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A comparison of cortical button with interference screw versus suture anchor techniques for distal biceps brachii tendon repairs
J Shoulder Elbow Surg (2014) 23, 1607-1611
www.elsevier.com/locate/ymse
A comparison of cortical button with interference screw versus suture anchor techniques for distal biceps brachii tendon repairs Joshua R. Olsen, MD, Edward Shields, MD, Richard B. Williams, MD, Richard Miller, MD, Michael Maloney, MD, Ilya Voloshin, MD* Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY, USA Background: Distal biceps brachii tendon repairs performed by a ‘‘tension slide technique’’ with a cortical button and interference screw (CB) are stronger than repairs by suture anchor (SA) techniques in biomechanical studies. However, clinical comparison of the 2 techniques is lacking in the literature. Methods: Distal biceps tendon ruptures repaired with either a CB or SA technique through a single incision were identified from 2008 to 2013 at a single institution. Patients more than a year out from surgery completed a Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. In addition, patients were assessed for range of motion, strength, and complications. All assessments were performed by individuals blinded to the surgical technique. Strength and motion values from the operative extremity minus the nonoperative arm values yielded differential values that were averaged and used to compare treatment groups. Results: The CB (n ¼ 20) and SA (n ¼ 17) groups had similar demographics, except for the time from the surgery to evaluation (18 5 vs 32 15 months, respectively; P ¼ .007). Range of motion differed slightly between the groups. The CB group demonstrated better pronation (0 5 vs 4 10 ; P < .05), and the SA group demonstrated better flexion (2 0 vs 3 5 ; P < .05) and supination (2 5 vs 7 12 ; P < .05). Strength did not differ significantly between the groups. DASH scores did not significantly differ between the groups with univariate analysis, but multivariate analysis demonstrated slightly better DASH scores with the CB technique (4.5 4.4 vs 10.3 14.9; P < .0009). Complication rates were similar between groups (CB 30%, SA 35%; P > .05). Conclusion: CB and SA techniques provide good clinical results with similar complication rates. Level of evidence: Level III, Retrospective Cohort Design, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Distal biceps brachii tendon repair; cortical button; suture anchor; interference screw
IRB approval was exempt for this study. *Reprint requests: Ilya Voloshin, MD, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14625, USA. E-mail address: [email protected] (I. Voloshin).
Surgical technique for distal biceps repair has evolved over the years in an effort to limit surgical morbidities. Early surgical techniques required an extensive anterior or double-incision approach to create bone tunnels through the radial tuberosity. These approaches were later modified to a
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.06.049
1608 muscle-splitting double-incision approach to avoid subperiosteal dissection of the ulna and the potential complication of heterotopic ossification.3,11 The advent of newer fixation devices has led to a renewed interest in the singleincision approach and includes suture anchors, interference screws, and cortical buttons. Biomechanically, the cortical button has superior fatigue and ultimate strength compared with interference screws, suture anchors, and transosseous tunnels.9 Tendon displacement or gap formation was similar among the fixation devices. The tension slide technique is a cortical button that allows intraosseous fixation of the distal biceps tendon.18 This construct has ultimate strength similar to that of the cortical button without interosseous placement of the tendon but results in less gap formation, which may have important clinical implications.17 The addition of an interference screw did not improve strength or reduce gap formation but did provide a more anatomic repair of the distal biceps.17 Careful assessment of postoperative supination strength demonstrates weakness if the distal biceps tendon footprint is not restored anatomically.16 In our study, we directly compare a tension slide technique performed with a cortical button and interference screw (CB) with a suture anchor (SA) technique. We hypothesize that these techniques will have similar clinical outcomes and complications.
J.R. Olsen et al. Flexion strength was measured with the hand supinated, and an average of 5 maximum exertions was recorded. Supination strength was measured with the hand in neutral position, and again the average of 5 maximum exertions was recorded. The operative arm was compared with the nonoperative arm to obtain differential ROM and strength measurements. Values were obtained by subtracting the operative arm values from the nonoperative arm values. A lower or more negative number indicated a greater level of stiffness or weakness (except for extension, which is opposite). The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale pain scores (range, 0-10), and complications were documented. DASH scores were obtained only from the operative extremity. Paresthesias and numbness of the dorsal hand and thumb were attributed to the superficial radial nerve; the same symptoms over the volar, lateral forearm distal to the incision were attributed to the lateral antebrachial cutaneous nerve. The primary outcome measure of this study was DASH scores. Statistical significance was set to P < .05. A priori power analysis (P ¼ .80) using a minimal meaningful clinical difference of 10.2 DASH score required 13 patients in each group.7,14 Univariate analyses were performed by 2-sample t tests to compare DASH, ROM, and strength between the CB and SA groups. After this, multivariate regression analysis was completed to adjust for time between injury and surgery, time between surgery and evaluation, existence of complications, smoking status, workers’ compensation, and arm dominance. All analyses were completed with R version 2.15.2 software (The R Foundation for Statistical Computing) on a Mac OS platform. All other analyses were carried out with 2-sample t tests, Mann-Whitney tests, and c2 tests. All data are presented as mean standard deviation.
