceps tendon structure, footprint anatomy, and biomechanics. Clinical data have further delineated the results of conservative and surgical management of both partial and complete tears in acute or chronic states. The current literature on the distal biceps tendon is described in detail.
    Full-text · Article · Mar 2013
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