DISTAL BICEPS TENDON RUPTURES David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD

DISTAL BICEPS TENDON RUPTURES David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD E...
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DISTAL BICEPS TENDON RUPTURES David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD

EDUCATIONAL OBJECTIVES

INTRODUCTION •  Acute distal biceps rupture is a rare injury

GOALS OF THE EXHIBIT – VIEWER WILL BE ABLE TO: 1)  Understand the importance of recognizing & diagnosing

•  Typically affects dominant hand in active males

distal biceps rupture

•  Occurs in the fourth – sixth decades of life

2)  Review the anatomy & biomechanics involved in biceps

•  Often associated with an eccentric load at 90º of flexion

ruptures, which is critical for its diagnosis & management

•  Non-operative management will result in weakness and deformity

3)  Be able to perform a comprehensive evaluation & diagnostic work-up for biceps ruptures

•  Restoration of function and strength often requires surgical

4)  Understand candidates and consequences of non-surgical

intervention

management

•  There are numerous techniques to repair the distal biceps tendon

5)  Review multiple surgical techniques for surgical management of distal biceps rupture including single and double incision techniques

DEMOGRAPHICS

Incidence per 10,000 Patients

1.6

Male versus Female

Facts

1.4

•  Smokers have 7.5 fold increased risk

1.2

•  71% of those injured are in low demand

1

occupations and/or not in competitive sports

0.8 0.6

•  Incidence is 0.9 - 1.8 per 100,000

0.4

•  Proximal biceps rupture is 9 - 32 times more

0.2 0 0-30

30-39

40-49

50-59

60+

Male Female

likely than distal biceps rupture

MECHANISM OF INJURY

•  Mechanism of injury is often associated with an eccentric load on a flexed, shortened and contracting muscle. •  Suspected chronic degenerative process near radial tuberosity. •  Partial tears are often from radial side of tuberosity. Modified from Wikipedia..com

ANATOMY, BIOMECHANICS & EXAM David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD

BICEPS ANATOMY AND BIOMECHANICS • 

•  • 

•  • 

• 

Biceps •  •  Triarticulate muscle that exerts forces on three joints: Glenohumeral, proximal radial-ulnar and ulno-humeral joints. The muscle unit rotates 90° from origin to insertion. •  Origin •  Short Head – Coracoid Process •  Long Head – Supraglenoid Tubercle Modified from Wikipedia..com Insertion •  Two distinct insertions at the radial tuberosity. The long head inserts more proximal starting approximately 23mm distal to articular margin •  •  Does not occupy entire radial tuberosity •  Length - 21 mm •  Width - 7 mm Nerve •  Innervated by muscolocutaneous nerve at approximately 134 mm distal to the acromion. Vascular supply •  Medial and proximal near musculotendinous junction - Brachial artery •  Distal at insertion site - branches from posterior interosseous recurrent artery •  Middle zone – transitional zone with supply from both sources. May be considered watershed zone. Lacertus fibrosis (bicipital aponeurosis) •  Broad aponeurosis of the biceps brachii that typically starts as three distinct layers that merge distally into a single aponeurosis that stabilizes the short head of the biceps.

Action •  Elbow flexion (30%) •  Forearm Supination (40-50%) Two Functional Components •  Short head •  Distal insertion allows for a higher moment arm with elbow flexion •  Long head •  Proximal and off axis insertion allows for higher moment arm to allow powerful forearm supination Dangers •  Lateral antebrachial cutaneous nerve – the terminal branch of the musculocutaneous nerve •  Variable course – It is often identified as it exits proximally between the brachialis and the biceps brachii. It is located just superficial to the deep fascia and underneath the cephalic vein in the anterolateral aspect of the elbow. •  Posterior Interosseous nerve – A deep branch of the radial nerve •  Pierces the supinator as it wraps around the radius. Its distance from the radio-capitellar joint in supination, neutral and pronation are 5.6 cm, 4.2 cm and 3.2 cm respectively. As the forearm is supinated, the nerve becomes a more lateral to posterior structure. •  Recurrent branch of radial artery •  A branch of the radial artery just distal to the elbow. This should be ligated during anterior exposure to reduce risk of hematoma and heterotopic ossification.