Materials and methods Distal biceps tendon ruptures repaired with CB or SA technique from 2008 to 2013 were identified among 3 orthopedic surgeons at a single academic institution. Patients were included if they were older than 18 years, at least 12 months from surgery, and repaired through a single incision with either CB or SA. Exclusion criteria included double-incision techniques, chronic biceps tendon tears requiring allograft or autograft tendons, bilateral biceps tendon repairs, and contralateral arm weakness from prior trauma or neurologic injuries. Ninety-three patients met enrollment criteria. The tension slide technique was performed with a cortical button and interference screw per the manufacturer’s technique guide (Arthrex, Naples, FL, USA). SA repair was performed with either two GII suture anchors (DePuy Mitek, Warsaw, IN, USA) or 3.0-mm suture tacks (SutureTak; Arthrex, Naples, FL, USA) as previously described.6 The surgical approach was the same for both techniques. All patients in both treatment groups underwent a standard rehabilitation protocol at our institution. Patients began active range of motion (ROM) at 5 to 7 days postoperatively as long as there were no signs of wound dehiscence. Beginning at 6 weeks, patients were advanced to a 10-pound lifting restriction, and at 12 weeks they were allowed to resume activity as tolerated. No bracing was used, and all patients attended formal physical therapy sessions. A total of 37 patients were enrolled in the study (20 CB, 17 SA). By investigators blinded to surgical technique, patients were assessed for ROM and strength with a standard goniometer (degrees) and dynamometer (pounds, hand held; Lafayette Instrument Co, Lafayette, IN, USA), respectively. Strength measurements were taken with the arm adducted and elbow flexed to 90 .
Results Both treatment groups were comparable with regard to sex, age, time from injury to surgery, number of active smokers, dominant extremity affected, and workers’ compensation cases (Table I). The time from surgery to evaluation was significantly shorter in the CB group (18 5 months; range, 12-25 months) than in the SA group (32 15 months; range, 12-55 months; P ¼ .007). The CB group demonstrated slightly better DASH scores than the SA group with multivariate analysis (4.5 4.4 vs 10.3 14.9; P ¼ .0009). Postoperative strength relative to the nonoperative extremity did not differ between the groups, and there were small differences in ROM (Table II). Average flexion ROM, relative to the nonoperative extremity, was slightly better in the SA group (2 0 ) compared with the CB group (3 5 ; P ¼ .0061) in the univariate model. In the multivariate analysis, flexion (CB 3 5 vs SA 2 0 ; P ¼ .0073) and supination (CB 7 12 vs SA 2 5 ; P ¼ .0166) ROM differences were again slightly better in the SA group. The CB group did have slightly better pronation relative to the nonoperative extremity in the multivariate analysis. The original strength and ROM measurements for the operative and nonoperative extremities in both treatment groups are presented in Table III, which demonstrates that supination was
Technique comparison for distal biceps repair Table I
Basic group characteristics
Age (years) Male Injury to surgery time (days) Surgery to evaluation time (months) Smokers Dominant extremity affected Workers’ compensation )
1609
CB (n ¼ 20)
SA (n ¼ 17)
P value
52 9.5 100% 16 16 18 5 0% 30% 20%
51 11 88% 9 6.7 32 15 17.6% 35% 29%
.59 .20 .42 .007) .08 .99 .70
(range, 32-66) (n ¼ 20) (range, 0-60) (range, 12-25) (n ¼ 0) (n ¼ 6) (n ¼ 4)
(range, 34-76) (n ¼ 15) (range, 0-22) (range, 12-55) (n ¼ 3) (n ¼ 6) (n ¼ 5)
P < .05.
