disposing factors include middle age, anabolic steroid use and body building [10, 55]. No complete distal biceps ten- don ruptures in women have been ...
Knee Surg, Sports Traumatol, Arthrosc (1999) 7 : 125–131
SHOULDER
© Springer-Verlag 1999
Scott A. Lynch David M. Beard Per A. F. H. Renström
Received: 15 April 1998 Accepted: 13 October 1998
S. A. Lynch Department of Orthopaedics, Pennsylvania State University, Hershey Medical Center, Hershey, PA 17033, USA D. M. Beard McClure Musculoskeletal Research Laboratory, Stafford Hall, University of Vermont, Burlington, VT 05405, USA P. A. F. H. Renström (쾷) Sports Medicine Section, Department of Orthopedics, Karolinska Hospital, S-17176 Stockholm, Sweden Tel.: +46-8-517-72720 Fax: +46-8-333 184
Repair of distal biceps tendon rupture with suture anchors
Abstract We retrospectively evaluated six cases of distal biceps tendon rupture that were treated by a two-incision operative repair using suture anchor attachment to the radial tuberosity for clinical outcome and strength testing. All patients had repair performed by the same surgeon. The average age of the patients, all male, was 43 years (range, 32–57 years). Average time from injury to operative repair was 22 days (range, 9–54 days). Follow-up time averaged 24 months after definitive treatment (range, 11–46 months). At follow-up no patient had limitation of activity and all patients were able to return to their previous employment, although three noted some minor antecubital fossa discomfort. No patient developed a synostosis. Cybex (Medway, Mass.) isokinetic testing revealed elbow flexion strength return for peak
Introduction Distal biceps tendon rupture is an uncommon injury. Dobbie and Gilcreest both reported that distal biceps tendon ruptures represent 3% of all biceps ruptures [12, 20]. Predisposing factors include middle age, anabolic steroid use and body building [10, 55]. No complete distal biceps tendon ruptures in women have been published, and only a few partial ruptures have been described [7, 17, 42]. Postacchini and Puddu have demonstrated degenerative changes both at the injury site and 2–3 cm proximal to it [44]. Their results indicate degenerative changes were present prior to rupture and could have been a predisposing factor for injury.
torque, total work, and average power, of 107%, 103%, and 110% of the uninjured arm, respectively. Elbow flexion endurance was 2% less in the injured arm. Forearm supination strength measured by peak torque, total work, and average power, was 97%, 85%, and 88% of the uninjured arm, respectively. Forearm supination endurance was 10% less in the injured arm. Our results using suture anchor repair are similar to those previously reported in the literature from bone tunnel repair. Based on our data, we believe that a two-incision repair with suture anchor attachment is a safe and effective method for treatment of distal biceps tendon ruptures. Key words Biceps tendon · Suture anchor · Surgical treatment
The most commonly reported mechanism of injury is an eccentric muscle contraction against a heavy load [11, 15, 31, 32, 41]. Most reports have indicated that rupture occurs at or very close to the tendon insertion on the radial tuberosity, with only a few reports of musculotendinous junction injury [4, 14, 16, 36, 37]. Patients usually present with an acute injury with pain and swelling in the antecubital fossa associated with loss of flexion and supination strength [45, 46, 51, 56]. The defect is usually palpable with a prominent biceps muscle belly proximally. Neurologic injury from the biceps tear is uncommon, but Foxworthy reported median nerve compression associated with a partial tear [16].
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Both operative and non-operative treatment has been reported in the literature [25, 26, 48, 50, 52, 53, 57]. Nonoperative treatment has consistently shown poor objective strength measurements, with significant losses of flexion and supination power [2, 6, 22, 23, 28, 29, 30, 39]. Operative repair has yielded better return of strength results but has had a higher complication rate with injury to radial, median and ulnar nerves being reported [6, 10, 12, 18, 24, 33, 38, 39, 43, 47, 49]. Because of the high incidence of nerve damage with operative treatment, some early authors recommended non-operative management [9, 12]. Several operative techniques have been described [21, 27, 35]. The single anterior approach of Henry with anatomic reattachment of the tendon to the tuberosity through bone tunnels has been associated with an increased incidence of nerve injury [6, 12, 18, 38, 43, 49]. This has led some authors to recommend transfer of the tendon to the brachialis tendon and/or coronoid process [12, 25, 38, 44]. This technique can restore flexor power but does not address the supinator weakness [19, 39]. Boyd and Anderson described the two-incision technique with anatomic reattachment through bone tunnels [8]. This lessens the risk of nerve injury and restores supinator function, but it also increases the incidence of radioulnar synostosis [13]. More recently, several studies have reported on the use of suture anchors to anatomically reattach the tendon, but these studies presented limited objective data [3, 34, 54]. An in vitro cadaveric study comparing suture anchors with traditional bone tunnel fixation of the distal biceps questioned the efficacy of suture anchor fixation [5]. Because of the rarity of this injury there have been no large series that provide well controlled groups utilizing different treatments. The purpose of the current paper is to review our experience with treatment of biceps tendon ruptures, and to compare the results of our repairs using Mitek (Mitek Products, Westwood, Mass.) suture anchors with historic literature reports of traditional repairs using bone tunnels. We had six biceps tendon ruptures treated at our institution by one surgeon using Mitek suture anchors for repair. In addition, one patient in the our consecutive series of seven patients, who was treated non-operatively, was included for analysis as a matter of interest. No attempt was made in our study to draw specific conclusions regarding Table 1 Patient demographics
operative versus non-operative treatment from our single non-operative case.
