Keywords
autografting - elbow - orthopedic procedures - tendon injuries - upper extremity
Introduction
The biceps brachii is the primary supinator and secondary flexor of the forearm.[1] Ruptures of the distal tendon of the biceps brachii are rare injuries, and usually
affect the dominant limb of middle-aged men. The injury typically occurs with an eccentric
contraction with the elbow at 90° of flexion.[2] The clinical condition is characterized by acute pain, edema and local ecchymosis,
associated with an audible click at the moment of the injury, besides the presence
of a proximal gap to the cubital fossa and loss of forearm supination force and elbow
flexion.
Significant loss of bending force and more pronounced loss of supination force are
often associated with chronic ruptures.[2] The main risk factors are: use of anabolic steroids, weight lifting, and smoking.[3] Degenerative tendinopathy and certain endocrine diseases are also implicated in
the appearance of this pathology.[4] The rupture is considered chronic after 4 to 6 weeks of the injury.[1] In these cases, the musculotendinous unit retracts and fibrosis formed, which makes
the repair of the radial tuberosity difficult.[5]
[6]
[7] However, the conservative treatment has shown unsatisfactory results.[8]
Several procedures have been described to treat chronic ruptures of the distal biceps
brachii tendon, including brachial tenodesis and the use of tendon grafting, such
as the long palmar, calcaneus tendon, tensor fasciae lata, and semitendinosus.[4]
[9]
[10] The aim of the present study was to describe the clinical and functional results
of the distal reconstruction of the biceps brachii using central distal triceps graft
by fixating two bioabsorbable anchors in the radial tuberosity in patients with distal
biceps injury for more than four weeks. This technique was recently published by the
authors.
Material and Methods
From February 2015 to February 2017, 7 patients with distal biceps injury for more
than 28 days were submitted to reconstruction of the distal biceps with triceps graft
([Table 1]). All patients were male, with an average age of 45 years (range: 30 to 60 years).
The injury was in the dominant limb in three cases. Three patients reported using
anabolic steroids.
Table 1
|
Patient 1
|
Patient 2
|
Patient 3
|
Patient 4
|
Patient 5
|
Patient 6
|
Patient 7
|
|
Affected limb and dominance
|
Left non-dominant
|
Left dominant
|
Right dominant
|
Left non-dominant
|
Right dominant
|
Left non-dominant
|
Left non-dominant
|
|
Gender and age
|
Male, 47 years
|
Male, 51 years
|
Male, 60 years
|
Male, 57 years
|
Male, 40 years
|
Male, 30 years
|
Male, 32 years
|
|
Injury duration
|
3 months
|
6 weeks
|
6 weeks
|
5 months
|
4 weeks
|
5 months
|
3 months
|
|
Use of anabolic steroids
|
No
|
No
|
No
|
No
|
Yes
|
Yes
|
Yes
|
|
Follow-up
|
18 months
|
36 months
|
24 months
|
24 months
|
12 months
|
12 months
|
12 months
|
|
Force:
operated side
|
Flexion: 22.4 N;
extension: 19.2 N;
eupination: 3.1 N
|
Flexion: 22.4 N;
extension: 18.7 N;
supination: 3.9 N
|
Flexion: 17.3 N;
extension: 13.4 N;
supination: 2.2 N
|
Flexion: 14.3 N;
extension: 13 N;
supination: 1.9 N
|
Flexion: 24.8 N;
extension: 24,8 N;
supination: 3.3 N
|
Flexion: 30.7 N;
extension: 28.4 N;
supination: 4.7 N
|
Flexion: 33.9 N;
extension: 31.9 N;
supination: 4.5 N
|
|
Force:
non-operated side
|
Flexion: 22.6 N;
extension: 20 N;
supination: 3.6 N
|
Flexion: 22.6 N;
extension: 18.8 N;
supination: 4 N
|
Flexion: 18.6 N;
extension: 15.3 N;
supination: 2.5 N
|
Flexion: 21.5 N;
extension: 13.1 N;
supination: 2.5 N
|
Flexion: 26 N;
extension: 25.5 N;
supination: 3.9 N
|
Flexion: 31.6 N;
extension: 29.5 N;
supination: 5.3 N
|
Flexion: 34.8 N;
extension: 32.3 N;
supination: 5.2 N
|
|
Comparison (%)
|
Flexion: 99.1%;
extension: 96%;
supination: 86%
|
Flexion: 99.1%;
extension: 99.4%;
supination: 97.5%
|
Flexion: 93%;
extension: 87.5%;
supination: 88%
|
Flexion: 66.5%;
extension: 99.2%;
supination: 76%
|
Flexion: 95.3%;
extension: 97.2%;
supination: 84.6%
|
Flexion: 97.1%;
extension: 96.2%;
supination: 88.6%
|
Flexion: 97.4%;
extension: 98.7%;
supination: 86.5%
|
|
Flexion:
operated side
|
140°
|
130°
|
130°
|
140°
|
135°
|
135°
|
140°
|
|
Extension:
operated side
|
5°
|
0°
|
0°
|
10°
|
0°
|
0°
|
0°
|
|
Supination:
operated side
|
85°
|
80°
|
90°
|
90°
|
90°
|
85°
|
90°
|
|
Pronation:
operated side
|
80°
|
80°
|
80°
|
80°
|
80°
|
80°
|
80°
|
|
Score on the MEPS
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
|
Score on the DASH
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
|
Satisfaction
|
Satisfied
|
Satisfied
|
Very satisfied
|
Satisfied
|
Very satisfied
|
Very satisfied
|
Satisfied
|
The mean postoperative follow-up was of 18 months (range: 12 to 36 months). The main
mechanism of injury was eccentric contraction of the biceps brachii. The patients
underwent surgery on average 3 months after injury (range: 1 to 5 months). Upon physical
examination, they showed loss of elbow flexion force, especially supination. The hook
test was positive for injury in all patients preoperatively, and negative at the last
follow-up. All of them had diagnoses confirmed by magnetic resonance imaging to evaluate
the degree of the injury and of the tendon shortening.