Table II
DASH scores with strength and ROM differences CB
DASH Flexion strength difference (pounds) Supination strength difference (pounds) Flexion ROM difference Extension ROM difference Supination ROM difference Pronation ROM difference
SA
Univariate (P value)
4.5 4.4 1.8 0.6
10.3 14.9 0.1 2.2
.22 .60
Multivariate (P value) .0009) .35
6.8 11.0
3.0 6.7
.49
.68
.006) .41 .09 .14
.0073) .24 .0166) .0027)
3 1 7 0
4.8 1.5 11.8 5.0
2 1 2 4
0.0 2.5 5.0 10.5
Strength (pounds) and ROM (degrees) were measured in operative and nonoperative extremities. Operative extremity values minus nonoperative extremity values yielded differential measurements in each category, from which the averages were used to compare the CB and SA groups. This was done for flexion strength, supination strength, ROM flexion, ROM extension, ROM supination, and ROM pronation. Positive values favor the operative extremity; negative values favor the nonoperative extremity. Lower or more negative values indicate more limitation or disability (except for extension, which is opposite). ) P < .05.
significantly decreased in the operative extremity (72 9 ) compared with the nonoperative limb (79 7 ; P ¼ .02) in the CB group. Visual analog scale pain scores in the CB group (0.79 1.9) were similar to those of the SA group (1.8 2.2; P ¼ .18). Complications were experienced by 6 patients in both the CB (30%) and SA (35%) groups (P ¼ .99). The distribution of complications was largely similar between the 2 groups, with the majority of nerve paresthesias still being present at time of follow-up (Table IV). The perception of weakness was present in 4 CB patients (20%) and 9 SA patients (53%; P ¼ .04). There were no reoperations or reruptures. All patients in each group could continue working, and only a single patient in the SA group changed employment for unrelated reasons.
Discussion Multiple studies have demonstrated the clinical benefit of distal biceps tendon repairs.1,5,13 Several single-incision techniques are described in the literature with good clinical results and low complication rates.2,10,15,19 Although the CB technique is biomechanically superior to other
fixation techniques,9,18 it is unclear if it provides clinical results superior to those of other single-incision techniques. Our study directly compared the clinical outcomes of CB to SA repair through a single incision for distal biceps tendon ruptures. The DASH scores were slightly higher in the SA group on multivariate analysis. However, the difference in the average DASH scores was approximately 6 points, with the minimally clinical important difference in DASH scores being recently reported as 10.2.14 The DASH scores in both groups were comparable to previous studies2,10,15,19 and were near or below the average U.S. normative DASH of 10.1.8 Quantitative flexion and supination strength in the operative extremity was similar between the 2 groups, yet significantly more patients reported subjective weakness in the operative extremity from the SA group compared with the CB group. A larger study would be needed to confirm this observation. There is no clear explanation from our data to explain this observation. On multivariate analysis, when referencing the nonoperative extremity, the CB group had slightly better pronation compared with the SA group. The SA group patients had slightly better ROM compared with the CB group with
(136 -150 ) (0 -20 ) (65 -90 ) (70 -90 ) (120 -148 ) (0 -18 ) (55 -90 ) (65 -90 )
48.8 57.3 143 6 79 79 26 32 6.2 5.1 9.5 6.8 49.6 50.3 140 7 72 79
Strength (pounds) and ROM (degrees) for the operative and nonoperative extremities for the 2 surgical techniques. All values are average standard deviation. Range in parentheses after all degree measurement averages. P values presented for CB operative vs nonoperative extremities and SA operative vs nonoperative extremities. ) P < .05.
(130 -148 ) (0 -15 ) (60 -90 ) (60 -87 ) 60.5 31 38.0 18 139 5.6 5 3.9 76 5.3 75 9.2 .92 .45 .44 .78 .02) .82
27 24 3.8 6.8 7.2 6.6
Nonoperative CB operative
Flexion strength (pounds) Supination strength (pounds) Flexion ROM Extension ROM Supination ROM Pronation ROM
Table III
Strength and ROM values of operative and nonoperative extremities
P value
SA operative
(130 -149 ) (0 -15 ) (60 -85 ) (62 -89 )
60.6 29 41.0 21 137 5.4 6 4.2 78 7.8 79 7.7
Nonoperative
.99 .67 .36 .66 .39 .19
J.R. Olsen et al. P value
1610 Table IV
Complications after surgery
All Superficial infection Superficial radial nerve paresthesias Lateral antebrachial nerve paresthesias Ulnar nerve paresthesias Hematoma
CB (n ¼ 20)
SA (n ¼ 17)
P value
30% (n ¼ 6) 10% (n ¼ 2)
35% (n ¼ 6) 0
>.99 .50
20% (n ¼ 4)
6% (n ¼ 1))
.35
0
18% (n ¼ 3)y
.09
0
6% (n ¼ 1)
.46
0
6% (n ¼ 1)
.46
)
This patient’s paresthesias resolved within 12 months from surgery. Only 1 of these patients’ paresthesias resolved within 12 months from surgery.
