RecoveRy ofmuscle strength after late RepaiR of distal biceps brachii tendon

Scandinavian Journal of Surgery 95: 68 72, 2006 RecoveRy ofmuscle strength after late RepaiR of distal biceps brachii tendon J. Ryhänen 1,o.Kaarela 1,p.siira 1,s.Kujala 1,t.Raatikainen 2 1 Department of Surgery, University of Oulu, Oulu, Finland 2 Department of Surgery, University of Helsinki, Helsinki, Finland abstract Background and Aims: Ruptures of the distal part of the biceps brachii tendon are rare. the diagnosis is often delayed and only late repair can be considered. in this study, the recovery of muscle strength after late repair ofthe distal biceps brachii tendon was evaluated. Materials and Methods: sixteen patients with aruptured distal biceps brachii tendon were analysed. the mean delay from the primary trauma to the operation was 35 weeks. thetendon wasanatomically re-attachedwith bone anchors.inthreecases atendon graft was needed. the operated arms were immobilised postoperatively for four weeks, after which mobilisation was allowed. Maximal static flexion and supination strength was measured after an average follow-up time of 12 weeks by using acomputer-based isokinetic dynamometer. Results: patient satisfaction and overall muscle strength recovery were very good. Compared to the non-operated side, average flexion strength recovery was 90% and corresponding recovery of supination strength 78%. Weakness on supination remained in the cases where atendon graft was used. one patient needed are-operation for are-rupture. there were three cases of transient paresthesia of the cutaneous nerve. all patients resumed their previous work. Conclusion: late anatomical repair of the biceps brachii tendon restores very good flexion and moderate supination strength. This operation should always be considered when the primary diagnosis is delayed. Key words: Rupture; tendon injuries; treatment outcome; reconstructive surgical procedures/methods; chronic disease INtRODUCtION Ruptures of the distal part of the biceps brachii tendon arenot common (1). Due to the rarity of the problem, the diagnosis is often delayed (2, 3). the rupture Correspondence: Jorma Ryhänen, M.D. Department of Surgery Oulu University Hospital P.O. Box 21 FIN -90029 OYS, Finland Email: Jorma.Ryhanen@oulu.fi is usually caused by lifting aheavy weight or by a sudden, violent pull on the forearm when the biceps muscle is maximally activated. In most cases, the mobility of the elbow remains normal, but strength in flexion and supination is decreased. Earlier,conservative treatment of distal biceps brachii ruptures was favoured, although it leads to a30 per cent decrease of flexion and a per cent decrease of supination (4, 5). Nowadays, operative treatment at the acute stage is considered the method of choice (2, 4, 5, 6). However, there isstill alack of consensus about the best procedure, as shown by the large number of different surgical techniques described in the

Recovery of muscle strength after late repair of distal biceps brachii tendon 69 literature (7, 8). Most of the discussion is focused on the question of whether to use the two-incision technique (Boyd et Anderson or its modification) (4, 5, 6, 9, 10) or to perform the re-attachment through asingle anterior incision (2, 11). Reported recovery of strength and endurance after surgery varies notably between studies. the factors contributing to final recovery may include the delay between the rupture and surgery, the surgical technique, the availability of physiotherapyand the dominance of the arm. Muscle strength recovery after delayed surgical repair ispoorly reported. this is because of the rarity of these traumas and because most ofthese cases are operated as acute cases. In this study, weevaluated the recovery of flexion and supination strength after anatomical, bone anchor-assisted late repair of aruptured distal biceps tendon. MatERIalS and MEtHODS Fig. 1. Static flexion strength measurement at 90º of flexion. The measurement was done with the patient lying down, to avoid the effect of using body pry.the test was carried out using acomputerbased isokinetic