- Email: [email protected]
The Intramedullary Cortical Button Technique for Distal Biceps Tendon Repair
Author’s Accepted Manuscript
image
The intramedullary cortical button technique for distal biceps tendon repair Arne Buchholz, Sebastian Siebenlist
www.elsevier.com/locate/bios
PII: DOI: Reference:
S1060-1872(18)30023-6 https://doi.org/10.1053/j.otsm.2018.02.012 YOTSM50632
To appear in: Operative Techniques in Sports Medicine Cite this article as: Arne Buchholz and Sebastian Siebenlist, The intramedullary cortical button technique for distal biceps tendon repair, Operative Techniques in Sports Medicine,doi:10.1053/j.otsm.2018.02.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The intramedullary cortical button technique for distal biceps tendon repair
Arne Buchholz1, MD, Sebastian Siebenlist2, MD
1 Clinic for Trauma Surgery, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675 Munich, Germany
Corresponding author: [email protected]
2 Department of Orthopaedic Sports Medicine, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675 Munich, Germany
Abstract The cortical button technique enables the surgeon to restore the distal biceps tendon anatomically to the posterior cortex of the radial tuberosity via single incision anterior approach. Providing high fixation strength it allows immediate postoperative rehabilitation and leads to excellent functional results. The button fixation technique requires a small 1-incision anterior approach without invasive exposure of the proximal radius. Nevertheless it runs the risk of iatrogenic posterior interosseous nerve (PIN) injury. The blind deployment of the button on the cortical bone at the dorsal aspect of the radial tuberosity places the PIN at risk. The intramedullary cortical button technique represents a further development of the initial cortical button fixation. The button positioning inside the intramedullary canal enables the repair of the distal
biceps tendon to its anatomic footprint without perforating the posterior cortex and consequently not affecting the PIN.
Introduction Bain et al. introduced in the year 2000 for the first time the Endobutton technique for distal biceps tendon repair [1] and encouraged the controversy discussion on the best fixation method for distal biceps tendon rupture. Biomechanical studies supported the cortical button repair showing improved biomechanics when compared to other fixation methods [2, 3]. Bain et al. shaped a cortical window in the radius and then flipped the button through a drill hole at the posterior cortex with excellent results in 12 patients. The extramedullary deployment of the button on the posterior cortex was performed with the help of a straight needle advanced percutaneously through the posterior forearm. In the same study the authors identified a safety zone to avoid injury of the PIN when drilling the posterior cortex and flipping the button percutaneously. Radial divergence of more than 30 degrees was advised against. The challenging part of the Endobutton technique was to predetermine the length of suture between the button and the biceps. When chosen to long, a gapping between the tendon and bone could compromise the strength and subsequent healing of the tendon. In order to solve this problem Sethi et al. developed the tension slide technique (TST) [4]. With this technique the surgeon is able to draw the tendon against the posterior cortex of the bone socket, which allows for improved contact between tendon and bone. A premeasuring of the suture length between the button and the biceps is not required. Furthermore this technique simplifies the button flipping on the posterior cortex. There is no need for passing a needle percutaneously through the posterior forearm. The biomechanical evaluation of the
tensioning technique showed a minimizing of the gap formation between the biceps tendon and the bone under cyclic loading compared to the existing button technique. However the “classic” Endobutton technique and the TST as well involves the fixation of the button on the cortical bone at the dorsal aspect of the radius and places the posterior interosseous nerve PIN at iatrogenic risk [5]. In several studies, partially high rates of PIN injuries have been reported with cortical button repair via single anterior approach [6-8]. Most of the PIN palsies are transient and resolve during months after surgery; nevertheless, the risk of a permanent nerve injury remains [9]. The intramedullary cortical button technique is an expedient modification of the existing cortical button technique [10]. It enables the repair of the distal biceps tendon to its anatomic footprint through a minimally invasive single anterior approach without perforating the posterior cortex and consequently not affecting the PIN. The biomechanical testing of this technique has shown excellent results with respect to fixation strength and displacement [11, 12]. In the following, the intramedullary cortical button repair is described in detail.