The complications and risks involved in the treatment were explained to the patients,
as well as the need for autologous tissue for grafting if primary reinsertion of the
bicipital tendon was not possible. In the postoperative period, the Disabilities of
the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS) intruments
were applied, and the movement test of the operated and non-operated elbows was performed
through a manual goniometer. Moreover, the flexion, extension and supination forces
of the operated and non-operated limbs were evaluated, comparing the results. A digital
dynamometer (Lafayette Hand-Held Dynamoneter, model 01163, Lafayette Instrument, Lafayette,
IN, US) was used to measure the flexion, extension and supination forces using properly-marked
a wooden rod to facilitate the measurement of the supination and not interfere with
the momentum of the applied forces. Four measurements were always taken by the same
evaluator, and the average of the last three was obtained. The first measurement was
disregarded to avoid the learning bias of the way of measuring by the patient. Finally,
the patients were evaluated as to the degree of satisfaction (dissatisfied, not satisfied,
satisfied and very satisfied).
The work was approved by the ethics committee of the institution under CAAE number
69377517.5.0000.0023.
Surgical Technique
The surgeries were performed under general anesthesia associated with locoregional
block of the brachial plexus in horizontal dorsal decubitus without the use of tourniquets.
We opted for the two-incision technique described by Boyd and Anderson[11] and modified by Morrey et al.,[7] and used a graft from the distal tendon of the triceps brachii. The criterion used
to define the tendon reconstruction was the impossibility of excursion of the remnant
tendon up to the radial tuberosity, even after release of the lacertus fibrosus. A
transverse incision of ∼ 3 cm is made in the anterior cubital fold. The biceps tendon
is easily captured when the skin is pulled proximally and is removed from the deep
tissues. The most distal portion of the degenerated tendon is resected and repaired
with Bunnell stitches using #5 nonabsorbable sutures ([Fig. 1]). Then, the radial tuberosity is palpated, and a curved Kelly caliper is passed
through the biceps tendon tunnel between the ulna and the radius, advancing until
its apex is palpated in the dorsal aspect of the proximal forearm. The second incision
is made on the caliper. The tuberosity is exposed by means of muscular divulsion,
with the forearm at maximum pronation. The radial tuberosity is scarified until it
starts bleeding, and two double-loaded bioabsorbable 2.9-mm anchors are positioned
in it.
Fig. 1 Distal biceps tendon after release showing the impossibility of direct repair.
Next, the graft of the triceps brachii is collected without olecranon bone fragments
through a posterior longitudinal incision and subcutaneous dissection until its tendon
is exposed. We chose to remove a 1-cm wide and 10-cm long strip of its average portion,
without the need for ulnar nerve exploration. Later, we approached the medial and
lateral borders to the removed portion and closed the gap that was left ([Fig. 2]).
Fig. 2 I) Incision for the triceps tendon graft; II) ressection of the central part of the
tendon measuring 10 cm x 1 cm; III) triceps tendon graft; IV) suture of the remaining
triceps tendon.
The most distal end of the graft is attached to the tuberosity through four U-stitches
with the anchor sutures ([Fig. 3]). The other end of the tendon is then passed to the region of the incision of the
antecubital fossa with Krackow #5 nonabsorbable sutures to pull the tendon through
the tunnel previously occupied by the biceps tendon. The biceps is mobilized and then
pulled by using Allis tweezers. We positioned the elbow between 40° and 60° of flexion,
with the forearm in full supination. Moderate traction is applied to the graft while
distal traction is applied to the tendon stump. The two structures are initially stabilized
with a #5 nonabsorbable U-shaped suture, and then several simple stitches are applied
to their edges ([Fig. 4]). Once the reconstruction is completed, the wounds are closed, and compressive dressings
and immobilization are performed with a plaster brachial splint, keeping the elbow
at 90∘ of flexion and the forearm at light supination.
