Optimizing Fixation for Distal Biceps Tendon Repairs: A Systematic Review and Meta-regression of Cadaveric Biomechanical Testing

Abstract

Background: Various surgical techniques can be used to repair acute distal biceps tendon (DBT) tears; however, it is unknown which type of repair or implant has the greatest biomechanical strength and presents the lowest risk of type 2 failure. Purpose: To identify associations between the type of implant or construct used and the biomechanical performance of DBT repairs in a review of human cadaveric studies. Study Design: Systematic review and meta-regression. Methods: We systematically searched the EMBASE and Medline (PubMed) databases for biomechanical studies that evaluated DBT repair performance in cadaveric specimens. Two independent reviewers extracted data from 14 studies that met our inclusion criteria. The pooled data set was subjected to meta-regression with adjusted failure load (AFL) as the primary outcome variable. Procedural parameters, such as number of sutures, cortices, locking stitches, and whipstitches, served as covariates. Adjusted analysis was performed to determine the differences among implant types. The alpha level was set at .05. Results: When using no implant (bone tunnels) as the referent, no fixation type or procedural parameter was significantly better at predicting AFL. Cortical button fixation had the highest AFL (370 N; 95% CI, −2 to 221). In an implant-to-implant comparison, suture anchor alone was significantly weaker than cortical button (154 N; 95% CI, 30 to 279). Constructs using a cortical button and interference screw were not stronger (as measured by AFL) than those using a cortical button alone. The presence of a locking stitch added 113 N (95% CI, 29 to 196) to the AFL. The use of cortical button instead of interference screws or bone tunnels was associated with lower odds of type 2 failure. Avoiding locking stitches and using more sutures in the construct were also associated with lower odds of type 2 failure. Conclusion: Cortical button fixation is associated with greater construct strength than is suture anchor repair and a lower risk of type 2 failure compared with interference screw fixation or fixation without implants. The addition of an interference screw to cortical button fixation was not associated with increased strength. The presence of a locking stitch added 113 N to the failure load but also increased the odds of type 2 failure.

Suture Button Repair for Lateral Ulnar Collateral Ligament in Terrible Triad Injuries: Surgical Technique

“…Biomechanical studies have shown adequate repair of using transosseous sutures, suture anchors, and suture buttons in a variety of pathologies, including distal biceps and pectoralis major repair. 9 , 14 , 15 , 16 , 17 , 18 The senior author began using the cortical button because of its improved control during the tensioning of the LUCL repair, aiming to provide anatomic fixation and prevent postoperative instability. The allowance for free sliding with the suture button permits minor adjustments in tension and, ultimately, a more anatomic repair.…”

Biomechanical Comparison of Distal Biceps Tendon Repair Techniques: Extracortical Single-Button Inlay Fixation Versus Intracortical Double-Button Onlay Anatomic Footprint Fixation

“…The extracortical SB repair technique is widely considered to be biomechanically superior to other techniques owing to its superior tensile load. 28,40,42 Besides the fact that the extracortical SB repair technique did not reveal superior fixation strength as compared with the anatomic DB technique, extramedullary button fixation has demonstrated an increase in rates of intraoperative posterior interosseous nerve complications. 11,26,30 This has driven more anatomic and less dangerous techniques, such as intracortical fixation, to eliminate the requirement for far cortex drilling and button stabilization, thus minimizing posterior interosseous nerve injuries.…”

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

“…With regard to the tendon-to-bone fixation technique, a cortical-button fixation has been shown to be associated with greater mechanical strength and load to failure than other methods [ 19 ]. Camp et al described the surgical fixation of the acute distal biceps tendon rupture using a single intramedullary cortical-button with the advantages of minimizing the amount of native bone sacrifice and absence of violation of the far cortex, thereby reducing the risk of fracture [ 20 ].…”