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Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series
J Shoulder Elbow Surg (2015) 24, 928-933
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Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series James A.F. Recordon, MBCHB*, Peter N. Misur, FRACS, Fredrik Isaksson, MD, Peter C. Poon, FRACS Orthopaedics, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand Background: The purpose of this study was to report the outcome of a large cohort of patients undergoing distal biceps tendon repair. We compared the endobutton and transosseous suture repair techniques, both performed through a 2-incision approach. Method: At an average of 2.1 years after a distal biceps repair, 46 male patients (19 endobutton and 27 transosseous suture) were reviewed. The mean age of our patients was 50 years. Results: Forty-three patients (93%) were satisfied with the results of their distal biceps tendon repair. The average pain score was 1.3 of 10 at a mean 2.1 years after repair. More than 80% of patients had regained their premorbid function in both recreational and occupational activities. The mean Mayo Elbow Performance Score was 93 of 100. Biodex strength testing demonstrated restoration of 92% of low-velocity supination power, 102% of high-velocity supination power, and 104% endurance compared with the contralateral limb. There was no statistically significant difference in postoperative strength between the transosseous suture and endobutton groups. There were 3 complications in this series, 1 case of heterotopic ossification and 2 cases of injury to the lateral cutaneous nerve of the forearm. Conclusion: In this large cohort of 2-incision distal biceps repairs, we found a high degree of patient satisfaction and a low complication rate. We did not find any difference in clinical outcome with regard to subjective patient rating, pain, range of motion, or supination strength when comparing the 2-incision endobutton and transosseous suture fixation techniques. Level of evidence: Level III, Retrospective Cohort, Treatment Study. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Distal biceps repair; endobutton; two-incision; Biodex
Ethics approval was provided by the Northern X Regional Ethics Committee, Ministry of Health NZ: No. NTX/12/EXP/041. Funding was provided by the Wishbone Trust, Wellington, New Zealand. *Reprint requests: James A. F. Recordon, MBCHB, Orthopaedics, North Shore Hospital, Waitemata District Health Board, Private Bag 93503, Takapuna, Auckland 9, New Zealand. E-mail address: [email protected] (J.A.F. Recordon).
The biceps brachii muscle spans the glenohumeral and elbow joints. Its primary function is supination of the forearm while being a secondary flexor of the elbow. This 2-headed muscle takes origin from the coracoid process and the supraglenoid tubercle of the scapula and inserts on the posterior aspect of the radial tuberosity at the proximal radius. A North American study reported an
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.12.032
Two-incision distal biceps tendon repairs incidence of distal biceps rupture of 1.2 per 100,000 patient-years.18 Ruptures of the distal biceps usually occur at the tendoosseous junction as a result of a sudden eccentric muscle contraction, such as when catching a heavy object. Patients often describe a ‘‘popping’’ sensation at the time of injury, followed by pain, swelling, and ecchymosis at the antecubital fossa. Clinically, the patient is weak in supination. The hook test has been shown to be both sensitive and specific for distal biceps rupture.16 Ruptures of the distal biceps most commonly occur in the dominant arm. This injury is almost exclusively seen in men, and previous studies have found a peak incidence in the fifth decade of life.7 The etiology of a distal biceps rupture is likely to be multifactorial. Degeneration of the tendon may result from repeated mechanical impingement, and reduced vascularity of the tendon may also play a role.4,21 The proximal part of the distal biceps tendon is supplied by the brachial artery, whereas the insertion is supplied by the posterior interosseous recurrent artery. A relative hypovascular zone exists between these areas, and this may be an important etiologic factor in tendon rupture.21 Smoking has been shown to increase the risk of tendon rupture by 7.5%.18 Operative management is generally recommended in active patients for whom a significant loss of supination power would create a major functional deficit. Previous studies have reported up to a 40% decrease in supination strength, a 79% decrease in supination endurance, and a 30% decrease in both elbow flexion strength and endurance after a distal biceps tendon rupture.2 Studies consistently show superior functional outcomes when surgical treatment is compared with nonoperative management.5,9,14,22 A meta-analysis of 174 patients showed that 90% achieved good or excellent results after surgical reattachment at 3 years.17 There are various methods of tendon repair, with singleincision, 2-incision, and endoscopic techniques described. Each approach may employ a variety of fixation techniques. A number of publications have recently detailed the anatomy of the distal biceps insertion. Cadaver and magnetic resonance imaging studies have shown that the orientation of the bicipital tuberosity is highly variable, ranging from 15 to 120 posteriorly.6 The footprint of the biceps brachii insertion is on the far posterior-ulnar side of the bicipital tuberosity. The location of this insertion means that the tuberosity acts as a lever arm, increasing the supination torque generated by the muscle.20 In their anatomic study, Hutchinson et al11 described the ideal tendon insertion angle to be just 30 from the coronal plane when in full supination. Hasan et al10 compared anatomic repair on cadavers and showed that on average only 9.7% of the footprint was covered through the anterior 1-incision technique, whereas 73.4% of the footprint was covered by the repair site when a 2-incision technique was used. We use the 2-incision technique as it allows reliable exposure
929 of the posterior aspect of the bicipital tuberosity, enabling a more anatomic repair. There are a wide array of tendon fixation techniques. The transosseous suture technique was previously the standard method of fixation and generally mandated a period of postoperative splinting and gradual assisted range of motion to protect the initial repair. In 2000, Bain et al1 described the use of the endobutton in distal biceps repair, and Greenberg et al8 demonstrated its higher load to failure in biomechanical models. The purpose of this study was to compare the clinical results of a large cohort of patients who underwent distal biceps repair. We aimed to investigate whether the endobutton repair achieves a superior functional outcome compared with the transosseous suture technique.
