REINSERTION OF RUPTURE OF THE DISTAL BICEPS BRACHII TENDON - OUR EXPERIENCE

Summary

OBJECTIVE: T o evaluate the treatment of rupture of the distal biceps brachii tendon in a group of patients treated at the UHO Department of Trauma Surgery. To evaluate the results of the treatment, including the representation of individual complications. It is a retrospective study.

INTRODUCTION: It summarizes the results of treatment of the ruptures of distal biceps brachii tendon using a single-incision approach and reinsertions using fixation anchors.

METHODOLOGY: Retrospective study of a cohort of 69 patients treated with this injury at the Department of Trauma Surgery between 2010 and 2019.

RESULTS: During this period, 69 patients were treated using the studied surgical technique. In the majority of patients, right upper limb injuries were predominant. The predominant mechanism of injury was load lifting. Most of the patients were male. The average surgery time from injury was 1.4 days. All patients were operated using a single-incision approach and a fixation anchor, the most commonly used type of anchor being the Fastin anchor. The average treatment period was 4.13 months. The limitation of elbow joint mobility as a permanent consequence after completion of the treatment was as follows: on average, extension was limited by 3.35 degrees, flexion by 6.58 degrees, forearm supination by 8.53 degrees, and forearm pronation by 7.42 degrees. The average Mayo elbow score was 93.5 degrees. Postoperative complications occurred in 14.5 % of cases, most of them were transient neurological complications and fewer were early infections. In one case there was a release of the fixation anchor.

CONCLUSION: Reinsertion of rupture of the distal biceps brachii tendon by a single-incision approach using fixation anchors appears to be a suitable method of surgical treatment of this injury.

Keywords:

Rupture of the distal biceps brachii tendon – reinsertion – single-incision technique – fixation anchor

INTRODUCTION

Rupture of the distal biceps brachii tendon is a relatively rare injury occurring mainly in men [19]. Its incidence is 1.2/100,000 per year, with an increased risk in smokers [16]. In most cases there is a tear of the distal tendon attachment from the radial tuberosity, usually associated with avulsion of the bicipital aponeurosis. Partial tendon ruptures are also described, mostly on a degenerative basis [3]. The cause is usually a sudden overload of the distal attachment of the biceps brachii muscle during excessive load – lifting heavy loads, holding during a fall, etc. The injury is manifested by sharp pain and often an audible crack. Clinically, a hematoma of the distal arm is obvious at the site of the muscle-tendon transition; mobility is painful but not limited; the distal attaching tendon of the biceps is not palpable. The Hook test for pain and swelling is not always conclusive, although some papers describe its high sensitivity [14]. The diagnosis can be refined by sonographic examination and also by magnetic resonance imaging, especially for obsolete or partial ruptures [13]. Surgical treatment is currently preferred, especially in young and manually working patients. Different types of operations and surgical approaches are described, which can be divided into single-incision and double-incision techniques [12].

AIM OF THE PAPER

To evaluate the clinical results after reinsertion of a severed distal biceps brachii tendon using a single-incision technique. It is a retrospective study.

MATERIAL AND METHOD

We retrospectively evaluated a series of patients after distal biceps brachii tendon rupture who underwent tendon reinsertion to the tuberositas radii using a single-incision technique between 2010 and 2019. As a fixing element we used most often the Fastin anchor, less often the Lupine, G II anchor, all by Mitek (USA). We developed a minimally invasive technique using the anatomical approach to the radial tuberosity. Through an oblique skin incision in the central part of the elbow socket, we penetrate under the anterior muscle fascia of the front portion of the arm, usually finding a hematoma under it, and, after its evacuation, a proximally severed distal biceps brachii tendon (Fig. 1). Palpation detects the original anatomical space for the tendon, and the radial tuberosity between m. brachioradialis and m. pronator teres at its base. Langenbeck hooks are used to dilate this space without dissection of the surrounding neurovascular structures (Fig. 2, 3). Then we perform decortication of the bone tuberosity. We then drill a canal for the fixation anchor monocortically into the prepared bone bed using a 2.5-2.8 mm drill bit and insert the anchor with two threads. After suturing the severed tendon using the slide suture technique, we reinsert the tendon to the bone bed (Fig. 3-8). After surgery, the limb was fixed with a high plaster splint for four weeks with subsequent rehabilitation. Gradual loading was allowed three months after surgery. Patients were followed up at regular intervals of 10, 30, 90 days and one year after the surgery.

From a total of 82 patients, we excluded eight patients from the follow-up due to continuation of the treatment at another institution, five patients due to pathology of the secondary elbow limiting mobility. In a selected cohort of 69 patients, we evaluated the healing time, which was manifested by stabilization of clinical condition without further progression. We also evaluated the type of material used, the side of the injured limb, the clinical condition according to the Mayo Elbow Performance Score, and the limitation of mobility compared to the healthy side.