dynamometer. Between November 1992 and November 1997, sixteen patients were operated for acomplete rupture ofthe distal biceps brachii tendon. There were fifteen men and one woman, and their mean age was 41 years (28 to 59 years). the diagnosis was established exclusively by aclinical examination in two cases. It was confirmed by ultrasound in six cases and by magnetic resonance imaging (MRI) in three cases, and five patients underwent both imaging examinations. the ruptures were caused by lifting aheavy object or by asudden, violent pull with the elbow in flexion. Three of the traumas weresport injuries. the diagnosis was delayed as arule. Five of the patients were operated within four weeks after the accident, but the remaining 11 cases were operated 5 weeks after the accident or later.the mean delay from the primary trauma to the operation was 35 weeks (248 days). During the operation, the proximal end of the distal biceps tendon and the biceps muscle were released to make it easier for the tendon to reach its original insertion. the radial tuberosity was exposed with the forearm supinated. the tendon was attached to arongeur-roughened radial tuberosity with two bone anchors (Mitek ). Braided polyester (Ethibond )was used as suture material. tendon transfer was needed in three cases. In one case apalmaris longus (Pl) tendon and in two cases aslip of tensor fascia latae (tfl) were used as grafts. Because the transferred tendon was not vascularized, we preferred to attach it to the radial tuberosity through adrill canal and to suture the proximal side with the Pulvertaft technique. twopatients were operated on with atwo-incision technique, but their tendons were also further attached with bone anchors. all of the operated arms were immobilized postoperatively in long arm casts in supination and 90 degrees of flexion of the elbow for four weeks, after which mobilization was usually encouraged and facilitated by physiotherapy. Passive motion was started immediately, active motion within one week and strengthening exercises after two weeks. Physical and biomechanical testing was carried out a mean of 124 weeks postoperatively (41 to 312 weeks). Biomechanical strength testing was carried out using acomputer-based isokinetic dynamometer (lido Multi- Joint II, loredan Biomedical Inc., West Sacramento, Ca). The maximal static flexion strength of both arms was measured at three angles: at 45º, 90º and 130 degrees of flexion (Fig. 1). Static supination strength was measured at 0º of supination. RESUltS Overall recovery and subjective satisfaction were very good. Slight transitory nerve irritation was noted in three patients. total muscle strength recovery was good, but compared to the non-injured side, average muscle strength was not fully recovered during the follow-up period. the maximal static strength (Nm) of each patient in flexion at different elbow angles (45, 90 and 130 degrees) and in supination compared to the non-operated arm (control) are shown in Fig. 2. Compared to the non-operated side, average strength was 90% in 45º ºflexion (68.0 Nm vs 6. Nm), 90% in 90º ºflexion (65.4 Nm vs 4.1 Nm) and 90 %in 130º ºflexion (38.6 Nm vs 44. Nm). Static supination strength was 8% in the 0º ºposition (8. (8.7 Nm vs 11.1 Nm) compared to the non-operated side. One patient needed two re-operations. First, there was an early re-rupture, which was repaired using atendon graft.

70 J. Ryhänen, O. Kaarela, P. Siira, S. Kujala, T.Raatikainen 120 120 Flexion strength, 45 o (Nm) 100 80 Flexion strength, 90 o (Nm) 100 80 Operatad 70 20 18 16 Flexion strength, 130 o (Nm) 50 30 20 Supination strength (Nm) 14 12 10 8 6 4 2 0 Fig. 2. Maximal static strength (Nm) of each patient in flexion at different elbow angles (45º, 90º and 130 degrees) and in supination compared to the non-operated arm (). the tendon graft was stretched, however, and another operation was needed to shorten the tendon. this patient had the poorest strength recovery compared to thenon-injured arm (55 Nm vs 96 Nm in 45º flexion). the difference between the dominant ornon-dominant arm compared to the non-operated