Materials and methods At our institution between 2002 and 2011, 155 patients underwent a 2-incision distal biceps repair. Four consultant surgeons performed the procedure. Patients were assigned to the first available surgeon. All surgeons used the transosseous technique, but with a change of knowledge from recent literature, the senior author (P.C.P.) changed to the endobutton technique. Seventy-four patients were contactable, and 46 agreed to be in the study. Patients were reviewed at 2 time points. In 2007, 26 patients, all of whom had a transosseous repair, were reviewed in clinic (by S.P.). In 2012, a separate cohort of 20 patients (19 endobutton and 1 transosseous) were reviewed in clinic by authors J.A.F.R. and P.N.M. In total, 46 patients were reviewed in the outpatient clinic. Patients completed a focused questionnaire and a clinical examination. The questionnaire inquired as to subjective weakness with the question, Do you feel that after your injury your affected arm is weaker than your other arm? A satisfaction rating asked the patient about the result of the surgery with the options very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, and very dissatisfied. It also gathered data about occupational and recreational activities and how these were modified. The Mayo Elbow Performance Score was recorded. Elbow range of motion was assessed with a goniometer and reported to the nearest 5 . Anteroposterior and lateral radiographs of the elbow were taken to assess for heterotopic bone formation. Any complications were recorded. Within 1 month of their clinical assessment, the patients attended a sports laboratory (26 in 2007, 20 in 2012), and strength data were collected on a Biodex System 2 Isokinetic Dynamometer (Biodex Medical Systems Inc., Shirley, NY, USA). Low-speed supination (90 /s), and high-speed supination (240 /s) were measured by the following technique. Patients were asked to maximally supinate from full forearm pronation to full supination, eliciting a continuous torque reading through the entire range. The peak value of torque was recorded. The procedure was repeated for the uninjured arm and the torque values were divided, giving a percentage deficit. Endurance was assessed by measuring 30 cycles of continuous pronosupination at maximal effort and comparing the percentage reduction in work done during the firstthird vs. the last-third cycles. Again, this was measured of both the injured and uninjured arms.
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Figure 1 The ruptured tendon is delivered through a transverse wound just distal to the antecubital fossa. A hand-held retractor is used to avoid damage to the lateral cutaneous nerve of the forearm. Data from the transosseous suture and endobutton groups were compared by multivariate analysis of variance and Student t test. The minimum level of significance was P < .05.
Surgical technique All distal biceps repairs were performed by 4 consultant orthopedic surgeons with a subspecialty interest in shoulder and elbow surgery. In all cases, the surgical approach was the modified 2incision technique as described by the Mayo Clinic.15 The arm was supported on an arm board. The arm was exsanguinated and a high arm tourniquet was insufflated. A small transverse incision was made just distal to the antecubital skin crease. Care was taken with skin retraction to avoid damage to the lateral cutaneous nerve of the forearm (Fig. 1). The distal biceps sheath was identified and incised longitudinally. By digital palpation, the ruptured distal biceps tendon was identified, retrieved, and externalized. The bicipital aponeurosis, if still intact, was released from the medial border of the distal biceps tendon. Two No. 2 FiberWire sutures (Arthrex, Naples, FL, USA) with a noncutting needle were used to suture the ruptured distal biceps end with a tendon-grasping Krackow suture configuration. The 2 pairs of sutures were then cut to different lengths to aid later identification of each suture. The forearm was maximally supinated and the bicipital tuberosity was identified by digital palpation. A large artery forceps was passed distally into the distal biceps sheath, ensuring that it was on the ulna side of the bicipital tuberosity. As the forearm was flexed and maximally pronated, the artery forceps was passed into the proximal posterior forearm. A second posterior skin incision and extensor muscle-splitting approach around this artery forceps exposed the bicipital tuberosity. Two ‘‘baby’’ Hohmann retractors were used on the ulna side of the bicipital tuberosity and a Langenbeck retractor on the radial side to avoid injury to the posterior interosseous nerve. The penetrating artery forceps was then used to retrieve a looped No. 2 Ethibond (Ethicon, Somerville, NJ, USA) relay suture through to the volar aspect of the forearm. Under direct vision, the posterior part of the bicipital tuberosity was then prepared. For the transosseous suture repair, an oval trough was made in the posterior part of the bicipital tuberosity, entering the canal of the radius. On
J.A.F. Recordon et al.
Figure 2 The suture ends are tied over an endobutton through a posterior muscle-splitting incision. the radial side of the bicipital tuberosity, 3 transosseous tunnels were made. For the endobutton fixation, the posterior part of the bicipital tuberosity was roughened with a burr to produce bleeding, with care taken not to reduce the height of the bicipital tuberosity. A small burr was used to make a small tunnel in the center of the prepared posterior bicipital tuberosity. On the radial side, ensuring a good bone bridge of at least 5 mm, the burr was used to complete this single transosseous tunnel. The relay suture was then used to retrieve the distal biceps tendon-grasping sutures through the posterior wound. Ensuring that the distal biceps tendon was correctly oriented, the tendon sutures were used to retrieve the distal biceps tendon into the posterior wound. The tendon sutures were then relayed through the transosseous tunnels. In the case of a transosseous repair, a single suture was passed through the most distal and proximal bone tunnel, while a member of both pairs of tendon sutures were passed through the middle tunnel. The distal biceps tendon was tractioned onto the posterior bicipital tuberosity, and each pair of tendon sutures were securely tied. In the case of the endobutton fixation, both pairs of tendon sutures were passed through the single transosseous tunnel. The distal biceps tendon was similarly tractioned onto the posterior bicipital tuberosity, and the sutures were then securely tied over the endobutton (Fig. 2). Both wounds were copiously lavaged with saline to remove any bone debris and closed in layers. The postoperative management of the 2 groups of patients was different. The elbows that had transosseous repair were placed into an above-elbow plaster of Paris cast with the elbow at a right angle. This treatment was designed to avoid any excessive premature load, which may fracture the bone bridges created in the radius. The elbow wounds were checked in clinic at 2 weeks, and the elbow was again splinted in an elbow cast, giving a total immobilization period of 6 weeks. At 6 weeks after surgery, patients were allowed gentle protected mobilization of the elbow and use of the arm for driving and light activities of daily living. Three months after surgery, they were allowed strengthening and unprotected use of the elbow. Elbows that had endobutton fixation had a pressure dressing to minimize postoperative bleeding. The elbow was placed into a sling, and the patients were allowed immediate assisted active gentle mobilization of the elbow. The wounds were checked at 2 weeks. One month after surgery, patients were allowed to use the arm for driving and light activities of daily living. Three months after surgery, they were allowed to commence strengthening activities with unrestricted use of the elbow.