y
respect to flexion and supination. These differences were small, all less than 6 , and are likely to bear no clinical significance. Overall, motion of the operative extremity was excellent in all patients at follow-up, with all patients displaying an adequate range for everyday function.12 Previous studies have also reported minimal or no significant limitations to elbow motion after distal biceps repair with single-incision techniques.10,19 Complication rates were similar in both groups and consistent with previous reports, with nerve paresthesia or numbness being the most common.7,10 Unlike in previous studies, the majority of nerve paresthesias were not transient and were still present at time of follow-up.7,10 Although both surgical approaches were the same, there was a trend for more lateral antebrachial cutaneous nerve paresthesias in the SA group (P ¼ .09) and more superficial radial nerve palsies in the CB group. This may be due to chance alone, as these differences did not meet statistical significance, or from subtle differences in retractor placement. In general, the authors think that more retraction is needed during acorn reaming for the cortical button to ensure that no cortical blowout occurs. This could potentially explain more superficial radial nerve complications. No Hohmann retractors were used radial to the tuberosity in either group. Two patients in the CB group were treated with oral antibiotics (cephalexin) for 7 days after development of superficial cellulitis around the incision, which completely resolved in both cases. The rehabilitation and outcomes of these 2 patients were not affected, and neither carried risk factors predisposing them to infection. Ultimately, the best technique for distal biceps tendon repairs may be the technique surgeons are most comfortable using on the basis of experience. Many reports are case series by authors who have no doubt mastered the technique under scrutiny.2,4,10,15 Although retrospective, our study does provide for some meaningful comparison
Technique comparison for distal biceps repair between 2 common techniques used for distal biceps repair, further reinforcing the safety and efficacy profiles for these techniques. Limitations of this study include its retrospective nature and low percentage of recruitment among patients in the cohort we identified. Because of our retrospective design, the patient follow-up visits were at varying times from surgery, and the suture anchor group had significantly longer follow-up compared with the tension slide technique group. However, on the basis of previous studies, there is no reason to believe that this difference in follow-up would influence outcomes significantly. To make sure, the difference in follow-up was adjusted for with multivariate analysis. Decreased recruitment is unfortunately the reality of studying this active, predominantly male patient population that achieves a high level of function. Most of the patients were active men with active employment and unwilling to come back for study follow-up, and this creates a risk for potential bias in our results. Despite this limitation, our power analysis did suggest that the study was adequately powered a priori for the DASH scores. This study may not have enough power to detect differences in strength or ROM measures.
Conclusion Despite biomechanical data suggesting superiority of cortical button and interference screw fixation by the tension slide technique, our study suggests that singleincision repair of distal biceps tendon rupture by tension slide technique with cortical button and interference screw leads to similar clinical outcomes and complications compared with the suture anchor repair technique. Patients may feel weaker in the operative extremity when repair is by suture anchor, although this weakness is not present with objective strength measures.
Disclaimer Michael Maloney is a paid consultant for Arthrex and receives financial payments for lectures and educational programs from Arthrex. Ilya Voloshin is a paid consultant for Zimmer, Pfizer, and Acumed. He receives speaking fees from Arthrex and Acumed. The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
1611
References 1. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am 1985;67:414-7. 2. Balabaud L, Ruiz C, Nonnenmacher J, Seynaeve P, Kehr P, Rapp E. Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach. J Hand Surg Br 2004;29:178-82. http://dx.doi.org/ 10.1016/j.jhsb.2003.07.002 3. Boyd H, Anderson L. A method for reinsertion fo the distal biceps brachii tendon. J Bone Joint Surg Am 1961;43:1041-3. 4. Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: a systematic review. Am J Sports Med 2008;36:1618-24. http://dx.doi.org/10.1177/0363546508321482 5. Chillemi C, Marinelli M, De Cupis V. Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertiondclinical and radiological evaluation after 2 years. Arch Orthop Trauma Surg 2007;127:705-8. http://dx.doi.org/10.1007/s00402-007-0326-7 6. Galantz L, Jani M, Yamaguchi K. Single anterior incision exposure for distal biceps tendon repair. Tech Shoulder Elbow Surg 2002;3:63-7. 7. Grewal R, Athwal GS, MacDermid JC, Faber KJ, Drosdowech DS, ElHawary R, et al. Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am 2012;94:1166-74. http://dx.doi.org/10.2106/JBJS.K.00436 8. Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am 2002;84:208-15. 9. Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA, Arciero RA. Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med 2007;35:252-8. http://dx.doi. org/10.1177/0363546506294854 10. McKee MD, Hirji R, Schemitsch EH, Wild LM, Waddell JP. Patientoriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique. J Shoulder Elbow Surg 2005; 14:302-6. http://dx.doi.org/10.1016/j.jse.2004.09.007 11. 