arm was 91% vs 89% in 45º ºflexion, 91% vs 89% in 90º ºflexion, 96% vs 83% in 130º ºflexion and 4% vs 82% in supination strength. When agraft was used, flexion was 83%, % and 85% weaker at angles of 45º,,90º ºand 130 degrees, respectively, compared to the non-operated extremity. When grafts were used, supination strength decreased by as much as 54%. all patients resumed their previous work after recovery. the average duration of sick-leave was 10.5 weeks (3 weeks to 41 weeks). All patients had full ROM at the last postoperative control visit. DISCUSSION Rupture ofthe distal biceps tendon usually occurs when an unexpected extension force is applied to a flexed arm.palpable and visible deformity of the distal biceps muscle belly is usually obvious when there is acomplete rupture. MRI and ultrasound areuseful to differentiate between complete and partial ruptures (12, 13, 14). Early anatomical repair usually yields good restoration of flexion and supination, and it should be the golden standardoftreatment. In general practice, the diagnosis is often delayed and early treatment missed. the reasons for treatment delay with our patients included the missed diagnosis in primary care, but also the long waiting inaconsultation line after that. Some of the patients with insurance might have their ruptures operated quickly in a private sector. also some patients with lighter work

Recovery of muscle strength after late repair of distal biceps brachii tendon 71 may try to manage without operation, but finally are willing to surgery after delay period. Poor results have been reported in these cases (15, 16, 1 ). The fi - nal recovery of strength and endurance varies notably between studies. almost all of postoperative muscle strength studies concentrate on acute cases. after early operation, the ROM and strength in elbow flexion are expected to be restored to normal levels, but deficits in endurance may remain. In pro-supination, limitations of ROM and decreased strength are very common (6, 18). In our study of patients operated late, full ROM was achieved in all cases. the injured arm was 10% weaker in flexion and 22% weaker in supination. This is no worse than in acute repairs. Endurance data werenot analysed. Resumption of normal physical work was reported by all patients, indicating quite good recovery. The factors contributing to final recovery may also include the surgical technique, physiotherapy and the dominance of the arm. Various repair techniques have been used and recommended in theliterature(7, 8, 19, 20). It seems that the anteriorone-incision approachwith bone anchors is widely used (21), but the two-incision (Boyd-anderson) approach has also been used successfully(22, 23, 24). Heterotopic ossification or radio-ulnar synostosis at the proximal radio-ulnar joint has been reported after use of the two-incision technique (18, 25). On the other hand, repair through asingle anterior incision requires more dissection and involves a greater risk of injury to the posterior interosseous nerve (26, 2 ). There were no heterotopic ossification or synostosis problems in our study. Slight transitory nerve irritation was seen in three patients, but there were nodifferences as to whether the one- or twoincision technique was used. there are very few reports on the treatment of chronic distal biceps tendon ruptures using tendon grafts (28, 29). the delay from the trauma to the operation causes the muscle and the distal tendon to retract proximally. Direct surgical re-attachment of the tendon is not easy or may be downright impossible. In these cases, some authors have recommend attachment of the distal biceps tendontothe brachialis muscle (5). However, poor results have been reported, and especially supination strength is not adequately restored (2, 15). We herepreferred re-attachment using atendon graft in three cases where direct fixation was not possible. In two of these cases a TFL graft was used. One patient was grafted in primary operation,but the other was grafted after rerupturing of direct repair. Inthis case the graft was still found to be too loose. After 90 