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Double intramedullary cortical button versus suture anchors for distal biceps tendon repair: a biomechanical comparison

Knee Surgery, Sports Traumatology, Arthroscopy volume 23, pages 926–933 (2015)Cite this article

Abstract

Purpose

The aim of this biomechanical in vitro study was to compare the novel technique of double intramedullary cortical button (DICB) fixation with the well-established method of suture anchor (SA) fixation for distal biceps tendon repair.

Methods

A matched-pair analysis (24 human cadaveric radii) was performed with respect to cyclic loadings and failure strengths. Twelve specimens per group were cyclically loaded for 1,000 cycles at 1.5 Hz from 5 to 50 N and from 5 to 100 N, respectively. The tendon–bone displacement was optically analysed using the Image J Software (National Institute of Health). Afterwards, all specimens were pulled to failure. Maximum load to failure and mode of failure were recorded.

Results

All DICB constructs passed the cyclic loading test, whereas 4 of the 12 specimens within the SA group failed by anchor pull-out. Cyclic loading showed a mean tendon–bone displacement of 0.6 ± 1.4 mm for the DICB group and 1.4 ± 1.4 mm for the SA group (n.s.) after 1,000 cycles with 50 N, and a mean displacement of 2.1 ± 2.4 mm for the DICB group and 3.5 ± 3.7 mm for the SA group (n.s.) after 1,000 cycles with 100 N. Load to failure testing showed a mean failure load of 312 ± 76 N and a stiffness of 67.1 ± 11.7 N/mm for the DICB technique. The mean load to failure for the SA repair was 200 ± 120 N (n.s.) and the stiffness was 55.9 ± 21.3 N/mm (n.s.).

Conclusions

The novel technique of DICB fixation showed small tendon–bone displacement during cyclic testing and reliable fixation strength to the bone in load to failure. Moreover, all DICB constructs passed cyclic loadings without failure. Based on the current findings, a more aggressive postoperative rehabilitation may be allowed for the DICB repair in clinical use.

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References

  1. An KN, Hui FC, Morrey BF, Linscheid RL, Chao EY (1981) Muscles across the elbow joint: a biomechanical analysis. J Biomech 14:659–669

    Article  CAS  PubMed  Google Scholar 

  2. Athwal GS, Steinmann SP, Rispoli DM (2007) The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am 32:1225–1229

    Article  PubMed  Google Scholar 

  3. Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D (2000) Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Should Elb Surg 9:120–126

    Article  CAS  Google Scholar 

  4. Baker BE, Bierwagen D (1985) Rupture of the distal biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am 67:414–417

    CAS  PubMed  Google Scholar 

  5. Berlet GC, Johnson JA, Milne AD, Patterson SD, King GJ (1998) Distal biceps brachii tendon repair: an in vitro biomechanical study of tendon reattachment. Am J Sports Med 26:428–432

    CAS  PubMed  Google Scholar 

  6. Chavan PR, Duquin TR, Bisson LJ (2008) Repair of the ruptured distal biceps tendon: a systematic review. Am J Sports Med 36:1618–1624

    Article  PubMed  Google Scholar 

  7. Cho CH, Song KS, Choi IJ et al (2011) Insertional anatomy and clinical relevance of the distal biceps tendon. Knee Surg Sports Traumatol Arthrosc 19:1930–1935

    Article  PubMed  Google Scholar 

  8. Dirim B, Brouha SS, Pretterklieber ML et al (2008) Terminal bifurcation of the biceps brachii muscle and tendon: anatomic considerations and clinical implications. AJR Am J Roentgenol 191:245–255

    Article  Google Scholar 

  9. Eames MH, Bain GI, Fogg QA, van Riet RP (2007) Distal biceps tendon anatomy: a cadaveric study. J Bone Joint Surg Am 89:1044–1049

    Article  CAS  PubMed  Google Scholar 

  10. Forthman CL, Zimmerman RM, Sullivan MJ, Gabel GT (2008) Cross-sectional anatomy of the bicipital tuberosity and biceps brachii tendon insertion: relevance to anatomic tendon repair. J Should Elb Surg 17:522–526

    Article  Google Scholar 

  11. Greenberg JA, Fernandez JJ, Wang T, Turner C (2003) EndoButton-assisted repair of distal biceps tendon ruptures. J Should Elb Surg 12:484–490