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;67:418-21. 12. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872-7. 13. Nesterenko S, Domire ZJ, Morrey BF, Sanchez-Sotelo J. Elbow strength and endurance in patients with a ruptured distal biceps tendon. J Shoulder Elbow Surg 2010;19:184-9. http://dx.doi.org/10.1016/j.jse.2009.06.001 14. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum 2009;61: 623-32. http://dx.doi.org/10.1002/art.24396 15. Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N. Distal biceps tendon rupture: current concepts. Injury 2013;44:417-20. http://dx.doi.org/10.1016/j.injury.2012.10.029 16. Schmidt CC, Diaz VA, Weir DM, Latona CR, Miller MC. Repaired distal biceps magnetic resonance imaging anatomy compared with outcome. J Shoulder Elbow Surg 2012;21:1623-31. http://dx.doi.org/10.1016/j.jse. 2012.03.009 17. Sethi P, Obopilwe E, Rincon L, Miller S, Mazzocca A. Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation. J Shoulder Elbow Surg 2010;19:53-7. http://dx.doi.org/10.1016/j.jse.2009.05.007 18. Sethi PM, Tibone JE. Distal biceps repair using cortical button fixation. Sports Med Arthrosc 2008;16:130-5. http://dx.doi.org/10.1097/ JSA.0b013e31818247cb 19. Silva J, Eskander MS, Lareau C, DeAngelis NA. Treatment of distal biceps tendon ruptures using a single-incision technique and a BioTenodesis screw. Orthopedics 2010;33:477. http://dx.doi.org/10.3928/ 01477447-20100526-09
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A comparison of cortical button with interference screw versus suture anchor techniques for distal biceps brachii tendon repairs Joshua R. Olsen, MD, Edward Shields, MD, Richard B. Williams, MD, Richard Miller, MD, Michael Maloney, MD, Ilya Voloshin, MD* Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY, USA Background: Distal biceps brachii tendon repairs performed by a ‘‘tension slide technique’’ with a cortical button and interference screw (CB) are stronger than repairs by suture anchor (SA) techniques in biomechanical studies. However, clinical comparison of the 2 techniques is lacking in the literature. Methods: Distal biceps tendon ruptures repaired with either a CB or SA technique through a single incision were identified from 2008 to 2013 at a single institution. Patients more than a year out from surgery completed a Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. In addition, patients were assessed for range of motion, strength, and complications. All assessments were performed by individuals blinded to the surgical technique. Strength and motion values from the operative extremity minus the nonoperative arm values yielded differential values that were averaged and used to compare treatment groups. Results: The CB (n ¼ 20) and SA (n ¼ 17) groups had similar demographics, except for the time from the surgery to evaluation (18 5 vs 32 15 months, respectively; P ¼ .007). Range of motion differed slightly between the groups. The CB group demonstrated better pronation (0 5 vs 4 10 ; P < .05), and the SA group demonstrated better flexion (2 0 vs 3 5 ; P < .05) and supination (2 5 vs 7 12 ; P < .05). Strength did not differ significantly between the groups. DASH scores did not significantly differ between the groups with univariate analysis, but multivariate analysis demonstrated slightly better DASH scores with the CB technique (4.5 4.4 vs 10.3 14.9; P < .0009). Complication rates were similar between groups (CB 30%, SA 35%; P > .05). Conclusion: CB and SA techniques provide good clinical results with similar complication rates. Level of evidence: Level III, Retrospective Cohort Design, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Distal biceps brachii tendon repair; cortical button; suture anchor; interference screw
IRB approval was exempt for this study. *Reprint requests: Ilya Voloshin, MD, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14625, USA. E-mail address: [email protected] (I. Voloshin).
Surgical technique for distal biceps repair has evolved over the years in an effort to limit surgical morbidities. Early surgical techniques required an extensive anterior or double-incision approach to create bone tunnels through the radial tuberosity. These approaches were later modified to a
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.06.049
1608 muscle-splitting double-incision approach to avoid subperiosteal dissection of the ulna and the potential complication of heterotopic ossification.3,11 The advent of newer fixation devices has led to a renewed interest in the singleincision approach and includes suture anchors, interference screws, and cortical buttons. Biomechanically, the cortical button has superior fatigue and ultimate strength compared with interference screws, suture anchors, and transosseous tunnels.9 Tendon displacement or gap formation was similar among the fixation devices. The tension slide technique is a cortical button that allows intraosseous fixation of the distal biceps tendon.18 This construct has ultimate strength similar to that of the cortical button without interosseous placement of the tendon but results in less gap formation, which may have important clinical implications.17 The addition of an interference screw did not improve strength or reduce gap formation but did provide a more anatomic repair of the distal biceps.17 Careful assessment of postoperative supination strength demonstrates weakness if the distal biceps tendon footprint is not restored anatomically.16 In our study, we directly compare a tension slide technique performed with a cortical button and interference screw (CB) with a suture anchor (SA) technique. We hypothesize that these techniques will have similar clinical outcomes and complications.
