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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 162-167

Functional outcome of complete distal biceps tendon repair following noninvasive operative management in the west of Iran


1 Orthopaedy Department, Kermanshah University of Medical Science, Kermanshah, Iran
2 Pathology Department, Iran University of Medical Science, Tehran, Iran
3 Internal Medicine Department, Iran University of Medical Science, Tehran, Iran
4 Premedical School Department, Santa Monica College, California, USA

Date of Web Publication1-Nov-2018

Correspondence Address:
Dr. Matab Rahbar
Iran University of Medical Science, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_22_18

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  Abstract 


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.

Keywords: Distal biceps tendon repair, Iran, outcome, two incisions


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

How to cite this URL:
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 [serial online] 2018 [cited 2022 Jun 27];15:162-7. Available from: https://www.jcsjournal.org/text.asp?2018/15/3/162/244742




  Introduction Top


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 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],[3],[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 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],[7],[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 Top


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 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d,[Figure 1]e,[Figure 1]f. Retrospective data were collected for all patients following institutional review board approval.
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

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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 Top


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 injury to surgery, return to daily activity, and satisfaction range shows significantly better results in the first age groups (<40 years) (P < 0.04), and there was no complication in the first aging group (age <40 years) compared to other aging groups (age ≥40 years) (P < 0.167).
Table 1: Epidemiological data and outcome data on patients with distal injury of the tendon of the biceps brachii muscle

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The mean follow-up period of the patients was 42 ± 25 months (ranging from 19 to 73). The average Mayo Elbow Performance and DASH score were, respectively, 98.6 and 3.8. The elbow flexion range was 42° (98%), the extension was −3°, the supination was 82° (96%), and the pronation was 68° (97%) compared with the uninjured limb. The normal range of motion for uninjured elbow is 0° for an extension, 45° for flexion, 70° for pronation, and also 85° for supination. The mean grip strength, expressed as a percentage of respective contralateral limb, was 91%. The average patient satisfaction rating on a Likert scale (from 0 to 10) was 9.6. The overall incidence of complications was 7.2%, including one case of temporary sensory nerve paresthesias (3.5%) in lateral antebrachial cutaneous and superficial radial nerve and one case of temporary anterior elbow pain (3.5%). There is no evidence of posterior interosseous nerve palsy, heterotopic ossification, superficial infection, and re-rupture of tendon. All patients returned to their previous level of activity and employment in the accepted timetable. However, there are no significant differences between dominant versus nondominant side injury (P < 0.958).

There were no significant differences detected when comparing isokinetic flexion strength or endurance, supination strength or endurance, and range of motion in two velocities of injured hand with uninjured hand (P < 0.02, P < 0.02, and P < 0.04, respectively). Isokinetic strength data and endurance data are depicted graphically in [Figure 2], [Figure 3], [Figure 4], respectively.
Figure 2: Isokinetic strength testing is compared with uninjured hand (SED = supination endurance, FSD = flexion endurance)

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Figure 3: This graph compares the endurance deficit in supination and flexion between injured and uninjured hands at each patient (SED = supination endurance, FSD = flexion endurance)

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Figure 4: A graphic comparison of the range of motion achieved between injured and uninjured hands at each patient (FLX = flexion, EXT = extension, SUP = supination, PRO = pronation)

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There were 93% postoperative complications. Postoperative radiohumeral synostosis was not present in any patient. There is no evidence of heterotopic ossification which is most probably related to using indomethacin after surgery. Complications occurred after surgery are summarized in [Table 2]. Physical examination revealed no statistically significant difference between injured and uninjured hands at each patient with regard to the degree of active or passive elbow range of motion.
Table 2: Complications occurring after surgery