    Article  Google Scholar 

  12. Grewal R, Athwal GS, Macdermid JC, Faber KJ et al (2012) Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg 94:1166–1174

    Article  PubMed  Google Scholar 

  13. Heinzelmann AD, Savoie FH 3rd, Ramsey JR, Field LD, Mazzocca AD (2009) A combined technique for distal biceps repair using a soft tissue button and biotenodesis interference screw. Am J Sports Med 37:989–994

    Article  PubMed  Google Scholar 

  14. Hetsroni I, Pilz-Burstein R, Nyska M et al (2008) Avulsion of the distal biceps brachii tendon in middle-aged population: is surgical repair advisable? A comparative study of 22 patients treated with either nonoperative management or early anatomical repair. Injury 39:753–760

    Article  PubMed  Google Scholar 

  15. Hutchinson HL, Gloystein D, Gillespie M (2008) Distal biceps tendon insertion: an anatomic study. J Should Elb Surg 17:342–346

    Article  Google Scholar 

  16. Iriuchishima T, Shirakura K, Yorifuji H, Aizawa S, Murakami T, Fu FH (2013) ACL footprint size is correlated with the height and area of the lateral wall of femoral intercondylar notch. Knee Surg Sports Traumatol Arthrosc 21:789–796

    Article  PubMed  Google Scholar 

  17. Iriuchishima T, Yorifuji H, Aizawa S, Tajika Y, Murakami T, Fu FH (2012) Evaluation of ACL mid-substance cross-sectional area for reconstructed autograft selection. Knee Surg Sports Traumatol Arthrosc, doi:10.1007/s00167-012-2356-0

  18. Jobin CM, Kippe MA, Gardner TR, Levine WN, Ahmad CS (2009) Distal biceps tendon repair: a cadaveric analysis of suture anchor and interference screw restoration of the anatomic footprint. Am J Sports Med 37:2214–2221

    Article  PubMed  Google Scholar 

  19. John CK, Field LD, Weiss KS, Savoie FH 3rd (2007) Single incision repair of acute distal biceps ruptures by use of suture anchors. J Should Elb Surg 16:78–83

    Article  Google Scholar 

  20. Khan AD, Penna S, Yin Q, Sinopidis C, Brownson P, Frostick SP (2008) Repair of distal biceps tendon ruptures using suture anchors through a single anterior incision. Arthroscopy 24:39–45

    Article  PubMed  Google Scholar 

  21. Kettler M, Lunger J, Kuhn V, Mutschler W, Tingart MJ (2007) Failure strengths in distal biceps tendon repair. Am J Sports Med 35:1544–1548

    Article  PubMed  Google Scholar 

  22. Kettler M, Tingart MJ, Lunger J, Kuhn V (2008) Reattachment of the distal tendon of biceps: factors affecting the failure strength of the repair. J Bone Joint Surg Br 90:103–106

    Article  CAS  PubMed  Google Scholar 

  23. King J, Bollier M (2008) Repair of distal biceps tendon ruptures using the Endobutton. J Am Acad Orthop Surg 16:490–494

    PubMed  Google Scholar 

  24. Krushinski EM, Brown JA, Murthi AM (2007) Distal biceps tendon rupture: biomechanical analysis of repair strength of the Bio-Tenodesis screw versus suture anchors. J Should Elb Surg 16:218–223

    Article  Google Scholar 

  25. Lemos SE, Ebramzedeh E, Kvitne RS (2004) A new technique: in vitro suture anchor fixation has superior yield strength to bone tunnel fixation for distal biceps tendon repair. Am J Sports Med 32:406–410

    Article  PubMed  Google Scholar 

  26. Lo EY, Li CS, Van den Bogaerde JM (2011) The effect of drill trajectory on proximity to the posterior interosseous nerve during cortical button distal biceps repair. Arthroscopy 27:1048–1054

    Article  PubMed Central  PubMed  Google Scholar 

  27. Mazzocca A, Burton KJ, Romeo AA, Santangelo S, Adams DA, Arciero RA (2007) Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med 35:252–258

    Article  PubMed  Google Scholar 

  28. Mazzocca AD, Cohen M, Berkson E et al (2007) The anatomy of the bicipital tuberosity and distal biceps tendon. J Should Elb Surg 16:122–127

