Modified Biceps Repair

Completed Research

Clinical outcomes and safety of distal Biceps repairs using a modified entry point

Background    

Distal biceps repairs are indicated post injury in young patients with good function. This aims primarily to maintain strength of elbow flexion and forearm supination.

Recently, a move away from the two incision technique has made the repair a less invasive procedure. A more proximal insertion point for the repaired tendon is also thought to reduce the risk of damage to the posterior interosseous nerve (PIN) whilst maintaining good functional outcomes.

The purpose of this follow up study was to evaluate the clinical results of the one incision repair technique with particular emphasis on flexion and supination strength in post-operative patients.

Rationale

The rationale for this study was to evaluate our operative outcomes for distal biceps repairs utilising a one incision technique, and compare these outcomes to pre-morbid function and current literature.

Objectives

To retrospectively assess a cohort of patients at 1 year or more after surgery for distal biceps repair, reviewing functional outcomes including strength and range of motion measures and compare these with current literature.

Design

This study combined retrospective medical records review with long term clinical follow up.

Study Procedure

Relevant patients were identified from surgical log books. A retrospective medical record review was undertaken. Information utilised included routine functional outcome measures recorded at time of follow up. Patients were not asked to undergo any investigations specifically for this research project – the study design was equivalent to a routine clinical visit that many of these patients already attend regularly. Data analysis documented the findings of the long-term follow up. Correlations with pre-operative presentations and surgical treatment were examined.

Inclusion Criteria

  • Patients >1 year post surgery for distal biceps repair

Exclusion Criteria

  • Nil

Ethics and Governance

Results

Ten unpaired cadavers (6 left, 4 right) were used. With the guide wire inserted through the centre of the tuberosity the mean distance from exit point to the PIN was 7.33mm (95 CI% 5.61 to 9.05). With the guide wire inserted at a more proximal entry point, the mean distance from the exit point to the PIN was 10.92mm (95 CI% 9.37 to 12.47). This results represents a statistically significant (P = 0.0036) difference between the two methods.

Strength and ROM measurements for a total of ten patients (all male) were available for analysis. Mean age was 49.2 years (range 34 to 61). In four participants, the repair was performed on the dominant arm. Supination and flexion strengths were on average 83% and 90% of the uninjured side respectively. There was a mean of 1.5° loss of flexion and 0° loss of extension. Pronation loss was 0.5° on average. Supination loss was 4.5° on average. All 10 patients had at least 1 year follow up with no complications reported including nerve palsies, fractures, wound infections or revisions The mean DASH score was calculated to be 6.3 on a scale of 0-100 (with higher numbers indicating increased functional impairment).

In this study, we have demonstrated a safer entry point, in regards to the PIN, for insertion of the radial guide wire during distal biceps tendon repair. The more proximal entry point represents a reliable and safe alternative for this type of repair.

Vikie at SECEC 2015

Dr Johanna Viktoria Leon from Royal North Shore Hospital presenting the paper for this completed research project:

