Revista Española de Cirugía Ortopédica y Traumatología

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1888-4415/ $ - see front mat t er © 2007 SECOT. Published by Elsevier España, S.L. All right s reserved.

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Revista Española de Cirugía

Ortopédica y Traumatología

EDITORIAL ... 145

ORIGINALES RODILLA Valoración clínica y radiológica de las prótesis unicompartimentales de rodilla implantadas con técnica mínimamente invasiva ... 146 P. Martínez-Victorio, M. Clavel Sainz-Nolla, P. Puertas García, J. Avellaneda Guirao, R. Cano Gea y A. Escámez Pérez Supervivencia y factores pronósticos de la osteotomía de valguización tibial en el tratamiento del genu varo artrósico ... 157 M.R. González-Panisello y J.A. Hernández-Hermoso Efecto de la implantación de una vía clínica de cirugía protésica de rodilla en el tiempo de ingreso ... 164 J.A. Hernández-Hermoso, J.J. Morales-Cano, A. Fernández-Sabaté y N. Iranzo Papiol COLUMNA Resultados del tratamiento de la escoliosis idiopática del adolescente mediante instrumentación posterior híbrida ... 173 R. Navarro-Navarro, F. Martín-García, A. Chirino-Cabrera, J.P. Rodríguez-Álvarez, R. Santana-Suárez, J. Molina-Cabrillana y R. Navarro-García Tratamiento de la fractura y luxación de la articulación sacroilíaca mediante un acceso anterior extraperitoneal ... 185 F.J. Ricón Recarey, P. Cano Luis, P. Sánchez Gómez y A. Fuentes Díaz PIE La osteotomía distal percutánea en el tratamiento de la metatarsalgia de los radios menores ... 192 J.E. Salinas Gilabert, F. Lajara Marco y M. Ruiz Herrera

MIEMBRO SUPERIOR Resultados del tratamiento quirúrgico de las roturas del tendón distal del bíceps braquial con técnicas de una y dos incisiones ... 198 A. Montiel-Giménez, F. Granell-Escobar y S. Gallardo Villares NOTAS CLÍNICAS Lesión de Monteggia inveterada. Resultados con la técnica de Bell-Tawse modificada en tres casos ... 205 P. Sánchez Gómez, D.M. Farrington Rueda, F.J. Downey Carmona y A. Tatay Díaz Absceso retroperitoneal gigante secundario a infección protésica de cadera: caso clínico ... 211 I. Ibor, I. Martín-Egaña e I. Calvo NUESTROS CLÁSICOS Osteosíntesis en las fracturas maleolares ... 215 M. Salaverri Bearán e I. Gorostidi Erro COMENTARIO Osteosíntesis en las fracturas maleolares ... 218 E. Gil Garay CARTA AL DIRECTOR Recurrencia de la enfermedad de Legg-Calve-Perthes. Caso clínico ... 220 P. Díaz de Rada Lorente, J.L. Beguiristáin Gúrpide y J. Duart Clemente CONGRESOS, CURSOS Y REUNIONES ... 222 CONVOCATORIAS ... 226 NOTICIAS ... 230 VOLUMEN 53 NÚMERO 3 MAYO JUNIO 2009 Cirugía Ortopédica y Traumatología

SOCIEDAD ESPAÑOLA DE CIRUGÍA ORTOPÉDICA Y TRAUMATOLOGÍA (SECOT)

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* Corresponding aut hor.

E-mail : amont ielgimenez@asepeyo.es (A. Mont iel-Giménez).

ORIGINAL PAPERS

Results of surgical treatment of ruptures of the distal biceps

brachii tendon by means of one and two-incision techniques

A. Montiel-Giménez *, F. Granell-Escobar and S. Gallardo Villares

Depart ment of Ort hopedic and Trauma Surgery. ASEPEYO Hospit al , Barcel ona, Spain

Received Oct ober 22, 2007; accept ed April 30, 2008

Avail abl e on t he int ernet from 22 April 2009

KEYWORDS

Elbow; Biceps t endon; Rupt ures;

Surgical t reat ment ; Sut ure anchors

Abstract

Purpose: To compare t he result s achieved by one- and t wo-incision t echniques in t he

reat t achment of t he dist al biceps t endon.