Two-incision distal biceps tendon repairs Table I
Age, injury side, delay to surgery, and time to follow-up
Total Endobutton Transosseous sutures
Table II
No.
Mean age (years)
Dominant limb injury
Average days to surgery (excluding 2 chronic repairs)
Average time to follow-up (months)
46 19 27
49.8 (28-73) 50 P ¼ .729 49.7
26 11 (56%) 15 (58%)
13 18 9.9
24 24 23
P ¼ .55
P ¼ .892
Patient-reported outcomes
Overall, N ¼ 46 Endobutton, n ¼ 19 Transosseous sutures, n ¼ 27 )
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Pain score
Satisfaction (average score))
Subjective weakness
Made changes to recreational activities
Made changes to occupational activities
Mayo Elbow Performance Score
1.3 1.2 1.4
4.6 4.8 4.4
25 (54%) 10 (53%) 15 (55%)
5 1 4
3 1 2
91 92 90
Scoring: 5, very satisfied; 4, satisfied; 3, neither satisfied nor dissatisfied; 2, dissatisfied; 1, very dissatisfied.
Table III
Range of motion (average, to nearest degree)
Endobutton Transosseous P value
Supination
Pronation
Extension
Flexion
81 82 .36
72 70 .24
3 2 .21
129 125 .11
Results All patients were male, with a mean age of 50 years (range, 3573 years; 25th and 75th quartiles, 44 and 56, respectively). Time to surgery was on average 13 days from injury (1-35 days). Two patients were treated for chronic ruptures and were not included in the analysis of time from injury to surgery. The mean follow-up time was 2.1 years from the time of surgery (6 months-5 years). Just more than half (57%) were injuries to the dominant limb. Univariate analysis demonstrated wellmatched comparison groups (Table I). At a mean of 2.1 years after surgery, 46 patients were reviewed; 43 patients (93%) were either very satisfied or satisfied with their outcome. Four patients made changes to their occupation, 3 moved to more supervisory roles, 1 patient changed his line of work from stonemasonry, 3 patients had discontinued high-impact sports, and 38 patients (82%) reported that they had returned to their premorbid level of function in both recreational and vocational activities. Of those 38 patients, 18 classed their work as strenuous and 20 as moderate. The mean pain score was 1.3 of 10, and the Mayo Elbow Performance Score was 91 (Table II). There was no statistically significant difference in range of motion for the 2 fixation methods (Table III). The most significant flexion contracture was 20 . There was a tendency for pronation to be limited by 10 to 15 compared with the other side.
Overall, average supination strength was 92% (low speed) and 102% (high speed). At low velocity, supination peak torque was reduced to 95% in the endobutton patients and 90% in the transosseous suture group compared with the contralateral limb. This difference was not statistically significant. At high velocity, there was no deficit. Both treatment groups demonstrated greater endurance on the surgical side compared with the unaffected limb, with the endobutton fatiguing 4.5% less than the contralateral limb compared with 3.4% for the transosseous group. There was no appreciable alteration of the data when standardized for arm dominance, using a conversion factor of 8%.23 The strength data are outlined in Table IV and Supplementary Online Table. More than half of the patients reported subjective weakness of the arm compared with before their injury. The rate was similar in each group (Table II). Age, delay to surgery, and time to follow-up were examined with multivariate regression analysis. None of these variables were found to correlate with a statistically significant difference in outcome scores. Fourteen patients (30%) reported some degree of postoperative lateral forearm paresthesia. Twelve of these patients had complete resolution of their neurapraxia within 2 weeks of surgery. The remaining 2 patients reported that mild symptoms were still present at 1 year. There was no case of injury to the posterior interosseous nerve of the forearm. One patient from the transosseous suture group developed heterotopic ossification (HO) with reduced range of motion, which necessitated surgical debridement. In this case, a range of motion deficit was noted at 5 months postoperatively, and the patient underwent successful debridement without disruption of the repair at 9 months. At the time of this study, the patient had preserved range of motion, with no strength deficit (108% low-speed peak
932 Table IV
J.A.F. Recordon et al. Biodex strength data Low-speed (90 /s) peak torque, affected arm vs. nonaffected arm
Endobutton Transosseous sutures
95% 90%
P ¼ .585
torque, 113% high-speed peak torque) and was satisfied with his result. There were 6 cases of asymptomatic radiologic HO with 3 in each treatment group, demonstrating no significant difference between the 2 techniques. There was 1 case of superficial wound infection, which resolved with oral antibiotics. There were no reruptures at the time of follow-up. Two patients, within the transosseous suture group, were treated for chronic lesions and deserve specific mention. Both were able to be repaired primarily, with a surgical technique identical to that of the acute group. The first patient had a delay of 180 days and the second 270 days. Both patients had neurapraxia of the lateral forearm, the second still persisting at 1 year.
