Distal biceps reconstruction using an Achilles tendon allograft, transosseous EndoButton, and Pulvertaft weave with tendon wrap technique for retracted, irreparable distal biceps ruptures

doi:10.1016/j.jse.2016.01.014

Journal of Shoulder and Elbow Surgery

Volume 25, Issue 6, June 2016, Pages 1013-1019

https://doi.org/10.1016/j.jse.2016.01.014 Get rights and content

Background

Distal biceps ruptures can result in ongoing pain and weakness when treated nonoperatively. If retraction of the tendon renders primary repair impossible, reconstruction using a graft is recommended. The current literature includes a variety of techniques with studies reporting small patient numbers. The aim of this study was to report the results of a larger cohort of patients using a technique modified from those previously described in the literature.

Methods

Twenty-one consecutive male patients underwent distal biceps reconstruction through 2 small anterior incisions using an Achilles tendon allograft that was fixed distally using a transosseous EndoButton and secured proximally using a Pulvertaft weave and tendon wrap. The mean age was 44 years, and the mean time to surgery was 25 months (range, 2-96 months). Functional outcomes were collected prospectively.

Results

The mean preoperative Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score (11 patients) was 1.9 (range, 0-4.5). The mean postoperative Oxford Elbow Score, QuickDASH score, and Mayo Elbow Performance Score were 44.7 (range, 35-48), 4 (range, 0-20.5), and 92.9 (range, 70-100), respectively, at a mean follow up of 15 months (range, 6-35 months). The mean postoperative QuickDASH score was significantly improved compared with preoperatively (P < .001). All patients were satisfied and all returned to their previous level of activity. There were 2 transient lateral antebrachial cutaneous nerve paresthesias, and 2 patients had a 5° extension lag. There were no other complications.

Conclusion

Achilles allograft reconstruction of retracted irreparable distal biceps ruptures provides consistently good results with few complications using this technique.

Section snippets

Patients and methods

Twenty-one consecutive patients underwent reconstruction by a single technique performed by or under the direct supervision of the senior author (A.C.W.). All patients were men, and the mean age was 44 years. The indication for reconstruction was a symptomatic, retracted distal biceps rupture that could not be fixed directly to the radial tuberosity using a transosseous EndoButton technique in up to 90° of elbow flexion.

Preoperative demographic data and postoperative outcome scores, range of

Results

Table I shows individual preoperative patient demographic data. The mean follow-up period for the 21 patients was 15 months (range, 6-35 months). The mean age was 44 years (range, 20-62 years). Seventeen patients were right handed, and 11 right arms were treated. Of the patients, 12 had a manual occupation, 8 had a sedentary occupation, and 1 was a rugby player. Seven of the 12 patients with manual jobs were heavy-goods vehicle drivers. In 12 patients, the initial biceps rupture occurred while

Discussion

In this series of 21 patients with retracted, irreparable distal biceps ruptures, we found consistently good functional outcomes, a high level of patient satisfaction, and few complications. The surgical technique described uses an Achilles tendon allograft, EndoButton fixation distally, and a Pulvertaft weave with tendon wrap to secure the graft proximally. The use of Achilles tendon allograft avoids additional graft-site morbidity and is known to have equivalent mechanical properties to

Conclusion

Patients treated with Achilles allograft reconstruction of the distal biceps using an EndoButton and Pulvertaft weave reconstruction with tendon wrap had good clinical results with an improvement in preoperative disability and few complications. This technique is recommended for patients who have a retracted, irreparable distal biceps rupture.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Cited by (26)