Mat erial s and met hods: Review of 59 pat ient s wit h an acut e rupt ure of t he dist al biceps

brachii t endon diagnosed over a 14-year period (1990-2004). All pat ient s were male, of a mean age of 46 years. In most cases t he rupt ure had been brought about by a forceful fl exion of t he elbow in combinat ion wit h resist ed supinat ion. Fift y-seven pat ient s were subj ect ed t o surgery: t endon det achment was found in 50 cases, a fully rupt ured t endon at 1-2 cm of t he at t achment sit e in 5 cases and a part ial rupt ure in 2. Henry’s ant erior approach was used in 36 cases and Boyd and Anderson’s combined approach in 21. The use of sut ure anchors facilit at es reat t achment . Result s were assessed by means of Bro-berg and Morrey’s scale.

Resul t s: The most usual complicat ions were radial nerve lesions, wound dehiscences and

complex regional pain syndrome t ype 1. No signifi cant differences were found bet ween t he t wo approaches in t erms of complicat ions. Mean t ime t o work resumpt ion was 21 weeks. None of t he cases result ed in occupat ional disabilit y. The fi nal result was rat ed as excellent in 54 pat ient s and good in 3.

Concl usion: Surgical t reat ment affords good result s in rupt ures of dist al biceps brachii,

alt hough it is not exempt from complicat ions.

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t echniques 199

Introduction

The dist al biceps t endon plays a key role in elbow fl exion and forearm supinat ion. It may be inj ured acut ely as a result of abrupt biceps cont ract ion or overst rain when t he elbow is fl exed and t he forearm supinat ed.

Clinically, inj ury st art s wit h sudden pain on t he ant erior aspect of t he elbow. Physical examinat ion usually reveals loss of st rengt h as well as limit ed fl exion and above all supinat ion of t he forearm. There may be proximal displacement of t he biceps muscle (fi g. 1), alt hough t his is not a consist ent fi nding; hemat oma or ecchymosis may also be present on t he ant erior aspect of t he elbow. The course

of t he t endon cannot be palpat ed wit h t he elbow fl exed against resist ance.

The inj ury may occur in a healt hy t endon or in a previously degenerat ed one. In t he lat t er case, less force is needed t o cause t he lesion. Because of t he t orque experienced by t he t endon fi bers at t heir at t achment , t his area is exposed t o repeat ed frict ion wit h t he bone on pronosupinat ion, which favors t he onset of degenerat ive processes. Seiler et al report t hat t ears occur chiefl y in an area wit h scarce blood

supply locat ed 10-12 mm away from t he insert ion point1.

Alt hough t he fi rst surgical repair of t he dist al biceps t endon is at t ribut ed t o Acquaviva (1898), it was Dobbie who, in 1941, published t he fi rst series, made up of 51 cases. The t reat ment consist ed in sut uring t he avulsed t endon t o t he brachialis muscle. A good funct ional result was obt ained, albeit wit h signifi cant loss of st rengt h. In 1948, Debeyre performed t he fi rst bony reat t achment of t he dist al biceps t endon t o t he radial t uberosit y.

The available surgical approaches for t his condit ion are t hose developed by Henry (single incision) and Boyd and Anderson (t wo incisions). Since t he single incision t echnique increased t he incidence of radial nerve inj uries, use of t he 2-incision t echnique became widespread, alt hough it can also inj ure t he radial nerve and, in addit ion, provoke radioulnar synost hosis. The t echnical modifi cat ion int roduced by Bourne and Morrey has reduced t he prevalence

of t he lat t er complicat ion2. More recent ly, inst rument ed

anchors have facilit at ed manipulat ion of t he t uberosit y, so t hat Henry’s approach can be used wit h fewer complicat ions.

