Olympic Elbow Comprising Lateral Epicondylitis, Cubital Tunnel Syndrome, and Distal Biceps Tendon Rupture.

There is a wide range of elbow injuries including chronic injuries such as lateral epicondylitis, medial epicondylitis, and cubital tunnel syndrome, or acute injuries such as elbow fracture-dislocations and distal biceps tendon ruptures. Combinations of acute and chronic elbow injuries have been reported including country club elbow and terrible triad of the elbow which are important to identify to properly treat. Thus, we report for the first time a new elbow injury triad termed Olympic elbow in a 65-year-old man comprising lateral epicondylitis, cubital tunnel syndrome, and a distal biceps tendon rupture. After initially failing conservative management, the patient was successfully treated with surgery and has returned to full physical activity at four and a half years postoperatively.

Patient-Reported Outcome Measures of a Novel Cortical Button System for Distal Biceps Tendon Repair: A Retrospective Study.

Background There are a number of different techniques available for the repair of distal biceps tendon ruptures. Recent evidence has revealed satisfactory clinical outcomes for suture button techniques. Aims The aim of this study was to determine if the ToggleLocTM soft tissue fixation device (Zimmer Biomet, Warsaw, Indiana) confers satisfactory clinical outcomes in the surgical management of distal biceps ruptures. Methods Twelve consecutive patients underwent distal biceps repair using the ToggleLocTM soft tissue fixation device over a two-year period. Patient-Reported Outcome Measures (PROMs) were collected by means of validated questionnaires on two occasions. Symptoms and function were quantified using the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Oxford Elbow Score (OES). Patient-reported health scores were determined using the EQ-5D-3L (European Quality of Life 5 Dimensions 3 Level Version) questionnaire. Results The mean initial follow-up time was 10.4 months and the mean final follow-up time was 34.6 months. The mean DASH score at the initial follow-up was 5.9 (se = 3.6), compared to 2.9 (se = 1.0) at the final follow-up (p = 0.30). The mean OES at the initial follow-up was 91.5 (se = 4.1); and 91.5 (se = 5.2) at the final follow-up (p = 0.23). The mean EQ-5D-3L level sum score at the initial follow-up was 5.3 (se = 0.3); and 5.8 (se = 0.5) at the final follow-up (p = 0.34). Discussion The ToggleLocTM soft tissue fixation device confers satisfactory clinical outcomes, as determined by PROMS, in the surgical management of distal biceps ruptures.

Impact of Bracing and Therapy Services on Perioperative Costs for Patients Undergoing Distal Biceps Tendon Repair.

PURPOSE: This study aimed to quantify and assess perioperative costs in an integrated healthcare system for patients undergoing distal biceps tendon (DBT) repair with and without the use of postoperative bracing and formal physical (PT) or occupational (OT) therapy services. In addition, we aimed to define clinical outcomes after DBT repair using a brace-free, therapy-free protocol. METHODS: We retrospectively reviewed all cases of DBT repairs within our integrated system from 2015 to 2021. We performed a retrospective review of a series of DBT repairs utilizing the brace-free, therapy-free protocol. For patients with our integrated insurance plan, a cost analysis was conducted. Claims were subdivided to assess total charges, costs to the insurer, and patient costs. Three groups were created for comparisons of total costs: (1) patients who had both postoperative bracing and PT/OT, (2) patients who had either postoperative bracing or PT/OT, and (3) patients who had neither postoperative bracing nor PT/OT. RESULTS: A total of 36 patients had our institutional insurance plan and were included in the cost analysis. For patients using both bracing and PT/OT, these services contributed 12% and 8% of the total perioperative costs, respectively. Implant costs accounted for 28% of the overall cost. Forty-four patients were included in the retrospective review with a mean follow-up of 17 months. The overall QuickDASH was 12; two cases resulted in unresolved neuropraxia, and there were no cases of re-rupture, infection, or reoperation. CONCLUSIONS: Within an integrated healthcare system, postoperative bracing and PT/OT services increase the cost of care for DBT repair and account for 20% of the total perioperative charges in cases where bracing and therapy are used. Considering the results of prior investigations indicating that formal PT/OT and bracing offer no clinical advantages over immediate range of motion (ROM) and self-directed rehabilitation, upper-extremity surgeons should forego routine brace and PT/OT utilization after DBT repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Results of single-incision distal biceps tendon repair for early-career upper-extremity surgeons.

