Distal Biceps Tendon Repair: Comparison of Surgical Techniques

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1 Distal Biceps Tendon Repair: Comparison of Surgical Techniques Ron El-Hawary, MD, Joy C. MacDermid, PhD, Kenneth J. Faber, MD, London, Ontario, Canada, Stuart D. Patterson, MB, Winter Haven, FL, Graham J.W. King, MD, London, Ontario, Canada Purpose: Various surgical repair techniques for distal biceps tendon ruptures have been reported, however, the optimal technique is unknown. Methods: Over a 4-year period 19 distal biceps tendon ruptures were repaired: 9 using a single anterior incision and 10 using a modified 2-incision Boyd and Anderson technique. The patients were followed-up prospectively and independently reviewed. Results: Patient-rated elbow evaluation and Short Form-36 (SF-36) scores improved with time independent of surgical technique. At 1 year the 1-incision group regained more flexion (142.8 vs ) than the 2-incision group. There was no difference between groups in supination motion, supination strength, or flexion strength, although recovery of flexion strength was initially more rapid for the 2-incision group. Complications were encountered in 44% of cases treated with a 1-incision technique and in 10% of cases treated with the 2-incision technique; however, most of these were minor transient paresthesias. Conclusions: The differences between the 2 groups were relatively minor with the Morrey 2-incision technique showing a slightly more rapid recovery of flexion strength and fewer complications as compared with the 1-incision technique. (J Hand Surg 2003;28A: Copyright 2003 by the American Society for Surgery of the Hand.) Key words: Elbow, biceps, surgery, comparison, techniques. From the Division of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada; and the Bond Clinic, P.A., Winter Haven, FL. Received for publication January 29, 2002; accepted in revised form February 6, No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Graham J. W. King, MD, Hand and Upper Limb Centre, St. Joseph s Health Care London, 268 Grosvenor St, London, Ontario, Canada N6A 4L6. Copyright 2003 by the American Society for Surgery of the Hand /03/28A $30.00/0 doi: /jhsu Avulsion of the distal biceps tendon is an uncommon clinical entity accounting for 3% of all biceps tendon injuries. 1 4 The injury typically occurs in the dominant upper extremity of middle-aged men when an eccentric load is applied to the flexed elbow. 4 8 Tendon hypovascularity and intrinsic degeneration may be factors contributing to tendon rupture The early literature reported good results after nonsurgical treatment. 11,12 In recent biomechanical studies flexion strength was reduced by 30% and supination strength was reduced by 40% if anatomic reattachment of the tendon was not obtained. 5 The earliest reports of surgical repair were in 1897 by Johnson and 1898 by Acquaviva. 8,13,14 In 1941 a survey of surgeons who had treated 51 cases of distal biceps tendon rupture by using a variety of methods 2 showed good to excellent results regardless of the technique used. Transfer of the distal biceps tendon to the brachialis has been 496 The Journal of Hand Surgery

2 El-Hawary et al / Distal Biceps Tendon Repair 497 Table 1. Surgeon Characteristics Surgeon 1-Incision 2-Incision Total 9 10 advocated but has failed to restore supination strength. 5,15 In 1956 Fischer and Shepanek 16 used a volar Henry approach to reattach the distal biceps tendon to the radial tuberosity. 17 This improved flexion and supination strength, but because of the extensive exposure necessary several cases of radial nerve palsy were reported subsequently. 2,18 20 To limit the amount of exposure needed and to decrease the risk for neurologic injury Boyd and Anderson 21 described a 2-incision approach to access the tuberosity more easily. Unfortunately this resulted in reports of postoperative radioulnar synostosis. 5,6,20,22,23 Morrey et al 5,8 modified this 2-incision technique by using a dorsal muscle-splitting approach that avoided subperiosteal elevation of the ulna in an attempt to reduce the incidence of radioulnar synostosis. By splitting the extensor carpi ulnaris muscle dissection of the supinator is avoided and the risk for posterior interosseous nerve injury is minimized. Excellent strength restoration and a low incidence of complications have been reported with this modified 2-incision approach. 8 More recently fixation of distal biceps tendon avulsions by using suture anchors and a limited anterior incision has been reported. 