RESULTS

One year after surgery, we evaluated a series of 69 patients, in this 68 men and one woman. The average age was 42.3 years (ranging from 28 to 68). Right upper limb injuries were predominant (n=42) in the cohort compared to left upper limb injuries (n=27). The predominant mechanism of injury was lifting a load (n=58), followed less frequently by falling (n=5), being struck by an object (n=2), as well as the traction mechanism of one’s limb being caught while skiing (n=1) and bobsledding (n=3). The average time from injury to surgery was 1.4 days (ranging from 0.5 to 14). In most cases, Fastin anchor was used for reinsertion (n=62); the Lupine (n=2) and G II (n=5) anchors were used less frequently. The average time to healing and clinical stabilisation was 4.13 months (ranging from 3 to 12). The limitation of elbow joint mobility as compared to the uninjured limb was as follows: extension was limited on average by 3.35 degrees (ranging from 0 to 20 degrees), flexion by 6.58 degrees (ranging from 0 to 30), forearm supination by 8.53 degrees (ranging from 0 to 20) and forearm pronation by 7.42 degrees (ranging from 0 to 20). The average Mayo Elbow Score was 93.5 degrees (ranging from 50 to 100).

Complications after surgery occurred in 14.5 % of cases (n=10). Of these, we observed damage to the superficial branch of the radial nerve in three cases and damage to the deep branch of the radial nerve in one case. We observed median nerve damage in one case, ulnar nerve damage also in one case. All nerve damage was of a temporary character. Development of infection in the wound was observed in three patients; in all patients, the infection was cured by antibiotic and local therapy. Only one case of fixation anchor dislodgement occurred with subsequent extraction of the anchor in the scarred area without clinical consequences for the patient (Fig. 9).

DISCUSSION

Various surgical methods of this injury are described in the literature. In recent years, the single-incision technique as we perform it at our site has become more popular. Běhounek and a team of authors published a study of the surgical treatment of ruptures of the distal biceps brachii tendon in a group of 19 patients operated with a modified Mac Reynolds method using a screw and washer and a group of 18 patients operated with Mitek GII anchors. All patients were operated on using a single-incision approach. The results show a clear benefit of using the fixation anchors [7]. In their study, Grinac and co-authors compared the surgical treatment of ruptures of the distal biceps brachii tendon using the Boyd and Anderson two-incision method in five patients and the single-incision method in 15 patients. The results of their study show comparable functional results of both surgical techniques, but they clearly prefer the surgical technique using the fixation anchors, due to its simpler technical design [8]. Agins and colleagues describe good results after the Boyd-Anderson double-incision technique, but in a smaller number of 14 patients [1]. A retrospective study conducted by Kelly and the team of authors observed 74 patients after anatomical reinsertion using the Boyd-Anderson two-incision technique. Postoperative complications were observed in 23 patients in 31 %, which is more than in our study [18]. A prospective study of 19 patients compares two-incision and single-incision techniques and demonstrates greater flexion limitation in the two-incision technique as well as greater infectious complications [1]. Complications in a larger percentage of cases (36 versus 14 %) are described in the study of Cain and co-authors, but the time from injury to surgery is significantly longer in their cohort, averaging 72 days versus 1.4 days in our study [5]. In their study, Sotereanos and colleagues evaluate a minimally invasive single-incision technique using a reinsertion anchor with excellent results and minimal complications in a sample of 16 patients, regardless of the timing of the surgery [18]. An interesting study on cadavers shows the high strength of fixation using the interference screw, which is comparable to anatomical insertion, while the two-incision technique with tendon fixation using sutures shows less strength [9]. Good clinical results and minimal mobility limitation in 13 patients after the two-incision reinsertion technique are demonstrated in a study by Cheung and colleagues [10]. Meta-analysis of 72 studies with a total of 3,091 reinsertions showed an overall complication rate of 25 %, which is higher than the one in our study. This analysis includes both single and double-incision techniques [2]. The method of slide sutures using an anchor and a locking screw is described by Sochacki et al. However, this system requires an 8 mm canal to the area of tuberositas radii, in contrast to our method where we drill a 2.5-2.8 mm canal depending on the type of anchor [17]. The use of two anchors and a similar re-insertion technique is used by Cross et al. However, it is necessary to drill two monocortical canals into the tuberositas radii as opposed to our single monocortical canal method [6]. In a comparative study, no differences were found between anchor fixation and the endobutton implant [15]. In our department, we prefer anchor fixation because of concerns about canal enlargement and ossification as seen in other endobutton surgeries (Minar acromioclavicular dislocation solutions or Dog bone implants). We do not consider arthroscopic control of the operation after testing to be beneficial, but sufficient illumination of the working canal is necessary.

CONCLUSION

With sufficient mastery of the minimally invasive singleincision surgical technique, this operation is relatively safe and simple. During dissection, it is necessary to protect the neurovascular structures in the area, which in our procedure is due to minimal dilatation of the original space for the distal tendon of the biceps brachii muscle. The results of this treatment are favourable and most patients do not experience a major deficit in function and limitation of the range of motion in the elbow joint after the injury has healed.

This paper was supported by project No. CZ.02.1.01/0.0 /0.0/17_049/0008441 „Innovative Therapeutic Methods of Musculoskeletal System in Accident Surgery“ within the Operational Programme Research, Development and Education financed by the European Union and by the state budget of the Czech Republic.