Outcomes and complications after different surgical techniques for the treatment of chronic distal biceps tendon ruptures: a systematic review and quantitative synthesis
2022, JSES Reviews, Reports, and Techniques
The purpose of this study was to perform a systematic review of the available literature evaluating surgical outcomes after chronic distal biceps tendon rupture. Surgical techniques, including primary repair, autograft reconstruction, and allograft reconstruction, were compared, as well as subjective and objective clinical outcomes and complication rates.
A systematic literature search of Level I-IV studies reporting outcomes of surgically treated chronic distal biceps tendon ruptures were performed via PubMed, Cochrane Collaboration, Science Direct, and Google Scholar databases. Twenty-two papers were identified in the review, with 236 patients. A Modified Coleman Methodological Score (CMS) was determined for every article to assess study quality. Patient-reported outcomes, postoperative range of motion, flexion and supination strength, and postoperative complications were recorded. MAYO elbow scores (MEPS) were reported more consistently than the other outcome tools.
No Level I or level II studies were identified in our search, and the heterogeneity of outcome measures precluded meta-analysis. Studies demonstrated mean MEPS scores ranging between 86 and 100, regardless of the surgical technique utilized. All studies reported a mean flexion-extension arc equal to or greater than 5-130°. The reported mean postoperative flexion strength was within 10% of the unaffected contralateral side. The most common complication for both direct repair and reconstruction groups was paresthesia of the lateral antebrachial cutaneous nerve [direct repair: 18–16.8%; reconstruction: 8–6.2% (allograft: 4–6%; autograft: 4–7%)]. Rerupture was uncommon and occurred in three patients who had undergone direct repair and in one patient after autograft reconstruction.
Surgical treatment of chronic distal biceps injuries yields favorable objective and subjective outcomes. Currently, available evidence suggests that direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes.
Distal biceps ruptures repair: Experience with 80 cases
2021, Revista Espanola de Cirugia Ortopedica y Traumatologia
La rotura de bíceps distal tiene una frecuencia de 1,2 casos por 100.000 habitantes. El tratamiento conservador supone un detrimento supinador del 40% y flexor del 30%, al igual que las transferencias al braquial. Nuestro objetivo es revisar nuestra experiencia con la reinserción anatómica.
Estudio comparativo de cohortes, entre una cohorte histórica, aunque reciente, en la que se aplicó doble abordaje, o de Boyd-Anderson, frente a una cohorte prospectiva donde se aplicó abordaje simple y doble. Tamaño muestral de 80 pacientes. Edad media de 48,9 ± 5,9 años. Analizamos lateralidad, tiempos para diagnóstico, prequirúrgico, quirúrgico, tipo de vía, tipo de reinserción, tiempo de rehabilitación, escala Mayo Elbow Performance Score (MEPS), estudio biomecánico y complicaciones. Seguimiento mínimo en 2 años y máximo en 7 años.
Tiempo para el diagnóstico, con mediana de 4 días. Tiempo prequirúrgico: 12,2 ± 6,4 días. Tiempo quirúrgico: 61,9 ± 15,7 min. Doble vía (Boyd-Anderson-Morrey) en el 78,8%, vía única (Henry) en el 21,2%. Reinserción transósea (45%), con anclaje roscado (40%) y con botón cortical (15%). Tiempo rehabilitador: 91 ± 29,7 días. MEPS: 88 ± 11,7 puntos. Déficit de fuerza flexora final del 28 ± 16,6%. Complicaciones: 1 caso de sinostosis radiocubital proximal, 2 neuroapraxias radiales y 5 casos con rigidez residual. Contraste de hipótesis: mejor resultado MEPS para doble vía (p = 0,009), con menos complicaciones (p = 0,008). Mayor dolor con botones corticales (p < 0,05). Menor tiempo quirúrgico si se operaban antes de una semana (p = 0,03). Riesgo relativo de 0,2 al comparar tipo de abordaje con riesgo de lesión radial, siendo el doble abordaje el que menos lo presentaba, lo que lo configuraría como factor protector frente a esta lesión.
En nuestra experiencia, consideramos que la reinserción anatómica es un tratamiento eficaz. La doble vía supone mejor resultado en escala MEPS, con menos complicaciones, que en la vía única.
Rupture of distal biceps has a frequency of 1.2 cases per 100,000 population. Conservative treatment presents a loss in supination of 40% and flexion of 30%, like transfers to the brachialis. Our goal is to review our experience with anatomical reattachment.