Patients and methods This was a retrospective review of all patients treated for distal biceps tendon rupture between the years of 1991–1995 by a single surgeon (P.R.) at the University of Vermont Department of Orthopaedics and Rehabilitation McClure Musculoskeletal Research Center. This was a consecutive series of patients who sustained distal biceps tendon ruptures. All patients returned for follow-up. Patient charts and radiographs were reviewed and all patients had a follow-up evaluation consisting of a history, physical examination, radiographs, and Cybex isokinetic testing of elbow flexion, and extension, and forearm supination and pronation. Patient demographics are shown in Table 1. Seven males with an average age of 43 years (range, 32–57 years) sustained complete biceps tendon ruptures. Five men were right hand dominant, and three of these injured their dominant biceps tendon. Of the two patients that were left hand dominant, one injured his dominant biceps tendon. This made a total of four dominant and three nondominant injuries, with one of the non-dominant injuries being a non-operatively treated patient. Follow-up time averaged 24 months after definitive treatment (range, 11–46 months). No patient had sustained a previous injury. All injuries occurred with eccentric overloading of the contracting biceps muscle. All patients heard a snap and experienced immediate pain. Not all patients sought immediate treatment, however. On initial physical examination all patients had no palpable distal biceps tendon, a prominent biceps muscle belly, and weakness of elbow flexion and forearm supination. The acute cases also had tenderness in the antecubital fossa. Injury radiographs showed no bony avulsions. Patients were made aware of their diagnosis and treatment options, including operative and non-operative management. The patient chose the final management. Six patients chose operative repair and one patient chose non-operative management. Non-operative management consisted of initial pain control, followed by progressive physical therapy that included flexion and supination strengthening exercises. Return to unrestricted activity was allowed when the patient could tolerate it. Operative management consisted of a two-incision approach as described by Boyd and Anderson. The traditional Boyd and Anderson technique creates bone tunnels in the radial tuberosity to anchor the repaired tendon. Our modification utilized Mitek GII suture anchors to reattach the avulsed biceps tendon instead of the traditional bone tunnels. The GII are titanium suture anchors that have a “memory”. The anchors are designed to be placed just beneath the cortical bone so that the metal fans out underneath the cortical bone to prevent pullout. Pullout strength reported by the manufacturer is 25 lbs. The anchors were inserted according to the manufacturer’s guidelines. We believe the use of suture anchors allowed for a less traumatic dissection. The number of anchors was
Patient
Injury
Age
Time to surgery (days)
Follow-up time (months)
Dominant side
Job type
D.K. P.C. R.E. R.P. S.M. W.B. P.O.
Dominant Dominant Dominant Dominant Nondominant Nondominant Nondominant
57 48 44 39 32 44 40
9 24 14 54 17 13 NA
15 21 46 32 11 18 26
Right Right Right Left Right Left Right
Desk Desk Desk Manual labor Manual labor Manual labor Manual labor
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chosen by the surgeon at the time of repair. Three patients had two suture anchors, and three patients had three suture anchors. Average time from injury to operative repair was 22 days (range, 9– 54 days). Operative patients were initially immobilized until the incision healed and staples were removed at about 7–10 days, at which time the patients began physical therapy. Physical therapy consisted of initial protected range of motion with extension limited to 40°. Unlimited passive and active assisted full flexion were allowed within this range. Range of motion limits were progressively reduced up to 4 weeks, at which time unlimited motion was allowed. Pronation and supination progressed along the same course with initial restrictions limited by pain. Exercises in flexion and supination with 2 lb resistance were also begun at 4 weeks and this gradually increased up to 10–15 lb by week 10. Patients returned to work when the arm was no longer tender and they had a painless, nearly normal range of motion of the elbow and forearm. Follow-up consisted of subjective questioning of outcome based on patient satisfaction, limitations of activities and return to work. Objective evaluation consisted of a physical exam for range of motion, neurovascular changes, and incision site problems. Anteroposterior (AP) and lateral radiographs were also taken of the patient’s elbow to evaluate for suture anchor placement and stability, and to detect synostosis. Cybex isokinetic testing was utilized to assess peak torque, total work, average power, and endurance. Each patient performed bilateral Cybex isokinetic testing at 60° (five repetitions) and 180° (25 repetitions) per second for elbow flexion and extension, and forearm supination and pronation. Peak torque, total work, and average power were chosen from the average values of the total number of repetitions at 60° per second. Peak torque, total work and average power were expressed as a percentage of the uninjured side. Endurance was assessed at 180° per second, and was defined as the percentage of total work from the second half of the repetitions divided by the total work from the first half of the repetitions.