Fig. 3 The distal end of the graft attached to the biceps tuberosity.
Fig. 4 Suture between the proximal part of triceps graft and the distal biceps tendon.
The immobilization was maintained for two weeks, when the physiotherapeutic treatment
was initiated. Initially, passive flexion exercises and limited active extension with
the supinated forearm were performed, in addition to passive and active supination-pronation
up to 50∘. The patients maintained the limb in the sling as long as they weres not
undergoing physiotherapy. This phase lasted four weeks, when the flexion and active
supination gain began without load and the patient was advised to remain without the
sling. Light muscle strengthening exercises were started after the sixth week, with
progressive increase in the load.
Statistical Analysis
The descriptive analysis presented in tables the observed data, which were expressed
as measurements of central tendency and adequate dispersion.
The inferential analysis was composed of the Mann-Whitney test to verify if there
was a significant difference in the strength parameter between the operated and non-operated
sides.
The normality in the distribution of numerical data was assessed by the Shapiro-Wilk
test and graphical analysis of the histograms. The criterion to determine significance
was the level of 5%. The statistical analysis was processed using the Statistical
Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, US) software, version
26.
Results
All patients were satisfied/very satisfied with the functional results. The average
flexion was of ∼ 133.5∘, corresponding to 95.9% of that of the non-operated limb.
The mean extension was of 3.5°, and it corresponded to 97.5% of that of the non-operated
limb. One patient had a flexion contracture of 10° that was maintained at the last
follow-up visit (24 months after surgery). The mean supination was of 86.5°, and the
pronation level was of 80°, which corresponded to 96% and 100% relative to the contralateral
limb respectively ([Table 2]).
Table 2
|
Flexion
|
Average, Minimum, Maximum
|
|
|
Operated limb
|
133.5°, 130°, 140°
|
95.9%
|
|
Non-operated limb
|
139.2°, 135°, 140°
|
|
Extension
|
|
Operated limb
|
3.5°, 10°, 0°
|
97.5%
|
|
Non-operated limb
|
0°, 0°, 0°
|
|
Supination
|
|
Operated limb
|
86.5°, 80°, 90°
|
96%
|
|
Non-operated limb
|
90°, 90°, 95°
|
|
Pronation
|
|
Operated limb
|
80°, 80°, 80°
|
100%
|
|
Non-operated limb
|
80°, 80°, 80°
|
Based on the MEPS, all patients achieved excellent results, with a score of 100. According
to the DASH questionnaire, all patients presented a result of 0. The average flexion
force was of 23.7 N, whereas the supination was of 3.4 N, and the extension, 21.3 N,
and they corresponded respectively to 92.5%, 86.8% and 96.4% of the average of the
force on the non-operated side ([Table 3]).
Table 3
|
Flexion
|
Average, Median, Interquartile Range
|
p
|
|
Operated side
|
23.7 N, 22.4 N, 17.3–30.7
|
0.48
|
|
Non-operated side
|
25.4 N, 22.6 N, 21.5–31.6
|
|
%
|
92.5, 97.2, 93.0–99.1
|
|
Supination
|
|
Operated side
|
3.4 N, 3.3 N, 2.2–4.5
|
0.37
|
|
Non-operated side
|
3.9 N, 3.9 N, 2.5–5.2
|
|
%
|
86.8, 86.5, 84.6–88.7
|
|
Extension
|
|
Operated side
|
21.3 N, 19.2 N, 13.4–28.4
|
0.65
|
|
Non-operated side
|
22.1 N, 20.0 N, 15.3–29.5
|
|
%
|
96.4, 97.3, 96.0–99.2
|
Due to the very small sample size, wes proposed to analyze the data using the nonparametric
approach. In addition certain parameters under study did not show normal (Gaussian)distribution
according to the Shapiro-Wilk test. Therefore, the most appropriate measurements to
summarize these data are by quartiles (median and interquartile range: Q1–Q3). There
was no statistically significant difference in the strength parameter.
There were no neurovascular complications, surgical site infection, tendon rerupture,
cortical radius fracture or heterotopic ossification.
Discussion
The primary repair of a chronic rupture of the distal biceps brachii is technically
challenging. Non-anatomical tenodesis in the brachialis muscle has been proposed as
a treatment option. However, despite the high satisfaction rate of patients undergoing
this procedure, Klonz et al.[12] observed that half of their patients lost more than 50% of the supination force.