Cohorts study. We analized an historic cohort, although recent, treated with double approach (Boyd-Anderson) compared to another prospective cohort (treated with single and double approach). Sample size of 80 patients. Mean age of 48.9 ± 5.9 years. We analyzed laterality, time to diagnosis, presurgery time, surgery time, approach, type of reintegration, rehabilitation time, Mayo Elbow Performance Score (MEPS), biomechanical study and complications. Follow up from 2 years to 7 years.
Time for diagnosis was about 4 days. Preoperative time: 12.2 ± 6.4 days. Surgical time: 61.9 ± 15.7 minutes. We used the two-way surgical approach (Boyd-Anderson-Morrey) in 78.8% of patients, and the anterior surgical approach (Henry) in 21.2% of cases. Transosseous reinsertion was made in 45% of cases, with screw anchor in 40% and with cortical button in 15%. Rehabilitation time: 91 ± 29.7 days. MEPS: 88 ± 11.7 points. There was loss of flexor strength of 28 ± 16.6%. Complications: 1 case of proximal radioulnar synostosis, 2 radial transient paralysis and 5 cases with residual stiffness. Hypothesis contrast: We reached best results in MEPS with double surgical approach (P = .009), with fewer complications (P = .008). We observed increased pain with cortical buttons (P < .05) and less surgical time if patient was operated before 1 week (P = .03). Relative risk of 0.2 when we compared type of approach with radial nerve lesion risk, considering that double approach had less cases, what it would be consider as a protective factor.
In our experience, we believe that anatomic reattachment is an effective treatment. Double surgical approach presents best result in MEPS, with fewer complications than with anterior approach.
Chronic Distal Biceps Tendon Tear Reconstruction With Tibialis Anterior Allograft
2021, Arthroscopy Techniques
Chronic distal biceps tendon ruptures present a unique surgical challenge due to tendon retraction and shortening as well as muscle atrophy. Several graft choices and fixation methods have been described, with no one technique proving superior to date. We describe a technique wherein a tibialis anterior tendon allograft is Pulver-Taft weaved through the muscle belly to achieve incorporation with the muscle and tendonous fascia to achieve superior pull-out strength.
Outcomes of chronic distal biceps reconstruction with tendon grafting: a matched comparison with primary repair
2021, JSES International
Citation Excerpt :
The present study found functional elbow range of motion was reliably restored in patients undergoing allograft reconstruction or direct primary repair. This is consistent with previous reports on elbow range of motion after graft reconstruction.8,10,23,28 Although the present study did not evaluate postoperative elbow strength—previous studies have reported similar restoration of postoperative supination strength between graft reconstruction and direct primary repair.
The purpose of this analysis was to analyze outcomes of distal biceps reconstruction with soft tissue allograft in the setting of chronic, irreparable distal biceps ruptures. The outcomes of these cases were then compared with a matched cohort of distal biceps ruptures that were able to be repaired primarily.
Retrospective review of an institutional elbow surgery database was conducted. All cases of distal biceps repairs were identified by Common Procedural Terminology, ICD-9, and ICD-10 codes from January 2009 to March 2018. A direct review of operative reports was then conducted to identify which cases required allograft reconstruction. After identification of this population, a 2:1 manually matched cohort of patients who underwent primary repair was generated using age, gender, body mass index, and age-adjusted Charlson Comorbidity Index. Finally, the allograft reconstruction and matched primary repair cohorts were compared for reoperation, range of motion, and patient-reported outcomes scores.
There were 46 male patients who underwent distal biceps reconstruction with allograft (14 Achilles tendon, 32 semitendinosus) and they were matched to 92 male patients that underwent primary distal biceps repair. Mean patient age (46.9 ± 10.3 vs. 47.0 ± 9.8 years, P = .95), BMI (31.3 ± 5.3 vs. 31.3 ± 4.8 kg/m², P = .60), and Charlson Comorbidity Index (1.2 ± 1.1 vs. 1.3 ± 0.9, P = .64) were similar between allograft reconstruction and primary repair groups. Disability of the Arm, Shoulder and Hand score (7.4 ± 18.0 vs. 1.6 ± 4.1, P = .23), Mayo Elbow Performance Score (92.1 ± 19.7 vs. 97.3 ± 6.4, P = .36), and Oxford Elbow Score (43.4 ± 11.0 vs. 46.8 ± 3.2, P = .25) were not significantly different between groups at mean 5.1 years (range, 1.5-10.9 years) after surgery. There were 1 of 42 (2.2%) allograft patients who require revision compared with 3 of 92 (3.3%, P = .719) in the primary repair group. In addition, one primary repair required reoperation for scar tissue excision and lateral antebrachial cutaneous neurolysis. Final range of motion data (twelve-week follow-up) for the allograft reconstruction group was similar to primary repair group in flexion (136.1° ± 5.3° vs. 135.9° ± 2.7°, P = .81), extension (0.8° ± 2.9° vs. 0.4° ± 1.7°, P = .53), pronation (78.0° ± 9.0° vs. 76.4° ± 15.4°, P = .50), supination (77.4° ± 10.7° vs. 77.5° ± 11.9°, P = .96).