Intramedullary cortical button technique The patient is placed in the supine position with the injured arm on a radiolucent hand table. A tourniquet is not applied because it clasps the biceps muscle and can hinder the mobilisation of a retracted tendon. After marking the radial tuberosity on the skin under fluoroscopic control, a 5 cm longitudinal incision is performed from the distal end of the tuberosity to the antecubital flexion crease. Then the lateral antebrachial cutaneous nerve is located in the subcutaneous tissue and carefully protected (Fig. 1). The biceps muscle is carefully mobilized with blunt dissection and the retracted distal tendon stump is identified. Then the radial tuberosity is exposed with careful dissection between the brachioradialis muscle laterally and the pronator
teres muscle medially. Venous vessels and the radial recurrent vessels deep in the wound are preserved if possible; otherwise, they are ligated or cauterized enough to visualize the biceps tuberosity. The biceps tuberosity is cleared of soft tissue and roughened to provide optimal condition for tendon to bone healing. Then two 2.0 mm K-wires are primary advanced at the radial tuberosity at an angle of 60° into the anterior cortex (inclined toward the radial head) to determine the optimal positioning of the BicepsbuttonsTM (Arthrex, Naples, FL, USA) (Fig. 2). The biomechanical in vitro validation of this fixation technique has shown the mean intramedullary vertical diameter to be too small to flip the BicepsbuttonTM (12 mm in length) inside of the medullary cavity of the radial tuberosity when drilling perpendicular to the radial shaft [11]. To optimize anatomic placement of the K-wires, the forearm needs to be fully supinated. The proximal K-wire is positioned to the proximal beginning of the tuberosity ridge. Furthermore, to prevent the buttons from interfering with each other inside the medullary canal, a minimum of 12 mm distance (= length of the BicepsButton) between both K-wires has to be observed. After ensuring radiologically the correct position, the K-wires are removed and the holes are widened with a 3,2mm drill according to the trajectory of the K-wires. Copious irrigation of the wound to remove bone dust is routinely performed at this point. Next, the both buttons are single loaded with one nonabsorbable suture (No. 2 FibreWire, Arthrex, Naples, FL, USA) and passed through the anterior cortex with a button inserter. Each suture has to be strongly tightened after button flipping, first to test the anchoring of the buttons and second to compress the cancellous bone at the intramedullary canal. Radiological examination is additionally used to visualize the correct position of the buttons. Then, the distal biceps tendon stump is freshened and sutured using continuous ‘‘baseball stitches’’ with one end of both FibreWires. The other suture end of each FibreWire is then tightened simultaneously to move the tendon firmly to the
radial tuberosity with the elbow in 20° of flexion and full supination. Both suture ends are tied directly to the surface of the tuberosity. Finally the elbow is taken through a full range of motion to ensure that the tendon is secure. Skin closure is performed in a standard manner.
Postoperative Protocol Immediately after surgery, the patient is placed in a posterior splint in 90° elbow flexion and full forearm supination. At two days postoperatively the splint is removed and a mobile elbow orthosis is applied for 4 weeks with limiting the last 20° of extension. At the same time the patient begins with passive and active (gravityassisted) mobilization under physiotherapist’s supervision. Forearm rotation is not restricted however the patients are encouraged not to supine the forearm actively. After 4 weeks, the patient is instructed to remove the orthosis to perform pain-free active extension and forearm rotation. Unrestricted activities were commenced at 6 weeks postoperatively; resistance exercises 8 weeks after surgery. Sporting activities are allowed after 12 weeks.