Discussion This study is one of the largest series of distal biceps ruptures to be reported in the literature and was unique in being able to compare 2 different fixation techniques from the same institution. Our findings indicate that repair of the acute distal biceps tendon rupture by the 2-incision approach restored strength and premorbid function and is associated with a low rate of complications. There is yet to be consensus regarding the optimal approach for distal biceps repair. We use the musclesplitting 2-incision technique as it allows direct visualization of the bicipital tuberosity through the posterior incision, consistently enabling repair of the distal biceps tendon to the posterior part of the bicipital tuberosity. Recent studies have elucidated the anatomy of the footprint of the distal biceps tendon insertion and osteology of the bicipital tuberosity. In some cases, the anatomy of the bicipital tuberosity is such that it is difficult to reach the tendon footprint through an anterior approach. A recent study by Schmidt et al19 showed that the supination strength correlated positively to the distal biceps tendon healing on the posterior aspect of the bicipital tuberosity. More than half of the patients in both groups rated their repaired arm as weaker than before surgery. Biodex testing is a more objective assessment of strength but has its limitations. To account for substitution by other muscles, we reported our results of Biodex testing of the repaired arm relative to the contralateral uninjured arm. Even after we standardized for arm dominance, the results of the Biodex
High-speed (240 /s) peak torque, affected arm vs. nonaffected arm 103% 101%
P ¼ .647
Endurance (% reduction in work done, affected arm vs. nonaffected arm) 4.5% 3.4%
P ¼ .562
strength testing were higher than we expected. This may be due to patients having a higher level of motivation when their repaired arm is tested. Injury to the posterior interosseous nerve is a serious potential complication when a second posterior incision is used. Passing through the anterior incision, we ensure that the artery forceps is on the ulna side of the bicipital tuberosity. Exposure of the bicipital tuberosity is performed with the forearm in maximal pronation, and we do not use Hohmann retractors on the radial side of the bicipital tuberosity to avoid undue traction on this nerve. In our study, we had no case of injury to the posterior interosseous nerve. HO is a known complication of distal biceps repair surgery. This can occur with both a single anterior or a 2incision approach. The reported rates of HO in both the 1incision and 2-incision approaches are similar.3,13 Using the muscle-splitting 2-incision approach, we had 7 cases of HO; 1 was symptomatic and required surgical excision. We perform the muscle split sharply with a knife, and we irrigate the posterior wound copiously to remove bone particles. Our rate of HO was similar to that reported in the literature8 and was rarely symptomatic. Schmidt et al19 performed magnetic resonance imaging after singleincision repairs and reported that 8 of 19 patients had heterotopic bone, noting that the ossification occurred within the tendon substance itself. Despite the endobutton repair’s being superior to transosseous sutures in biomechanical models of strength to failure, our study did not show any clinical difference between the 2 fixation techniques. However, the postoperative rehabilitation was different between the 2 modes of fixation. The suture tunnel technique relies on sutures tied over 2 cortical bone bridges between 3 drill holes, which can fracture, leading to failure of the repair.12 In our study, patients with transosseous repairs were therefore splinted postoperatively for 6 weeks to prevent this mode of failure. In contrast, the higher load to failure of the endobutton repair means that we allow those patients to have immediate gentle assisted active elbow mobilization. Despite 6 weeks of postoperative immobilization of elbows with transosseous repair, we did not find any significant difference in postoperative elbow range of motion at the time of review for this study (Table III). The distal biceps repair involves surgery that is extrinsic to the elbow joint, and all patients underwent postoperative rehabilitation, which may be reasons that the elbow ranges of motion were similar at final follow-up. However, an advantage in the postoperative care
Two-incision distal biceps tendon repairs of patients who had an endobutton repair is a lack of splintage and the allowance of immediate albeit gentle mobilization of their elbows. We do not know if elbows that had transosseous repairs can also be safely mobilized immediately after surgery without disrupting the repair. A limitation of this study is that we were able to review only 46 of our series of 155 patients. Nevertheless, we have presented a study of a large number of patients who have undergone objective postoperative strength testing.
Conclusion This review of 46 distal biceps repairs by the 2-incision technique found a high degree of patient satisfaction, the restoration of strength and premorbid function, and a low complication rate. We did not find any difference in clinical outcome with regard to subjective scoring, pain, range of motion, or supination strength between the 2incision endobutton and transosseous suture fixation techniques.
Acknowledgment We wish to acknowledge Mr. C. Ball, Mr. T. Astley, and Mr. P. Mutch for allowing us to include their patients in this study; Mr. S. Pandit (S.P.) for data collection; Lifeng Zhou for statistical assistance; and Auckland University of Technology for laboratory facilities.
Disclaimer The 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.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jse.2014.12.032.
References 1. 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;9:120-6. 2. 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.
933 3. Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal biceps rupture using the modified two-incision technique. J Shoulder Elbow Surg 2008;17:67S-71S. http://dx.doi. org/10.1016/j.jse.2007.04.008 4. Bourne MH, Morrey BF. Partial rupture of the distal biceps tendon. Clin Orthop Relat Res 1991;271:143-8. 5. Boyd JB, Anderson LD. A method for the reinsertion of the distal biceps tendon. J Bone Joint Surg Am 1961;43:1041-3. 6. Forthman CL, Zimmerman RM, Sullivan MJ, Gabel GT. Crosssectional anatomy of the bicipital tuberosity and biceps brachii tendon insertion: relevance to anatomic tendon repair. J Shoulder Elbow Surg 2008;17:522-6. http://dx.doi.org/10.1016/j.jse.2007.11.002 7. Friedmann E. Rupture of the distal biceps brachil tendon. Report on 13 cases. J Am Med Assoc 1963;184:60-3. 8. Greenberg JA, Fernandez JJ, Wang T, Turner C. EndoButton-assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 2003; 12:484-90. http://dx.doi.org/10.1016/S1058-2746(03)00173-3 9. Hartman MW, Merten SM, Steinmann SP. Mini-open 2-incision technique for repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 2007;16:616-20. http://dx.doi.org/10.1016/j.jse.2006.10.021 10. Hasan SA, Cordell CL, Rauls RB, Bailey MS, Sahu D, Suva LJ. Twoincision versus one-incision repair for distal biceps tendon rupture: a cadaveric study. J Shoulder Elbow Surg 2012;21:935-41. http://dx.doi. org/10.1016/j.jse.2011.04.027 11. Hutchinson HL, Gloystein D, Gillespie M. Distal biceps tendon insertion: an anatomic study. J Shoulder Elbow Surg 2008;17:342-6. http://dx.doi.org/10.1016/j.jse.2007.05.005 12. Idler CS, Montgomery WH 3rd, Lindsey DP, Badua PA, Wynne GF, Yerby SA. Distal biceps tendon repair: a biomechanical comparison of intact tendon and 2 repair techniques. Am J Sports Med 2006;34:96874. http://dx.doi.org/10.1177/0363546505284185 13. John CK, Field LD, Weiss KS, Savoie FH. Single-incision repair of acute distal biceps ruptures by use of suture anchors. J Shoulder Elbow Surg 2007;16:78-83. http://dx.doi.org/10.1016/j.jse.2006.03.002 14. Karunakar MA, Cha P, Stern PJ. Distal biceps ruptures. A follow-up of Boyd and Anderson repair. Clin Orthop Relat Res 1999:100-7. 15. 