Background: The purpose of this investigation was to assess surgical outcomes after distal biceps tendon (DBT) repair for upper-extremity surgeons at the beginning of their careers, immediately following fellowship training. We aimed to determine if procedure times, complication rates, and clinical outcomes differed during the learning curve period for these early-career surgeons. Methods: All cases of DBT repairs performed by 2 fellowship-trained surgeons from the start of their careers were included. Demographic data as well as operative times, complication rates, and patient reported outcomes were retrospectively collected. A cumulative sum chart (CUSUM) analysis was performed for the learning curve for both operative times and complication rate. This analysis continuously compares performance of an outcome to a predefined target level. Results: A total of 78 DBT repairs performed by the two surgeons were included. In the CUSUM analysis of operative time for surgeon 1 and 2, both demonstrated a learning curve until case 4. In CUSUM analysis for complication rates, neither surgeon 1 nor surgeon 2 performed significantly worse than the target value and learning curve ranged from 14 to 21 cases. Mean Disabilities of Arm, Shoulder, and Hand score (QuickDASH) (10.65 ± 5.81) and the pain visual analog scale scores (1.13 ± 2.04) were comparable to previously reported literature. Conclusions: These data suggest that a learning curve between 4 and 20 cases exists with respect to operative times and complication rates for DBT repairs for fellowship-trained upper-extremity surgeons at the start of clinical practice. Early-career surgeons appear to have acceptable clinical results and complications relative to previously published series irrespective of their learning stage.

All-suture anchors for distal biceps tendon repair: a preliminary outcome study.

INTRODUCTION: The aim of this study was to retrospectively evaluate the clinical outcome of double intramedullary all-suture anchors' fixation for distal biceps tendon ruptures. MATERIALS AND METHODS: A retrospective case series of patients who underwent primary distal biceps tendon repair with all-suture anchors was conducted. Functional outcome was assessed at a minimum follow-up of at 12 months based on the assessments of the Mayo Elbow Performance Score (MEPS), Andrews-Carson Score (ACS), Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the Visual Analog Scale (VAS) for pain. Maximum isometric strength test for flexion and supination as well as postoperative range of motion (ROM) were determined for both arms. RESULTS: 23 patients treated with all-suture anchors were assessed at follow-up survey (mean age 56.5 ± 11.4 years, 96% male). The follow-up time was 20 months (range Q0.25-Q0.75, 15-23 months). The following outcome results were obtained: MEPS 100 (range Q0.25-Q0.75, 100-100); ACS 200 (range Q0.25-Q0.75, 195-200); QuickDASH 31 (range Q0.25-Q0.75, 30-31); VAS 0 (range Q0.25-Q0.75, 0-0). The mean strength compared to the uninjured side was 95.6% (range Q0.25-Q0.75, 80.9-104%) for flexion and 91.8 ± 11.6% for supination. There was no significant difference in ROM or strength compared to the uninjured side and no complications were observed in any patient. CONCLUSION: Distal biceps tendon refixation using all-suture anchors provides good-to-excellent results in terms of patient-reported and functional outcome. This repair technique appears to be a viable surgical option, although further long-term results are needed. LEVEL OF EVIDENCE: Level IV (case series).

Progressive Loading in a Strongman Following Distal Biceps Repair: Re-Thinking Load Progression - A Case Report.