Modified from arthrex.com

HISTORY, PHYSICAL EXAM AND IMAGING • 

History •  Often patients report performing an eccentric load or carrying a heavy object and hearing a “pop.” •  Complaints of pain and weakness. •  May have recent increase in activity/exercise load •  May have had pre-injury pain suggestive of tendinosis •  Physical Exam •  Patients present with a proximal biceps bulge from muscle retraction (reverse popeye deformity) and bruising in or proximal to the cubital fossa •  Asymmetric weakness with supination and elbow flexion. Supination should be tested with the elbow flexed to 90° and in maximal supination. This isolates the biceps from the supinator. •  Palpation of the brachialis or lacertus fibrosis may falsely suggest an intact biceps. •  Hook Test

Imaging •  Standard radiographs may on occasion show evidence of an avulsion injury to the distal biceps. Often these radiographs are without any evidence of pathology except for soft tissue swelling.

Modified from When Your Body Aches. © American Academy of Orthopaedic Surgeons, 2003

• 

•  MRI may be used in cases that are difficult to diagnose or to evaluate chronic injuries. The biceps muscle should be identified proximally at its muscle belly and traced distally to identify the tendon insertion. A FABS view (flexed elbow, abducted shoulder, forearm supinated) improves Modified from Sutton et al JAAOS 2010 visualization of the insertion of the biceps tendon.

Patient should actively flex elbow to 90° and supinate forearm. Examiner should use his/her finger to capture the lateral edge of the biceps tendon. The examiner should be able to insert a finger 1 cm underneath an intact biceps tendon.

Torn biceps tendon from anatomic footprint

Edema at biceps footprint with absent tendon at footprint

•  Ultrasound is a good dynamic tool to evaluate continuity of the biceps tendon, however its utility is technician dependent.

NON-SURGICAL MANAGEMENT •  This should be limited to patients with extensive medical co-morbidities, low demand and those who understand the consequences. •  Surgical management results in improved strength in flexion and supination as well as increased upper extremity endurance

Edema and incongruity at the biceps tendon

•  Expectations •  40-50% reduction in supination strength •  30% reduction in flexion strength •  15% reduction in grip strength

SURGICAL TECHNIQUE David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD

APPROACH Anterior Approach

Two incision Approach

1)  Patient should be positioned supine on the surgical table with an arm board attached. The patients arm should be draped free. We prefer the use of a sterile tourniquet. A single longitudinal incision should be made medial to the brachioradialis from the antecubital fossa and directed 3-4 cm distally.

1)  A two incision approach (Modified Boyd and Anderson) can be used. The anterior incision is similar to the Modified Henry Approach. The posterior incision should be created after completing the anterior approach. With the arm in maximal pronation to protect the posterior interosseous nerve, a curved clamp should be passed medial to the radial tuberosity between the radius and ulna and directed posteriorly. It is important to avoid damaging the periostium on the ulna when passing between the radius and ulna.

2)  A single (Modified Henry Approach) or double transverse incision can be used. In the two anterior incision approaches, the proximal incision is used for capturing the biceps tendon. This may also be performed using only the distal incision. The distal incision start distal to the transverse elbow crease at the level of the radial tuberosity. 2)  The clamp is passed through the common extensor muscles and is palpated subcutaneously. A 3 cm posterior incision should be made.

biceps tendon

3)  The dissection should be carried down towards the radial tuberosity. The brachioradialis should be retracted laterally and pronator teres medially which should expose the biceps tendon sheath if still intact. During this exposure multiple recurrent branches of the radial artery and the lateral antebrachial cutaneous nerve may be seen and should be protected.

Clamp marking posterior incision

3)  A muscle splitting approach through the common extensor origin is preferred to a subperiosteal dissection and reduces the risk of synostosis. The approach should be in line with the muscle fibers.

Intact biceps tendon

4)  The biceps tendon sheath may be intact. A longitudinal incision through the sheath should be used to evacuate the hematoma. The biceps should then be retrieved from inside the tendon sheath.