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. 16. O’Driscoll SW, Goncalves LBJ, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med 2007;35:1865-9. http://dx.doi. org/10.1177/0363546507305016 17. Rantanen J, Orava S. Rupture of the distal biceps tendon. A report of 19 patients treated with anatomic reinsertion, and a meta-analysis of 147 cases found in the literature. Am J Sports Med 1999;27:128-32. 18. Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res 2002: 275-83. 19. 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 20. Schmidt CC, Jarrett CD, Brown BT. The distal biceps tendon. J Hand Surg Am 2013;38:811-21. http://dx.doi.org/10.1016/j.jhsa.2013.01. 042. quiz 821. 21. Seiler JG 3rd, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA. The distal biceps tendon. Two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg 1995;4:149-56. 22. Weinstein DM, Ciccone WJ II, Buckler MC, Balthrop PM, Busey TD, Elias JJ. Elbow function after repair of the distal biceps brachii tendon with a two-incision approach. J Shoulder Elbow Surg 2008;17:82S-6S. http://dx.doi.org/10.1016/j.jse.2007.07.006 23. Wittstein J, Queen R, Abbey A, Moorman CT 3rd. Isokinetic testing of biceps strength and endurance in dominant versus nondominant upper extremities. J Shoulder Elbow Surg 2010;19:874-7. http://dx.doi.org/ 10.1016/j.jse.2010.01.018
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Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series James A.F. Recordon, MBCHB*, Peter N. Misur, FRACS, Fredrik Isaksson, MD, Peter C. Poon, FRACS Orthopaedics, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand Background: The purpose of this study was to report the outcome of a large cohort of patients undergoing distal biceps tendon repair. We compared the endobutton and transosseous suture repair techniques, both performed through a 2-incision approach. Method: At an average of 2.1 years after a distal biceps repair, 46 male patients (19 endobutton and 27 transosseous suture) were reviewed. The mean age of our patients was 50 years. Results: Forty-three patients (93%) were satisfied with the results of their distal biceps tendon repair. The average pain score was 1.3 of 10 at a mean 2.1 years after repair. More than 80% of patients had regained their premorbid function in both recreational and occupational activities. The mean Mayo Elbow Performance Score was 93 of 100. Biodex strength testing demonstrated restoration of 92% of low-velocity supination power, 102% of high-velocity supination power, and 104% endurance compared with the contralateral limb. There was no statistically significant difference in postoperative strength between the transosseous suture and endobutton groups. There were 3 complications in this series, 1 case of heterotopic ossification and 2 cases of injury to the lateral cutaneous nerve of the forearm. Conclusion: In this large cohort of 2-incision distal biceps repairs, we found a high degree of patient satisfaction and a low complication rate. We did not find any difference in clinical outcome with regard to subjective patient rating, pain, range of motion, or supination strength when comparing the 2-incision endobutton and transosseous suture fixation techniques. Level of evidence: Level III, Retrospective Cohort, Treatment Study. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Distal biceps repair; endobutton; two-incision; Biodex
Ethics approval was provided by the Northern X Regional Ethics Committee, Ministry of Health NZ: No. NTX/12/EXP/041. Funding was provided by the Wishbone Trust, Wellington, New Zealand. *Reprint requests: James A. F. Recordon, MBCHB, Orthopaedics, North Shore Hospital, Waitemata District Health Board, Private Bag 93503, Takapuna, Auckland 9, New Zealand. E-mail address: [email protected] (J.A.F. Recordon).
The biceps brachii muscle spans the glenohumeral and elbow joints. Its primary function is supination of the forearm while being a secondary flexor of the elbow. This 2-headed muscle takes origin from the coracoid process and the supraglenoid tubercle of the scapula and inserts on the posterior aspect of the radial tuberosity at the proximal radius. A North American study reported an
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.12.032
Two-incision distal biceps tendon repairs incidence of distal biceps rupture of 1.2 per 100,000 patient-years.18 Ruptures of the distal biceps usually occur at the tendoosseous junction as a result of a sudden eccentric muscle contraction, such as when catching a heavy object. Patients often describe a ‘‘popping’’ sensation at the time of injury, followed by pain, swelling, and ecchymosis at the antecubital fossa. Clinically, the patient is weak in supination. The hook test has been shown to be both sensitive and specific for distal biceps rupture.16 Ruptures of the distal biceps most commonly occur in the dominant arm. This injury is almost exclusively seen in men, and previous studies have found a peak incidence in the fifth decade of life.7 The etiology of a distal biceps rupture is likely to be multifactorial. Degeneration of the tendon may result from repeated mechanical impingement, and reduced vascularity of the tendon may also play a role.4,21 The proximal part of the distal biceps tendon is supplied by the brachial artery, whereas the insertion is supplied by the posterior interosseous recurrent artery. A relative hypovascular zone exists between these areas, and this may be an important etiologic factor in tendon rupture.21 Smoking has been shown to increase the risk of tendon rupture by 7.5%.18 Operative management is generally recommended in active patients for whom a significant loss of supination power would create a major functional deficit. Previous studies have reported up to a 40% decrease in supination strength, a 79% decrease in supination endurance, and a 30% decrease in both elbow flexion strength and endurance after a distal biceps tendon rupture.2 Studies consistently show superior functional outcomes when surgical treatment is compared with nonoperative management.5,9,14,22 A meta-analysis of 174 patients showed that 90% achieved good or excellent results after surgical reattachment at 3 years.17 There are various methods of tendon repair, with singleincision, 2-incision, and endoscopic techniques described. Each approach may employ a variety of fixation techniques. A number of publications have recently detailed the anatomy of the distal biceps insertion. Cadaver and magnetic resonance imaging studies have shown that the orientation of the bicipital tuberosity is highly variable, ranging from 15 to 120 posteriorly.6 The footprint of the biceps brachii insertion is on the far posterior-ulnar side of the bicipital tuberosity. The location of this insertion means that the tuberosity acts as a lever arm, increasing the supination torque generated by the muscle.20 In their anatomic study, Hutchinson et al11 described the ideal tendon insertion angle to be just 30 from the coronal plane when in full supination. Hasan et al10 compared anatomic repair on cadavers and showed that on average only 9.7% of the footprint was covered through the anterior 1-incision technique, whereas 73.4% of the footprint was covered by the repair site when a 2-incision technique was used. We use the 2-incision technique as it allows reliable exposure
929 of the posterior aspect of the bicipital tuberosity, enabling a more anatomic repair. There are a wide array of tendon fixation techniques. The transosseous suture technique was previously the standard method of fixation and generally mandated a period of postoperative splinting and gradual assisted range of motion to protect the initial repair. In 2000, Bain et al1 described the use of the endobutton in distal biceps repair, and Greenberg et al8 demonstrated its higher load to failure in biomechanical models. The purpose of this study was to compare the clinical results of a large cohort of patients who underwent distal biceps repair. We aimed to investigate whether the endobutton repair achieves a superior functional outcome compared with the transosseous suture technique.