Background: Rupture of the distal biceps is relatively rare and post-operative protocols are typically vague and are used on many patients, regardless of pre-morbid status. The primary objective is to share the progressive loading strategy used in the rehabilitation of a strongman athlete following a surgical repair of the distal biceps. An additional objective is to highlight the need for individualized protocols and progressions with respect to patient goals and sport demands, as well as the need for shared decision making (SDM) between the medical doctor, patient, and rehabilitation provider. Case Presentation: The subject is a 39-year-old strong man competitor who suffered a distal biceps rupture while doing a tire flip during training. After having it repaired, the post-operative recovery was unremarkable. The focus of the described intervention was establishing load during rehabilitation exercises that were unique to this individual based on his pre-morbid level of strength and training history as well as the unique demands of his sport. Outcomes: The patient achieved symmetrical isokinetic strength of the elbow flexors at 60°/second in supine at six months post-operative. Discussion: The case highlights a successful outcome in a strongman competitor with a distal biceps rupture repair. Typically, protocols are vague and lack specific standards for establishment of load for exercises. Often starting points and progressions are arbitrary and lack rationale tailored to individual needs and/or pre-morbid status. The case offers a framework for establishing and progressing load while also discussing how a shared decision-making model can lead to positive outcomes.

Prevalence of Amyloid Deposition in Patients Undergoing Surgical Repair of Traumatic Distal Biceps Tendon Ruptures.

Purpose: As many as one-third of patients with heart failure secondary to systemic, wild-type transthyretin amyloidosis have an associated distal biceps tendon (DBT) rupture. Our purpose was to identify the prevalence of amyloid deposition in patients undergoing operative repair of acute traumatic DBT ruptures. Methods: In this prospective investigation, a consecutive series of patients who underwent repair of an acute traumatic DBT rupture underwent a tendon biopsy to assess for amyloid deposition. All specimens were viewed under gross microscopy by a board-certified pathologist. For initial screening, either Congo red or Thioflavin-T immunohistochemistry analysis was conducted to determine amyloid status. If staining was positive for amyloid deposition using either technique, the tissue sample was sent to an outside facility for specific amyloid protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were also recorded for each patient. Results: A total of 30 patients who underwent biopsy and repair of an acute DBT rupture were included. The mean age was 48 years, and all patients were men. Seven (23%) patients had a history of carpal tunnel syndrome, and 1 (3%) patient had evidence of heart failure at the time of surgery. One (3%) patient had evidence of amyloid deposition in the DBT, which was confirmed using liquid chromatography-tandem mass spectrometry. Conclusions: Although one-third of patients with heart failure secondary to cardiac amyloidosis have an associated DBT rupture, younger patients with acute traumatic DBT ruptures do not appear to be uniquely at risk for amyloid deposition at the time of DBT repair. Larger registry studies may be necessary to define the risk of developing cardiac amyloidosis years after sustaining an acute DBT rupture. Type of study/level of evidence: Prognostic IV.

Complete Isolated Ruptures of the Distal Biceps Brachii During Athletic Activity: A Systematic Review.

Complete, isolated ruptures of the distal biceps brachii sustained during athletic activities are uncommon. A systematic review of the literature was performed to identify complete distal biceps brachii tears experienced during athletic activities to determine injury prevalence, athletic activities/mechanisms responsible for injury and return to activity timing following operative management. A total of 10 studies, comprising 16 athletes undergoing surgery for 18 cases, were identified. Injuries were predominately associated with weightlifting. Injuries were treated utilizing a single incision in 56% of cases and primary repair performed in 89% of cases. Mean time to return to activity was 4.86 ± 1.14months. Athletes undergoing surgery ≤ 10 days following injury and those undergoing primary repair returned to activity significantly quicker. Isolated tears of the distal biceps remain uncommon during athletic activities, occurring primarily during weightlifting. Return to activity timing was not significantly delayed based on surgical approach, steroid use, or athlete age.

Staged Achilles Allograft Reconstruction of Chronic Bilateral Simultaneous Tears of the Retracted Distal Biceps Tendon Using a Novel Fixation Technique.

Bilateral simultaneous rupture of distal biceps tendons is an extremely rare clinical entity that can result in significant morbidity for an active person if not addressed appropriately. Treatment becomes more complicated in a delayed presentation as the tendon retracts and scars to the adjacent tissues, thus precluding a primary tendon-to-bone repair. The present study is a case report of an active male with a two-month-old simultaneous rupture of both distal biceps tendons managed by Achilles allograft reconstruction and double cortical-button fixation technique that provided a satisfactory functional outcome.

