Journal Article Review June 2016
When to Mobilize Elbows after Distal Biceps Tendon Repairs
Smith JR, Amirfeyz R: Does immediate elbow mobilization after distal biceps tendon repair carry the risk of wound breakdown, failure of repair, or patient dissatisfaction? J Shoulder Elbow Surg. 2016 May;25(5):810-5.
Two British orthopedists report their results for immediate elbow mobilization following distal biceps tendon reattachment. Over 2 years they repaired 22 distal biceps tendon ruptures in 20 patients using an identical surgical technique and toggle washer and an identical rehabilitation protocol.
All patients were men with an average age of 41, range 27-62. Surgery is performed through a single transverse incision just distal to the elbow flexion crease. Heavy suture material is placed in the ruptured biceps tendon. A rectangular washer attached to the suture material is then passed through a drill hole beginning in the biceps tuberosity of the radius and ending on the dorsal cortex of the radius. Once the washer exits the radius, it toggles to lock itself and the suture in place. See drawings.
The surgeons applied soft dressings only and encouraged the patient to begin immediately with active elbow and forearm motions. At two weeks, the patients started in therapy for mobilization of all joints in the affected limb and for recovery of passive and unresisted active motion. At six weeks, one-kilogram (2.2 pounds) resistance was added, and at twelve weeks patients returned to full activity including sports.
RESULTS: There were no wound healing problems. One patient with bilateral repairs did not return for late follow-up, so only the remaining 20 repairs were monitored for outcome determination at a mean follow-up of 17 months (range 4-29 months). At final follow-up, all tendon repairs were intact. Elbow motion averaged 99% of the opposite side (range 94-111%). Forearm rotation was full in all patients. QuickDASH scores averaged 3 (0 is entirely normal on a 100 point scale). Mayo Elbow Performance Index scores averaged 98 (100 is entirely normal on a 100 point scale). Oxford Elbow Score ratings averaged 47 (48 is entirely normal on a 48 point scale).
Two-thirds of patients had transient paresthesias: six had involvement of the superficial radial nerve and eight had involvement of the lateral antebrachial cutaneous nerve. All paresthesias resolved by eight weeks after surgery.
COMMENT: Distal biceps tendon rupture most commonly occurs in men in their 40s. The patients followed in this study were therefore entirely typical. Without surgery, the intact brachialis can provide nearly normal elbow flexion strength, but supination weakness is permanent. Techniques for surgical reattachment include use of bone anchors, sutures passing through the radius, and cortical buttons. In the laboratory, the strength of many of these repairs approaches that of the healthy tendon. Never-the-less, surgeons have been reluctant to allow motion during the first two weeks after repair. This, of course, limits activities of daily living and risks permanent elbow or forearm stiffness.
The results reported in this article are excellent. If you receive a prescription for immediate or early active motion following biceps tendon reattachment, this article should provide some assurance the risk of detachment is low providing resisted flexion is delayed two weeks and limited to one kilogram for six weeks. Should you patient note numbness in the superficial radial nerve or lateral antebrachial nerve distribution, you can offer reassurance that these findings are common and are likely to resolve over several months.