SURGICAL TECHNIQUE David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD

BICEPS REPAIR TECHNIQUES For all repairs, the distal end of the biceps and the radial tuberosity should be debrided of any necrotic, degenerative tissue or unhealthy tissue.

TENSION SLIDE TECHNIQUE 1)  Using #2 braided non-absorbable suture a locking whip stitch starting from approximately 0.5 cm from the distal end of the tendon is run. We typically suture until we reach 2.5 cm proximal from the end of the tendon which usually equates 6 throws in each direction.

5)  Once the tendon is fully seated, one limb of the suture should be passed through the biceps tendon just proximal to the radial tuberosity using a free suture needle. The two ends of the suture are then secured using multiple knots. Intraoperative imaging may be used to confirm appropriate deployment on the posterior surface of the proximal radius. 6)  A tenodesis screw may be added for additional security. A 7mm tenodesis screw can be added to the radial side of the tendon to push the tendon more ulnar. This theoretically gives the biceps a mechanical advantage for supinating the forearm.

SELF LOCKING CORTICAL BUTTON TECHNIQUE

2)  Using a biceps button, one strand should be fed in one end and out through the other. The second strand of suture is fed back through the button in the opposite direction. 3)  The radial tuberosity is prepared first by debriding off any remnant biceps tissue. With the forearm in maximal supination, a 3.2 mm guide wire is inserted through two cortices starting at the center of the radial tuberosity. Slight ulnar deviation helps reduce risk of PIN injury. The proximal cortex is then reamed through the near cortex. The reamer should be sized aproximately 0.5-1 mm larger then the sized tendon.

4)  The button should the loaded on the inserter and tension is held on the sutures. The button should then be passed through the far cortex to the posterior radius. Pulling on the free sutures will seat the button and dock the biceps into the radial tuberosity.

1)  After running a locking whip stitch, one end of the suture should be passed through the loop of the self locking cortical button and then the free suture ends are tied securely. The radius should be prepared using the same technique as for the tension slide technique with a guide wire and an appropriately sized unicortical reamer. 2)  The button should be loaded on button inserter and passed through the guide wire hole through the radial tuberosity. The self locking cortical button device should then be firmly pulled to dock it to the posterior surface of the proximal radius. Intraoperative imaging may be used to confirm appropriate deployment on the posterior surface of the proximal radius. Each suture limb from the device should then be sequentially pulled to seat the biceps tendon into the radial tuberosity. If a tenodesis screw is desired one limb may be passed through the tenodesis screw and a tenodesis screw can be inserted on the radial side of the tendon.

SURGICAL TECHNIQUE David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD

BICEPS REPAIR TECHNIQUES TWO INCISION BONE TUNNEL TECHNIQUE 1)  A standard two incision muscle splitting approach is used for this procedure. The tendon is prepared using a standard locking whip stitch.

2)  The radial tuberosity should be identified from the dorsal approach. Biceps tendon remnants are debrided. A high speed burr should carefully be used to create a trough approximately 8 mm in width and 10 mm in length.

SINGLE INCISION BONE TUNNEL 1)  A tunnel creation device such as those typically used for anchorless rotator cuff repair, is used for this technique. This device allows use of a single incision and passage of sutures through two drill tunnels through the radial tuberosity. This allows the graft to be placed at the most medial/ulnar aspect of the radial tuberosity and allows the biceps to be sewn directly to the radial tuberosity. This creates a double rowlike construct with a more anatomic footprint as the medial edge of the tendon is taut and secured by being passed medial around the radial tuberosity. The sutures that are pulled from posterior to anterior and will re-create the lateral footprint as the tendon is reduced to the radial tuberosity and sutures sewn around the biceps tendon.

Arthrotunneler By Tornier

3)  Once the trough is prepared, two drill holes should be created. These drill holes should be be proximal and/or lateral to the trough. A passing suture should be passed through each drill hole for later passage of the free suture on the biceps tendon. The biceps tendon is then brought medial to the radius retrieved through the posterior incision.

4)  The free ends of the biceps suture should be shuttled through the drill holes and tied securely over a bone bridge.

