Supination torque following single- versus double-incision repair of acute distal biceps tendon ruptures.

BACKGROUND: Compared with single-incision (SI) distal biceps repair, double-incision (DI) repair has been described as permitting a more anatomic repair. We hypothesized that DI repair would result in greater terminal supination torque compared with SI repair for acute distal biceps ruptures. METHODS: Patients were included if they sustained an isolated, acute distal biceps rupture repaired between January 2012 and December 2017. Isometric forearm supination torque in 4 positions was measured using a validated uniaxial torque-testing device. Testing took place at least 12 months from surgery. The primary outcome was supination torque in the 60° supinated position. Secondary outcomes included supination torque in other forearm positions and functional outcome scores. RESULTS: The study included 37 patients: 15 underwent repair with the DI technique and 22 with the SI technique. The mean age was 47.3 years, the median follow-up time was 28.1 months, and demographic data were similar between cohorts. Mean supination torque, relative to the unaffected side, was 61% (95% confidence interval, 45%-77%) for DI repair vs. 80% (95% confidence interval, 69%-92%) for SI repair in the 60° supinated position (P = .036). In a multivariable linear regression model controlling for arm dominance, age, follow-up time, and workers' compensation status; SI repair was associated with greater mean supination torque than DI repair by 20% (P = .015). CONCLUSIONS: Contrary to our hypothesis, we found a 20% mean improvement in terminal supination torque for acute distal biceps ruptures repaired with the SI technique compared with the DI technique. This finding may have clinical significance for the more discerning, high-demand patient.

Elbow flexion and forearm supination strength in a healthy population.

BACKGROUND AND HYPOTHESIS: Despite the lack of representative data of a healthy population, many clinical trials concerning the measurement of postoperative elbow flexion or forearm supination strength use the contralateral side as a control. We hypothesized that there are no differences in elbow flexion and supination strength between the dominant and nondominant sides in healthy volunteers. METHODS: The study was performed on a cross-sectional cohort of healthy subjects without any prior injuries or surgical interventions of the upper extremities. Isometric elbow flexion strength and supination strength were measured on both the dominant and nondominant sides. The results were analyzed for the entire group and subanalyzed for female vs. male, for different age groups, and according to handedness and regular practice of overhead sports. RESULTS: A total of 150 subjects (75 female and 75 male subjects; mean age, 44 ± 15 years [range, 18-72 years]) were included in this study. Within the entire collective, no significant differences concerning the elbow flexion strength between the dominant and nondominant sides could be detected, whereas the supination strength was 7% higher on the dominant side (P = .010). Women, right-hand-dominant subjects, and subjects who do not regularly practice overhead sports have a significant 8% higher supination strength on the dominant side compared with the nondominant side (P < .05). Left-hand-dominant subjects have an 8% higher elbow flexion strength on the nondominant right side (P < .05). CONCLUSION: Elbow flexion strength and forearm supination strength differ between the dominant and nondominant sides. The contralateral upper extremity cannot be used as a matched control without some adjustments.

Factors affecting supination strength after a distal biceps rupture.

HYPOTHESIS: This study quantified pain (visual analog pain scale [VAPS]), disability (Disabilities of the Arm, Shoulder and Hand [DASH]) and isometric supination torque at 3 forearm positions in a prospective cohort of biceps-deficient arms to assess the potential for functional return with nonoperative treatment. MATERIALS AND METHODS: Twenty-three men (50 ± 11 years) with complete unilateral distal biceps avulsion underwent isometric supination strength testing of both limbs at 60° of supination, 0° (neutral), and 60° of pronation. After exclusion of 1 outlier patient, the mean time from injury to evaluation was 44 days (range, 4-455 days). Pain level (VAPS) and functional outcome (DASH) were assessed; supination strength was normalized to the uninjured arm. RESULTS: The uninjured arm was stronger (P < .001), and peak torque varied with forearm position (P < .043). Peak torque was greater in pronation compared with supination, regardless of injury (P < .002). No differences were detected in supination strength as a result of forearm position or arm dominance. Supination strength did not correlate with time from injury to evaluation. One patient regained supination strength (115%) at 60° of pronation and 72% in neutral with a lengthy time from injury. VAPS (5 of 10) and DASH (39 of 100) scores decreased with time and did not relate to supination strength. CONCLUSION: Biceps tendon rupture led to a 60% decrease in supination strength in the neutrally oriented forearm. Peak torque observations can be explained using forearm moment arms. VAPS and DASH scores decreased with time but did not affect strength. We speculate that supination strength from pronation to neutral can improve as one strengthens the brachioradialis but strength deficits from neutral to supination are more difficult to overcome.

Minimal Damage to the Supinator Muscle After the Double-Incision Technique for Distal Biceps Tendon Repair.