J.R. Olsen et al. Flexion strength was measured with the hand supinated, and an average of 5 maximum exertions was recorded. Supination strength was measured with the hand in neutral position, and again the average of 5 maximum exertions was recorded. The operative arm was compared with the nonoperative arm to obtain differential ROM and strength measurements. Values were obtained by subtracting the operative arm values from the nonoperative arm values. A lower or more negative number indicated a greater level of stiffness or weakness (except for extension, which is opposite). The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale pain scores (range, 0-10), and complications were documented. DASH scores were obtained only from the operative extremity. Paresthesias and numbness of the dorsal hand and thumb were attributed to the superficial radial nerve; the same symptoms over the volar, lateral forearm distal to the incision were attributed to the lateral antebrachial cutaneous nerve. The primary outcome measure of this study was DASH scores. Statistical significance was set to P < .05. A priori power analysis (P ¼ .80) using a minimal meaningful clinical difference of 10.2 DASH score required 13 patients in each group.7,14 Univariate analyses were performed by 2-sample t tests to compare DASH, ROM, and strength between the CB and SA groups. After this, multivariate regression analysis was completed to adjust for time between injury and surgery, time between surgery and evaluation, existence of complications, smoking status, workers’ compensation, and arm dominance. All analyses were completed with R version 2.15.2 software (The R Foundation for Statistical Computing) on a Mac OS platform. All other analyses were carried out with 2-sample t tests, Mann-Whitney tests, and c2 tests. All data are presented as mean standard deviation.
Materials and methods Distal biceps tendon ruptures repaired with CB or SA technique from 2008 to 2013 were identified among 3 orthopedic surgeons at a single academic institution. Patients were included if they were older than 18 years, at least 12 months from surgery, and repaired through a single incision with either CB or SA. Exclusion criteria included double-incision techniques, chronic biceps tendon tears requiring allograft or autograft tendons, bilateral biceps tendon repairs, and contralateral arm weakness from prior trauma or neurologic injuries. Ninety-three patients met enrollment criteria. The tension slide technique was performed with a cortical button and interference screw per the manufacturer’s technique guide (Arthrex, Naples, FL, USA). SA repair was performed with either two GII suture anchors (DePuy Mitek, Warsaw, IN, USA) or 3.0-mm suture tacks (SutureTak; Arthrex, Naples, FL, USA) as previously described.6 The surgical approach was the same for both techniques. All patients in both treatment groups underwent a standard rehabilitation protocol at our institution. Patients began active range of motion (ROM) at 5 to 7 days postoperatively as long as there were no signs of wound dehiscence. Beginning at 6 weeks, patients were advanced to a 10-pound lifting restriction, and at 12 weeks they were allowed to resume activity as tolerated. No bracing was used, and all patients attended formal physical therapy sessions. A total of 37 patients were enrolled in the study (20 CB, 17 SA). By investigators blinded to surgical technique, patients were assessed for ROM and strength with a standard goniometer (degrees) and dynamometer (pounds, hand held; Lafayette Instrument Co, Lafayette, IN, USA), respectively. Strength measurements were taken with the arm adducted and elbow flexed to 90 .
