Rev. bras. ortop. vol.52 número2

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Acute

distal

biceps

ruptures:

single

incision

repair

by

use

of

suture

anchors

夽

Rafael

Almeida

Maciel

_,

_Priscilla

_Silva

_Costa,

_Eduardo

_Antônio

_Figueiredo,

Paulo

Santoro

Belangero,

Alberto

de

Castro

Pochini,

Benno

Ejnisman

UniversidadeFederaldeSãoPaulo,DepartamentodeOrtopediaeTraumatologia,CentrodeTraumatologiadoEsporte,SãoPaulo,SP, Brazil

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Articlehistory:

Received27January2016 Accepted31May2016 Availableonline9March2017

Keywords: Elbow/surgery Elbow/injuries Treatmentoutcome

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Objective:Clinicalandfunctionalassessmentofthesurgicaltreatmentforacuteinjuryof thedistalinsertionofthebicepsbrachialperformedwithasurgicaltechniqueusingasingle incisioninproximalforearmandfixationwithsutureanchorsintheradialtuberosity. Methods:This study reviewed the medical recordsofpatients who underwent surgical treatmentofdistalbicepsinjuryduringtheperiodbetweenJanuary2008andJuly2014. Ina mean follow-up of12 months,22 patients with completeand acute injury, diag-nosedthroughphysicalexaminationandimagingstudies,werefunctionallyassessedin thepostoperativeperiodregardingtherangeofmotion(degreesofflexion-extensionand pronation–supination),thepresenceofpain(VAS),theAndrewsCarson-score,andtheMayo ElbowPerformanceScore(MEPS).

Results:Duringthepostoperativefollow-upassessment,nopatientreportedpainbyVAS scale;allweresatisfiedwiththeestheticappearanceofthesurgery.Therangeofarticular movementremainedunchangedat95.4%ofpatients,withthelossof8◦_{ofsupinationin} onepatient.Nochangesinmusclestrengthwereobserved.Theresultsofthe Andrews-Carsonscoreweregoodin4.6%andexcellentin95.4%ofcases;theMEPSpresented100% ofexcellentresults.Therateofcomplicationswas27.2%,similartotheliterature. Conclusion:Surgicalrepairofacuteinjuryofthedistalbicepstroughasingleincisioninthe proximalforearmandfixationwithtwosutureanchorsintheradialtuberosityisaneffective andsafetherapeuticoption,allowingearlymotionandgoodfunctionalresults.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedattheUniversidadeFederaldeSãoPaulo,DepartamentodeOrtopediaeTraumatologia,CentrodeTraumatologiado Esporte,GrupodeOmbroeCotovelo,SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:rafaelalmeidamaciel@gmail.com(R.A.Maciel). http://dx.doi.org/10.1016/j.rboe.2017.03.004

Lesão

do

bíceps

distal

aguda:

reparo

por

via

única

e

fixac¸ão

por

âncora

de

sutura

Palavras-chave: Cotovelo/cirurgia Cotovelo/lesões Resultadodetratamento

r

e

s

u

m

o

Objetivo: Avaliac¸ãoclínicaefuncionaldotratamentocirúrgicodalesãoagudadainserc¸ão distaldobícepsbraquialpelatécnicacirúrgicaporviadeacessoúnicanoantebrac¸oproximal efixac¸ãocomâncorasdesuturanatuberosidaderadial.

Método: Estudofeitopormeiodarevisãodosprontuáriosdepacientessubmetidosa trata-mentocirúrgicodelesãodainserc¸ãodistaldobícepsbraquialentrejaneirode2008ejulho de2014.Emumseguimentomédiode12meses,22pacientescomlesãocompletaeaguda, diagnosticadosporexamefísicoeexamesdeimagem,foramavaliadosfuncionalmenteno pós-operatóriopormeiodamensurac¸ãodaamplitudedemovimentos(grausde flexoex-tensãoepronossupinac¸ão),pelapresenc¸adedor(EVA)epelasescoresdeAndrews-Carson eMayoElbowPerformanceScore(MEPS).