Ruptura de bíceps braquial distal en paciente con COVID-19 / Distal biceps brachii rupture in a patient with COVID-19

Resumen: Introducción: La lesión del tendón distal del bíceps se presenta comúnmente en pacientes masculinos entre la quinta y sexta década de la vida. El mecanismo de la lesión es una contracción excéntrica con el codo en flexión de 90o. Para su tratamiento quirúrgico, en la literatura se describen varias opciones con diferentes abordajes, tipo de sutura a utilizar y diversos métodos de fijación de la reparación del tendón distal de bíceps. Las manifestaciones clínicas musculoesqueléticas del COVID-19 son fatiga, mialgia, artralgia, pero los efectos musculoesqueléticos del COVID-19 continúan siendo poco claros. Caso clínico: Paciente masculino de 46 años, COVID-19 positivo, con una lesión aguda del tendón distal del bíceps y secundaria a un trauma mínimo, sin otros factores de riesgo. El paciente fue tratado quirúrgicamente siguiendo las guías ortopédicas y de seguridad para el paciente y el personal médico debido a la pandemia COVID-19. El procedimiento quirúrgico de la técnica de double tension slide (DTS) con una sola incisión es una opción confiable y en nuestro caso de una baja morbilidad, con pocas complicaciones y una buena opción cosmética. Conclusión: El manejo de patologías ortopédicas en pacientes COVID-19 positivos va en aumento, así como las implicaciones éticas y ortopédicas del manejo de estas lesiones y/o el retraso de su atención durante la pandemia.

Abstract: Introduction: Distal biceps tendon injury commonly occurs in male patients between the fifth and sixth decade of life. The mechanism of the injury is an eccentric contraction with the elbow in flexion of 90 degrees. For its surgical treatment, several options have been described in the literature with different approaches, type of suture to be used and various methods of fixing the repair of the distal biceps tendon. The musculoskeletal clinical manifestations of COVID-19 are fatigue, myalgia, arthralgia, but the musculoskeletal effects of COVID-19 remain unclear. Case report: 46-year-old COVID-19 positive male patient with acute distal biceps tendon injury and secondary to minimal trauma, with no other risk factors. The patient was treated surgically following orthopedic and safety guidelines for the patient and medical staff due to the COVID-19 pandemic. The surgical procedure of the double tension slide (DTS) technique with a single incision in a reliable option and our case of a low morbidity, few complications and a good cosmetic option. Conclusion: The management of orthopedic pathologies in COVID-19 positive patients is increasing as well as the ethical and orthopedic implications of the management of these injuries and/or the delay of their care during the pandemic.

Distal Biceps Tendon Rupture Videos on YouTube: An Analysis of Video Content and Quality.

Purpose: Our purpose was to analyze the content and quality of YouTube videos related to distal biceps tendon (DBT) ruptures and repair. We aimed to compare differences between academic and nonacademic video sources. Methods: The most popular YouTube videos related to DBT injuries were compiled and analyzed according to source. Viewing characteristics were determined for each video. Video content and quality were assessed by 2 reviewers and analyzed according to the Journal of the American Medical Association benchmark criteria, DISCERN criteria, and a Distal Biceps Content Score. Cohen's kappa was used to measure interrater reliability. Results: A total of 59 DBT YouTube videos were included. The intraclass correlation coefficients ranged from moderate to excellent for the content scores. The mean DISCERN score was 29, and no videos were rated as either "good" or "excellent" for content quality. With the exception of the mean Journal of the American Medical Association criteria score (1.5 vs 0.5), videos from academic sources did not demonstrate significantly higher levels of content quality. Only 4/59 videos (7%) discussed the natural history of nonsurgically treated DBT ruptures. Of the 32 videos that discussed surgical techniques, only 3/32 (9%) had a preference for 2-incision techniques. No videos discussed the association between spontaneous DBT ruptures and cardiac amyloidosis. Conclusions: The overall content, quality, and reliability of DBT videos on YouTube are poor. Videos from academic sources do not provide higher-quality information than videos from nonacademic sources. Videos related to operative treatment of DBT ruptures more frequently discuss single-incision techniques. Clinical relevance: Social media videos can function as direct-to-consumer marketing materials, and surgeons should be prepared to address misconceptions regarding the management of DBT tears. Patients are increasingly seeking health information online, and surgeons should direct patients toward more reliable and vetted sources of information.

