distal biceps tendon ruptures - denver, colorado€¦ · distal biceps tendon ruptures michelle...
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Biceps Tendon Anatomy
Two indistinct insertions
Short head inserts distally on the
radial tuberosity
Long head inserts proximally on the
radial tuberosity
Lacertus Fibrosis
Aponeurosis that comes off of the
medial tendon
Can be mistaken for intact tendon
Biceps Biomechanics
Short head medial to the long
head at myotendinous junction
Tendon externally rotates 90 deg
to place the short head distal to
the long head on the radial
footprint
Short head exerts 15% greater
flexion torque due to distal
attachment
Long head exerts greater
supination moment due to
posterior insertion
Presentation
Males, 40s (93%)
Dominant arm (86%)
Risk factors
Smoking
Hypovascularity
Mechanical impingement?
Presentation
Eccentric load on a flexed elbow
Often accompanied by a ”pop”
Pain in antecubital fossa
Pain or weakness in supination
and/or elbow flexion
”Hook” sign/deformity
MRI
May be helpful to determine
complete vs partial rupture
Helpful to determine tendon
retraction
Muscle vs tendon tear
Treatment
Non operative repair
Generally reserved for low-
demand or high-risk patients
Results in up to 30% elbow flexion
weakness, 40-50% supination
weakness
Partial tears < 50%
Treatment
Operative Repair
One Incision
Suture anchors
Cortical button
Interference screw
Two Incision
Bone tunnels
Results
Overall results are excellent
regardless of technique
Clinical results
Avg 85-90% return of flexion and supination strength
Slightly decreased ROM and increased incidence of HO with 2-incision technique
Mazzocca, et.al. AJSM 2007
Biomechanical testing
Bone tunnel, suture anchor, cortical button, interference screw
Evaluated load to failure and cyclic loading
No significant difference in displacement of repair
Greater load to failure with Endobutton
Presentation
Chronic pain and weakness with
elbow flexion and supination
Following an acute injury (usually
remote)
Physical exam findings are most
often normal
Treatment
Nonoperative
Same indications as complete
rupture
Low demand
Operative
Chronic symptoms
Antecubital pain
Supination, occasional flexion
weakness
Chronic Biceps Ruptures
Typically presents with stiff,
proximally contracted, shortened,
atrophic tendon
Bosman, et.al. JSES 2012
6 patients
FROM
Mild supination weakness
No reruptures
Morrey, et.al. JSES 2014
Retrospective study
Fixed in 60-90 deg flexion
No difference in clinical strength,
rerupture rates, range of motion, or
complications
Chronic Biceps Ruptures
Allograft or autograft
augmentation
Musculotendinous junction tears
Poor tendon quality
Flexion greater than 90 deg?
References
Cheung, E. V., Lazarus, M., & Taranta, M. (2005). Immediate range of motion after distal biceps tendon repair. Journal of Shoulder and Elbow Surgery, 14(5), 516-518. doi:10.1016/j.jse.2004.12.003
El-Hawary, R., MacDermid, J. C., Faber, K. J., Patterson, S. D., & King, G. J. (2003). Distal biceps tendon repair: Comparison of surgical techniques. The Journal of Hand Surgery, 28(3), 496-502. doi:10.1053/jhsu.2003.50081
Kettler, M., Lunger, J., Kuhn, V., Mutschler, W., & Tingart, M. J. (2007). Failure Strengths in Distal Biceps Tendon Repair. The American Journal of Sports Medicine, 35(9), 1544-1548. doi:10.1177/0363546507300690
Mazzocca, A. D., Burton, K. J., Romeo, A. A., Santangelo, S., Adams, D. A., & Arciero, R. A. (2006). Biomechanical Evaluation of 4 Techniques of Distal Biceps Brachii Tendon Repair. The American Journal of Sports Medicine, 35(2), 252-258. doi:10.1177/0363546506294854
Panagopoulos, A., Tatani, I., Tsoumpos, P., Ntourantonis, D., Pantazis, K., & Triantafyllopoulos, I. K. (2016). Clinical Outcomes and Complications of Cortical Button Distal Biceps Repair: A Systematic Review of the Literature. Journal of Sports Medicine, 2016, 1-11. doi:10.1155/2016/3498403
Schmidt, C. C., Savoie, F. H., Steinmann, S. P., Hausman, M., Voloshin, I., Morrey, B. F., … Brown, B. T. (2016). Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting—2015. Journal of Shoulder and Elbow Surgery, 25(10), 1717-1730. doi:10.1016/j.jse.2016.05.025