Resultados: Durantea avaliac¸ão dos pacientesnoseguimento pós-operatório,nenhum pacientereferiadorpelaescalaEVAetodosestavamsatisfeitoscomaaparênciaestética dacirurgia.Aamplitudedemovimentoarticularencontrava-seinalteradaem95,4%dos pacientes,coma perda de 8◦ _{de supinac¸ãoem um paciente.Os resultados segundoo} escoredeAndrews-Carsonforambonsem4,6%eexcelentesem95,4%doscasos;noMEPS, observaram-se100%deresultadosexcelentes.Ataxadecomplicac¸õesfoide27,2%,valor semelhanteaosdadosdaliteratura.

Conclusão: Otratamentocirúrgicodaslesõesagudasdobícepsdistalporviaúnicacom fixac¸ãocomousodeduasâncorasdesuturamostrou-seumaopc¸ãoterapêuticasegurae eficaz,permitiumovimentac¸ãoprecoceebonsresultadosclínicosefuncionais.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Injuriesofthedistalinsertionofthebicepsbrachiiare uncom-mon,withanincidenceof1.2per100,000patientsperyear.1

Themostcommonmechanismofinjuryischaracterizedby aneccentricmusclecontraction,withtheelbowflexedat90◦ andtheforearminsupination,occurringpredominantlyinthe dominantupperlimbofmalesaround40–50years.2

Surgical treatmentis superior toconservative approach regardingclinicalandfunctionalresults.Conservative treat-mentsusuallyleadtomuscleweakness,mobilitydisorders, andestheticdeformities.3,4

Numeroussurgicaltechniquesarereportedforthe reinser-tionofdistalbiceps, throughdoubleor singleaccessroute, withdifferentfixationmethods,amongwhichthemost com-monlyusedarebonetunnel,interferencescrew,endobutton, andsutureanchor.5_{Clinicalstudieshavedemonstratedthe}

advantagesofsingleaccess route,withexcellent resultsin repairsusingsutureanchors.6,7

Thisstudyaimedtodescribeaminimallyinvasivesurgical techniqueforrepairofthedistalbicepstendonthroughtwo double-loadedsutureanchors,aswellastodescribeitsclinical andfunctionalresults.

Material

and

methods

This study reviewed the medical records of patients who underwent surgical treatment ofdistal biceps brachii

insertioninjuryduringtheperiodbetweenJanuary2008and July2014.

Atfirst,39casesofdistalbicepsinjurywereretrieved. Inclu-sioncriteriaweredistal,isolatedandclosedbicepslesion;less than sixweeksbetweeninjuryand surgicaltreatment; use ofthesamesurgicaltechnique;andaminimum postopera-tivefollow-upofsixmonths.Exclusioncriteriawerepartial andchronicinjuriesofthedistalbicepstendon;surgical tech-niquewithdoubleaccessroute;fixationmaterialotherthan sutureanchors;useofgraftfortendonfixation;and postoper-ativefollow-upoflessthansixmonths.Thus,afterreviewing charts,22patientswereincludedinthepresentstudy(Table1). Lesions were diagnosed by physical examination (hook test)andimaging(magneticresonanceimaging[MRI]or ultra-sound)confirmingacompleteruptureofthedistalinsertion ofthebiceps.

Patientswereassessedregardingrangeofmotionwitha goniometer,whichmeasuredthedegreesofflexion-extension andpronosupination,andpresenceofpain,assessedbythe visualanalogscale(VAS);theAndrews-Carson8_andtheMayo

ElbowPerformanceScore(MEPS)scoreswereapplied.9

Allpatientssignedaninformedconsentformpriortotheir participationinthisstudy,whichwassubmittedtothe eval-uationandapprovaloftheEthicsCommitteeforResearchin HumanBeings.

Surgicaltechnique

Table1–Epidemiologicaldataofpatientswithacute injuryofthedistalbicepsbrachiiinsertion.