Results At the time of repair all of the operative patients had sustained an avulsion of the distal biceps tendon from the radial tuberosity. There were no intra-operative com-
plications and no difficulties with suture anchor placement. Subjective evaluation revealed that all of the operatively treated patients were pleased with their result, but three of the six patients had some anterior arm and skin discomfort with prolonged activity. None of the patients noted any limitation in his activity level, and all patients had returned to their previous employment (four manual laborers and three desk jobs). The non-operative patient was a construction worker. He noted less strength in the injured extremity and anterior arm tightness with prolonged use. Objective examination revealed four of the six operative patients had some adhesions and/or webbing at the anterior incision site. No patient had a neurovascular deficit. With regard to the operatively treated arms, elbow flexion ranged from 135°–142° with an average of 139°. Elbow extension ranged from full extension to a 10° flexion contracture with an average of 2° of flexion contracture. Forearm supination – pronation arc ranged from 120°–150° with an average of 140°. The non-operatively treated patient had full extension, 140° of flexion, and a supination – pronation arc of 140°. All patients had normal range of motion of the opposite arm. Lateral and AP radiographs revealed that all suture anchors were still in place with no evidence of pullout. Three of six patients had developed small calcifications in the area of the distal biceps tendon insertion. No patient had a synostosis. The results of Cybex isokinetic testing are shown in Tables 2 through 5. The operative patients exhibited good return of flexion and flexion endurance (Table 2). If we consider only the dominantly injured biceps tendons, the measurements improve. Flexion values are 111%, 111%, and 119% for peak torque, total work, and average power, respectively, and the flexion endurance ra-
Table 2 Cybex (Medway, Mass.) isokinetic results for elbow flexion (D dominant injury, ND non-dominant injury, I injured arm, U uninjured arm) Patient
D.K. P.C. R.E. R.P. S.M. W.B. Average P.O.a
Injury
D D D D ND ND ND
a Non-operative
Flexion Peak torque (ft-lbs)
Total work (ft-lbs)
Average power (watts)
Endurance ratio
60°/s
60°/s
60°/s
180°/s
I/U(%) 60°/s
I
U
33 34 32 50 39 29 36.17 52
33 27 31 43 38 31 33.83 59
treatment
100% 126% 103% 116% 103% 94% 107% 88%
I/U (%) 60°/s
I
U
66 57 61 69 67 39 59.83 65
52 51 56 72 65 53 58.17 79
127% 112% 109% 96% 103% 74% 103% 82%
I/U (%) 60°/s
I
U
35 33 32 53 38 24 35.83 53
29 27 31 41 36 32 32.67 65
121% 122% 103% 129% 106% 75% 110% 82%
I
U
92% 79% 84% 86% 81% 70% 82% 122%
84% 77% 96% 84% 87% 73% 84% 79%
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Table 3 Cybex (Medway, Mass.) isokinetic results for forearm supination Patient
D.K. P.C. R.E. R.P. S.M. W.B. Average P.O.a
Injury
D D D D ND ND ND
a Non-operative
Supination Peak torque (ft-lbs)
Total work (ft-lbs)
Average power (watts)
Endurance ratio
60°/s
60°/s
60°/s
180°/s
I/U (%) 60°/s
I
U
4 6 6 8 6 4 5.67 6
6 6 7 5 4 7 5.83 12
67% 100% 86% 160% 150% 57% 97% 50%
I/U (%) 60°/s
I
U
6 10 10 16 7 4 8.83 6
