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Miniopen incision for distal biceps repair by suture anchors: followup of eighteen patients L. Pangallo 1 A. Valore 1 L. Padovani 1 G. Coratella 1 F. Schena 1 B. Magnan 1 R. Adani 1,2,* Email
[email protected] 1 Department of Hand Surgery and Microsurgery, University Hospital of Verona, Verona, Italy 2 UOC Chirurgia della Mano, Ospedale G.B.Rossi, Azienda Ospedaliera Universitaria Integrata Verona, P.le L.Scuro, 10, Verona, Italy
Abstract Background This clinical trial was done to describe a minisingleincision approach for distal biceps repair using two or three suture anchors. AQ1 AQ2
Patients and methods Twenty patients have undergone surgical repair over the last 10 years. http://eproofing.springer.com/journals/printpage.php?token=ur48Q3LiDovX6hBzBKtCNrmIaoTuxTFOUEHwI5XWvTlsbmit5TNgqxPxF8IPUDcw
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All patients were males with mean age 46.8 (range 35–72), and dominant arm was involved in 70 %. Eighteen patients were evaluated with subjective and objective criteria including patient’s satisfaction, active range of motion (ROM), and maximum isometric strength (in supination and flexion) using Cybex dynamometer. Functional scoring included Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score and Oxford Elbow Score. AQ3
Results Eighty percent of patients were highly satisfied, with excellent results as defined by Mayo and Oxford Elbow score. Compared to contralateral, the active ROM was not affected in flexion and extension, but pronation and supination were decreased by 5°–10° in two cases. One of eighteen showed hypoesthesia of first and second fingers, and one of eighteen showed a symptomatic heterotopic ossification. There were no reruptures.
Conclusions Surgical repair of distal biceps tendon with a minisingleincision as we described provides patient’s satisfaction and very good results with respect to ROM and functional scoring, with a low complication rate.
Keywords Distal biceps repair Single incision Suture anchor Supination strength
Introduction Rupture of the distal biceps tendon is a relatively rare injury. It usually occurs in the dominant arm of male patients between the 30 and 60 years. Safran and Graham [ 1 ] reported an incidence of 1.24 per 100,000 patients per year and suggested that smokers have a 7.5 times greater risk of distal http://eproofing.springer.com/journals/printpage.php?token=ur48Q3LiDovX6hBzBKtCNrmIaoTuxTFOUEHwI5XWvTlsbmit5TNgqxPxF8IPUDcw
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biceps rupture compared with nonsmokers. Anabolic and androgen replacement steroids have been also associated with biceps tendon injury [ 2 ]. The typical mechanism is an extension force against a flexed and supinated forearm. Without surgical repair, a loss of supination (40 %) and flexion (30 %) strength and endurance can be expected. Furthermore, patients can suffer from cramps and intermittent pain in the arm along and discomfort for the esthetic result [ 3 ]. Evidence of poor outcomes with conservative management supports the operative treatment of distal biceps injury [ 4 – 6 ]. The fixation of the distal tendon can be anatomic to the radial tuberosity [ 7 ] or nonanatomic to the brachialis muscles [ 8 ]. Surgical approaches include the Boyd and Anderson’s twoincision technique using transosseous tunnels [ 9 ] and the singleincision approach using Endobutton [ 10 ], interference screw or suture anchors [ 11 , 12 ]. Complications can accompany both approaches. Heterotopic ossification, radioulnar synostosis, posterior interosseous nerve palsy and loss of rotation have been associated more frequently with the doubleincision technique [ 13 , 14 ]. The complication rate decreased significantly with the singleincision approach, but neuropraxia of the lateral cutaneous nerve remains the major risk related to this approach [ 15 , 16 ]. The purpose of this study is to describe a miniinvasive singleincision approach for distal biceps repair using two or three suture anchors and to evaluate subjective and objective outcomes, including an isokinetic power analysis of the arm injured compared with the opposite.
Patients and methods Twenty male patients (46.8 ± 10.4 years) with acute traumatic rupture of distal tendon biceps were treated operatively from 2004 to 2014. The right and dominant arm was involved in 14 of 20 cases (70 %). Nineteen patients were workers at the time of trauma, 40 % were heavy workers, 25 % were sportsmen, and 30 % were work accidents. Mean time to surgery was 5 days (range 1–10 days).