Discussion Currently, the ideal method of fixation of the distal biceps tendon is controversially discussed in the literature. For long time the gold standard were bone tunnels. In the meantime, however, numerous new fixation techniques are used. Mazzocca et al. performed a cadaveric biomechanical study comparing the relative strengths of the four most commonly used fixation types; bone tunnels, suture anchors, interference screws and cortical buttons [2]. The cortical button was found to have significantly higher load to failure than the other three techniques, with no significant difference in displacement rates after cyclical loading. The good biomechanical characteristics are
consistent with the good clinical results of the cortical button technique shown in previous published studies [7, 13-15]. However with the increasing clinical practice of this technique, the safety of the PIN was brought into question when deploying the button on the posterior cortex. It may occur via errant guide wire and/or drill placement, incarceration by a cortical button. Cadaveric studies have shown that drilling distally or radially place the PIN at significantly increased risk [16, 17]. The reported incidence of PIN lesions for cortical button repair varies up to 11%. With the intramedullary button implantation the posterior cortex remains intact and PIN injury as an iatrogenic complication is very unlikely. Another potential advantage of the double intramedullary cortical button fixation for distal biceps tendon rupture is the 2-point fixation principle, which allows a wider, more anatomic reconstruction of the native tendon footprint. Anatomic studies described the distal biceps tendon as a double unit consisting of two separated cords with different insertion areas at radial tuberosity [18, 19]. The anterior layer linked to the short head and a posterior layer linked to the long head of the biceps brachii muscle are supposed to maintain independently the dual function of flexion and supination [20, 21]. Basically, the present technique also allows the surgeon to control exactly the tension of each cord. In comparison to the conventional bicortical button technique, which relies on intraosseous fixation of the tendon drawn in the intramedullary canal through a cortical window in the anterior cortex, the intramedullary button technique fixes the tendon on the surface of the bone. Several studies showed that there are no major differences in tendon healing to cortical bone compared with healing in cancellous bone [22, 23]. However, the Intramedullary button technique with only one cortex drilling may reduce the potential risk of radius fracture through the repair site. A
fracture through the proximal radius after distal biceps tendon repair is a theoretical concern and has been reported in the literature occurring after a revision distal biceps repair [24].
Concerning the potential drawbacks, the intramedullary button technique doesn’t differ from the bicortical button techniques. The risks are interrelated with the single anterior approach. A number of cadaveric studies showed that the distal biceps tendon repair to its original anatomic footprint might be extremely challenging through a single anterior approach [25, 26]. The tendon repair tends to be too much anterior, which might lead to supination weakness. An additional posterior approach might improve the anatomic reattachment of the tendon with intramedullary buttons [27], however a clinical randomized trial reported no differences between single- and double incision technique in functional outcomes [28]. Furthermore a recent retrospective study of 784 distal biceps tendon repairs reported a higher rate of PIN heterotopic bone formation and reoperation rate for the double incision technique [29]. The most common complication overall was an injury of the lateral antebrachial cutaneous nerve (LACN), mostly associated with the single incision technique. To sum up, we gained very good experiences with the clinical practise of the intramedullary button technique. It can be performed in a safe efficient, and reliable manner. The clinical results are promising. The intramedullary cortical button provides high patient’s satisfaction and good results with respect to strength and functional outcome. Lesions of the PIN did not occur in any case so far. The exact clinical evaluation of this technique is subject of a current follow-up study.
Figure Legend
Fig. 1: Longitudinal anterior approach with identification of the lateral lateral antebrachial cutaneous nerve (LACN).
Fig. 2: Placing of the K-wires at an angle of 60° to the radial shaft (inclined toward the radial head) and with a minimum distance of 12 mm.
Fig. 3: The two lead sutures (stars) are simultaneously tensioned to deliver the tendon to the radial tuberositiy.
Fig. 4: The reattached distal biceps tendon.
Fig 5: Postoperative radiographic control.
References 1.
Bain, G.I., et al., Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Shoulder Elbow Surg, 2000. 9(2): p. 120-6.
2.
Mazzocca, A.D., et al., Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med, 2007. 35(2): p. 252-8.
3.
Kettler, M., et al., Failure strengths in distal biceps tendon repair. Am J Sports Med, 2007. 35(9): p. 1544-8.
4.
Sethi, P.M. and J.E. Tibone, Distal biceps repair using cortical button fixation. Sports Med Arthrosc, 2008. 16(3): p. 130-5.
5.
Thumm, N., et al., Proximity of the posterior interosseous nerve during cortical button guidewire placement for distal biceps tendon reattachment. J Hand Surg Am, 2015. 40(3): p. 534-6.
6.
Cain, R.A., et al., Complications following distal biceps repair. J Hand Surg Am, 2012. 37(10): p. 2112-7.
7.
Kodde, I.F., M.P. van den Bekerom, and D. Eygendaal, Reconstruction of distal biceps tendon ruptures with a cortical button. Knee Surg Sports Traumatol Arthrosc, 2015. 23(3): p. 919-25.
8.
Banerjee, M., et al., High complication rate following distal biceps refixation with cortical button. Arch Orthop Trauma Surg, 2013. 133(10): p. 1361-6.
9.
Van den Bogaerde, J. and E. Shin, Posterior interosseous nerve incarceration with endobutton repair of distal biceps. Orthopedics, 2015. 38(1): p. e68-71.