Failure of Primary Distal Biceps Repair After Cortical Button Fixation With Whipstitch Technique: A Root Cause Analysis.

Rerupture after cortical button fixation and whipstitch suture technique is a rare complication of distal biceps tendon repair. The tendon-bone fixation construct can fail for various reasons, including cortical breach, pull out or disengagement of a cortical button, suture breakage, or knot slippage. Occasionally, a cut-through of the tendon substance by the high-tensile strength suture material, called the 'cheese-wire' effect, can happen, especially with premature loading during the early postoperative period. The clinical presentation is more subtle, and the rerupture may go unnoticed. A high index of suspicion and a low threshold for ordering a magnetic resonance imaging (MRI) scan are necessary for a prompt diagnosis and early treatment. We describe the management of a reruptured distal biceps in an active male that happened in the early postoperative period, along with a critical analysis of the failure pattern and potential preventive measures.

Distal biceps tendon repair: cost analysis of single- versus double-incision techniques in an ambulatory surgery center.

Background: The purpose of this study was to compare the cost differences for single- versus double-incision distal biceps repair at an ambulatory surgery center (ASC) given that similar clinical outcomes have been reported between these methods. Methods: A retrospective review of financial and medical records was completed for patients who underwent distal biceps tendon repair over a three-year period at a single private orthopedic practice. Variables analyzed include the cost to the ASC of operative time and the cost of differential surgical supplies, specifically implants and disposable supplies. Results: A total of 10 surgeons performed 104 repairs. Nine surgeons performed repairs through a single incision with use of cortical button or suture anchor fixation, and one surgeon performed transosseous suture fixation through a double-incision approach. The median tourniquet time and procedure length were 31 (interquartile range [IQR] 27-40) and 44 (IQR 39-54) minutes for single-incision repairs and 68 minutes (IQR 61-75) and 110 minutes (IQR 103-113) for double-incision repairs which were significantly different across groups (P < .001, P < .001). The total surgical cost (operative time, implants, and disposables) for single-incision repairs was a median of $758 (IQR 732-803) compared with $606 (IQR 567-629) for double-incision repairs (P < .001). However, the procedure cost with implants (not including disposables) was not significantly different for single- (median [Mdn] = $500 [IQR 475-552]) and double-incision repairs (Mdn $552 [IQR 514-564]) (P = .14) although the procedure cost with disposables (not including implant costs) favored single-incision repairs (Mdn = $478 [IQR 452-523]) over double-incision repairs (Mdn = $606 [IQR 567-629]) (P < .001). Conclusion: In a single surgery center, single-incision distal biceps repairs utilizing an implant were performed more expeditiously than double-incision repairs with a transosseous technique but incurred greater surgical costs. Differences in surgical time cost between the two approaches could be consequential for ASCs and other stakeholders.

[Distal biceps brachii rupture in a patient with COVID-19]. / Ruptura de bíceps braquial distal en paciente con COVID-19.

INTRODUCTION: distal biceps tendon injury commonly occurs in male patients between the fifth and sixth decade of life. The mechanism of the injury is an eccentric contraction with the elbow in flexion of 90 degrees. For its surgical treatment, several options have been described in the literature with different approaches, type of suture to be used and various methods of fixing the repair of the distal biceps tendon. The musculoskeletal clinical manifestations of COVID-19 are fatigue, myalgia, arthralgia, but the musculoskeletal effects of COVID-19 remain unclear. CASE REPORT: 46-year-old COVID-19 positive male patient with acute distal biceps tendon injury and secondary to minimal trauma, with no other risk factors. The patient was treated surgically following orthopedic and safety guidelines for the patient and medical staff due to the COVID-19 pandemic. The surgical procedure of the double tension slide (DTS) technique with a single incision in a reliable option and our case of a low morbidity, few complications and a good cosmetic option. CONCLUSION: the management of orthopedic pathologies in COVID-19 positive patients is increasing as well as the ethical and orthopedic implications of the management of these injuries and/or the delay of their care during the pandemic.