BACKGROUND: The effect of the double-incision technique on the supinator muscle is unclear. PURPOSE: The aim of this study was to quantify fatty atrophy of the supinator muscle and map the area of muscle damage. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 19 male patients (median age, 43 years) who underwent distal biceps tendon repair were included in the analysis. Patients with a minimum of 12 months of follow-up were included. The following variables were analyzed: range of motion; shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) score; Summary Outcome Determination (SOD) score; and isokinetic peak force and endurance in supination. Quantitative analysis and mapping of fatty infiltration of the supinator muscle were based on the calculation of proton density fat fraction on magnetic resonance imaging scans of both elbows using the IDEAL (Iterative Decomposition of Echoes of Asymmetrical Length) sequence. RESULTS: At an average follow-up of 24 months (range, 12-64 months), the median SOD score was 9.0 (95% CI, 7.8-9.4), and the mean QuickDASH score was 6.7 (95% CI, 0.0-14.1). A difference of 17% in peak torque was measured between repaired and nonrepaired elbows (repaired elbow: 9.7 N·m; nonrepaired elbow: 11.7 N·m; P = .11). Endurance was better in the repaired elbow than the nonrepaired elbow (8.4% vs 14.9% work fatigue, respectively; P = .02). The average fat fraction of the supinator muscle was 19% (95% CI, 16%-21%) in repaired elbows and 14% (95% CI, 13%-16%) in contralateral elbows (P = .04). The increase in fat fraction was located in a limited area between the radius and ulna at the level of the bicipital tuberosity. CONCLUSION: The assessment of the supinator muscle showed a limited increase in fat fraction between the radius and ulna at the level of the bicipital tuberosity. No significant effect on supination strength was highlighted.

Primary repair of severely retracted nonchronic distal biceps tendon rupture using 2-incision anterior-approach repair.

BACKGROUND: Primary repair of a severely retracted distal biceps tendon can pose a technical challenge. We sought to describe the method and clinical outcomes of a surgical technique used as an adjunct to the conventional anterior single-incision repair for severely retracted biceps tendons. This technique involves a second anterior incision proximally to retrieve a severely retracted tendon followed by passing the tendon through a soft-tissue tunnel. METHODS: We identified 30 consecutive patients who had undergone a primary distal biceps tendon repair by an anterior-approach cortical-button technique. A phone survey was conducted for patient-reported outcomes. Patients returned for bilateral forearm supination strength testing in 2 positions (45º of pronation and 45º of supination). Outcomes were compared between patients who required a second incision and high elbow flexion (>60º) because of severe tendon retraction and those who did not require such interventions. RESULTS: No significant differences in elbow range of motion, supination strength, or patient-reported outcomes were found between the 2 groups of patients (P > .05). Regarding supination strength, the operated side was significantly weaker than the uninjured side in both pronated and supinated positions (P < .05). Both the operated and uninjured sides showed significantly higher torque in a pronated position than in a supinated position (P < .05). CONCLUSIONS: Severely retracted distal biceps tendons can be successfully repaired using a second incision and high elbow flexion without negative effects on the outcomes. Supination strength was decreased following an anterior-approach cortical-button technique, but patient-reported outcomes were not affected negatively.

Mini-open incision for distal biceps repair by suture anchors: follow-up of eighteen patients.

BACKGROUND: This clinical trial was done to describe a mini approach for distal biceps repair using two or three suture anchors. PATIENTS AND METHODS: Twenty patients have undergone surgical repair over the last 10 years. All patients were males with mean age 46.8 (range 35-72), and dominant arm was involved in 70 %. Eighteen patients were evaluated with subjective and objective criteria including patient's satisfaction, active range of motion (ROM), and maximum isometric strength (in supination and flexion) using Cybex dynamometer. Functional scoring included Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score and Oxford Elbow Score. RESULTS: Eighty percent of patients were highly satisfied, with excellent results as defined by Mayo and Oxford Elbow score. Compared to contralateral, the active ROM was not affected in flexion and extension, but pronation and supination were decreased by 5°-10° in two cases. One of eighteen showed hypoesthesia of first and second fingers, and one of eighteen showed a symptomatic heterotopic ossification. There were no reruptures. CONCLUSIONS: Surgical repair of distal biceps tendon with a mini-single-incision as we described provides patient's satisfaction and very good results with respect to ROM and functional scoring, with a low complication rate.

Surgical management of acute distal biceps tendon rupture associated with contralateral radial palsy.

Acute distal biceps tendon rupture constitute a rare lesion of biceps injuries, typically, easy to diagnosis after lifting a heavy object. Treatment is controversial, nonoperative for sedentary and elderly patients; surgical for young and active individuals. Many operative techniques are described, they all aim to restore an excellent strength of flexion and supination. We opted for one-incision method and fixation using trans-osseous anchoring for our patient, because we are convinced that is a simpler and safer technique. Postoperative rehabilitation, after a period of elbow immobilization, must be operated for returning to full activity. Biceps tendon repair has permitted to our patient who suffer from right upper limb handicap due to radial nerve palsy, recuperating the lost strength and force in his dominant limb and maintaining some quality of life.

Supination and Pronation Strength Deficits Persist at 2-4 Years after Treatment of Distal Radius Fractures.

Forearm rotation is a key function in the upper extremity. Following distal radius fracture, residual disability may occur in tasks requiring forearm rotation. The objectives of this study are to define pronation and supination strength profiles tested through the range of forearm rotation in normal individuals, and to evaluate the rotational strength profiles and rotational strength deficits across the testing range in a cohort of patients treated for distal radius fracture associated with an ulnar styloid base fracture. In a normative cohort of 29 subjects the supination strength profile showed an increasing linear relationship from supination to pronation. Twelve subjects were evaluated 2-4 years after anatomical open reduction and volar plate fixation of a distal radius fracture. The injured wrist was consistently weaker (corrected for hand dominance) in both supination and pronation strength in all testing positions, with the greatest loss in 60 degrees supination. Mean supination strength loss across all testing positions was significantly correlated with worse PRWE scores, highlighting the importance of supination in wrist function.