degrees of flexion there was no adequate power. Inthe second operation the graft was abbreviated. At the final control both of the patients repaired using tfl graft showed the poorest strength recovery. When the Pl graft was used, the flexion power recovered very good, while the supination strength was still quite poor. Inthese cases the patients subjective satisfaction did not correlated to strengthrecovery results (table 1). However,strength recovery was clearly poorer compared to the other cases of chronic direct re-attachment. this was especially evident in view of supination strength. table 1 Patient data. Patient Occupation Preoperative Delay to technique Subjective Complication examination surgery satisfaction (days) Strength recovery comparing to healthy arm (%) 90 degrees Supination Flexion 0 1 crane-driver US 0 41 1-i, 2ba 0 75 0 90 good transient n. cutaneus antebrachii irritation 0 2 forest workes US +MRI 341 1-i, 2ba 0 72 0 66 good transient n. cutaneus antebrachii irritation 0 3 teacher none 007 2-i, 2ba 102 100 excellent 0 4 plater MRI 250 1-i, 2ba 0 85 0 85 excellent 0 5 car mechanic none 542 1-i, 2ba 0 70 0 4 satisfactory 0 6 car driver MRI 0 63 1-i, 2ba, tfl 0 54 0 44 satisfactory 1. reoperation with TFL graft, 2. abbreviation of the graft 0 officer US 18 0 1-i, 2ba 0 89 103 good limited pronation 0 8 builder US +MRI 009 2-i, 2ba 101 0 65 excellent 0 9 shopkeeper MRI 24 1-i, 2ba, TFL 0 71 0 68 excellent 10 maintenance man US 0 17 1-i, 2ba 110 0 88 excellent 11 farmer US +MRI 0 63 1-i, 2ba 0 98 0 77 good transient radial nerve irritation 12 maintenance man US 0 25 1-i, 2ba 0 92 0 90 excellent 13 shopkeeper US 170 1-i, 2ba, Pl 105 0 50 excellent 14 baker US 0 31 1-i, 2ba 107 116 excellent 15 baker US +MRi 279 1-i, 2ba 101 0 80 excellent 16 engineer US +MRI 0 19 1-i, 2ba 0 97 0 83 excellent tfl =tensor fascia latae tendon graft, Pl =palmaris longus tendon graft, 1-i =single incision technique, 2-i =two incision technique, ba =bone anchor

72 J. Ryhänen, O. Kaarela, P. Siira, S. Kujala, T.Raatikainen Non-dominant extremities may require aggressive therapy to achieve maximal strength (3). In the study of agins et al., strengthinthe repaired dominant arm was roughly equal to that in the non-injured, nondominantarm, but strength in the repaired non-dominant arm was only 64% of that of the dominant arm (7). according to D alessandro etal., the repaired dominant extremity demonstrated normal strength, while the non-dominant extremity repair showed a supination strengthdeficit of 25% (16). Leighton et al. reported fully restored supination and flexion strength after repair in the dominant extremities. In the non-dominant extremities, marked weakness in supination but also in flexion were reported (3). In our study, there were nosignificant differences as to whether the dominant or the non-dominant arm was affected. Only maximum strength at 130 degrees of flexion showed differences between the dominant and non-dominant extremities compared to the nonoperated side (96% vs. 83%). this dominance-independent recovery was an unexpected observation and might be explained by our good postoperative physiotherapy and control protocol. Rehabilitation of the operated arm is very important, especially when the non-dominant extremity is affected (16). Based onthe present study, late repair of the distal biceps brachii tendon seems to provide very good functional recovery and patient satisfaction even in chronic cases. It is considered areliable method for restoring good flexion and moderate supination strength. If agraft has to be used, the expected outcome will be weaker. REFERENCES 0 1. Kristensen PW: Distal avulsion of the biceps brachii tendon. Injury 1991;22:151 152 0 2. le Huec JC, Moinard M,liquois F, Zipoli B, Chauveaux D, le Rebeller a: Distal rupture ofthe tendon of biceps brachii. Evaluation by MRI and the results of repair. JBone Joint Surg Br 1996;78:767 770 0 3. leighton MM, Bush-Joseph Ca, Bach BRJ: Distal biceps brachii repair.results in dominant and nondominant extremities. Clin Orthop 1995;31 :114 121 0 4. Baker BE, Bierwagen D: Rupture ofthe distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint SurgAm1985;6 :414 41 0 5. Morrey BF, askew lj, an KN, Dobyns JH: Rupture ofthe distal tendon of the biceps brachii. abiomechanical study. J Bone Joint SurgAm1985;6 :418 421 0 6. Davison Bl, Engber WD, tigert lj: long term evaluation of repaired distal biceps brachii tendon ruptures. Clin Orthop 1996;333:186 191 0 7. agins HJ, Chess Jl, Hoekstra DV, teitge Ra: Rupture ofthe distal insertion of the biceps brachii tendon. Clin Orthop1988;234:34 38 0 8. Hegelmaier C, Schramm W, lange P: Die distale Bizepssehnenruptur: therapie und versicherungsrechtliche beurteilung. Unfallchirurg 1992;95:9 16 0 9. Hang DW, Bach BJ, Bojchuk J: Repair of chronic distal biceps brachii tendon rupture using free autogenous semitendinosus tendon. Clin Orthop 1996;323:188 191 10. Vastamäki M, Brummer H, Solonen Ka:avulsionavulsion of the distal biceps brachii tendon. Acta Orthop Scand 1981;52:45 48 11. lintner S, Fischer t: Repair of the distal biceps tendon using suture anchors and an anterior approach. Clin Orthop 1996;322:116 119 12. Falchook FS, Zlatkin MB, Erbacher GE, Moulton JS, Bisset GS, Murphy BJ: Rupture ofthe distal biceps tendon: evaluation with MR imaging. Radiology 1994;190:659 663 13. Miller tt, adler RS: Sonography oftears of the distal biceps tendon. am JRoentgenol 2000;175:1081 1086 14. Weiss C, Mittelmeier M, Gruber G: Do we need MR images for diagnosing tendon ruptures of the distal biceps brachii? the value of ultrasonographic imaging. Ultraschall Med 2000;21:284 286 15. Catonne Y, Delattre O,Pascal-Mousselard H,d Istria FC, Busson J, Rouvillain Jl: les ruptures de l extremite inferieure du biceps brachial. Apropos de 43 cas. Rev Chir Orthop Reparatrice appar Mot 1995;81:163 172 16. D alessandro DF, Shields ClJ, tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. am JSports Med 1993;21:114 119 17. Rantanen J, Orava S: Rupture ofthe distal biceps tendon. a report of 19 patients treated with anatomic reinsertion, and a meta-analysis of 14 cases found in the literature. Am am JSports Med 1999;27:128 132 18. Karunakar Ma, Cha P, Stern PJ: Distal biceps ruptures. afol- low-up of Boyd and anderson repair. Clin Orthop 1999;363:100 107 19. Berlet GC, Johnson Ja, Milne ad, Patterson SD, King GJ: Distal biceps brachii tendon repair. aninvitro biomechanical study of tendon reattachment. Am JSports Med 1988;26:428 432 20. Seitz HD, Riege W: Der distale Bizepssehnenabriss und seine behandlung. Handchirurgie 19 ;9:143 145 21. Brunner F, Gelpke H, Hotz t, Kach K: Distale Bizepssehnenrupturen-erfahrungen mit der weichteilschonenden reinsertion mittels knochenankern. Swiss Surg 1999;5:186 190 22. Bell RH, Wiley WB, Noble JS, Kuczynski DJ: Repair of distal biceps brachii tendon ruptures. J Shoulder Elbow Surg 2000;9:223 226 23. D arco P, Sitler M, Kelly J, Moyer R, Marchetto P, Kimura I, Ryan J: Clinical, functional, and radiographic assessments of the conventional and modified Boyd-Anderson surgical pro- cedures for repair of distal biceps tendon ruptures. am JSports Med 1998;26:254 261 24. Kelly EW, Morrey BF, O Driscoll SW: Complications of repair of the distal biceps tendon with the modified two-incision technique. JBone Joint Surgam2000;82:1575 1581 25. Failla JM, amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture bythe two-incision technique. Report of four cases. Clin Orthop 1990;253:133 136 26. Sotereanos DG, Pierce TD, Varitimidis SE: Asimplified method for repair of distal biceps tendon ruptures. JShoulder Elbow Surg 2000;9:227 233 27. Strauch RJ, Michelson H, Rosenwasser MP: Repair of rupture of the distal tendon of the biceps brachii. Review of the literature and report of three cases treated with asingle anterior incision and suture anchors. am JOrthop 1997;26:151 156 28. Bayat a, Neumann l, Wallace Wa:late repair of simultaneous bilateral distal biceps brachii tendon avulsion with fascia lata graft. Br JSports Med 1999;33:281 283 29. Hovelius l, Josefsson G:Rupture ofthe distal biceps tendon. Report of five cases. Acta Orthop Scand 19 ;48:280 282 Received: September 16, 2005 accepted: November 18, 2005