2)  The radial tuberosity should be debrided, the device is placed around the ulnar side of the radial tuberosity. We feel slight ulnar deviation from the center of the radial tuberosity is an ideal location for the drill holes. The first drill hole should be performed through the device, the free suture should be passed and captured on the posterior aspect of the radius and then pulled out using this device. This step is repeated for a second drill hole. The drill holes should be approximately 8-10 mm apart.

3)  Each of the sutures from the biceps tendon should then be passed through one of the drill holes using the passing suture. The biceps is reduced onto the radial tuberosity and the sutures are tied securely around the biceps, which restores the lateral edge of the footprint.

SURGICAL CONSIDERATIONS David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD

ONE VS TWO INCISION Surgical Technique

Overall Complication Rate

(Data from Watson et al 2014, n= 498 elbows

Lateral antebrachial cutaneous nerve palsy

Heterotopic Ossification

Loss of elbow Re-rupture Rate Range of Motion

Snyostosis

Infection Rate

One Incision

23.9%

11.6%*

3.1%

1.8%

1.8%

0%

1.2%*

Two Incision

25.7%

5.8%

7.0%*

5.7%*

1.2%

2.3%*

0%

FIXATION METHOD Surgical Technique

Overall Complication Rate

Re-rupture Rate

Nerve Injury

Long Term Nerve Deficit

(Data from Watson et al 2014, n= 494 Patients

Cortical Button n = 17

0%

0%

0%

0%

Interference screw n = 29

44.8%

0%

34.5%

3.4%

Suture Anchor n = 282

26.4%

2.5%

15.6%

1.4%

Bone Tunnel n = 166

20.4%

0.6%

6.0%

0.6%

Cortical Button Studies

Surgical Technique

Complications

Cusick 2014

Single Incision cortical Button with interference screw – n=170

Banerjee 2013

Re-rupture Rate

Complications/Outcomes

1.2%

Single incision cortical button n=27

Acute – 7.3% Sub-acute – 13% Chronic – 20% Overall – 33.3% Requiring revision surgery – 14.8% (HO resection, button re-insertion after disengagement, wound revision

PIN neuropraxia – 2.4% LABCN – 10% Superficial radial nerve numbness – 2.3% Patients with complications had decreased supination strength, Mayo score and ASES score,, an increased VAS pain score and overall patient satisfaction •  22/27 patients with no pain at final follow up

Bain 2000

Single incision cortical button N=12

8.3% - wound abscess

0%

•  Al patients satisfied with good function •  No HO, weakness or loss of motion noted

Peeters 2009

Single incision cortical button N=23

13.0% - HO x 2 without any impairment, removal of symptomatic button. Button malposition 13%

4.3%

•  All patients had good to excellent results •  Flexion and supination strength respectively at 80% and 91% whencompared to contralateral limbs.

•  •  •  • 

3.7% (one patient 51 months post-op)

BIOMECHANICAL EVALUATION Author/Year

Fixation Method

Results

Pereira 2002

Suture Anchor (SA) vs Bone Tunnel (BT)

Yield Force (SA) 45.67N vs (BT) 71.25N Failure load (SA) 56.67N vs (BT) 73.75N

Sethi 2010

Standard cortical button(CB) vs Tension Slide Technique(TST) with cortical button

Failure Load (CB) 389N vs (TST) 432N (P > 0.05) Interference screw did not affect pullout strength. Gapping after cyclic: (CB) 2.79 mm vs (TST) 1,26 mm

Siebenlist 2013

Double Intramedullary cortical button (DICB) v suture anchors (SA)

Mazzocca 2007

Bone tunnel (BT) vs suture anchor (SA), cortical button (CB), interference screw (IS) Cortical button (CB) vs bone tunnels (BT) vs suture anchors (SA) Suture Anchor (SA) vs Biotenodesis Srew (BS)

Gapping after cyclic loading: All DICB passed loading, 4/12 SA failed with anchor pull out. DICB had decreased gapping at all intervals. Failure load: (DICB) 312N vs (SA) 200N No significant difference in gapping. Failure load: (CB) 440N vs (SA) 381N vs (BT) 310N vs (IS) 232N Failure Load: (CB) 259 N vs (BT) 210N. SA failure load overall was not significantly different than BT, however some brands performed better than others. Failure load (BS) 192 N vs (SA) 147N. No difference in stiffness (resistance to gapping)

Kettler 2006 Krushinski 2007

PHYSICAL THERAPY & REHABILITATION •  Patients are kept in shoulder sling until their first post-operative visit, which is usually within 5-7 days.