The purpose of t his review was t o compare t he result s of one and 2 incision t echniques for t he bony reat t achment of

PALABRAS CLAVE

Codo;

Tendón del bíceps; Rot uras;

Trat amient o quirúrgico; Anclaj es

inst rument adoss

Resultados del tratamiento quirúrgico de las roturas del tendón distal del bíceps braquial con técnicas de una y dos incisiones

Resumen

Obj et ivo: Comparar los result ados de las t écnicas de una y dos incisiones para la

reinser-ción ósea del t endón dist al del bíceps.

Mat erial y mét odos: Serie de 59 suj et os diagnost icados de rot ura aguda del t endón dist al

del bíceps braquial durant e 14 años (desde 1990 hast a 2004). El 100% eran varones y su edad media era de 46 años; en la mayoría, la rot ura se había producido por fl exión for-zada cont ra resist encia asociada a supinación. Se int ervino quirúrgicament e a 57 suj et os, en los que se encont raron 50 desinserciones óseas, en 5 suj et os se encont ró rot ura com-plet a a 1 o 2 cm de la inserción, y en 2 suj et os se encont ró rot ura parcial. En 36 casos se ut ilizó la vía ant erior de Henry y en 21 casos se ut ilizó la doble vía de Boyd y Anderson. El uso de los anclaj es inst rument ados facilit ó la reinserción. Los result ados se valoraron según la escala para codo de Broberg y Morrey.

Resul t ados: Las complicaciones más frecuent es fueron las lesiones del nervio radial, las

dehiscencias de la herida y los síndromes de dolor regional complej o t ipo I. No se encon-t raron diferencias signifi caencon-t ivas enencon-t re los 2 abordaj es en cuanencon-t o a la incidencia de com-plicaciones. El t iempo promedio para la reincorporación laboral fue de 21 semanas. Nin-gún caso derivó a incapacidad laboral. Se valoró el result ado fi nal como excelent e en 54 suj et os y como bueno en 3 suj et os.

Concl usión: El t rat amient o quirúrgico consigue buenos result ados en la rot ura dist al del

t endón del bíceps braquial, aunque no est á exent o de complicaciones.

© 2007 SECOT. Publicado por Elsevier España, S.L. Todos los derechos reservados.

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t he dist al biceps t endon, as well as t o det ermine whet her inst rument ed anchors can decrease t he risk t o inj ure t he radial nerve.

Materials and methods

We ret rospect ively reviewed t he records of 59 subj ect s diagnosed wit h a rupt ure or det achment of t he dist al biceps t endon from 1990 unt il 2004. Mean age was 45 years (range: 30-58). All pat ient s were male wit h a predominance of t he right side (32 cases). The maj orit y of pat ient s were manual workers wit h ext remely burly arms and forearms. In 36 of t hese pat ient s (63%), t he inj ury was caused by forceful elbow fl exion against resist ance, wit h a supinat ed forearm (t able 1).

Supplement ary t est s carried out included 42 x-rays, 47 sonograms and 11 magnet ic resonances (MR).

We obt ained informed consent from all pat ient s before t reat ment and follow-up.

Two cases were excluded: t he fi rst one (diagnosed clinically and by MRi) was administ ered conservat ive t reat ment because a diagnost ic sonogram revealed a non-t endinous myonon-t endinous rupnon-t ure; non-t he second panon-t iennon-t (diagnosed clinically and sonographically) was subj ect ed t o surgery, wit h t endon int act ness being revealed int raoperat ively.

Time t o surgery was a mean of 8 days (range: 0-28) from inj ury. In t he 57 subj ect s operat ed t here were 55 full and 2 part ial t ears. Of t he 55 full t ears, 50 were det achment s or avulsions of t he t uberosit y and 5 rupt ures occurred at 1 or 2 cm from t he insert ion point .