4,20,24,25 Currently there are no reports in the literature prospectively comparing this technique with Morrey s modification of the 2-incision technique. The purpose of this study was to evaluate prospectively the functional and clinical outcomes of these 2 repair techniques for distal biceps tendon ruptures. Methods Over a 4-year period at a single institution 19 consecutive acute distal biceps tendon ruptures were treated by 3 surgeons (K.F., S.P., G.K.). All patients were men with an average age of 45.7 years (range, y) and the dominant extremity was involved in 12 of 19 cases (Table 1). At the preference of the operating surgeon 9 patients were treated with a 1-incision technique through a limited anterior approach and fixation with 2 suture anchors. The other 10 patients were treated with the modified 2-incision technique. The average time to repair was 13.6 days (range, 4 30 d). Surgical Technique For both techniques patients were placed supine with a sterile tourniquet on the arm. For the 1-incision group a 4-cm transverse incision was made in the antecubital fossa and a radial limb was extended distally approximately 6 cm. The basilic vein and lateral antebrachial cutaneous nerve were identified and protected. The biceps tendon was identified and the degenerative tendon was debrided. The brachioradialis was retracted laterally and the pronator teres was retracted medially. The bicipital tuberosity was roughened. Two suture anchors (Mitek Super G; Mitek Surgical Products Inc., Norwood, MA) loaded with sutures (Number two Ti-Cron sutures; Davis & Geck, St. Louis, MO) were placed 1 cm apart into the tuberosity. A sliding stitch was placed into the distal limb of the biceps tendon, the tendon was pulled onto the tuberosity with the elbow at 60 of flexion, and the sutures were tied. The repair was reinforced with the ends of these sutures by using a Bunnell technique above the sliding suture. The 2-incision technique consisted of a transverse incision in the antecubital crease. The biceps tendon was identified and the distal degenerative tendon was resected. Two sutures (Ti-Cron number 2) were placed into the end of the tendon by using the Bunnell technique. The biceps tuberosity was palpated and a curved forceps was placed into the interosseous space. The forceps was palpated on the dorsal proximal forearm and a second incision was made over it. The tuberosity was exposed with a muscle-splitting technique with the forearm maximally pronated. 8 The ulna was not exposed. A burr was used to evacuate the tuberosity. Three 2.0-mm drill holes were placed 7 to 8 mm apart through the dorsal cortical margin of the tuberosity. The tendon sutures were passed through these holes, 2 in the middle hole and one in each of the proximal and distal holes. With the elbow at 90 flexion and the forearm in supination the biceps tendon was pulled into the radial tuberosity and the sutures were tensioned and tied. The postoperative routine was identical for both treatment groups. The elbow was immobilized in 90 of flexion and full supination. Motion was started on the third postoperative day. This included active elbow extension and passive flexion with the forearm fully supinated as well as active pronation and pas-

3 498 The Journal of Hand Surgery / Vol. 28A No. 3 May 2003 Table 2. Comparison of Preoperative Patient Characteristics Between the 1-Incision and 2-Incision Treatment Groups 1-Incision 2-Incision Mean Range Mean Range n 9 10 Dominant extremity injured 6 6 Workers compensation case 3 0 Age (y) 47 (37 60) 44 (29 60) Timing to surgery (d) 13 (6 22) 15 (4 30) Patient-rated elbow evaluation 48 (19 95) 33 (8 51) Flexion range ( ) 127 ( ) 122 ( ) Extension range ( ) 12 (1 23) 8 (1 13) Supination range ( ) 61 (39 80) 68 (61 86) Pronation range ( ) 81 (69 89) 82 (74 90) Isometric flexion strength (%) 53 (0 100) 56 (48 67) Isometric supination strength (%) 33 (0 73) 33 (13 58) Isokinetic flexion strength (%) 49 (0 157) 62 (33 96) Isokinetic supination strength (%) 46 (0 103) 42 (23 68) No statistically significant differences were observed (p.05). sive supination with the elbow maintained at 90 flexion. A resting splint at 90 with the forearm maintained in supination was worn between exercises for 6 weeks. Extension was permitted to 60 during week one and increased 10 per week until full extension was permitted at 6 weeks. Active motion was permitted after 6 weeks and strengthening was permitted after 3 months. Full activity was resumed after 6 months. Patients received prophylaxis against heterotopic ossification with indomethacin 25 mg 3 times a day and misoprostol 200 mcg twice a day for 6 weeks. Outcomes Standardized patient assessments were performed by an independent research assistant before surgery, and at 3, 6, and 12 months after surgery. Outcome measures included patient rating scales, range of motion, isometric strength, isokinetic strength, and elbow radiograph review. Patient satisfaction assessment included the Short Form-36 (SF-36) health survey (Physical and Mental Component Summary scores) 26 and the Patient Rated Elbow Evaluation (elbow pain and disability). 