Age Sex Dominance

1 53 M +

2 35 M

3 43 M +

4 31 M +

5 39 M +

6 67 M +

7 65 M +

8 37 M +

9 61 M +

10 42 M +

11 47 M +

12 40 M

13 38 M +

14 64 M +

15 35 M +

16 41 M

17 56 M +

18 55 M +

19 36 M

20 28 M +

21 38 M +

22 43 M +

Fig.1–Intraoperativelocationoftheradialtuberosity, usingradioscopy.

tourniquet,astheauthors believethattheuse ofa tourni-quetincreasesthedifficultyoftheprocedurebylimitingthe mobilizationofthedistalbicepstendon.

Asingle accessroute was created approximately 2.5cm fromthecubitalflexioncrease,guidedbyfluoroscopyfor ini-tiallocationoftheradialtuberosityonitsulnaredge(Fig.1).A 5-cmsurgicalincisionintheanteriorregionoftheproximal

thirdofthe forearm, atthe radial tuberosity,inthe trans-verseplane,withcarefuldissectionofsoft tissues,allowed thesearchinthesuperficialplaneforthedistalbiceps ten-donstump,proximallyretracted(Fig.2).Tractionsutureswere passedthroughthebicepstendoninitstendinousportionto enableitsmobilizationandre-approximationatits anatomi-calinsertion,attheulnaredgeoftheradius,withtheforearm incompletesupinationandat10◦_{ofelbowflexion(Fig.3).The}

Fig.2–Singleaccessroute.

Fig.3–Tractionsutureintheruptureddistalbicepstendon.

soft tissueand thelacertusfibrosus werereleased toallow increasedmobilitywhennecessary.Theradialtuberositywas exposed bydelicatelydisplacingsoft tissues,thus avoiding neurologicalandvascularinjury.Then,theradialtuberosity wasdebridedforremovalofresidualtendontissueand scar-ring,inordertoallowbleeding,aimingtopotentiateadhesion ofthereinsertion.

Two3-mmsutureanchors,loadedwithhigh-resistance fil-aments,werepositionedintheradialtuberosity,aligned(one proximalandonedistal),withapproximately1cmdistance betweenthem.Twoindependentsutureswerepassedthrough the regularized distal stump, with self-locking stitches, to allowthetendontobere-attachedtothebone(Fig.4).The distalanchorrepairwasfixatedfirsttoestablishthelength of the tendon;then, proximalanchor repairswere fixated, whichallowedthetendonfootprinttoberecreated maximiz-ingtendon-bonecontactarea.

Stabilityoftherepairwasconfirmedunderdirect visual-ization,withevaluationofthebicepsbrachiitendontension. Woundwasthenstitched,withapproximationofthe subcu-taneoustissueandsteriledressing.

Results

Fig.4–Self-lockingstitchtoallowthetendontobe re-approximatedtothebone.

All patients presented elbow flexion against resistance withtheforearminsupinationasthemechanismoftrauma; onlytwooccurredduringsportstraining.Allpatients under-wentphysicalexaminationwithhooktest,whichwasfound tobepositivein19patients(86.3%).Thefollowing comple-mentaryexamswererequested:elbowradiographs(frontand profile)inallcases;14 elbowMRIs(63.6%);and eight ultra-sounds(36.3%)forconfirmationandassessmentoftheelbow lesion.

Mean time between injury and surgery was eightdays (1–35).

Meanfollow-upwas12months(6–18).During postopera-tivefollow-upassessment,nopatientreportedpainbyVAS scale;allwere satisfiedwiththeestheticappearanceofthe surgery.Range ofmotionremained unchanged at95.4% of patients,withlossof8◦_{ofsupinationinonepatient.Results} oftheAndrews-Carsonscoreweregoodin4.6%andexcellent in95.4%ofcases;MEPSpresentedexcellentresultsin100%.

Inthepresentsample,acomplicationrateof27.2%was observed. Sixcases were reported: four patients presented neuropraxia ofthelateral cutaneous nerveofthe forearm; one, radialneuropraxia; and one, partialloss of ROM, but withoutclinicalrepercussionsduringdailyactivitiesandwith improvementinclinicalfollow-up.