Henry’s approach (single incision) was used in 36 subj ect s (64%). In 3 of t hese t he t endon was reat t ached wit h t ransosseous sut ures (drilling of a bony t rough, perforat ion of a t ransosseous t unnel and passage of a non-resorbable sut ure) and in 33 subj ect s inst rument ed anchors were used (sut ure mat erials or screws).

The t wo-incision approach promot ed by Boyd and Anderson was applied in 21 cases (36%); in 11 subj ect s t he reat t achment was carried out wit h t ransosseous st it ches and in 10 subj ect s wit h inst rument ed anchors.

During t he post -operat ive period, pat ient s had t o wear a brachio-ant ebrachial cast wit h t he elbow at 90º fl exion for 5 t o 6 weeks. This was followed by an 11-week (range: 4-48 weeks) rehabilit at ion program consist ing in gent le act ive and passive mobilizat ion exercises where range of mot ion was gradually increased. At 8 weeks, t he muscle

st rengt hening phase was st art ed, also in a progressive way, unt il full recovery was achieved. Only in a few isolat ed cases did we use, aft er 3 weeks’ immobilizat ion wit h a plast er splint at 90°, art iculat ed ort hoses for act ive and passive mobilit y for 3 addit ional weeks, as described by

Morrey3.

Mean follow-up was 3 years (range: 6 mont hs-15 years).

Result s were assessed on t he Broberg and Morrey’s scale4.

Results

Complicat ions occurred in 31 subj ect s (t able 2). The most usual complicat ion was radial nerve involvement (8 cases, 14%). Four of t hese pat ient s (7%) went on t o develop radial nerve palsy. Among t he subj ect s operat ed t hrough an ant erior approach t here were 5 cases wit h radial nerve problems (14%). Among t hose operat ed wit h t ransosseous sut ures t here was one case of dysest hesia (33%) and among t he 33 subj ect s t reat ed wit h inst rument ed anchors t here was one case of nerve palsy (3%) and 3 cases of dysest hesia (9%). Among t he subj ect s operat ed t hrough a combined approach t here were 3 subj ect s who developed radial nerve palsy (14%); in all of t hem t ransosseous sut ures were applied. All nerve lesions recovered spont aneously aft er variable periods of t ime.

Ot her complicat ions included 2 het erot opic ossifi cat ions (fi g. 4) and one inst ance of hardware avulsion; none of t hese had funct ional repercussions. Two pat ient s developed radioulnar synost hosis; bot h experienced funct ional repercussions and required secondary surgery t o resect t he bony bridge. Addit ional surgery was also necessary in cases of t endon escharifi cat ions and bone perforat ions result ing from secondary t endonit is. Six subj ect s developed t ype I refl ex complex regional pain syndrome, which evolved favorably wit h pharmacological t reat ment wit h calcit onin, calcium, anxiolyt ics, gabapent in and mild rehabilit at ion. No nerve or int ravenous blocks were necessary.

Mean t ime off work was 38 weeks (range: 8-195), wit h all pat ient s going back t o t heir previous j obs. No subj ect developed any permanent disabilit y.

Ten subj ect s experienced a decrease in st rengt h and mobilit y, quant ifi ed on Broberg and Morrey’s scale (t able 3), which does not refl ect ext ension lags. According t o t his

Table 1 Mechanisms of inj ury in t his series

Mechanism of inj ury N. of cases

Overst rain when lift ing weight 36

Be hanging by one arm 7

Sudden muscle st rain 7

Fall 4

Direct concussion 2

Elbow hyperext ension 1

Table 2 Complicat ions in t his st udy

Complicat ion t ype N.of cases Evolut ion

Radial nerve lesion 8 Resolved

Refl ex sympat het ic dyst rophy 6 Resolved

Delayed healing 7 Resolved

Ect opic calcifi cat ions 2 Resolved

Wound infect ions 2 Resolved

Hemat oma or seroma 2 Resolved

Radiounlar synost hosis 2 Required

surgery

Hardware avulsion 1 Resolved

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t echniques 201

scale, fi nal result s were excellent in 54 cases and good in 3 cases.