  • SECEC Annual Congress (Milan, Italy), September 2015

References

  • Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D. Repair of distal biceps tendon rupture: A new technique using the EndoButton. J Shoulder Elbow Surg 2000;9:120-126. http://dx.doi.org/10.1067/2000.102581
  • Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Br. 1985;67(3):414
  • Boyd HB, Anderson LD. A Method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Br. 1961;43(7):1041–3.
  • Dobbie RP. Avulsion of the lower biceps brachii tendon. Am J Surg 1941;51:662-683.
  • Duncan D, Lancaster G, Marsh SG, Michaelson JE, Lemos SE. Anatomical evaluation of a cortical button for distal biceps tendon repairs. 2013;8:201–204. http://dx.doi.org/10.1007/s11552-013-9496-7
  • Hunsaker FG, Cioffi DA, Amadio PC., Wright JG, Caughlin B. The American Academy of Orthopaedic Sugeons outcome instruments. Normative values from the general population. J Bone Joint Surg. 2002;84-A(2):208-215.
  • Keener JD. Controversies in the surgical treatment of distal biceps tendon ruptures: single versus double-incision repairs. J Shoulder Elbow Surg. 2011;20:S113–25. http://dx.doi.org/10.1016/j.jse.2010.11.009
  • Khan AD, Penna S, Yin Q, Sinopidis C, Brownson P, Frostick SP. Repair of distal biceps tendon ruptures using suture anchors through a single anterior incision. 2008;24:39-45. http://dx.doi.org/10.1016/j.arthro.2007.06.019
  • Lo EY, Li C-S, Van den Bogaerde JM. The effect of drill trajectory on proximity to the posterior interosseous nerve during cortical button distal biceps repair. Arthrosc J Arthrosc Relat Surg. 2011;27(8):1048–54. http://dx.doi.org/10.1016/j.arthro.2011.03.084
  • Mazzocca AD, Cohen M, Berkson E, Nicholson G, Carofino BC, Arciero R, Romeo AA. The anatomy of the bicipital tuberosity and distal biceps tendon. J Shoulder Elbow Surg. 2007 Jan-Feb;16(1):122-7 http://dx.doi.org/10.1016/j.jse.2006.04.012
  • Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am. 1985;67:418-421.
  • Peeters T, Ng CS, Jansen N, Sneyers C, Declercq G, Verstreken F. Functional outcome after repair of distal biceps tendon ruptures using the endobutton technique. J Shoulder and Elbow Surg. 2009;18:283-287. doi:10.1016/j.jse.2008.10.004
  • Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002;404:275–83. http://dx.doi.org/10.1097/00003086-200211000-00042
  • Saldua N, Carney J, Dewing C, et al. The effect of drilling angle on posterior interosseous nerve safety during open and endoscopic anterior single-incision repair of the distal biceps tendon. Arthrosc J Arthrosc Relat Surg. 2008;24(3):305–10. http://dx.doi.org/10.1016/j.arthro.2007.09.016
  • Siebenlist S, Fischer SC, Sandmann, GH, Ahrens P, Wolf P, Stöckle U, Imhoff A. Brucker P. The functional outcome of forty-nine single incision suture anchor repairs for distal biceps tendon ruptures at the elbow. Int Orthop. 2014;38:873-879. doi:10.1007/s00264-013-2200-2
  • Sutton KM, Dodds SD, Ahmad CS, et al. Surgical treatment of distal biceps rupture. J Am Acad Orthop Surg. 2010;18(3):139–48.
  • Thumm N, Hutchinson D, Zhang C, Drago S, Tyser AR. Proximity of the Posterior Interosseous Nerve During Cortical Button Guidewire Placement for Distal Biceps Tendon Reattachment. J Hand Surg. 2015. 40:534-536. doi:10.1016/j.jhsa.2014.10.03

sydney-shoulder-research-institute-projects

Lead Investigator:

Dr Benjamin Cass

Commenced:

2014

Completed:

2014

Published:

Submitted for publication

Presented:

SECEC Annual Congress (Milan, Italy), September 2015
Royal North Shore Hospital Shoulder Symposium, September 2015
Australian Orthopaedic Association conference (Brisbane), October 2015

Category:

Current Research

In Research - Completed

Retrospective Review of the use of the Rota-Lok system for massive rotator cuff repairs

In Research - Completed

Early mobilisation following rotator cuff repair

Propionibacterium acnes
In Research - Completed

Propionibacterium acnes contamination in shoulder surgery

In Research - Completed

Modified Biceps Repair

In Research - Completed

Improving medial footprint coverage in double row cuff repair using FiberTape

In Research - Completed

Rate of P Acnes in arthritic shoulders undergoing primary total shoulder replacement surgery using a strict specimen collection technique

In Research - Completed

Comparative study of physician applied and patient reported Constant Scores utilising bathroom scales to derive force measurements

In Research - Completed

Precision and Accuracy of Pumps used in Shoulder Arthroplasty