INTRODUCCIÓN: la lesión del tendón distal del bíceps se presenta comúnmente en pacientes masculinos entre la quinta y sexta década de la vida. El mecanismo de la lesión es una contracción excéntrica con el codo en flexión de 90o. Para su tratamiento quirúrgico, en la literatura se describen varias opciones con diferentes abordajes, tipo de sutura a utilizar y diversos métodos de fijación de la reparación del tendón distal de bíceps. Las manifestaciones clínicas musculoesqueléticas del COVID-19 son fatiga, mialgia, artralgia, pero los efectos musculoesqueléticos del COVID-19 continúan siendo poco claros. CASO CLÍNICO: paciente masculino de 46 años, COVID-19 positivo, con una lesión aguda del tendón distal del bíceps y secundaria a un trauma mínimo, sin otros factores de riesgo. El paciente fue tratado quirúrgicamente siguiendo las guías ortopédicas y de seguridad para el paciente y el personal médico debido a la pandemia COVID-19. El procedimiento quirúrgico de la técnica de double tension slide (DTS) con una sola incisión es una opción confiable y en nuestro caso de una baja morbilidad, con pocas complicaciones y una buena opción cosmética. CONCLUSIÓN: el manejo de patologías ortopédicas en pacientes COVID-19 positivos va en aumento, así como las implicaciones éticas y ortopédicas del manejo de estas lesiones y/o el retraso de su atención durante la pandemia.

Epidemiologic impact of COVID-19 on a multi-subspecialty orthopaedic practice.

The purpose of this study is to report the change in surgical case volume and composition encountered by a multi-subspecialty orthopaedic practice due to COVID-19. We reviewed electronic medical records for patients who had surgery at our institution and collected multiple variables including age and the joint that was operated on. In the post-COVID-19 period, we found a significant increase in the percentage of hip procedures, and a significant decrease in the percentage of hand/wrist procedures. Overall, the total surgical volume of our multi-subspecialty orthopaedic practice decreased due to the COVID-19 pandemic, and the composition of surgical cases changed.

Outcomes of chronic distal biceps reconstruction with tendon grafting: a matched comparison with primary repair.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Endoscopic anatomy of distal biceps tendon insertion and bicipitoradial bursa: a cadaveric study.

BACKGROUND: Distal biceps endoscopy has emerged as a minimally invasive alternative to open procedures for distal biceps tendon (DBT) pathology. The purpose of this study was to systematically describe the static and dynamic appearance and variations of the DBT insertional region using a standardized endoscopic technique and dissection in healthy cadaveric elbows. METHODS: Endoscopic assessment of the DBT insertional region was performed using a standard proximal parabiceps portal in 20 fresh frozen cadaveric upper extremities. A 6-point endoscopic evaluation of the DBT and bicipitoradial bursa was performed in a static supination position and with dynamic rotation. Anatomic variations in the DBT insertional characteristics, as well as the extent and appearance of the intrabursal space, were documented. Each cadaver was then dissected to correlate endoscopic findings with gross anatomic structures. RESULTS: A bare oval tuberosity area (n = 20) bounded by the supinator and DBT was observed. The DBT inserted ulnar to the bare area (n = 16) and the presence of an intervening wide (n = 1) or narrow (n = 3) tuberosity sulcus were documented. The dorsoradial DBT surface was consistently intrabursal and was differentiated into 2-5 fiber bundles (n = 15). The volar-ulnar DBT surface was always extrabursal and was associated with endoscopically identifiable proximal and distal fat pads. The bicipitoradial bursa formed a bursal sac that was attached to the dorsoradial (n = 13) or volar (n = 7) aspect of the tuberosity and extended proximally along the DBT for 3-5 cm (parabiceps space). A distinct ligament-like band (transverse radioulnar ligament) extended transversely across the proximal radioulnar space and appeared to form a sling that provided ulnar support to the DBT during dynamic rotation. The intact DBT surface was robust and could not be breached, even with firm pressure using a probe. CONCLUSIONS: The bare tuberosity area, the bursal sac, and the parabiceps space are consistent anatomic landmarks that can be used during DBT endoscopy. An insertional tuberosity sulcus and DBT surface differentiation are normal anatomic variations. The transverse radioulnar ligament provides ulnar support for the DBT during pronation and forms a pulley mechanism for smooth tendon gliding motion.