10.
Siebenlist, S., et al., The double intramedullary cortical button fixation for distal biceps tendon repair. Knee Surg Sports Traumatol Arthrosc, 2011. 19(11): p. 1925-9.
11.
Siebenlist, S., et al., Biomechanical in vitro validation of intramedullary cortical button fixation for distal biceps tendon repair: a new technique. Am J Sports Med, 2011. 39(8): p. 1762-8.
12.
Siebenlist, S., et al., Double intramedullary cortical button versus suture anchors for distal biceps tendon repair: a biomechanical comparison. Knee Surg Sports Traumatol Arthrosc, 2015. 23(3): p. 926-33.
13.
Greenberg, J.A., et al., EndoButton-assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg, 2003. 12(5): p. 484-90.
14.
Peeters, T., et al., Functional outcome after repair of distal biceps tendon ruptures using the endobutton technique. J Shoulder Elbow Surg, 2009. 18(2): p. 283-7.
15.
Legg, A.J., et al., A comparison of nonoperative vs. Endobutton repair of distal biceps ruptures. J Shoulder Elbow Surg, 2016. 25(3): p. 341-8.
16.
Lo, E.Y., C.S. Li, and J.M. Van den Bogaerde, The effect of drill trajectory on proximity to the posterior interosseous nerve during cortical button distal biceps repair. Arthroscopy, 2011. 27(8): p. 1048-54.
17.
Saldua, N., et al., The effect of drilling angle on posterior interosseous nerve safety during open and endoscopic anterior single-incision repair of the distal biceps tendon. Arthroscopy, 2008. 24(3): p. 305-10.
18.
Mazzocca, A.D., et al., The anatomy of the bicipital tuberosity and distal biceps tendon. J Shoulder Elbow Surg, 2007. 16(1): p. 122-7.
19.
Athwal, G.S., S.P. Steinmann, and D.M. Rispoli, The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am, 2007. 32(8): p. 1225-9.
20.
Eames, M.H., et al., Distal biceps tendon anatomy: a cadaveric study. J Bone Joint Surg Am, 2007. 89(5): p. 1044-9.
21.
Hutchinson, H.L., D. Gloystein, and M. Gillespie, Distal biceps tendon insertion: an anatomic study. J Shoulder Elbow Surg, 2008. 17(2): p. 342-6.
22.
St Pierre, P., et al., Tendon-healing to cortical bone compared with healing to a cancellous trough. A biomechanical and histological evaluation in goats. J Bone Joint Surg Am, 1995. 77(12): p. 1858-66.
23.
Shaieb, M.D., et al., Evaluation of tendon-to-bone reattachment: a rabbit model. Am J Orthop (Belle Mead NJ), 2000. 29(7): p. 537-42.
24.
Badia, A., S.N. Sambandam, and P. Khanchandani, Proximal radial fracture after revision of distal biceps tendon repair: a case report. J Shoulder Elbow Surg, 2007. 16(2): p. e4-6.
25.
Hasan, S.A., et al., Two-incision versus one-incision repair for distal biceps tendon rupture: a cadaveric study. J Shoulder Elbow Surg, 2012. 21(7): p. 935-41.
26.
Forthman, C.L., et al., Cross-sectional anatomy of the bicipital tuberosity and biceps brachii tendon insertion: relevance to anatomic tendon repair. J Shoulder Elbow Surg, 2008. 17(3): p. 522-6.
27.
Schmidt, C.C., C.D. Jarrett, and B.T. Brown, The distal biceps tendon. J Hand Surg Am, 2013. 38(4): p. 811-21; quiz 821.
28.
Grewal, 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(13): p. 1166-74.
29.
Dunphy, T.R., et al., Surgical Treatment of Distal Biceps Tendon Ruptures: An Analysis of Complications in 784 Surgical Repairs. Am J Sports Med, 2017: p. 363546517720200.
30.