Results Both treatment groups were comparable with regard to sex, age, time from injury to surgery, number of active smokers, dominant extremity affected, and workers’ compensation cases (Table I). The time from surgery to evaluation was significantly shorter in the CB group (18 5 months; range, 12-25 months) than in the SA group (32 15 months; range, 12-55 months; P ¼ .007). The CB group demonstrated slightly better DASH scores than the SA group with multivariate analysis (4.5 4.4 vs 10.3 14.9; P ¼ .0009). Postoperative strength relative to the nonoperative extremity did not differ between the groups, and there were small differences in ROM (Table II). Average flexion ROM, relative to the nonoperative extremity, was slightly better in the SA group (2 0 ) compared with the CB group (3 5 ; P ¼ .0061) in the univariate model. In the multivariate analysis, flexion (CB 3 5 vs SA 2 0 ; P ¼ .0073) and supination (CB 7 12 vs SA 2 5 ; P ¼ .0166) ROM differences were again slightly better in the SA group. The CB group did have slightly better pronation relative to the nonoperative extremity in the multivariate analysis. The original strength and ROM measurements for the operative and nonoperative extremities in both treatment groups are presented in Table III, which demonstrates that supination was
Technique comparison for distal biceps repair Table I
Basic group characteristics
Age (years) Male Injury to surgery time (days) Surgery to evaluation time (months) Smokers Dominant extremity affected Workers’ compensation )
1609
CB (n ¼ 20)
SA (n ¼ 17)
P value
52 9.5 100% 16 16 18 5 0% 30% 20%
51 11 88% 9 6.7 32 15 17.6% 35% 29%
.59 .20 .42 .007) .08 .99 .70
(range, 32-66) (n ¼ 20) (range, 0-60) (range, 12-25) (n ¼ 0) (n ¼ 6) (n ¼ 4)
(range, 34-76) (n ¼ 15) (range, 0-22) (range, 12-55) (n ¼ 3) (n ¼ 6) (n ¼ 5)
P < .05.
Table II
DASH scores with strength and ROM differences CB
DASH Flexion strength difference (pounds) Supination strength difference (pounds) Flexion ROM difference Extension ROM difference Supination ROM difference Pronation ROM difference
SA
Univariate (P value)
4.5 4.4 1.8 0.6
10.3 14.9 0.1 2.2
.22 .60
Multivariate (P value) .0009) .35
6.8 11.0
3.0 6.7
.49
.68
.006) .41 .09 .14
.0073) .24 .0166) .0027)
3 1 7 0
4.8 1.5 11.8 5.0
2 1 2 4
0.0 2.5 5.0 10.5
Strength (pounds) and ROM (degrees) were measured in operative and nonoperative extremities. Operative extremity values minus nonoperative extremity values yielded differential measurements in each category, from which the averages were used to compare the CB and SA groups. This was done for flexion strength, supination strength, ROM flexion, ROM extension, ROM supination, and ROM pronation. Positive values favor the operative extremity; negative values favor the nonoperative extremity. Lower or more negative values indicate more limitation or disability (except for extension, which is opposite). ) P < .05.
significantly decreased in the operative extremity (72 9 ) compared with the nonoperative limb (79 7 ; P ¼ .02) in the CB group. Visual analog scale pain scores in the CB group (0.79 1.9) were similar to those of the SA group (1.8 2.2; P ¼ .18). Complications were experienced by 6 patients in both the CB (30%) and SA (35%) groups (P ¼ .99). The distribution of complications was largely similar between the 2 groups, with the majority of nerve paresthesias still being present at time of follow-up (Table IV). The perception of weakness was present in 4 CB patients (20%) and 9 SA patients (53%; P ¼ .04). There were no reoperations or reruptures. All patients in each group could continue working, and only a single patient in the SA group changed employment for unrelated reasons.
Discussion Multiple studies have demonstrated the clinical benefit of distal biceps tendon repairs.1,5,13 Several single-incision techniques are described in the literature with good clinical results and low complication rates.2,10,15,19 Although the CB technique is biomechanically superior to other
fixation techniques,9,18 it is unclear if it provides clinical results superior to those of other single-incision techniques. Our study directly compared the clinical outcomes of CB to SA repair through a single incision for distal biceps tendon ruptures. The DASH scores were slightly higher in the SA group on multivariate analysis. However, the difference in the average DASH scores was approximately 6 points, with the minimally clinical important difference in DASH scores being recently reported as 10.2.14 The DASH scores in both groups were comparable to previous studies2,10,15,19 and were near or below the average U.S. normative DASH of 10.1.8 Quantitative flexion and supination strength in the operative extremity was similar between the 2 groups, yet significantly more patients reported subjective weakness in the operative extremity from the SA group compared with the CB group. A larger study would be needed to confirm this observation. There is no clear explanation from our data to explain this observation. On multivariate analysis, when referencing the nonoperative extremity, the CB group had slightly better pronation compared with the SA group. The SA group patients had slightly better ROM compared with the CB group with
(136 -150 ) (0 -20 ) (65 -90 ) (70 -90 ) (120 -148 ) (0 -18 ) (55 -90 ) (65 -90 )
48.8 57.3 143 6 79 79 26 32 6.2 5.1 9.5 6.8 49.6 50.3 140 7 72 79
Strength (pounds) and ROM (degrees) for the operative and nonoperative extremities for the 2 surgical techniques. All values are average standard deviation. Range in parentheses after all degree measurement averages. P values presented for CB operative vs nonoperative extremities and SA operative vs nonoperative extremities. ) P < .05.