•  Rehabilitation programs will depend on the repair construct integrity. Cheung et al 2006, Hartman et al 2007 and Bain et al 2000 advocate for early range of motion with no deleterious effects •  In our institution we start early active range of motion with a one pound weight limit after the first post operative visit. •  Patient should focus on regaining flexion, extension pronation and supination.

•  Strengthening starting 3 months postoperatively with no restrictions • 

Focus on elbow flexion and supination

DISTAL BICEPS RUPTURES David D Savin MD, Simon Lee MPH, Jonathan N Watson MD, Ari R Youderian MD, Mark R Hutchinson MD, Benjamin Goldberg MD

SELECTED REVIEW OF LITERATURE Author Year Subjects Study design

Follow-up

Shields

2015

41

Cohort – Level 3

Grewal

2012

91

Randomized Control 24 months Study - Level 1

Olsen

2014

37

Retrospective Cohort 18-32 months - Level III

Hasan

2012

20 Cadavers Anatomic study

NA

Cain

2012

198

8-144 wks

Level IV

12 months minimum

Comparison Groups

Outcomes

1 – Single incision with tension •  Demographic differences – CB was older, shorter follow up slide cortical button( CB) n = 20 and less likely to smoke. 2 – Dual incision with bone •  No difference in DASH tunnels (BT) n = 21 •  No difference in ROM or strength •  CB had higher complication rate (30% vs 4.8%) •  No failures or re-operations in either group 1 – Single incision with two •  No difference in DASH, ASES pain or function and PREE suture anchors ( SA) scores. 2 – Dual incision with bone •  Dual incision with BT had 10% increased isometric flexion tunnels (BT) strength. •  Similar rates of strength recovery •  Single incision with SA had increased LABCN neuropraxia 1 – Single incision with tension •  No difference in demographics (longer f/u with SA) slide cortical button( CB) n = 20 •  Difference in ROM – SA had better flexion and supination, 2 Single incision with two suture CB had better pronation anchors ( SA) n=17 •  No difference in strength •  CB had improved DASH •  No difference in complication rates 1 – Single incision •  73.4% of virtual tunnels in two incision but only 9.6% of 2 – Dual incision single incision were located within the anatomic footprint Assessment of guide pin placement within the anatomic footprint Retrospective review of 198 •  36% complication rate, 3% requiring additional surgery. elbows •  Major complication rate of 8%, minor complication rate of 28% •  Chronic tear more likely to have complication •  Fixation method did not affect complication rate, however likely underpowered with cortical button having the highest complication rate.

CONCLUSIONS •  Acute distal biceps ruptures are rare but potentially debilitating injuries •  Non operative management should only be reserved for low demand patients who are poor

surgical candidates •  Surgical treatment will typically result in high patient satisfaction with good functional results •  Multiple surgical techniques available, all with a unique complication profile, but a debilitating