Materials and methods At our institution between 2002 and 2011, 155 patients underwent a 2-incision distal biceps repair. Four consultant surgeons performed the procedure. Patients were assigned to the first available surgeon. All surgeons used the transosseous technique, but with a change of knowledge from recent literature, the senior author (P.C.P.) changed to the endobutton technique. Seventy-four patients were contactable, and 46 agreed to be in the study. Patients were reviewed at 2 time points. In 2007, 26 patients, all of whom had a transosseous repair, were reviewed in clinic (by S.P.). In 2012, a separate cohort of 20 patients (19 endobutton and 1 transosseous) were reviewed in clinic by authors J.A.F.R. and P.N.M. In total, 46 patients were reviewed in the outpatient clinic. Patients completed a focused questionnaire and a clinical examination. The questionnaire inquired as to subjective weakness with the question, Do you feel that after your injury your affected arm is weaker than your other arm? A satisfaction rating asked the patient about the result of the surgery with the options very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, and very dissatisfied. It also gathered data about occupational and recreational activities and how these were modified. The Mayo Elbow Performance Score was recorded. Elbow range of motion was assessed with a goniometer and reported to the nearest 5 . Anteroposterior and lateral radiographs of the elbow were taken to assess for heterotopic bone formation. Any complications were recorded. Within 1 month of their clinical assessment, the patients attended a sports laboratory (26 in 2007, 20 in 2012), and strength data were collected on a Biodex System 2 Isokinetic Dynamometer (Biodex Medical Systems Inc., Shirley, NY, USA). Low-speed supination (90 /s), and high-speed supination (240 /s) were measured by the following technique. Patients were asked to maximally supinate from full forearm pronation to full supination, eliciting a continuous torque reading through the entire range. The peak value of torque was recorded. The procedure was repeated for the uninjured arm and the torque values were divided, giving a percentage deficit. Endurance was assessed by measuring 30 cycles of continuous pronosupination at maximal effort and comparing the percentage reduction in work done during the firstthird vs. the last-third cycles. Again, this was measured of both the injured and uninjured arms.
930
Figure 1 The ruptured tendon is delivered through a transverse wound just distal to the antecubital fossa. A hand-held retractor is used to avoid damage to the lateral cutaneous nerve of the forearm. Data from the transosseous suture and endobutton groups were compared by multivariate analysis of variance and Student t test. The minimum level of significance was P < .05.
Surgical technique All distal biceps repairs were performed by 4 consultant orthopedic surgeons with a subspecialty interest in shoulder and elbow surgery. In all cases, the surgical approach was the modified 2incision technique as described by the Mayo Clinic.15 The arm was supported on an arm board. The arm was exsanguinated and a high arm tourniquet was insufflated. A small transverse incision was made just distal to the antecubital skin crease. Care was taken with skin retraction to avoid damage to the lateral cutaneous nerve of the forearm (Fig. 1). The distal biceps sheath was identified and incised longitudinally. By digital palpation, the ruptured distal biceps tendon was identified, retrieved, and externalized. The bicipital aponeurosis, if still intact, was released from the medial border of the distal biceps tendon. Two No. 2 FiberWire sutures (Arthrex, Naples, FL, USA) with a noncutting needle were used to suture the ruptured distal biceps end with a tendon-grasping Krackow suture configuration. The 2 pairs of sutures were then cut to different lengths to aid later identification of each suture. The forearm was maximally supinated and the bicipital tuberosity was identified by digital palpation. A large artery forceps was passed distally into the distal biceps sheath, ensuring that it was on the ulna side of the bicipital tuberosity. As the forearm was flexed and maximally pronated, the artery forceps was passed into the proximal posterior forearm. A second posterior skin incision and extensor muscle-splitting approach around this artery forceps exposed the bicipital tuberosity. Two ‘‘baby’’ Hohmann retractors were used on the ulna side of the bicipital tuberosity and a Langenbeck retractor on the radial side to avoid injury to the posterior interosseous nerve. The penetrating artery forceps was then used to retrieve a looped No. 2 Ethibond (Ethicon, Somerville, NJ, USA) relay suture through to the volar aspect of the forearm. Under direct vision, the posterior part of the bicipital tuberosity was then prepared. For the transosseous suture repair, an oval trough was made in the posterior part of the bicipital tuberosity, entering the canal of the radius. On
J.A.F. Recordon et al.
