Functional outcome of complete distal biceps tendon

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ORIGINAL RESEARCH REPORT

Functional outcome of complete distal biceps tendon repair following noninvasive operative management in the west of Iran Keykhosro Mardanpour, Matab Rahbar1, Nyousha Mardanpour2, Sourena Mardanpour3 Orthopaedy Department, Kermanshah University of Medical Science, Kermanshah, 1Pathology Department, 2Internal Medicine Department, Iran University of Medical Science, Tehran, Iran, 3Premedical School Department, Santa Monica College, California, USA

ABSTRACT

Address for correspondence: Dr. Matab Rahbar, Iran University of Medical Science, Tehran, Iran. E‑mail: [email protected]

Background and Objectives: Avulsion of the distal biceps tendon insertion from the radial tuberosity is rare. It is an opportunity for a double‑incision surgical technique for repairing a complete tear of the distal biceps tendon. The aim of this study is to evaluate the double‑incision technique with regard to full functional restoration, complication rate, and safety. Materials and Methods: A retrospective review of consecutive complete biceps tendon repair was performed at one institution over a 6‑year period. Thirty‑two patients met the inclusion criteria and 28 were available for follow‑up which included subjective assessment, physical examination, and strength testing. The mean age of patients was 40 ± 28 years (ranging from 25 to 71 years). Modified two‑incision surgical approach (Boyd and Anderson) was performed for all the patients. Functional outcome after repairs was measured by physical examination, range of motion measurements using a goniometer and radiographic follow‑up, as well as isokinetic tests and Disability of the Arm, Shoulder, and Hand scores. Furthermore, the average patient satisfaction rating on a Likert scale associated with complications was documented. Results: There were no statistically significant differences in regard to flexion strength or endurance and supination strength or endurance between the injured and uninjured arm in each patient. The overall incidence of complications was 7.2%. The average patient satisfaction rating was 9.6. Conclusion: The modified Boyd–Anderson two‑incision produced adequate and full functional restoration of strength with a low complication rate. This technique is safe to perform by a surgeon. Key words: Distal biceps tendon repair, Iran, outcome, two incisions

INTRODUCTION The detachment of the distal biceps tendon completely from the radial tuberosity and retraction toward the shoulder, i.e., proximally, is the most common acute tendinous injury around the elbow.[1] In most cases, tears of the distal biceps tendon are complete. Initially, the diagnosis of complete distal biceps tendon tears can often be established based on patient history and physical examination. Distal biceps tendon ruptures are most common in middle‑aged men and often result from the uncontrolled eccentric load on the bicep tendon; the elbow is forcibly extended at the time of Access this article online

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DOI: 10.4103/jcls.jcls_22_18

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injury while the bicep is actively contracting. Patients may report a painful “pop” at the time of injury. Manual labor, weight training, and use of anabolic steroids are known risk factors.[2‑4] However, nonsurgical treatment is a reasonable option for patients who may not require full arm function. To return arm strength to near‑normal levels, surgery to repair the torn tendon is usually recommended. Surgery to repair the tendon should be performed during the first 2–3 weeks after injury. After this time, the tendon and This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: [email protected]

How to cite this article: Mardanpour K, Rahbar M, Mardanpour N, Mardanpour S. Functional outcome of complete distal biceps tendon repair following noninvasive operative management in the west of Iran. J Clin Sci 2018;15:162-7.

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Mardanpour, et al.: Outcome, distal biceps tendon repair; Iran

biceps muscles begin to scar and shorten, and restoring arm function with surgery may not be possible. There are multiple different procedures to reattach the distal biceps tendon to the forearm bone. There are pros and cons to each approach. The decision between the different techniques is currently guided by surgeon preference and comfort with the approach. Boyd and Anderson[5] reduced this risk by developing a two‑incision approach that exposed the radial tuberosity through a second posterolateral incision with the subperiosteal elevation of the common extensor muscle mass of the ulna. While effective in restoring the function of the biceps, this technique was maybe complicated by postoperative proximal radioulnar synostosis. [6‑8] A modification of the Boyd–Anderson technique was then performed using a muscle‑splitting approach through the common extensor. This modification, combined with an early passive range of motion, has led to favorable results and reduced the risk of synostosis because exposure of the radial tuberosity is easier and safer and leads to a better functional outcome.[1,9] A previous study demonstrated that the two‑incision technique had fewer complications and a slightly more rapid recovery of flexion strength.[10] Based on the experience at our institution, the modified Boyd–Anderson two‑incision technique led to adequate and full functional restoration of strength with a low complication rate including the risk of developing heterotopic ossification.