The risk of supination weakness following the employment of this technique may be
unacceptable for patients with high functional demand. Several techniques for the
reconstruction of the distal biceps brachii have been described; they differ in terms
of access, grafting choice, and type of fixation.[1]
[2]
[5]
[6] Both autografts and allografts have been used for this purpose.
Several allograft options have been described in the literature,[1]
[13]
[14] including the Achilles tendon, the semitendinosus, the tibialis anterior, and the
gracilis. With respect to autografts,[1]
[2]
[5]
[6] we find descriptions of the use of the fascia lata, the semitendinosus and the long
palmar. We did not find in the literature a description of the use of the distal tendon
of the triceps brachii for this purpose. The use of this tendon as an autograft for
chronic ruptures of the distal biceps brachii was designed by us to avoid the inconveniences
of the recovery period observed when the donor area is not located in the same joint
as the recipient area. Additionally, other advantages are the presence of this donor
tendon in all members of the population, the absence of neurovascular risks during
its collection, and the possibility of variable lengths and sizes, according to the
need.
Martin et al.[15] evaluated the biomechanical characteristics of the graft of the central portion
of the triceps brachii and concluded that the triceps graft is comparable to the long
palmar tendon in terms of final load failure and rigidity . They also observed that
the triceps tendon presents greater deformation, but this finding had no statistical
significance. In another biomechanical study, Baumfeld et al.[16] evaluated the properties of the medial, central and lateral distal triceps, and
concluded that the lateral portion is significantly thinner and less rigid in relation
to the central and medial portions, and that the central portion of the triceps brachii
presents a final failure load of 704 N, against 357 N of that of the long palmar.
Wiley et al.[2] compared two groups of patients with chronic ruptures of the distal biceps brachii,
one treated conservatively, and the other, submitted to reconstruction with semitendinosus
autograft using the two-incision technique. They concluded that the patients submitted
to reconstruction obtained an improvement in flexural and supination strength, when
compared with patients treated conservatively.
Hallam and Bain[10] evaluated nine patients after repair using autologous semitendinosus grafts, fixation
with the Endobutton (Smith & Nephew, Inc., Andover, MA, US) device, and anterior aproach
in S. As in the present study, they also observed an excellent MEPS score in all cases,
range of motion close to normal, and no complications regarding the postoperative
results.
Terra et al.[17] evaluated 8 patients after direct repair of chronic injuries, with an average time
between injury and surgery of 71.8 days (range: 28 to 180 days). They used the anterior
aproach, and the fixation method was Endobutton associated with an interference screw.
These authors also obtained excellent results on the MEPS; however, a flexion strength
of 79.25% of that of the contralateral strength and supination of 89.75% was observed.
The results of the present study show a similar supination strength, but superior
flexion strength. Furthermore, in our series, direct repair of the lesions was not
possible, not even with the elbow in flexion.
Using an Achilles tendon allograft, Sanchez-Sotelo et al.,[13] in their study with 4 patients, showed excellent results according on the MEPS (score
of 100 in all cases), with normal range of motion and normal strength in relation
to the contralateral side in 2 patients, and slightly decreased in the other 2.
There are several options for the fixation of the tendon to the radial tuberosity
(bone tunnel, interference screw, Endobutton, and suture anchors), with the Endobutton
having the highest biomechanical strength, followed by suture anchors. However, when
subjected to physiological forces, there is no statistically significant difference
between them.[18]
[19] There is also the possibility of repairing the tendon with the Endobutton and interference
screw for chronic injuries of the distal biceps, which enable a more rigid and resistant
fixation with two implants and early rehabilitation.[17] However, anchorage techniques demonstrate optimal clinical and functional results.[20]
Although there is still a debate about the best access for the fixation of distal
biceps tendon ruptures, whether through double or single incision, recent studies[21]
[22] show a negligible difference in results and complications between the two techniques.
The choice of the best access for these pathologies should be guided by the experience
and familiarity of the surgeon.
The negative points of the present study are: we do not have data for a comparison
between the pre- and postoperative periods, due to its retrospective nature; the limited
sample size (n = 7), a problem also present in most studies in the literature on this subject; and
the short follow-up of the patients.
Conclusion
The graft of the central strip of the triceps tendon presents biomechanical characteristics
suitable for its use in the reconstruction of the distal biceps. In addition, it presents
as advantages the safety of its collection and the possibility of removal of grafts
of variable sizes. We observed that, since it is a rare injury, there is great difficulty
in carrying out large prospective studies to compare the methods of surgical treatment
for such injury. However, the distal reconstruction of the biceps brachii with triceps
grafting through double incision, with radial tuberosity fixation with two bioabsorbable
suture anchors, seems to be an effective and safe option for the treatment of chronic
distal biceps injuries, with good clinical and functional outcomes.