Caekebeke, P., et al., Radiological and Clinical Evaluation of the Transosseous Cortical Button Technique in Distal Biceps Tendon Repair. J Hand Surg Am, 2016.
image
The intramedullary cortical button technique for distal biceps tendon repair Arne Buchholz, Sebastian Siebenlist
www.elsevier.com/locate/bios
PII: DOI: Reference:
S1060-1872(18)30023-6 https://doi.org/10.1053/j.otsm.2018.02.012 YOTSM50632
To appear in: Operative Techniques in Sports Medicine Cite this article as: Arne Buchholz and Sebastian Siebenlist, The intramedullary cortical button technique for distal biceps tendon repair, Operative Techniques in Sports Medicine,doi:10.1053/j.otsm.2018.02.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The intramedullary cortical button technique for distal biceps tendon repair
Arne Buchholz1, MD, Sebastian Siebenlist2, MD
1 Clinic for Trauma Surgery, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675 Munich, Germany
Corresponding author: [email protected]
2 Department of Orthopaedic Sports Medicine, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675 Munich, Germany
Abstract The cortical button technique enables the surgeon to restore the distal biceps tendon anatomically to the posterior cortex of the radial tuberosity via single incision anterior approach. Providing high fixation strength it allows immediate postoperative rehabilitation and leads to excellent functional results. The button fixation technique requires a small 1-incision anterior approach without invasive exposure of the proximal radius. Nevertheless it runs the risk of iatrogenic posterior interosseous nerve (PIN) injury. The blind deployment of the button on the cortical bone at the dorsal aspect of the radial tuberosity places the PIN at risk. The intramedullary cortical button technique represents a further development of the initial cortical button fixation. The button positioning inside the intramedullary canal enables the repair of the distal
biceps tendon to its anatomic footprint without perforating the posterior cortex and consequently not affecting the PIN.
Introduction Bain et al. introduced in the year 2000 for the first time the Endobutton technique for distal biceps tendon repair [1] and encouraged the controversy discussion on the best fixation method for distal biceps tendon rupture. Biomechanical studies supported the cortical button repair showing improved biomechanics when compared to other fixation methods [2, 3]. Bain et al. shaped a cortical window in the radius and then flipped the button through a drill hole at the posterior cortex with excellent results in 12 patients. The extramedullary deployment of the button on the posterior cortex was performed with the help of a straight needle advanced percutaneously through the posterior forearm. In the same study the authors identified a safety zone to avoid injury of the PIN when drilling the posterior cortex and flipping the button percutaneously. Radial divergence of more than 30 degrees was advised against. The challenging part of the Endobutton technique was to predetermine the length of suture between the button and the biceps. When chosen to long, a gapping between the tendon and bone could compromise the strength and subsequent healing of the tendon. In order to solve this problem Sethi et al. developed the tension slide technique (TST) [4]. With this technique the surgeon is able to draw the tendon against the posterior cortex of the bone socket, which allows for improved contact between tendon and bone. A premeasuring of the suture length between the button and the biceps is not required. Furthermore this technique simplifies the button flipping on the posterior cortex. There is no need for passing a needle percutaneously through the posterior forearm. The biomechanical evaluation of the
tensioning technique showed a minimizing of the gap formation between the biceps tendon and the bone under cyclic loading compared to the existing button technique. However the “classic” Endobutton technique and the TST as well involves the fixation of the button on the cortical bone at the dorsal aspect of the radius and places the posterior interosseous nerve PIN at iatrogenic risk [5]. In several studies, partially high rates of PIN injuries have been reported with cortical button repair via single anterior approach [6-8]. Most of the PIN palsies are transient and resolve during months after surgery; nevertheless, the risk of a permanent nerve injury remains [9]. The intramedullary cortical button technique is an expedient modification of the existing cortical button technique [10]. It enables the repair of the distal biceps tendon to its anatomic footprint through a minimally invasive single anterior approach without perforating the posterior cortex and consequently not affecting the PIN. The biomechanical testing of this technique has shown excellent results with respect to fixation strength and displacement [11, 12]. In the following, the intramedullary cortical button repair is described in detail.