27 The operating surgeon also completed a history and physical examination at each clinic visit. A computerized goniometer (NK Biotechnical Engineering company, Minneapolis, MN) was used to measure active elbow flexion/extension and forearm pronation/supination. 28 This device uses an electrical potentiometer to quantify joint motion. The system is operated by a footswitch so that angular position of the goniometer arm is read directly into the computer avoiding some test biases. 28 Isometric and isokinetic (75 /sec) elbow flexion/extension and forearm pronation/supination strength was measured (LIDO workset; Loredan Biomedical Incorporated, West Sacramento, CA). 29 Strength measurements were expressed as a percentage of the strength of the unaffected extremity. Statistical Analysis Differences in outcomes over time (before surgery, and 3, 6, and 12 months after surgery) and between treatment groups were measured statistically by using a 2-way ANOVA with repeated measures on one factor (time) in a statistical software package (SPSS 10.0, SPSS Inc., Chicago, IL). Post hoc testing was performed by using Student Newman Keuls tests. Statistical significance was defined as p.05. Results Three surgeons performed 19 acute repairs of avulsed distal biceps tendons (Table 1). Before surgery there were no statistically significant differences between groups for patient age, dominant extremity affected, timing to surgery, Patient Rated Elbow Evaluation score, SF-36 score, or elbow and forearm motion and strength (Table 2). Preoperative elbow radiographs were all normal. Postoperative heterotopic ossification prophylaxis was similar between groups. One patient in each group did not comply with the full 6-week course of indomethicin (p.05). After surgery elbow and forearm strength im-

4 El-Hawary et al / Distal Biceps Tendon Repair 499 Table 3. Range of Motion and Strength Comparison Between the 1-Incision and 2-Incision Groups Before Surgery 3 Mo 6 Mo 12 Mo Flexion ( ) One incision incision * 131 7* Extension ( ) One incision incision Supination ( ) One incision incision Pronation ( ) One incision incision Isometric flexion (%) One incision incision * * Isometric supination (%) One incision incision Isokinetic flexion (%) One incision incision * Isokinetic supination (%) One incision incision Strength represented as percentage of uninjured extremity. Mean SD. *p.05. proved with time regardless of the surgical technique used. Comparison between the 1-incision and 2-incision groups revealed that elbow flexion motion was significantly better in the 1-incision group at 6 and 12 months after surgery: 141 versus 128 and 143 versus 131, respectively (Table 3) (p.05). Isometric elbow flexion strength was significantly better in the 2-incision group at 3 and 6 months after surgery: 81% versus 65% and 106% versus 85%, respectively (Table 3) (p.05). Isokinetic elbow flexion strength was significantly improved at 6 months after surgery in the 2-incision group: 108% versus 81% (Table 3) (p.05). There was no statistically significant difference in flexion strength 1 year after surgery (Table 3) (p.05). There were no statistical differences between the groups supination, pronation, or extension range of motion or strength at the 3, 6, or 12-month examinations (Table 3). The patient-rated elbow evaluation showed no statistically significant differences between the groups at any time despite a trend for the 2-incision group to have a more favorable score before surgery and at 3 and 6 months after surgery. There were no differences between the groups SF-36 scores with mental health and physical health scores returning to normal by 1 year after surgery in both groups. Complications in the 1-incision group included 3 cases of lateral antebrachial cutaneous nerve paresthesia, one flexion contracture, and one case of het- Figure 1. Lateral elbow radiograph showing heterotopic ossification volar to the bicipital tuberosity 1 year after surgery. Note the suture anchors from the 1-incision repair.