Returntoactivityand thepracticeofsportsoccurred in threemonths,atthesamelevelasbeforeinjury.

Discussion

Distal biceps tendon ruptures represent 3% of biceps ruptures.10 _{However,arecentstudybySafranandGraham}1

showedanapproximateincidenceof10%.Itoccurs preferen-tiallyinmalesinthefifthandsixth decadesoflife,mostly inthedominantlimb,andtraumamechanismismainlyan eccentricbicepscontractiononaflexedelbow.Inthepresent study,onlymalepatientswereincluded,withameanageof45 years,involvementofthedominantsidein86%ofthelesions, analogoustotheliteraturedata.3

Diagnosticevaluationofacutedistalbicepsinjuryis ini-tiated by medical history and physical examination, with

specifictestssuchasthehooktest.Basedonclinicalhistory, withreportsofthemaintraumamechanismbyeccentric con-traction,followedbyclinicaldevelopmentofpain,edema,and ecchymosesinthecubital fossa,aswell asapositivehook test,wecanestablishdistalbicepsinjuryasthemain diag-nostichypothesis.Intheliterature,thehooktestpresentsa sensitivityandspecificity of100%.11 _{Nonetheless,complete}

rupture,degreeofretractionofthetendonstump,and pres-enceofassociatedlesionswereconfirmedthroughadditional tests.Ultrasonographyallowsidentificationoflesionas par-tialorcomplete,withstudiesshowing95%sensitivityand71% specificity.Itisalsopossibletodeterminedegreeofretraction ofthetendonstump.12_{Thisexamisinexpensiveandeasyto}

performinBrazil;therefore,itwasusedin40%ofthe sam-ple.MRIisconsideredthegoldstandardexamfordefinitive diagnosis;italsoaidssurgicalplanninganddiscards associ-atedlesions.13_{Thus,thismethodwaspreferredandapplied}

in60%ofthepresentcases(Fig.5).

The best treatment for distal biceps injuries, whether conservative or surgical, is no longer questioned in the literature.14_{Conservativetreatmentresultsinmuscle}

weak-ness,withlossofsupinationforceofapproximately40%and flexionforceofapproximately30%,aswellasrestrictionsin activities ofdailyliving.4 _{Thus,the authorsagreewith the}

literature,reservingconservativemodality forpatientswho cannotbesubmittedtosurgeryandelderlypatientswithlow functionaldemands.4,14

Surgicaltreatmentisthechosenapproachandshouldbe performedasearlyaspossible;aperiodofuptosixweeks hasbeenestablished,asitallowsrecoveryandmobilizationof theretracteddistalbicepstendonand,thus,allows anatom-icalfixationofthetendonintheradialtuberosity.Another importantfactoristoavoidclosureofthespacepreviously occupiedbythetendontotheplaceofitsinsertion,byfibrous tissueand/orpseudotendon.Thisclosureleadstochangesin localanatomy, causedbyadhesionsandlocalfibrosis, hin-dering safeexposure and the identification and protection ofnoblestructures,especiallythelateralcutaneousnerveof theforearm.Thelateralcutaneousnerveislocatedlaterally tothedistalbicepstendon,closetotheradialtuberosity;it maybeaffectedinbothruptureandsurgicalreinsertion,being responsibleforthemostfrequentcomplicationinthistypeof procedure.3,15,16_{Therefore,thepresentapproachallowsfora}

safedissectionofsofttissues;thetunnelofthedistalbiceps tendoncanbevisualized,withtendonexcursiontoits reinser-tionpoint.Thisreducestheriskofneurologicalinjuries,which reducestheratesofcomplicationsrelatedtothetimeperiod betweeninjuryandsurgicalrepair.Thisapproachalsoallows restorationofforearmsupinationforceandelbowflexionto nearpre-injurylevel.6

There is no consensus in the literature regarding best approachandbestmethodoffixationfordistalbiceps rup-tures,andtherearemanypossibilities.Grewaletal.,17_intheir

randomized clinical trial, observedno difference inresults whencomparingsingleanddoubleaccessroutes.In2014,a systematicreviewbyWatsonetal.18_{foundsmalldifferences,}