Intramedullary cortical button technique The patient is placed in the supine position with the injured arm on a radiolucent hand table. A tourniquet is not applied because it clasps the biceps muscle and can hinder the mobilisation of a retracted tendon. After marking the radial tuberosity on the skin under fluoroscopic control, a 5 cm longitudinal incision is performed from the distal end of the tuberosity to the antecubital flexion crease. Then the lateral antebrachial cutaneous nerve is located in the subcutaneous tissue and carefully protected (Fig. 1). The biceps muscle is carefully mobilized with blunt dissection and the retracted distal tendon stump is identified. Then the radial tuberosity is exposed with careful dissection between the brachioradialis muscle laterally and the pronator
teres muscle medially. Venous vessels and the radial recurrent vessels deep in the wound are preserved if possible; otherwise, they are ligated or cauterized enough to visualize the biceps tuberosity. The biceps tuberosity is cleared of soft tissue and roughened to provide optimal condition for tendon to bone healing. Then two 2.0 mm K-wires are primary advanced at the radial tuberosity at an angle of 60° into the anterior cortex (inclined toward the radial head) to determine the optimal positioning of the BicepsbuttonsTM (Arthrex, Naples, FL, USA) (Fig. 2). The biomechanical in vitro validation of this fixation technique has shown the mean intramedullary vertical diameter to be too small to flip the BicepsbuttonTM (12 mm in length) inside of the medullary cavity of the radial tuberosity when drilling perpendicular to the radial shaft [11]. To optimize anatomic placement of the K-wires, the forearm needs to be fully supinated. The proximal K-wire is positioned to the proximal beginning of the tuberosity ridge. Furthermore, to prevent the buttons from interfering with each other inside the medullary canal, a minimum of 12 mm distance (= length of the BicepsButton) between both K-wires has to be observed. After ensuring radiologically the correct position, the K-wires are removed and the holes are widened with a 3,2mm drill according to the trajectory of the K-wires. Copious irrigation of the wound to remove bone dust is routinely performed at this point. Next, the both buttons are single loaded with one nonabsorbable suture (No. 2 FibreWire, Arthrex, Naples, FL, USA) and passed through the anterior cortex with a button inserter. Each suture has to be strongly tightened after button flipping, first to test the anchoring of the buttons and second to compress the cancellous bone at the intramedullary canal. Radiological examination is additionally used to visualize the correct position of the buttons. Then, the distal biceps tendon stump is freshened and sutured using continuous ‘‘baseball stitches’’ with one end of both FibreWires. The other suture end of each FibreWire is then tightened simultaneously to move the tendon firmly to the
radial tuberosity with the elbow in 20° of flexion and full supination. Both suture ends are tied directly to the surface of the tuberosity. Finally the elbow is taken through a full range of motion to ensure that the tendon is secure. Skin closure is performed in a standard manner.
Postoperative Protocol Immediately after surgery, the patient is placed in a posterior splint in 90° elbow flexion and full forearm supination. At two days postoperatively the splint is removed and a mobile elbow orthosis is applied for 4 weeks with limiting the last 20° of extension. At the same time the patient begins with passive and active (gravityassisted) mobilization under physiotherapist’s supervision. Forearm rotation is not restricted however the patients are encouraged not to supine the forearm actively. After 4 weeks, the patient is instructed to remove the orthosis to perform pain-free active extension and forearm rotation. Unrestricted activities were commenced at 6 weeks postoperatively; resistance exercises 8 weeks after surgery. Sporting activities are allowed after 12 weeks.
Discussion Currently, the ideal method of fixation of the distal biceps tendon is controversially discussed in the literature. For long time the gold standard were bone tunnels. In the meantime, however, numerous new fixation techniques are used. Mazzocca et al. performed a cadaveric biomechanical study comparing the relative strengths of the four most commonly used fixation types; bone tunnels, suture anchors, interference screws and cortical buttons [2]. The cortical button was found to have significantly higher load to failure than the other three techniques, with no significant difference in displacement rates after cyclical loading. The good biomechanical characteristics are
consistent with the good clinical results of the cortical button technique shown in previous published studies [7, 13-15]. However with the increasing clinical practice of this technique, the safety of the PIN was brought into question when deploying the button on the posterior cortex. It may occur via errant guide wire and/or drill placement, incarceration by a cortical button. Cadaveric studies have shown that drilling distally or radially place the PIN at significantly increased risk [16, 17]. The reported incidence of PIN lesions for cortical button repair varies up to 11%. With the intramedullary button implantation the posterior cortex remains intact and PIN injury as an iatrogenic complication is very unlikely. Another potential advantage of the double intramedullary cortical button fixation for distal biceps tendon rupture is the 2-point fixation principle, which allows a wider, more anatomic reconstruction of the native tendon footprint. Anatomic studies described the distal biceps tendon as a double unit consisting of two separated cords with different insertion areas at radial tuberosity [18, 19]. The anterior layer linked to the short head and a posterior layer linked to the long head of the biceps brachii muscle are supposed to maintain independently the dual function of flexion and supination [20, 21]. Basically, the present technique also allows the surgeon to control exactly the tension of each cord. In comparison to the conventional bicortical button technique, which relies on intraosseous fixation of the tendon drawn in the intramedullary canal through a cortical window in the anterior cortex, the intramedullary button technique fixes the tendon on the surface of the bone. Several studies showed that there are no major differences in tendon healing to cortical bone compared with healing in cancellous bone [22, 23]. However, the Intramedullary button technique with only one cortex drilling may reduce the potential risk of radius fracture through the repair site. A
fracture through the proximal radius after distal biceps tendon repair is a theoretical concern and has been reported in the literature occurring after a revision distal biceps repair [24].