Figure 2 The suture ends are tied over an endobutton through a posterior muscle-splitting incision. the radial side of the bicipital tuberosity, 3 transosseous tunnels were made. For the endobutton fixation, the posterior part of the bicipital tuberosity was roughened with a burr to produce bleeding, with care taken not to reduce the height of the bicipital tuberosity. A small burr was used to make a small tunnel in the center of the prepared posterior bicipital tuberosity. On the radial side, ensuring a good bone bridge of at least 5 mm, the burr was used to complete this single transosseous tunnel. The relay suture was then used to retrieve the distal biceps tendon-grasping sutures through the posterior wound. Ensuring that the distal biceps tendon was correctly oriented, the tendon sutures were used to retrieve the distal biceps tendon into the posterior wound. The tendon sutures were then relayed through the transosseous tunnels. In the case of a transosseous repair, a single suture was passed through the most distal and proximal bone tunnel, while a member of both pairs of tendon sutures were passed through the middle tunnel. The distal biceps tendon was tractioned onto the posterior bicipital tuberosity, and each pair of tendon sutures were securely tied. In the case of the endobutton fixation, both pairs of tendon sutures were passed through the single transosseous tunnel. The distal biceps tendon was similarly tractioned onto the posterior bicipital tuberosity, and the sutures were then securely tied over the endobutton (Fig. 2). Both wounds were copiously lavaged with saline to remove any bone debris and closed in layers. The postoperative management of the 2 groups of patients was different. The elbows that had transosseous repair were placed into an above-elbow plaster of Paris cast with the elbow at a right angle. This treatment was designed to avoid any excessive premature load, which may fracture the bone bridges created in the radius. The elbow wounds were checked in clinic at 2 weeks, and the elbow was again splinted in an elbow cast, giving a total immobilization period of 6 weeks. At 6 weeks after surgery, patients were allowed gentle protected mobilization of the elbow and use of the arm for driving and light activities of daily living. Three months after surgery, they were allowed strengthening and unprotected use of the elbow. Elbows that had endobutton fixation had a pressure dressing to minimize postoperative bleeding. The elbow was placed into a sling, and the patients were allowed immediate assisted active gentle mobilization of the elbow. The wounds were checked at 2 weeks. One month after surgery, patients were allowed to use the arm for driving and light activities of daily living. Three months after surgery, they were allowed to commence strengthening activities with unrestricted use of the elbow.
Two-incision distal biceps tendon repairs Table I
Age, injury side, delay to surgery, and time to follow-up
Total Endobutton Transosseous sutures
Table II
No.
Mean age (years)
Dominant limb injury
Average days to surgery (excluding 2 chronic repairs)
Average time to follow-up (months)
46 19 27
49.8 (28-73) 50 P ¼ .729 49.7
26 11 (56%) 15 (58%)
13 18 9.9
24 24 23
P ¼ .55
P ¼ .892
Patient-reported outcomes
Overall, N ¼ 46 Endobutton, n ¼ 19 Transosseous sutures, n ¼ 27 )
931
Pain score
Satisfaction (average score))
Subjective weakness
Made changes to recreational activities
Made changes to occupational activities
Mayo Elbow Performance Score
1.3 1.2 1.4
4.6 4.8 4.4
25 (54%) 10 (53%) 15 (55%)
5 1 4
3 1 2
91 92 90
Scoring: 5, very satisfied; 4, satisfied; 3, neither satisfied nor dissatisfied; 2, dissatisfied; 1, very dissatisfied.
Table III
Range of motion (average, to nearest degree)
Endobutton Transosseous P value
Supination
Pronation
Extension
Flexion
81 82 .36
72 70 .24
3 2 .21
129 125 .11
Results All patients were male, with a mean age of 50 years (range, 3573 years; 25th and 75th quartiles, 44 and 56, respectively). Time to surgery was on average 13 days from injury (1-35 days). Two patients were treated for chronic ruptures and were not included in the analysis of time from injury to surgery. The mean follow-up time was 2.1 years from the time of surgery (6 months-5 years). Just more than half (57%) were injuries to the dominant limb. Univariate analysis demonstrated wellmatched comparison groups (Table I). At a mean of 2.1 years after surgery, 46 patients were reviewed; 43 patients (93%) were either very satisfied or satisfied with their outcome. Four patients made changes to their occupation, 3 moved to more supervisory roles, 1 patient changed his line of work from stonemasonry, 3 patients had discontinued high-impact sports, and 38 patients (82%) reported that they had returned to their premorbid level of function in both recreational and vocational activities. Of those 38 patients, 18 classed their work as strenuous and 20 as moderate. The mean pain score was 1.3 of 10, and the Mayo Elbow Performance Score was 91 (Table II). There was no statistically significant difference in range of motion for the 2 fixation methods (Table III). The most significant flexion contracture was 20 . There was a tendency for pronation to be limited by 10 to 15 compared with the other side.