5 500 The Journal of Hand Surgery / Vol. 28A No. 3 May 2003 erotopic ossification (Fig. 1). The paresthesias resolved without the need for further intervention. The patient with the flexion contracture had a biceps tendon repair 22 days after his injury. The flexion contracture was treated with physiotherapy and improved to elbow extension of 13 at 6 months and 8 at 1 year after surgery. The patient with heterotopic ossification had a biceps tendon repair 10 days after his injury. After surgery he had been prescribed indomethacin and misoprostol and stated that he was compliant for the first 5 weeks. One year after surgery his motion (134 flexion, 41 supination) was still less than the mean range of motion of the 1-incision group but his strength was well maintained (111% flexion, 79% supination). Because this patient also had a paresthesia of the lateral antebrachial cutaneous nerve the overall complication rate for the 1-incision group was 44% (4 of 9 patients). The sole complication in the 2-incision group was a transient superficial radial nerve paresthesia for a rate of 10%. If the transient nerve paresthesias are excluded the complication rate decreases to 20% for the 1-incision group and 0% for the 2-incision group. Discussion In this nonrandomized prospective study the outcomes of 1- and 2-incision biceps tendon repairs were similar by 1 year. The recovery of strength was slower and the complication rate was higher in the 1-incision group relative to the 2-incision technique. This study presents a relatively credible sample size given the uncommon nature of distal biceps tendon avulsions. The group size has relatively low power for detection of statistical significance for small to moderate clinical effects. Study outcomes have high internal validity owing to the use of standardized prospective patient assessment procedures. Nevertheless the study was not randomized and the possibility that the differences observed might be related to the circumstances of entry into one arm of the study cannot be ruled out. Characteristics of the 19 patients in this study were consistent with the typical patient with a distal biceps tendon rupture: middle-aged men with the dominant extremity injured. 5 7 Before surgical treatment flexion strength was 54% and supination strength was 33% of the unaffected extremity as would be expected given the biceps considerable contribution to flexion and supination strength. Extension and pronation strength were affected minimally with strengths of 81% and 93%, respectively. Range of motion for the 1-incision group, 140 flexion and 64 supination at 1 year, was consistent with previous reports. Barnes et al 24 reported full motion by 7.6 months in a group of 4 men treated with a limited anterior approach and 3 suture anchors (Mitek). 24 By using a similar technique Lintner and Fischer 4 reported full range of motion at an average follow-up of 29 months. Similarly the 2-incision group s flexion and supination motion, 131 and 69 at 1 year, were consistent with previous reports of 5% less flexion and 19% less rotation by 44 months as recorded by Karunakar et al. 30 Because all patients followed the same postoperative physiotherapy routine it is difficult to determine why flexion was better for the patients with the 1-incision technique. A larger randomized trial is needed to investigate this issue further. A small loss of terminal extension was noted in both groups at 1 year, 8 (range, 4 to 12 ) and 7 (range, 3 to 14 ) for the 1- and 2-incision groups, respectively. At 3 and 6 months after surgery flexion strength in the 2-incision group was significantly better than the 1-incision group (p.05). This may be secondary to the anchor barbs slipping and anchor failure within the cancellous bone of the radial tuberosity. Although anchor migration was observed in a recent cadaveric study performed in osteoporotic bone 31 we did not observe any migration of the suture anchors radiographically in this clinical study. In addition the degree of anchor migration is unlikely to account for the deficit in strength. An alternative and more likely explanation may be that with the 1-incision anterior approach it is difficult to reattach the biceps tendon accurately on the radial tuberosity. There is a tendency to place the suture anchors too far radially, which may contribute to postoperative supination weakness. We speculate that the initial strength discrepancy also might be related to the differences in initial repair tension between the 2 groups. The change in resting tension may change the initial strength of the muscle by virtue of the Blix muscletension relationship. One year after surgery flexion strength in both groups approached normal (95% and 97%). Previously reported values in similar studies for the 1-incision technique are a 10% deficit at 7.6 months 24 and for the 2-incision technique are 91% at 2.2 years, 17 normal at 50 months, 7 and normal between 15 months and 6 years. 6 There were no differences between groups in supination strength with the 1-incision group having 81% isometric strength and 91% isokinetic strength. Barnes et al 24 found a 5% deficit in supination