Discussion

Dist al biceps t endon rupt ures are rare inj uries, account ing

for 3% of all brachial biceps lesions6–8; t heir incidence is 1.2

cases per 100.000 subj ect s a year8. This low incidence

explains t he low number of cases in t he published series,

most of t hem including 20 t o 30 subj ect s7,9-11, alt hough t here

is also a mult icent er st udy of 43 pat ient s12 and a series of 53

cases13. We only found one series t hat was larger t han t he

one report ed herein (74 cases)2.

This inj ury commonly occurs in middle-aged workers who do st renuous manual work, generally charact erized by brawny arms and forearms, such as t ruck-drivers, locomot ive drivers, polishers, st evedores, et c.

In t he series present ed herein, all cases were acut e. In acut e cases t here may be a previous subclinical degenerat ive process t hat weakens t he t endon and promot es it s

rupt ure7,14. This degenerat ive mechanism may result from

cont inuous frict ion bet ween t he t endon and t he radius and ulna during pronosupinat ion movement s in cases of maximum effort , which could lead t o impingement

associat ed t o hypovascularizat ion of t he dist al-most 2 cm1.

Anot her fact or t hat may infl uence t his cont inuous frict ion is

hypert rophy of t he bicipit al t uberosit y3,15. It has been

report ed t hat in smokers t he risk is 7.5 t imes higher10.

Diagnosis of t hese rupt ures is basically clinical: t he bulging t endon disappears int o t he ant ecubit al fossa when t he elbow is fl exed against resist ance. The most common

diagnost ic t est is ult rasound, which is economical, easily

performed and accept ably reliable8 (fi g. 2A). In t he event of

diagnost ic doubt , MRi offers great er accuracy when defi ning

t he inj ury, it s locat ion and t he t endon charact erist ics11,16

(fi g. 2B). A plain fi lm must always be performed t o rule out associat ed diseases and bony avulsions.

Treat ment of young pat ient s in t he occupat ional set t ing has consist ed chiefl y in dist al biceps t endon reat t achment . Surgery is performed at a mean of 8 days alt er inj ury, wit h maximum surgical delay at 28 days. These inj uries may go unnot iced at t he beginning and be diagnosed lat er during t heir evolut ion, which is why surgery may at t imes be delayed more t han it should. No signifi cant differences have been found regarding t ime-t o-surgery in cases where t he t endon has been properly reat t ached, alt hough in some cases t he t endinous canal may be oblit erat ed, complicat ing it s ident ifi cat ion. Tendon ret ract ions and t endinous canal oblit erat ion may preclude reat t achment , making it necessary t o resort t o ot her t echniques such as sut uring t he t endon t o t he brachialis muscle or using semit endinosus or

Achilles t endon allograft s17,18.

Different approaches and t echniques have been report ed in t he lit erat ure, alt hough t he most popular ones seem t o be Henry’s ant erior approach and Boyd and Anderson’s approach. Ot her approaches have been described, such as

t he post erior approach for t reat ment of part ial t ears25 and

mini-incisions for full t ears26, but t heir use is rat her limit ed.

The main advant age of t he ant erior approach is ease of access t o t he t uberosit y, but it has t he disadvant age of using a narrow passage t hat complicat es t he reat t achment maneuvers, wit h t he added risk of inj uring t he radial

nerve5,7,11. On t he ot her hand, t he combined approach

Table 3 Broberg and Morrey’s scale4

Mobilit y

Flexion 0,2 × ARC

Pronat ion 0,1 × ARC

Supinat ion 0,1 × ARC

St rengt h Normal Mild loss Moderat e loss Severe loss

No limit at ion Limit s everyday t asks Disabilit y 80% opposit e side 50% opposit e side

20 13 5 0

St abilit y Normal Mild loss Moderat e loss Severe loss

5 4 2 0

Pain None Mild Moderat e Severe

Wit h act ivit y Wit h and aft er act ivit y Disabilit y, medicat ion

35 28 15 0 Result Out of 100 95-100 Excellent 80-94 Good 60-79 Fair 0-59 Poor ARC: range of mot ion (in degrees).