MATERIALS AND METHODS

For this retrospective study, 28 elbows of 28 patients underwent two‑incision repair of the complete distal biceps tendon tear in the Department of Orthopaedic Surgery and Traumatology, Kermanshah University of Medical Sciences, between May 2010 and March 2016 by one surgeon at our institution. The mean age of patients was 40 ± 28 years (ranging from 25 to 71). All patients had a history of a complete, acute distal biceps tendon rupture that was repaired within 3–4 weeks after injury, while patients with chronic biceps rupture (>4‑week duration), bilateral injuries, and a history of inflammatory chronic disease such as autoimmune disease and finally corticosteroid‑dependent patients were excluded from the study. The repair had to read all repairs entailed reattachment of the tendon to its anatomic insertion using the two‑incision technique employing a bony trough in the tuberosity with anchors and tendon augmentation. Most of the patients were male (26 [93%]), and the dominant arm was affected (25 [90%]). Biceps squeeze and hook tests were performed for diagnosing distal biceps ruptures and confirmed by ultrasonography and magnetic resonance (MR) scanning. For all patients, Boyd–Anderson two‑incision approach was performed[9] [Figure 1a‑f ]. Retrospective data were collected for all patients following institutional review board approval.

Postoperative rehabilitation

Indomethacin administered for 6 weeks after surgery. All patients have been considered elbow immobilization in 90° flexion and neutral forearm rotation for about 10 days using flexion‑assisted brace (Bledsoe, Grand Prairie, TX, USA) and followed by passive flexion and extension to 45° which was advanced to obtain full range of extension and flexion of their forearm during 4–6 weeks. We began active range of motion at 6 weeks and followed by strengthening over the next 6 weeks. All patients completed a simple subjective survey questionnaire which evaluated patient’s satisfaction and functional outcome of their surgery. The patients were asked to compare their ability to return to their preinjury level of function and their daily activities beforehand injury. Functional outcome after repairs was measured by physical examination, range of motion measurements using a goniometer, and radiographic follow‑up as well as isokinetic tests. All measurements were recorded by two orthopedic surgeons. Anteroposterior and lateral radiographs were performed to evaluate possible heterotopic ossification and radioulnar synostosis. Disability of the Arm, Shoulder, and Hand (DASH) scores were obtained on all patients at the final follow‑up. The DASH instrument consists of 30 self‑reported questions that assess the function of the whole upper extremity; the maximum score is 100 and lower scores correspond with better function.[11] Isokinetic strength and endurance tests were performed at two velocities, 60°/s and 180°/s in both supination and flexion. Results were recorded at each speed, and tests were performed bilaterally using the uninjured arm as a control.

Statistical analysis

Descriptive statistics included means and standard deviations for continuous variables and frequencies and percentages for discrete variables. Inferential analysis consisted of the Mann–Whitney U‑test because the outcome variables were not normally distributed. The measurements were normalized using previously reported isometric elbow strength measurements in normal individuals to adjust for natural differences due to dominance versus due to the deficit from the injury and subsequent surgery.[12] A critical P = 0.05 was used for all hypotheses testing. All statistical analysis was done using SPSS version 16.0; SPSS Inc., Chicago, IL, USA.

RESULTS

All biceps tendon ruptures were diagnosed on physical examination and confirmed on MR imaging. Epidemiological data are summarized in Table 1. All patients were high‑functioning, active people. All patients were treated surgically at 4 weeks or less. Treatment data such as the ability to recover, ability to return to activities of daily living, and the time interval until total recovery were noted in age groups [Table 1]. The time between the

JOURNAL OF CLINICAL SCIENCES, VOLUME 15, ISSUE 3, July-September 2018

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Mardanpour, et al.: Outcome, distal biceps tendon repair; Iran

a

b

c

d

e

f

Figure 1: A transverse incision is made in the flexion crease. (a) The distal end of the biceps tendon was debrided back to a healthy tendon edge. (b) Sutures were weaved through it in a Krackow fashion. (c) The forearm is pronated, and the posterolateral muscle‑splitting dissection is executed, exposing the radial tuberosity. The biceps tendon is then passed from the anterior incision through the interosseous membrane to the ulnar side of the forearm. (d and e) Three small drill holes are then made through the cavity, traversing the far cortex of the radius. Sutures tied and the tendon into the radial tuberosity was fixed. (f) The wounds are copiously irrigated and closed in layers. The upper extremity is then immobilized with the elbow in 90° of flexion and the forearm in supination. The mean time of surgery was 25 ± 7.32 min

Table 1: Epidemiological data and outcome data on patients with distal injury of the tendon of the biceps brachii muscle Age groups

Sex n Hand Time DASH Return Mayo Elbow FLX EXT SUP PRO Grip Satisfaction Complication Time of (male/ side between score to daily Performance range range range range strength (mode) (%) follow‑up, female) (right/ injury to (mode) act, (mode) (mode) (mode) (mode) (mode) (mode) months (%) left) (%) surgery, days (%) (%) (%) (%) (mode) days (mode) (mode)

60 5/0 5 5/0 27 3.7 28 97 95 years Mean 24±2.63 3.8±0.12 24±4.12 98.6±1.15 98±1.04 Total 26/2 (93) 28 25/3 (90) numbers

−3°

97

98

93

9/9

0

34

−3°

95

95

91

9/5

1/15 (6.6)

43

−2°

95

95

89

9/5

1/5 (20)

38

−3°

96±2.23 97±1.56 91±3.12

9/7±0.03

42±25 2/28 (7)

DASH=Disability of the Arm, Shoulder, and Hand, FLX=flexion, EXT=extension, SUP=supination, PRO=pronation

injury to surgery, return to daily activity, and satisfaction range shows significantly better results in the first age groups (