6 El-Hawary et al / Distal Biceps Tendon Repair 501 strength. The 2-incision group had 70% isometric strength and 85% isokinetic strength. D Alessandro et al 7 found similar results with a 25% deficit at 50 months and 48% of patients had residual weakness at 44 months according to Karunakar et al. 30 The complication rate of the 1-incision technique was higher than the 2-incision technique (44% vs 10%). Most of these complications resolved spontaneously over time. We believe the patient with radial sensory nerve paresthesia in the 2-incision group likely developed this complication owing to pressure from a postoperative splint. Paresthesia of the lateral antebrachial cutaneous nerve is a well-known complication of the 1-incision technique 2,18 20 and is likely secondary to the exposure and retraction necessary to expose the biceps tuberosity. The use of a limited anterior incision and suture anchors subsequently has reduced the risk for nerve injury to 5% in one series. 19 In this study 3 patients treated with a limited anterior approach still developed transient paresthesias of this nerve. Heterotopic ossification has been associated previously with the 2-incision technique and thought to be a consequence of subperiosteal exposure of the ulna with the second incision. 5,8 Other causes of heterotopic ossification may include damage to the proximal interosseous membrane, hematoma formation, and bone debris from the use of a burr. 22 The risk for heterotopic ossification and radioulnar synostosis reportedly has been improved with the use of a one anterior incision. 4,24,25 Despite this the one case of heterotopic ossification in this study occurred with the use of a single anterior incision (Fig. 1). This occurred despite prophylaxis with indomethacin. Whether this medication reduces the incidence of heterotopic ossification with distal biceps tendon repair requires further study. The 10% incidence of complications reported in the 2-incision group is much lower than the 35% observed by Karunakar et al. 30 They reported 3 cases of heterotopic ossification, 4 cases of limited forearm rotation, and one lateral antebrachial cutaneous nerve paresthesia. 30 His rate of heterotopic ossification was similar to that previously reported in the literature for the Boyd and Anderson 21 technique. The use of a limited muscle-splitting approach and the avoidance of periosteal elevation off the ulna may have decreased the incidence of this complication. 22,30 Kelly, Morrey, and O Driscoll 19 recently completed a retrospective review of 76 patients treated with the Boyd and Anderson 21 technique and found a complication rate of 24% in those ruptures treated less than 10 days after injury. He reported that the complication rate increased significantly if time to surgery was greater. Our complications did not appear to be related to the timing of the surgical repair because 5 of the 6 complications occurred in patients whose surgery was less than 10 days after rupture. This was not a randomized trial, and this is a potential weakness of this study. The 3 upper-extremity surgeons who performed or supervised all of the repairs had experience with both surgical techniques before this series. One of the surgeons performed a 1-incision repair throughout the study period while the second consistently performed a 2-incision repair. The third surgeon had been using a 1-incision technique only for partial and delayed repairs but switched to the 1-incision technique for the last 4 patients in this series. Our higher complication rate with the 1-incision technique may reflect to some extent his experience with this procedure. In this study the 2-incision technique showed faster recovery of flexion strength and less risk for postoperative complications as compared with one anterior incision. A randomized study with a larger group of patients is required to further define differences between these 2 approaches. The authors would like to thank Carol Fazekas and Jan Smith for their assistance with the collection of data. References 1. Gilcreest EL. Rupture of muscles and tendons. Particularly subcutaneous rupture of the biceps flexor cubiti. JAMA 1925;84: Dobbie RP. Avulsion of the lower biceps brachii tendon. Analysis of fifty-one previously unreported cases. Am J Surg 1941;51: Norman WH. Repair of avulsion of insertion of biceps brachii tendon. Clin Orthop 1985;193: Lintner S, Fischer T. Repair of the distal biceps tendon using suture anchors and an anterior approach. Clin Orthop 1996; 322: Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii. A biomechanical study. 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