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  Discussions Top


Tears of the biceps tendon at the elbow are uncommon. They are most often caused by a sudden injury and tend to result in greater arm weakness than injuries to the biceps tendon at the shoulder.[13] 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 results from the uncontrolled eccentric load on the bicep tendon; the elbow is forcibly extended at the time of 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. Nonsurgical treatment may be considered if you are older and less active or if the injury occurred in your nondominant arm and you can tolerate not having full arm function. Nonsurgical treatment may also be an option for people who have medical problems that put them at higher risk for complications during surgery.[14] However, for patients with complete tears who continue to experience and want all of their arm strength back, such as athletes or manual laborers, surgery may be the best option. Surgery to reattach the tendon to the bone is necessary to regain full arm strength and function. There are a number of studies reporting success with the use of the double-incision technique for repair of the distal biceps tendon.[15],[16],[17],[18] Furthermore, clinical studies have found little difference between one- and two-incision approaches in terms of complications, re-ruptures, flexion, and supination strength as well as endurance.[1],[5],[10],[19] The double-access route technique was described by Boyd and Anderson[5] in 1961. Although it presents favorable results, it evolves with heterotopic ossification and proximal radioulnar synostosis as complications in some cases. In 1990, Failla et al.[8] reported on four cases of radioulnar synostosis, of which only two recovered movement after the resection. In 1985, Morrey et al.[6] modified this technique by dividing the dorsal musculature and avoiding subperiosteal dissection of the ulna along the interosseous membrane to the radial tuberosity. These modifications led to a diminution of the rates of heterotopic bone formation and synostosis. Over the last few years, several techniques and various fixation methods have been described.[20],[21],[22],[23] However, there is still no consensus regarding the best route and the best technique to use in these cases. We used the double-access technique described by Boyd and Anderson, as modified by Morrey et al.,[6] in 12 cases and did not observe any proximal radioulnar synostosis or heterotopic ossification in our sample. A double-access route surgical treatment on 15 distal biceps tear shows 100% satisfactory results, of which 85.7% were considered to be excellent and 14.3% good. They observed that when distal injuries of the biceps brachii muscle affected young and active patients, surgical treatment was a good option.[24] This study has confirmed that patient-reported clinical function remains very good at 6 years after modified Boyd–Anderson two-incision tenotomy. The modified two-incision approach has demonstrated excellent clinical results with regard to the postoperative range of motion, strength, and endurance.[25] Furthermore, the Morrey modification of the two-incision technique can be safe and provide full functional recovery in patients with ruptured distal biceps tendons. Patients in this study had a lower complication rate compared with previous studies.[15] Heterotopic bone formation is common following distal biceps tendon surgery and has been reported in double-incision repairs. Higher rates of heterotopic ossification have been described in double-incision treatments performed using the Boyd–Anderson method, where the posterior soft tissues are elevated off the ulna to expose the radial tuberosity.[8],[26] In our study, heterotopic bone formation is only in one patient (3.5%). Radioulnar synostosis, although rare, is seen with the Boyd–Anderson method, and the incidence of synostosis has substantially decreased.[27],[28] In our study, there is no evidence of radioulnar synostosis. Our rate of complications (10.5%) appears similar to the 10% of cases that reported in a previous study[10] using the two-incision technique, associated with 6-week prophylaxis with indomethacin 25 mg three times a day for 6 weeks. They did not observe any case of heterotopic ossification which happened in our study using indomethacin prophylaxis after surgery. The major weakness of the study is the small patient numbers. Only 28 eligible patients were operated by one surgeon and were available for review at a minimum of 4 years from surgery. Despite only 28 participants meeting the inclusion criteria and being available for long-term follow-up, no significant deficits were still identified in a range of elbow flexion and forearm supination. Increased study numbers may further.


  Conclusion Top


The modified Boyd–Anderson two-incision technique can be safe and provide full functional recovery in patients with complete ruptured distal biceps tendons, especially for young and active patients. This technique is safe to perform and leads to adequate and full functional restoration of strength with a low complication rate. For further assessment of functional outcomes of this surgery technique, a larger prospective study would be helpful.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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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.  Back to cited text no. 6
    
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Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD. Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique. Report of four cases. Clin Orthop Relat Res 1990;253:133-6.  Back to cited text no. 8
    
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D'Arco P, Sitler M, Kelly J, Moyer R, Marchetto P, Kimura I, et al. Clinical, functional, and radiographic assessments of the conventional and modified boyd-anderson surgical procedures for repair of distal biceps tendon ruptures. Am J Sports Med 1998;26:254-61.  Back to cited text no. 9
    
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Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected]. The upper extremity collaborative group (UECG) Am J Ind Med 1996;29:602-8.  Back to cited text no. 11
    
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Askew LJ, An KN, Morrey BF, Chao EY. Isometric elbow strength in normal individuals. Clin Orthop Relat Res 1987;222:261-6.  Back to cited text no. 12
    
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Behounek J, Hrubina M, Skoták M, Krumpl O, Zahálka M, Dvorák J, et al. Evaluation of surgical repair of distal biceps tendon ruptures. Acta Chir Orthop Traumatol Cech 2009;76:47-53.  Back to cited text no. 14
    
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Anakwenze OA, Kancherla VK, Warrender W, Abboud JA. Outcomes of modified 2-incision technique with use of indomethicin in treatment of distal biceps tendon rupture. Orthopedics 2011;34:e724-9.  Back to cited text no. 15
    
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Pascarelli L, Righi LC, Bongiovanni RR, Imoto RS, Teodoro RL, Ferro HF, et al. Technique and results after distal braquial biceps tendon reparation, through two anterior mini-incisions. Acta Ortop Bras 2013;21:76-9.  Back to cited text no. 16
    
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Amin NH, Volpi A, Lynch TS, Patel RM, Cerynik DL, Schickendantz MS, et al. Complications of distal biceps tendon repair: A meta-analysis of single-incision versus double-incision surgical technique. Orthop J Sports Med 2016;4:2325967116668137.  Back to cited text no. 18
    
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20.
Idler CS, Montgomery WH 3rd, Lindsey DP, Badua PA, Wynne GF, Yerby SA, et al. Distal biceps tendon repair: A biomechanical comparison of intact tendon and 2 repair techniques. Am J Sports Med 2006;34:968-74.  Back to cited text no. 20
    
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Miyazaki AN, Fregoneze M, Santos PD, da Silva LA, do Val Sella G, Duarte DC, et al. Functional evaluation of patients with injury of the distal insertion of the biceps brachii muscle treated surgically. Rev Bras Ortop 2014;49:129-33.  Back to cited text no. 24
    
25.
Cil A, Merten S, Steinmann SP. Immediate active range of motion after modified 2-incision repair in acute distal biceps tendon rupture. Am J Sports Med 2009;37:130-5.  Back to cited text no. 25
    
26.
Katzman BM, Caligiuri DA, Klein DM, Gorup JM. Delayed onset of posterior interosseous nerve palsy after distal biceps tendon repair. J Shoulder Elbow Surg 1997;6:393-5.  Back to cited text no. 26
    
27.
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28.
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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