10 10 12 10 7 13 10.33 15
60% 100% 83% 160% 100% 31% 85% 40%
I/U (%) 60°/s
I
U
3 5 5 8 5 2 4.67 3
5 5 5 6 4 7 5.33 11
60% 100% 100% 133% 125% 29% 88% 27%
I
U
75% 88% 72% 89% 83% 52% 77% 78%
124% 96% 86% 74% 43% 95% 86% 66%
treatment
Table 4 Cybex (Medway, Mass.) isokinetic results for elbow extension Patient
D.K. P.C. R.E. R.P. S.M. W.B. Average P.O.a
Injury
D D D D ND ND ND
a Non-operative
Extension Peak torque (ft-lbs)
Total work (ft-lbs)
Average power (watts)
Endurance ratio
60°/s
60°/s
60°/s
180°/s
I/U (%) 60°/s
I
U
25 41 31 49 43 31 36.67 56
29 20 27 46 42 29 32.17 51
86% 205% 115% 107% 102% 107% 114% 110%
I/U (%) 60°/s
I
U
59 80 68 71 75 53 67.67 75
38 33 50 85 72 54 55.33 72
155% 242% 136% 84% 104% 98% 122% 104%
I/U (%) 60°/s
I
U
30 43 35 53 45 34 40.00 61
23 17 28 47 39 33 31.17 59
130% 253% 125% 113% 115% 103% 128% 103%
I
U
88% 88% 92% 91% 95% 85% 90% 103%
100% 105% 127% 97% 91% 85% 101% 78%
treatment
Table 5 Cybex (Medway, Mass.) isokinetic results for forearm pronation Patient
D.K. P.C. R.E. R.P. S.M. W.B. Average P.O.a
Injury
D D D D ND ND ND
a Non-operative
Pronation Peak torque (ft-lbs)
Total work (ft-lbs)
Average power (watts)
Endurance ratio
60°/s
60°/s
60°/s
180°/s
I/U (%) 60°/s
I
U
9 11 9 13 6 8 9.33 4
4 8 5 12 10 8 7.83 15
treatment
225% 138% 180% 108% 60% 100% 119% 27%
I/U (%) 60°/s
I
U
12 16 14 23 7 16 14.67 5
7 12 10 23 14 12 13.00 14
171% 133% 140% 100% 50% 133% 113% 36%
I/U (%) 60°/s
I
U
7 7 7 12 6 6 7.50 2
3 6 4 11 5 6 5.83 8
233% 117% 175% 109% 120% 100% 129% 25%
I
U
98% 74% 83% 78% 66% 68% 78% 54%
114% 106% 93% 69% 98% 71% 92% 47%
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tio for the dominant extremities was equal to the uninjured side. As a group, the operative patients exhibited fairly good return of supination strength, but this was not as good as the flexion strength (Table 3). For the dominantly injured biceps tendons, return of supination strength was better, with values of 103%, 101%, and 98% for peak torque, total work, and average power, respectively. The supination endurance ratio for the dominant extremities was 10% less in the injured arm. We also measured the antagonistic muscle groups for strength and endurance. As a group, the operative patients exhibited extension values that were higher than the uninjured side (Table 4). If we consider only the dominantly injured arms, extension values were even better, with results of 128%, 154%, and 155% for peak torque, total work, and average power, respectively. The extension endurance ratio for the dominant extremities was 17% less in the injured arm. As a group, the operative patients exhibited excellent return of pronation strength (Table 5). For the dominantly injured arms, pronation values were 163%, 136%, and 158% for peak torque, total work, and average power, respectively. The pronation endurance ratio for the dominant extremities was 12% less in the injured arm. The non-operatively treated, non-dominant injured patient had a small flexion deficit still present (Table 2), with very poor supination strength (Table 3). For the antagonistic muscles, the non-operatively treated patient had extension strength similar to the uninjured side (Table 4) and extremely poor pronation strength (Table 5).