Three-dimensional measurement of proximal radioulnar space during active forearm pronation.

Distal biceps tendon ruptures have been reported to be associated with narrowing of the proximal radioulnar space. There have been no studies that three-dimensionally measured the distance between the bicipital tuberosity and the proximal ulna during active motion. The purpose of this study was to three-dimensionally measure the proximal radioulnar space during active forearm pronation in healthy subjects. Five healthy volunteers (10 forearms) were recruited for this study. They consisted of all males with a mean age of 37 years (range, 34-46 years). Lateral fluoroscopy of forearm rotation from maximum supination to maximum pronation was recorded for both forearms. Three-dimensional forearm kinematics were determined using model-image registration techniques with fluoroscopic images and CT-derived bone models, and the closest distance between the bicipital tuberosity and the proximal ulna was computed at each 30° increment of radial axial rotation relative to the distal humerus. The distance between the bicipital tuberosity and the proximal ulna decreased with pronation, reaching a minimum value at 90° of radial rotation (average 4.6 ± 1.3 mm), then increased with further rotation to maximum pronation (P = 0.004). The clearance between the proximal radioulnar space and the distal biceps tendon is very small (<1mm). Hypertrophy of the bicipital tuberosity or tendon can induce impingement and lead to tendon rupture.

Distal Biceps Tendon Rupture Surgery: Changing Incidence in Finnish and Swedish Men Between 1997 and 2016.

PURPOSE: Distal biceps tendon rupture is a relatively rare injury usually occurring with excess external extension force applied to a flexed elbow. The aim of this study was to examine the incidence of distal biceps tendon rupture surgery in the Finnish and Swedish adult population between the years 1997 and 2016. A secondary aim was to investigate the distal biceps rupture incidence in the Swedish population in 2001 to 2016. METHODS: We assessed the number and rate of distal biceps tendon rupture surgery using the Finnish and Swedish Hospital Discharge Register as databases. The study included the entire Finnish and Swedish adult population aged 18 years and older between January 1, 1997 and of December 31, 2016. RESULTS: During the study period, 2,029 patients had a distal biceps tendon rupture in Finland, and the corresponding figure was 2,000 in Sweden. The rate of distal biceps tendon rupture surgery increased steeply, but equally, in both countries, in Finnish men from 1.3 per 100,000 person-years in 1997 to 9.6 in 2016, and in Swedish men from 0.2 in 1997 to 5.6 in 2016. The incidence of distal biceps tendon rupture in Sweden increased in men from 1.6 to 10.0 per 100,000 person-years from 2001 to 2016. CONCLUSIONS: There was a 7-fold and a 28-fold increase in the incidence of distal biceps tendon rupture surgery in Finnish and Swedish men during 1997 to 2016. The incidence of distal biceps tendon rupture rose 6-fold in Swedish men in 2001 to 2016. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The effect of tendon rotation on distal biceps repair.

BACKGROUND: The distal biceps tendon externally rotates from proximal to distal before inserting onto the radius. Our hypothesis is that an externally rotated (anatomic) repair would re-create native supination moment arm and flexion force, whereas an internally rotated (nonanatomic) repair would result in reduced force transmission. METHODS: The mechanical tests performed in this study measured isometric moment arms and elbow flexion force using a validated elbow simulator as previously published. Mechanical testing was performed on 8 native cadaveric elbows (61 ± 15 years). The distal biceps tendons in all specimens were then incised from their footprint and repaired with anatomic and nonanatomic tendon rotations. After each repair, the specimens were retested. The repair sequence was randomly assigned. RESULTS: Gross observation showed repair site bunching with the nonanatomic repairs. There was no statistical difference in the moment arms between the native, anatomic, and nonanatomic rotations for the 3 forearm angles (P ≥ .352). Analysis showed no statistical difference in flexion force ratio for the elbow at 90° (P ≥ .283). DISCUSSION: The study showed that biceps tendon rotation does not play a role in supination moment arm or flexion force. Twisting the distal biceps tendon around the tendon axis does not change the direction of its applied force on the tuberosity. Tendon bunching in nonanatomic reattachments increases repair site width, which may lead to tendon-ulnar impingement during forearm rotation.