(130 -148 ) (0 -15 ) (60 -90 ) (60 -87 ) 60.5 31 38.0 18 139 5.6 5 3.9 76 5.3 75 9.2 .92 .45 .44 .78 .02) .82
27 24 3.8 6.8 7.2 6.6
Nonoperative CB operative
Flexion strength (pounds) Supination strength (pounds) Flexion ROM Extension ROM Supination ROM Pronation ROM
Table III
Strength and ROM values of operative and nonoperative extremities
P value
SA operative
(130 -149 ) (0 -15 ) (60 -85 ) (62 -89 )
60.6 29 41.0 21 137 5.4 6 4.2 78 7.8 79 7.7
Nonoperative
.99 .67 .36 .66 .39 .19
J.R. Olsen et al. P value
1610 Table IV
Complications after surgery
All Superficial infection Superficial radial nerve paresthesias Lateral antebrachial nerve paresthesias Ulnar nerve paresthesias Hematoma
CB (n ¼ 20)
SA (n ¼ 17)
P value
30% (n ¼ 6) 10% (n ¼ 2)
35% (n ¼ 6) 0
>.99 .50
20% (n ¼ 4)
6% (n ¼ 1))
.35
0
18% (n ¼ 3)y
.09
0
6% (n ¼ 1)
.46
0
6% (n ¼ 1)
.46
)
This patient’s paresthesias resolved within 12 months from surgery. Only 1 of these patients’ paresthesias resolved within 12 months from surgery.
y
respect to flexion and supination. These differences were small, all less than 6 , and are likely to bear no clinical significance. Overall, motion of the operative extremity was excellent in all patients at follow-up, with all patients displaying an adequate range for everyday function.12 Previous studies have also reported minimal or no significant limitations to elbow motion after distal biceps repair with single-incision techniques.10,19 Complication rates were similar in both groups and consistent with previous reports, with nerve paresthesia or numbness being the most common.7,10 Unlike in previous studies, the majority of nerve paresthesias were not transient and were still present at time of follow-up.7,10 Although both surgical approaches were the same, there was a trend for more lateral antebrachial cutaneous nerve paresthesias in the SA group (P ¼ .09) and more superficial radial nerve palsies in the CB group. This may be due to chance alone, as these differences did not meet statistical significance, or from subtle differences in retractor placement. In general, the authors think that more retraction is needed during acorn reaming for the cortical button to ensure that no cortical blowout occurs. This could potentially explain more superficial radial nerve complications. No Hohmann retractors were used radial to the tuberosity in either group. Two patients in the CB group were treated with oral antibiotics (cephalexin) for 7 days after development of superficial cellulitis around the incision, which completely resolved in both cases. The rehabilitation and outcomes of these 2 patients were not affected, and neither carried risk factors predisposing them to infection. Ultimately, the best technique for distal biceps tendon repairs may be the technique surgeons are most comfortable using on the basis of experience. Many reports are case series by authors who have no doubt mastered the technique under scrutiny.2,4,10,15 Although retrospective, our study does provide for some meaningful comparison
Technique comparison for distal biceps repair between 2 common techniques used for distal biceps repair, further reinforcing the safety and efficacy profiles for these techniques. Limitations of this study include its retrospective nature and low percentage of recruitment among patients in the cohort we identified. Because of our retrospective design, the patient follow-up visits were at varying times from surgery, and the suture anchor group had significantly longer follow-up compared with the tension slide technique group. However, on the basis of previous studies, there is no reason to believe that this difference in follow-up would influence outcomes significantly. To make sure, the difference in follow-up was adjusted for with multivariate analysis. Decreased recruitment is unfortunately the reality of studying this active, predominantly male patient population that achieves a high level of function. Most of the patients were active men with active employment and unwilling to come back for study follow-up, and this creates a risk for potential bias in our results. Despite this limitation, our power analysis did suggest that the study was adequately powered a priori for the DASH scores. This study may not have enough power to detect differences in strength or ROM measures.
Conclusion Despite biomechanical data suggesting superiority of cortical button and interference screw fixation by the tension slide technique, our study suggests that singleincision repair of distal biceps tendon rupture by tension slide technique with cortical button and interference screw leads to similar clinical outcomes and complications compared with the suture anchor repair technique. Patients may feel weaker in the operative extremity when repair is by suture anchor, although this weakness is not present with objective strength measures.
Disclaimer Michael Maloney is a paid consultant for Arthrex and receives financial payments for lectures and educational programs from Arthrex. Ilya Voloshin is a paid consultant for Zimmer, Pfizer, and Acumed. He receives speaking fees from Arthrex and Acumed. The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
1611
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