Overall, average supination strength was 92% (low speed) and 102% (high speed). At low velocity, supination peak torque was reduced to 95% in the endobutton patients and 90% in the transosseous suture group compared with the contralateral limb. This difference was not statistically significant. At high velocity, there was no deficit. Both treatment groups demonstrated greater endurance on the surgical side compared with the unaffected limb, with the endobutton fatiguing 4.5% less than the contralateral limb compared with 3.4% for the transosseous group. There was no appreciable alteration of the data when standardized for arm dominance, using a conversion factor of 8%.23 The strength data are outlined in Table IV and Supplementary Online Table. More than half of the patients reported subjective weakness of the arm compared with before their injury. The rate was similar in each group (Table II). Age, delay to surgery, and time to follow-up were examined with multivariate regression analysis. None of these variables were found to correlate with a statistically significant difference in outcome scores. Fourteen patients (30%) reported some degree of postoperative lateral forearm paresthesia. Twelve of these patients had complete resolution of their neurapraxia within 2 weeks of surgery. The remaining 2 patients reported that mild symptoms were still present at 1 year. There was no case of injury to the posterior interosseous nerve of the forearm. One patient from the transosseous suture group developed heterotopic ossification (HO) with reduced range of motion, which necessitated surgical debridement. In this case, a range of motion deficit was noted at 5 months postoperatively, and the patient underwent successful debridement without disruption of the repair at 9 months. At the time of this study, the patient had preserved range of motion, with no strength deficit (108% low-speed peak
932 Table IV
J.A.F. Recordon et al. Biodex strength data Low-speed (90 /s) peak torque, affected arm vs. nonaffected arm
Endobutton Transosseous sutures
95% 90%
P ¼ .585
torque, 113% high-speed peak torque) and was satisfied with his result. There were 6 cases of asymptomatic radiologic HO with 3 in each treatment group, demonstrating no significant difference between the 2 techniques. There was 1 case of superficial wound infection, which resolved with oral antibiotics. There were no reruptures at the time of follow-up. Two patients, within the transosseous suture group, were treated for chronic lesions and deserve specific mention. Both were able to be repaired primarily, with a surgical technique identical to that of the acute group. The first patient had a delay of 180 days and the second 270 days. Both patients had neurapraxia of the lateral forearm, the second still persisting at 1 year.
Discussion This study is one of the largest series of distal biceps ruptures to be reported in the literature and was unique in being able to compare 2 different fixation techniques from the same institution. Our findings indicate that repair of the acute distal biceps tendon rupture by the 2-incision approach restored strength and premorbid function and is associated with a low rate of complications. There is yet to be consensus regarding the optimal approach for distal biceps repair. We use the musclesplitting 2-incision technique as it allows direct visualization of the bicipital tuberosity through the posterior incision, consistently enabling repair of the distal biceps tendon to the posterior part of the bicipital tuberosity. Recent studies have elucidated the anatomy of the footprint of the distal biceps tendon insertion and osteology of the bicipital tuberosity. In some cases, the anatomy of the bicipital tuberosity is such that it is difficult to reach the tendon footprint through an anterior approach. A recent study by Schmidt et al19 showed that the supination strength correlated positively to the distal biceps tendon healing on the posterior aspect of the bicipital tuberosity. More than half of the patients in both groups rated their repaired arm as weaker than before surgery. Biodex testing is a more objective assessment of strength but has its limitations. To account for substitution by other muscles, we reported our results of Biodex testing of the repaired arm relative to the contralateral uninjured arm. Even after we standardized for arm dominance, the results of the Biodex
High-speed (240 /s) peak torque, affected arm vs. nonaffected arm 103% 101%
P ¼ .647
Endurance (% reduction in work done, affected arm vs. nonaffected arm) 4.5% 3.4%
P ¼ .562
strength testing were higher than we expected. This may be due to patients having a higher level of motivation when their repaired arm is tested. Injury to the posterior interosseous nerve is a serious potential complication when a second posterior incision is used. Passing through the anterior incision, we ensure that the artery forceps is on the ulna side of the bicipital tuberosity. Exposure of the bicipital tuberosity is performed with the forearm in maximal pronation, and we do not use Hohmann retractors on the radial side of the bicipital tuberosity to avoid undue traction on this nerve. In our study, we had no case of injury to the posterior interosseous nerve. HO is a known complication of distal biceps repair surgery. This can occur with both a single anterior or a 2incision approach. The reported rates of HO in both the 1incision and 2-incision approaches are similar.3,13 Using the muscle-splitting 2-incision approach, we had 7 cases of HO; 1 was symptomatic and required surgical excision. We perform the muscle split sharply with a knife, and we irrigate the posterior wound copiously to remove bone particles. Our rate of HO was similar to that reported in the literature8 and was rarely symptomatic. Schmidt et al19 performed magnetic resonance imaging after singleincision repairs and reported that 8 of 19 patients had heterotopic bone, noting that the ossification occurred within the tendon substance itself. Despite the endobutton repair’s being superior to transosseous sutures in biomechanical models of strength to failure, our study did not show any clinical difference between the 2 fixation techniques. However, the postoperative rehabilitation was different between the 2 modes of fixation. The suture tunnel technique relies on sutures tied over 2 cortical bone bridges between 3 drill holes, which can fracture, leading to failure of the repair.12 In our study, patients with transosseous repairs were therefore splinted postoperatively for 6 weeks to prevent this mode of failure. In contrast, the higher load to failure of the endobutton repair means that we allow those patients to have immediate gentle assisted active elbow mobilization. Despite 6 weeks of postoperative immobilization of elbows with transosseous repair, we did not find any significant difference in postoperative elbow range of motion at the time of review for this study (Table III). The distal biceps repair involves surgery that is extrinsic to the elbow joint, and all patients underwent postoperative rehabilitation, which may be reasons that the elbow ranges of motion were similar at final follow-up. However, an advantage in the postoperative care
Two-incision distal biceps tendon repairs of patients who had an endobutton repair is a lack of splintage and the allowance of immediate albeit gentle mobilization of their elbows. We do not know if elbows that had transosseous repairs can also be safely mobilized immediately after surgery without disrupting the repair. A limitation of this study is that we were able to review only 46 of our series of 155 patients. Nevertheless, we have presented a study of a large number of patients who have undergone objective postoperative strength testing.
Conclusion This review of 46 distal biceps repairs by the 2-incision technique found a high degree of patient satisfaction, the restoration of strength and premorbid function, and a low complication rate. We did not find any difference in clinical outcome with regard to subjective scoring, pain, range of motion, or supination strength between the 2incision endobutton and transosseous suture fixation techniques.
Acknowledgment We wish to acknowledge Mr. C. Ball, Mr. T. Astley, and Mr. P. Mutch for allowing us to include their patients in this study; Mr. S. Pandit (S.P.) for data collection; Lifeng Zhou for statistical assistance; and Auckland University of Technology for laboratory facilities.
Disclaimer The 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.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jse.2014.12.032.
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