Discussion The limitations of this study are evident in its nonrandomized retrospective nature. In addition, our endurance testing protocol could have been better selected, since many of our patients displayed only small amounts of fatigue. However, we believe the data can still be useful when compared to previously published work. Reports on distal biceps tendon injuries with objective strength testing are limited. Morrey et al., in one of the earliest attempts to objectively measure strength deficits, used a customized dynamometer to measure flexion and supinator peak isometric contraction [39]. In four cases of operative repair, flexor and supinator strength were nearly equal to that of the uninjured arm. Baker et al. compared 10 patients with a two-incision repair to three non-operatively treated patients [2]. They tested strength and endurance of elbow flexion and forearm supination using a Cybex isokinetic dynamometer. Comparisons were made to the uninjured arm. As a group, the operatively treated patients had supination strength that was 13% stronger and supination endurance that was
32% greater than the uninjured arm. Flexion strength and flexion endurance in the operative group both showed a 9% increase when compared to the uninjured extremity. Agins et al. used Cybex isokinetic testing on 10 operative repairs performed with the two-incision technique [1]. Only elbow flexion strength was measured. Dominant elbow repairs had strength equal to nondominant normal elbows, and nondominant repairs had a 46% deficit compared to normal dominant elbows. D’Alessandro et al. tested operatively treated two-incision repairs in 10 patients (eight competitive weight lifters or body builders) with the Biodex dynamometer [10]. Strength and endurance of elbow flexion and forearm supination were measured. They found repaired dominant supination strength and endurance to be 105% and 104%, respectively, compared to the uninjured arm. Flexion strength was 96% and flexion endurance was 88% of the uninjured arm. Nondominant elbow repairs had 71% supination strength and 106% endurance compared to the uninjured side. Flexion strength and endurance were 99% and 104%, respectively, compared to the uninjured arm. Leighton et al. reported nine cases, of which six were nondominant injuries [33]. They found return of supination and flexion strength to 105% and 103% of the uninjured arm, respectively, in the dominant extremities. Nondominant repairs showed a 17% supination strength deficit and a 3% supinator endurance deficit compared to the uninvolved arm. Flexor strength showed a 17% strength deficit and an 11% endurance deficit compared to the uninjured arm. Barnes et al. in the only report of objective strength data following suture anchor repair, reported a slight decrease in strength and endurance for both flexion and supination in their four cases [3]. However, one of their cases was assessed after only 4 months following repair, and this may have skewed the results. Our results are similar to those reported in the above studies, though comparison is not directly applicable due to the wide variation in isokinetic testing parameters used. Our study shows a good return of flexion strength as measured by all three parameters of peak torque, total work, and average power. Flexion endurance also shows promising results with a return to within 2% of the uninjured side. As a group, supination strength returned as well, but this was not quite as consistent on an individual basis as flexion strength return. Some patients continued to exhibit some minor strength deficits, and one nondominant repair still had a 43% difference in peak torque and a 71% difference in average power. This is not unlike cases in the previous studies showing some nondominant repairs to have supinator peak torque differences of 44% [10], and 33% [33]. Supination endurance gave similar results to supination strength with the same nondominant repair showing a 43% difference. Some of this can be explained by differences in normal dominant compared to nondominant strength and endurance. Data on normal subjects has
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shown some small variations in side-to-side strength and endurance [2, 10, 33, 39], with strength differences for supination between 3–27% greater on the dominant side and flexion peak torque differences between –5%–15% increase on the dominant side. Motzkin et al. showed that side-to-side differences for flexion endurance were small for the group as a whole, but on an individual basis were as much as 30% different [40]. Based on their data they concluded that the best control was the contralateral arm. Again, comparisons of the studies are difficult due to the wide variety of testing protocols. In evaluating the extension and pronation data, it is interesting to note that in the operative cases the injured side was equal to or much better than the uninjured side. Perhaps results of operative repair are not as good as they seem to appear based on measuring flexion and supination data only. Our non-operative patient gave similar results to those published elsewhere, with a significant supinator strength deficit and a less severe deficit of flexion when compared to the uninjured side [2, 39]. Extension testing on the injured side was also better for the non-operatively treated case. However, pronation side-to-side differences in the non-operative case were extreme, with a 73% deficit in peak torque and a 75% deficit in average power. It is impossible to determine if this has any meaning because there is only one non-operative case. But perhaps evaluation of the antagonistic muscle groups should be carried out.
We believe that operative repair is advisable in active people. However, strength probably does not entirely return to pre-operative levels, and results for nondominant extremities seem to be less optimal. Synostosis has been reported to be a complication of treatment with two-incision repair using bone tunnel fixation [13, 33, 39]. Treatment of synostosis is difficult and expensive and often results in poor patient outcomes. Our study had no synostosis present in any patient. One reason for this may be the smaller amount of dissection that is required for placing suture anchors as opposed to bone tunnels. While there is an increased cost associated with suture anchor use, the potential benefit of reducing the incidence of synostosis may be worth the added expense. In addition, the low complication rate and relative ease of suture anchor placement leads to a reduction in costs due to treatment of potential complications including synostosis and in reduced operative time. One biomechanical study has questioned the efficacy of using suture anchors for repair of distal biceps tendon lesions [5]. Our study shows that repair of distal biceps tendon ruptures using Mitek suture anchors with a two-incision technique is safe and gives clinically objective and functional results similar to bone tunnel fixation. We had no major complications, no suture anchor failures, and no occurrences of synostosis, which has been reported in previous studies on the bone tunnel technique [13, 33, 39].
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