Patients who underwent distal biceps reconstruction with a graft had similar failure rates, reoperation rates, final range of motion, and patient-reported outcomes scores as those treated without a graft. Patients can be consulted that direct repair in the acute setting is preferred; however, even in the setting of a distal biceps reconstruction with graft augmentation, they can expect low complications and good functional results.
B2B: A technical note and case report on long head of biceps tendon autograft for chronic distal biceps tendon reconstruction
2021, JSES Reviews, Reports, and Techniques
Chronic distal biceps tendon rupture presents a challenging surgical problem due to tendon quality and retraction. This case report presents a technique to use a free autograft from the proximal long head of biceps tendon in treatment of a patient with a chronic distal biceps tendon rupture, where primary fixation was not feasible. Distalization of the biceps long head muscle belly by long head tenotomy and resultant autograft for distal reconstruction has surgical advantages showing excellent results at short-term follow-up with good strength and a full range of motion. This technique can be an addition to existing grafting options in the treatment of distal biceps tendon ruptures, especially where shoulder arthroscopy to manage concomitant shoulder pathology, such as a rotator cuff tear, is also required.
Level V; Case Report;
Surgical outcomes and complications following distal biceps tendon reconstruction: a systematic review and meta-analysis
2021, JSES International
Primary repair of chronic distal biceps tendon ruptures may not be possible because of tendon retraction, and there remains no clear consensus on the type of reconstruction technique used. The purpose of this study was to report the clinical outcomes and complication rates following reconstruction of chronic distal biceps tendon ruptures.
A systematic review was performed following PRISMA guidelines. The following databases were searched: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials. The primary outcomes of interest included range of motion, strength, and functional outcome scores. Secondary outcomes included complication, reoperation, and revision rates. Outcomes and complication rates of each graft type and fixation technique were aggregated and compared with nonparametric Wilcoxon signed rank and rank sum tests. Spearman rank coefficients were calculated for time from injury to surgery on all outcomes.
There were no significant differences found between the graft type or fixation technique for postoperative range of motion, strength, and patient-reported outcomes. Postoperative complications were substantially higher in the autograft group (34%) as compared to the allograft group (14%). The fixation technique used also demonstrated a significantly increased complication rate in the weave group compared with the onlay group (34% and 9%, respectively).
Our results do not reveal any statistically significant differences between groups in the primary outcomes. However, substantially higher complication rates were observed in the autograft and weave cohorts; more than half of the complications related to the use of autograft were associated with donor site morbidity. No specific graft type was identified as superior, although this may be due to the small patient numbers included within this study.

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: Institutional review board/ethical committee approval was not required for this study in the United Kingdom because it was a standard follow-up of our clinical results, which we collect on all patients.

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Distal biceps reconstruction using an Achilles tendon allograft, transosseous EndoButton, and Pulvertaft weave with tendon wrap technique for retracted, irreparable distal biceps ruptures

Background

Methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Conclusion

Disclaimer

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