Surgical technique After peripheral regional anesthesia, patients were placed in the supine http://eproofing.springer.com/journals/printpage.php?token=ur48Q3LiDovX6hBzBKtCNrmIaoTuxTFOUEHwI5XWvTlsbmit5TNgqxPxF8IPUDcw
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position with the upper limb lying on an arm table. Under tourniquet induced ischemia, a 4cm skin incision was made over the anterior aspect of the elbow 2 cm distal to the crease, with oblique direction from medial to lateral. Once the antebrachial fascia was incised, the cephalic vein was protected medially and the lateral cutaneous nerve was isolated and retracted laterally. The bicipital aponeurosis was visualized: If the lacertus was found intact, it tethered the biceps tendon preventing its retraction in the antecubital fossa. In most cases, it was found torn and the biceps tendon was proximally retracted (Fig. 1 ). The local hematoma was evacuated, and the supinator muscle was split laterally to protect the deep branch of radial nerve. With maximum forearm supination and 30° of flexion, the bone plane was exposed and two little retractors were placed on the lateral and medial aspect of the radius. Under fluoroscopic guidance, the insertion area of the radial tuberosity was identified and the anterior surface was lightly decorticated. Two or three suture anchors (Minilok Quickanchor plus 2/0 absorbable suture) were then inserted distal to proximal. A modified Krackow stitch configuration was used for the tendon fixation (Fig. 2 ). One strand from the distal anchor passed up and down the lateral edge of the tendon, the biceps tendon stump was guided to the radial tuberosity by pulling the other limb; then, the two sutures were tied each other on bone. Equally, one strand from the second and proximal anchor was passed up and down the medial edge of the tendon, and it was tied on bone to its respective limb (Fig. 2 ). The suture from the third anchor if used was passed through the central aspect of the tendon and it was tied on bone to its respective limb. The periosteum was sutured with PDS 40. The incision was closed by planes, and the skin was sutured by intradermal technique. The arm was splinted at 90° of flexion with neutral rotation for 2 weeks. The wrist is unlocked. A hinged brace was applied for two more weeks allowing total passive flexion movement and limited extension movement from 90° to 60° for 7 days, 60° to 30° for 5 days and 30° to complete extension during last days. The brace was removed at 4 weeks, and a rehabilitation program was started. Weight exercises were not allowed for 2 months. Strength training exercises started at 3 months, with no restrictions from the fourth month forward. Fig. 1 .
http://eproofing.springer.com/journals/printpage.php?token=ur48Q3LiDovX6hBzBKtCNrmIaoTuxTFOUEHwI5XWvTlsbmit5TNgqxPxF8IPUDcw
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Fig. 2 .
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Patients attended the regular followup at 2 weeks, 1 months, 3 months, 6 months and 1 year. Subjective and objective criteria included patient’s satisfaction (1—highly satisfied, 2—satisfied, 3—moderate, 4—unsatisfied and 5—very unsatisfied), active range of motion (ROM) and maximum isometric strength (in forearm supination and flexion) using Cybex dynamometer for the injured and the uninjured upper extremity. Functional http://eproofing.springer.com/journals/printpage.php?token=ur48Q3LiDovX6hBzBKtCNrmIaoTuxTFOUEHwI5XWvTlsbmit5TNgqxPxF8IPUDcw
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scoring included Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand score (DASH) and Oxford Elbow Score (OES). Two patients were lost to followup. Eighteen patients underwent an isometric power analysis comparing the injured versus uninjured upper arm. The isometric peak torque was measured in four elbow flexion positions, in order to evaluate if the torque/angle relationship was totally restored after surgical repair. Statistical analysis was performed using SPSS 16.0 (SPSS, Chicago, IL). The differences, injured versus uninjured isometric peak torque, were analyzed using a twoway (limb X angle) repeated measures ANOVA. Post hoc analysis using Bonferroni correction was then performed to investigate the main effect of limb (2 levels: injured vs. uninjured) and angle (4 levels: 30°, 60°, 90° and 120°). Significance was set at p
