Factors That Determine Supination Strength Following Distal Biceps Repair

Schmidt, Christopher C.; Brown, Brandon T.; Qvick, Lars M.; Stacowicz, Rafal Z.; Latona, Carmen R.; Miller, Mark Carl

doi:10.2106/jbjs.15.01025

Cited by 48 publications

(26 citation statements)

References 28 publications

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“…However, in clinical practice, restoration of full supination strength comparable to that of the uninjured arm rarely occurs during a full range of motion 17, 4, 7. A study using postoperative magnetic resonance imaging scans verified an anatomic reattachment site and radial protuberance preservation, but the injured arm recovered 81.3% ± 16.4% of isometric supination strength normalized to the contralateral side in 60° of forearm supination ( P = .027) 17 …”

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confidence: 98%

“…Cadaveric mechanical studies have demonstrated that reattaching the distal biceps tendon to its anatomic footprint and preserving the radial protuberance lead to a return of native supination moment arms and flexion strength 16, 19, 21. However, in clinical practice, restoration of full supination strength comparable to that of the uninjured arm rarely occurs during a full range of motion 17, 4, 7. A study using postoperative magnetic resonance imaging scans verified an anatomic reattachment site and radial protuberance preservation, but the injured arm recovered 81.3% ± 16.4% of isometric supination strength normalized to the contralateral side in 60° of forearm supination ( P = .027) 17 …”

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The effect of tendon rotation on distal biceps repair

et al. 2019

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BackgroundThe 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.MethodsThe 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.ResultsGross 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).DiscussionThe 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.

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The effect of tendon rotation on distal biceps repair

et al. 2019

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“…Acute anatomic surgical repair of distal biceps brachii tendon has been shown to improve functional outcomes, strength, and muscle endurance after distal biceps rupture. 1 , 16 , 22 , 23 Cortical button fixation has been shown to outperform bone tunnels, intraosseous screws, and suture anchors in biomechanical studies. 7 , 12 , 16 , 19 As noted previously, the most common major complication following surgery is PIN palsy, and unicortical button fixation may have the advantage of avoiding inadvertent injury to the PIN.…”

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No Significant Difference Between Intramedullary and Extramedullary Button Fixation for Distal Biceps Brachii Tendon Rupture After Cyclic Loading in a Cadaver Model

Majumdar

Salas

Chavez

et al. 2021

Arthroscopy, Sports Medicine, and Rehabilitation

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To biomechanically compare intramedullary (IM) versus extramedullary (EM) distal biceps button fixation under cyclic loading conditions, which is most representative of postoperative physiologic status. Methods: This controlled laboratory study used 13 fresh-frozen matched paired cadaver elbows. One specimen from each pair was randomized to either IM (unicortical) or EM (bicortical) distal biceps button fixation via onlay technique. A servohydraulic actuator was used to cycle each specimen from full extension to 90 of flexion at 0.5 Hz for 3,000 cycles. All specimens were subsequently loaded to failure to simulate an acute postoperative load. Results: During cyclic loading, the mean change in force from cycle 5 to cycle 3000 was 2.1 AE 3.2 N for the IM group and 0.6 AE 4.2 N for the EM group (P ¼ .19). The increase in tendon gap for the IM group was 1.02 mm and for the EM group was 1.83 mm (P ¼ .37). During failure loading, the IM group had a mean failure load of 154.9 AE 44.5 N and the EM group a mean failure load of 191.1 AE 62.6 N (P ¼ .16). Conclusions: No significant differences exist between the IM and EM techniques in loss of force and tendon gap formation under cyclic loading or load to failure conditions. Thus, IM fixation may adequately facilitate optimal bonetendon apposition, with less risk of iatrogenic injury to the posterior interosseous nerve that can be seen with bicortical extramedullary fixation. Clinical Relevance: The most common major complication following distal biceps repair is PIN palsy. IM fixation may be sufficient in facilitating optimal bone-tendon apposition and healing with onlay technique, while minimizing risk of iatrogenic PIN injury associated with EM fixation.

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“…This more posterior attachment improves the rotational moment arm of the distal biceps to facilitate its most important function, supination. 2,[4][5][6] And because forceful retraction through the anterior wound is minimized, direct retraction of the nerves is reduced, leading to a lower reported rates of both LABC and PIN injury. 3 The greatest limitation of the 2-incision technique is that it carries a slightly higher rate of HO and synostis.…”

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confidence: 99%

“…3 The 2-incision approach yields direct access to the tuberosity and allows restoration of the anatomic attachment site, which improves supination strength, the most important function of the distal biceps. 2,[4][5][6] And because forceful retraction through the anterior wound is reduced, direct retraction of the nerves is reduced, leading to a lower reported rate of nerve injury. 3 Although the rate of heterotopic ossification (HO) and synostis is slightly higher, the use of indomethacin prophylaxis has been shown to mitigate them.…”

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Two-Incision Distal Biceps Repair with Cortical Button: A Technique to Improve Supination Strength

Amini

2021

Arthroscopy Techniques

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Tears of the distal biceps are common, and nonoperative treatment results in significant loss of supination strength. Surgery is indicated for most patients to restore this supination strength. Both 1-and 2-incision techniques are successful, but each has its own advantages and disadvantages. We believe the 2-incision technique better restores the anatomic attachment site of the tendon, which leads to better supination strength and has a lower rate of neurologic injury. Although it does have a slightly higher risk of synostis, this can be mitigated by routine prophylaxis with NSAIDs. Augmenting the repair with a cortical button has been shown to increase the load-to-failure better than the traditional 2incision technique that employs transosseous fixation. Here we present our technique of 2-incision distal biceps repair with cortical button, a technique intended to maximize supination strength.

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Factors That Determine Supination Strength Following Distal Biceps Repair

Abstract: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cited by 48 publications

References 28 publications

The effect of tendon rotation on distal biceps repair

The effect of tendon rotation on distal biceps repair

No Significant Difference Between Intramedullary and Extramedullary Button Fixation for Distal Biceps Brachii Tendon Rupture After Cyclic Loading in a Cadaver Model

Two-Incision Distal Biceps Repair with Cortical Button: A Technique to Improve Supination Strength

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