Fig.5–T2-weightedmagneticresonanceimagingoftheforearmafterinjury,withfatsuppression,showingcomplete ruptureofthedistalbiceps(arrows).A,coronalcut;B,axialcut;C,sagittalcut.

withtransverseorientation,asthisapproachprovides excel-lentvisualizationoftheradialtuberosity,allowsresectionof thestumpofthedistally-retractedrupturedtendonand lim-iteddissectionofsoftparts,reducestherisksofcomplications, andhasabetterestheticresult(Fig.6).Thechoiceofasingle accessrouteontheradialtuberosity,inwhichthecorrect fore-armpositioningformaximumsupinationandsemi-flexionfor thereinsertionofthedistaltendonofthebicepsare impor-tant, is based on the anatomical knowledge described by Mazzoccaetal.,19_{supplementedbyotheranatomicalstudies}

thatdescribethefootprintofthedistalbicepstendonregion locatedinpostero-ulnarradialtuberosity,measuring21mm inlengthand7mminwidth.20,21

Duetotheavailabilityofdifferentfixationmethodsforthe reinsertionofthedistalbiceps,eachwithitsown character-istics,advantages,anddisadvantages,severalbiomechanical studies comparing these methods have been conducted, showing divergent results, powering the doubt of which methodispreferential.Mazzocaetal.5_{assessedthefourmost}

common methods of treatment (bonetunnel, endobutton, interferencescrew,andsutureanchors)incadavericelbows subjectedtocyclicloadsof50Nforcefrom0◦_to90◦_flexionand concludedthat the endobutton technique presents greater resistancetofailure.However,mostclinicalstudiesusesuture anchorsasamethodofcomparisonbetweentheavailable fix-ation techniques,observing optimalclinicaland functional

Fig.6–Clinicalevaluationatfourweekspostoperative, withevaluationofsurgicalscarintheproximalforearm (arrow).

results.3,22_{Fewclinicalstudieswiththeuseofendobuttonare}

available;therefore,newstudiesare neededtoallowa bet-tercomparisonofthelattertwotechniques.23_Inthepresent

study,reinsertionwasmadewithtwosutureanchors,which reestablishedlengthandrecreatedthefootprintofthetendon. Inthepresentpractice,thismaterialisavailable,andgood sur-gicalresultsinshort-andlong-termfollow-upwereachieved withthistechnique,withoutlossoffixation.

Inthepresentsample,complicationratewas27.2%,similar tothat reportedinthe literature,which is26.4%.18

Associ-atedwiththisfactor,duringfollow-up4.6%goodand95.4% excellentresultswereobservedintheAndrews-Carsonscore, as well as100%excellent resultsin theMEPS scale.These findingsconfirmthesatisfactoryresultsofthissurgical tech-nique. Mostcommon complicationwas neuropraxia ofthe lateral cutaneousnerveoftheforearm;this wasalso men-tionedinmoststudiesasthemaincomplication.18_Recovery

fromneurologicalsymptomsoccurredinthefirstmonthsof postoperativefollow-up.Neuropraxiaoftheradialnervewas observedinthepatientwiththelongesttimeperiodbetween injuryandsurgicalprocedure(35days).

Allpatientsfollowedthespecificrehabilitationprotocolset forth bythisgroup.Therepairallowedearlypassive move-mentwithinoneweekpostoperatively;aslingwasusedfor two weeks, and active movements were initiated at four weeks,whichevidencedtheeffectivenessofthismethodof fixation.Meantimetoreturntoactivitieswithalevel simi-lartothatpresentedbeforeinjurywasthreemonths,withno complaintsandwithahighsatisfactionindex.

Conclusion

Earlysurgicalrepairofacuteinjuryofthedistalbicepsthrough asingleincisionattheproximalforearmandfixationwithtwo sutureanchorsintheradialtuberosityisaneffectiveandsafe therapeuticoption,allowingearlymotionandgoodfunctional results.

Conflicts

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