Concerning the potential drawbacks, the intramedullary button technique doesn’t differ from the bicortical button techniques. The risks are interrelated with the single anterior approach. A number of cadaveric studies showed that the distal biceps tendon repair to its original anatomic footprint might be extremely challenging through a single anterior approach [25, 26]. The tendon repair tends to be too much anterior, which might lead to supination weakness. An additional posterior approach might improve the anatomic reattachment of the tendon with intramedullary buttons [27], however a clinical randomized trial reported no differences between single- and double incision technique in functional outcomes [28]. Furthermore a recent retrospective study of 784 distal biceps tendon repairs reported a higher rate of PIN heterotopic bone formation and reoperation rate for the double incision technique [29]. The most common complication overall was an injury of the lateral antebrachial cutaneous nerve (LACN), mostly associated with the single incision technique. To sum up, we gained very good experiences with the clinical practise of the intramedullary button technique. It can be performed in a safe efficient, and reliable manner. The clinical results are promising. The intramedullary cortical button provides high patient’s satisfaction and good results with respect to strength and functional outcome. Lesions of the PIN did not occur in any case so far. The exact clinical evaluation of this technique is subject of a current follow-up study.
Figure Legend
Fig. 1: Longitudinal anterior approach with identification of the lateral lateral antebrachial cutaneous nerve (LACN).
Fig. 2: Placing of the K-wires at an angle of 60° to the radial shaft (inclined toward the radial head) and with a minimum distance of 12 mm.
Fig. 3: The two lead sutures (stars) are simultaneously tensioned to deliver the tendon to the radial tuberositiy.
Fig. 4: The reattached distal biceps tendon.
Fig 5: Postoperative radiographic control.
References 1.
Bain, G.I., et al., Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Shoulder Elbow Surg, 2000. 9(2): p. 120-6.
2.
Mazzocca, A.D., et al., Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med, 2007. 35(2): p. 252-8.
3.
Kettler, M., et al., Failure strengths in distal biceps tendon repair. Am J Sports Med, 2007. 35(9): p. 1544-8.
4.
Sethi, P.M. and J.E. Tibone, Distal biceps repair using cortical button fixation. Sports Med Arthrosc, 2008. 16(3): p. 130-5.
5.
Thumm, N., et al., Proximity of the posterior interosseous nerve during cortical button guidewire placement for distal biceps tendon reattachment. J Hand Surg Am, 2015. 40(3): p. 534-6.
6.
Cain, R.A., et al., Complications following distal biceps repair. J Hand Surg Am, 2012. 37(10): p. 2112-7.
7.
Kodde, I.F., M.P. van den Bekerom, and D. Eygendaal, Reconstruction of distal biceps tendon ruptures with a cortical button. Knee Surg Sports Traumatol Arthrosc, 2015. 23(3): p. 919-25.
8.
Banerjee, M., et al., High complication rate following distal biceps refixation with cortical button. Arch Orthop Trauma Surg, 2013. 133(10): p. 1361-6.
9.
Van den Bogaerde, J. and E. Shin, Posterior interosseous nerve incarceration with endobutton repair of distal biceps. Orthopedics, 2015. 38(1): p. e68-71.
10.
Siebenlist, S., et al., The double intramedullary cortical button fixation for distal biceps tendon repair. Knee Surg Sports Traumatol Arthrosc, 2011. 19(11): p. 1925-9.
11.
Siebenlist, S., et al., Biomechanical in vitro validation of intramedullary cortical button fixation for distal biceps tendon repair: a new technique. Am J Sports Med, 2011. 39(8): p. 1762-8.
12.
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