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permit s a much broader access t o t he t uberosit y, great ly

facilit at ing t he reat t achment maneuvers8,9.

The combined approach is allegedly associat ed t o a lower risk t o inj ure t he radial nerve, alt hough our own experience has not borne out t his cont ent ion: 3 inst ances of radial nerve palsy were det ect ed among subj ect s subj ect ed t o a combined approach. The radial nerve lesion can be caused by t he ret ract ors or when reaming t he t unnel t hat t he t endon must

follow unt il t he ext ernal incision2. Comparat ively, 5 inst ances

of nerve involvement (4 dysest hesias and 1 palsy) appeared in t he subj ect s operat ed wit h an ant erior approach. The t ot al number of palsies det ect ed following surgery is equivalent t o an incidence of 7%, which is close t o t hat report ed in t he

lit erat ure24. Fort unat ely, all inj uries have recovered

spont aneously. For t hat reason, t his t ype of surgery is not exempt from complicat ions, t he most usual and severe one being a lesion t o t he post erior int erosseous branch of t he

radial nerve3,4,6,10,24.

Moreover, among subj ect s operat ed wit h a combined approach t here were 2 cases of radioulnar synost hosis,

which required a new surgery6-8,27. Given t hat t he combined

approach is not exempt from complicat ions, some aut hors claim t hat Henry’s approach seems t he most suit able one,

especially since t he advent of inst rument ed anchors5,8,10,13,23,26.

Nevert heless, ot her aut hors do not see any differences bet ween bot h met hods and recommend t he use of eit her t echnique depending on t he preferences on t he individual

surgeon28,29.

As an at t achment procedure, t ransosseous sut ures19 are

used less and less oft en. Use of inst rument ed anchors is

quickly gaining ground because of t hey facilit at e surgery

and t he manipulat ion of t he whole area20 (fi gs. 3A–E). Some

st udies show t hat t here are no differences wit h t ransosseous

sut ures regarding mechanical st rengt h16,21. In 2002, Bain

st art ed using t he endobut t on t echnique for t hese fi xat ion maneuvers; t his is a but t on-based anchoring syst em t hat

had so far been used in ant erior cruciat e ligament repairs22,23.

The advent of inst rument ed anchors, mini-burrs for reaming t he bone t rough and t he use of sliding st it ches have facilit at ed manipulat ion of t he t uberosit y.

To conclude, dist al biceps t endon rupt ures, alt hough infrequent , are highly prevalent inj uries in t he workplace. Surgical t reat ment , even if not exempt from complicat ions, is indicat ed in t he maj orit y of cases and offers good result s.

Confl ict of interests

The aut hors have not received any fi nancial support in t he preparat ion of t his art icle. Nor have t hey signed any agreement ent it ling t hem t o receive benefi t s or fees from any commercial ent it y. Furt hermore, no commercial ent it y has paid or will pay any sum t o any foundat ion, educat ional inst it ut ion or ot her non-profi t -making organizat ion t o which t hey may be affi liat ed.

References

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A

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t echniques 203

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3. Kelly EW, Morrey BF, O’ Driscoll SW. Morrey BF. Mast er t echniques in ort hopedic surgery. En: Thompson Jr. R. New York: Raven Press; 1994.

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A

B

C

D

E

Figure 3 Int raoperat ive views of a t endon reat t achment (A, B) by means of inst rument ed anchors (C, D), (E) Post operat ive x-ray.

Figure 4 X-ray view of ect opic calcifi cat ions in a rupt ured biceps.

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