Operative Versus Nonoperative Management for Distal Biceps Brachii Tendon Lesions: A Systematic Review and Meta-analysis

Abstract

Background: Both nonoperative and operative treatments have been proposed to manage distal biceps brachii tendon avulsions. However, the advantages and disadvantages of these approaches have not been properly quantified. Purpose: To summarize the current literature on both nonoperative and operative approaches for distal biceps brachii tendon ruptures and to quantify results and limitations. The advantages and disadvantages of the different surgical strategies were investigated as well. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic literature search was performed in March 2020 using PubMed Central, Web of Science, Cochrane Library, MEDLINE, Iscrctn.com , clinicaltrials.gov , greylit.org , opengrey.eu , and Scopus literature databases. All human studies evaluating the clinical outcome of nonoperative treatment as well as different surgical techniques were included. The influence of the treatment approach was assessed in terms of the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Mayo Elbow Performance Index; extension, flexion, supination, and pronation range of motion (ROM); and flexion and supination strength ratio between the injured and uninjured arms. Risk of bias and quality of evidence were assessed using the Cochrane guidelines. Results: Of 1275 studies, 53 studies (N = 1380 patients) matched the inclusion criteria. The results of the meta-analysis comparing operative versus nonoperative approaches for distal biceps tendon avulsion showed significant differences in favor of surgery in terms of DASH score ( P = .02), Mayo Elbow Performance Index ( P < .001), flexion strength (94.7% vs 83.0%, respectively; P < .001), and supination strength (89.2% vs 62.6%, respectively; P < .001). The surgical approach presented 10% heterotopic ossifications, 10% transient sensory nerve injuries, 1.6% transient motor nerve injuries, and a 0.1% rate of persistent motorial disorders. Comparison of the different surgical techniques showed similar results for the fixation methods, whereas the single-incision technique led to a better pronation ROM versus the double-incision approach (81.5° vs 76.1°, respectively; P = .01). Conclusion: The results of this meta-analysis showed the superiority of surgical management over the nonoperative approach for distal biceps tendon detachment, with superior flexion and supination strength and better patient-reported outcomes. The single-incision surgical approach demonstrated a slightly better pronation ROM compared with the double-incision approach, whereas all fixation methods led to similar outcomes.

Distal Biceps Repair Using an All-Suture Anchor Technique

“…This is thought to be due to dissection of the supinator required by the 2-incision technique, resulting in increased postoperative fibrosis. 14 Initial studies demonstrated greater risk of nerve injury in the one incision technique; however, recent developments in fixation devices limit the need for extensive dissection of the cubital fossa and now demonstrate low level of transient nerve injury. 15 …”

“…A recent meta-analysis demonstrated no significant difference in postoperative strength ratio to the uninjured limb with flexion and supination strength when comparing cortical buttons, suture anchors, and transosseous suture. 14 The use of a knotless suture anchor compared with an inlay intraosseous screw decreases radial neck fracture risk, as well as radial tuberosity osteolysis. 16 This has been related to the substantially sized bone tunnel required for interference screws, without significant clinical benefit.…”

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

“…Indeed, in a recent survey of shoulder surgeons in the United Kingdom, 83% of respondents reported repairing more than half of these injuries [ 8 ]. Systematic reviews and meta-analyses comparing non-operative versus operative management have suggested operative management to result in improved strength and better patient-reported outcomes [ 9 , 10 ].…”

Minimally Invasive Distal Biceps Tendon Reconstruction With Semitendinosus Allograft and Dual Unicortical Button Fixation

“…Distal biceps ruptures occur after an eccentric load applied to the flexed elbow. Although surgical repair is most often advocated for restoration of flexion and supination strength, 1 in chronic cases or high energy mid-substance tears or in patients with substantial tendon degeneration, repair is not always possible. In these cases, reconstruction with either autograft or allograft tendon can be performed.…”