    Article  Google Scholar 

  29. Mokhtee DB, Brown JM, Mackinnon SE, Tung TH (2009) Reconstruction of posterior interosseous nerve injury following biceps tendon repair: case report and cadaveric study. Hand 4:134–139

    Article  PubMed Central  PubMed  Google Scholar 

  30. Peeters T, Soon C, Jansen N et al (2009) Functional outcome after repair of distal biceps tendon ruptures using the Endobutton technique. J Should Elb Surg 18:283–287

    Article  Google Scholar 

  31. Pereira DS, Kvitne RS, Liang M, Giacobetti FB, Ebramzadeh E (2002) Surgical repair of distal biceps tendon ruptures: a biomechanical comparison of two techniques. Am J Sports Med 30:432–436

    PubMed  Google Scholar 

  32. Rantanen J, Orava S (1999) Rupture of the distal biceps tendon: a report of 19 patients treated with anatomic reinsertion, and a meta-analysis of 147 cases found in the literature. Am J Sports Med 27:128–132

    CAS  PubMed  Google Scholar 

  33. Rose DM, Archibald JD, Sutter EG, Belkoff SM, Wilckens JH (2011) Biomechanical analysis suggests early rehabilitation is possible after single-incision EndoButton distal biceps repair with FiberWire. Knee Surg Sports Traumatol Arthrosc 19:1019–1022

    Article  PubMed  Google Scholar 

  34. Safran MR, Graham SM (2004) Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res 404:275–283

    Article  Google Scholar 

  35. Saldua N, Carney J, Dewing C, Thompson M (2008) The effect of drilling angle on posterior interosseous nerve safety during open and endoscopic anterior single-incision repair of the distal biceps tendon. Arthroscopy 24:305–310

    Article  PubMed  Google Scholar 

  36. Shin SH, Jeon IH, Kim HJ et al (2010) Articular surface area of the coronoid process and radial head in elbow extension: surface ration in cadavers and a computed tomography in vivo. J Hand Surg Am 35:1120–1125

    Article  PubMed  Google Scholar 

  37. Siebenlist S, Elser F, Sandmann GH et al (2011) The double intramedullary cortical button fixation for distal biceps tendon repair. Knee Surg Sports Traumatol Arthrosc 19:1925–1929

    Article  PubMed  Google Scholar 

  38. Siebenlist S, Lenich A, Buchholz A et al (2011) Biomechanical in vitro validation of intramedullary cortical button fixation for distal biceps tendon repair–a new technique. Am J Sports Med 39:1762–1768

    Article  PubMed  Google Scholar 

  39. Spang JT, Weinhold PS, Karas SG (2006) A biomechanical comparison of Endobutton versus suture anchor repair of distal biceps tendon injuries. J Should Elb Surg 15:509–514

    Article  Google Scholar 

  40. Thiel W (1992) The preservation of the whole corpse with natural color. Ann Anat 174:185–195

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

We thank Alexander Fingerle, MD, from the Department of Radiology, Klinikum rechts der Isar, Technical University Munich, Germany, for performing CT scans of the specimens tested. Further, we thank Arthrex for their equipment donation that made this research study possible.

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Affiliations

  1. Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany

    Sebastian Siebenlist, Arne Buchholz, Julian Zapf, Gunther H. Sandmann, Karl F. Braun & Peter Biberthaler

  2. Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany

    Frank Martetschläger & Andreas Lenich

  3. Institute of Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany

    Alexander Hapfelmeier

  4. BG Traumacenter, Eberhard Karls University, Tübingen, Germany

    Tobias M. Kraus

  5. Centre of Orthopaedic Surgery, Hessingpark-Clinic, Augsburg, Germany

    Florian Elser

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  1. Sebastian Siebenlist
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  2. Arne Buchholz
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Correspondence to Sebastian Siebenlist.

Additional information

S. Siebenlist and A. Buchholz contributed equally to this article.

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Siebenlist, S., Buchholz, A., Zapf, J. et al. Double intramedullary cortical button versus suture anchors for distal biceps tendon repair: a biomechanical comparison. Knee Surg Sports Traumatol Arthrosc 23, 926–933 (2015). https://doi.org/10.1007/s00167-013-2590-0

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Keywords

  • Distal biceps rupture
  • Tendon repair
  • Intramedullary cortical button
  • Suture anchor
  • Biomechanics