complication is rare

DISCLOSURES & ACKNOWLEDGEMENTS & REFERENCES Disclosures: Goldberg BA – Acumed, LLC; Stryker; Allen Medical; Aston; Medwest/Arthrex; Mako; Biomimetic., Savin D, Lee S, Watson J Youderian A– No corporate disclosures. Full disclosures are available on the AAOS website Acknowledgements: University of Illinois at Chicago – Department of Orthopedic Surgery, James Ho MD (narrator) References: 1) Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D. Repair of distal biceps tendon rupture: a new technique using the Endobutton. J. Shoulder Elb. Surg. Am. Shoulder Elb. Surg. Al. 2000 Apr;9(2):120–126. 2) Banerjee M, Shafizadeh S, Bouillon B, Tjardes T, Wafaisade A, Balke M. High complication rate following distal biceps refixation with cortical button. Arch. Orthop. Trauma Surg. 2013 Oct;133(10):1361–1366. doi:10.1007/s00402-013-1819-1 3) Cain RA, Nydick JA, Stein MI, Williams BD, Polikandriotis JA, Hess AV. Complications Following Distal Biceps Repair. J. Hand Surg. 2012 Oct;37(10):2112–2117. doi:10.1016/j.jhsa.2012.06.022 4) Cusick MC, Cottrell BJ, Cain RA, Mighell MA. Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw. J. Shoulder Elb. Surg. Am. Shoulder Elb. Surg. Al. 2014 Oct;23(10):1532–1536. doi:10.1016/j.jse.2014.04.013 5) Grewal R, Athwal GS, MacDermid JC, Faber KJ, Drosdowech DS, El-Hawary R, et al. Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J. Bone Joint Surg. Am. 2012 Jul 3;94(13):1166–1174. doi:10.2106/JBJS.K.00436 6) Hasan SA, Cordell CL, Rauls RB, Bailey MS, Sahu D, Suva LJ. Two-incision versus one-incision repair for distal biceps tendon rupture: a cadaveric study. J. Shoulder Elb. Surg. Am. Shoulder Elb. Surg. Al. 2012 Jul;21(7):935–941. doi:10.1016/j.jse.2011.04.027 7) Kettler M, Lunger J, Kuhn V, Mutschler W, Tingart MJ. Failure strengths in distal biceps tendon repair. Am. J. Sports Med. 2007 Sep;35(9):1544–1548. doi:10.1177/0363546507300690 8) Krushinski EM, Brown JA, Murthi AM. Distal biceps tendon rupture: biomechanical analysis of repair strength of the Bio-Tenodesis screw versus suture anchors. J. Shoulder Elb. Surg. Am. Shoulder Elb. Surg. Al. 2007 Apr;16(2):218–223. doi:10.1016/j.jse.2006.05.006 9) Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA, Arciero RA. Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am. J. Sports Med. 2007 Feb;35(2):252–258. doi:10.1177/0363546506294854 10) Olsen JR, Shields E, Williams RB, Miller R, Maloney M, Voloshin I. A comparison of cortical button with interference screw versus suture anchor techniques for distal biceps brachii tendon repairs. J. Shoulder Elb. Surg. Am. Shoulder Elb. Surg. Al. 2014 Nov;23(11):1607–1611. doi:10.1016/j.jse.2014.06.049 11) Peeters T, Ching-Soon NG, Jansen N, Sneyers C, Declercq G, Verstreken F. Functional outcome after repair of distal biceps tendon ruptures using the endobutton technique. J. Shoulder Elbow Surg. 2009 Mar;18(2):283–287. doi:10.1016/j.jse.2008.10.004 12) Pereira DS, Kvitne RS, Liang M, Giacobetti FB, Ebramzadeh E. Surgical repair of distal biceps tendon ruptures: a biomechanical comparison of two techniques. Am. J. Sports Med. 2002 Jun;30(3):432–436. 13) Sethi P, Obopilwe E, Rincon L, Miller S, Mazzocca A. Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation. J. Shoulder Elb. Surg. Am. Shoulder Elb. Surg. Al. 2010 Jan;19(1):53–57. doi:10.1016/j.jse.2009.05.007 14) Shields E, Olsen JR, Williams RB, Rouse L, Maloney M, Voloshin I. Distal Biceps Brachii Tendon Repairs: A SingleIncision Technique Using a Cortical Button With Interference Screw Versus a Double-Incision Technique Using Suture Fixation Through Bone Tunnels. Am. J. Sports Med. 2015 Feb 19;doi:10.1177/0363546515570465 15) Siebenlist S, Buchholz A, Zapf J, Sandmann GH, Braun KF, Martetschläger F, et al. Double intramedullary cortical button versus suture anchors for distal biceps tendon repair: a biomechanical comparison. Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA. 2015 Mar;23(3):926–933. doi:10.1007/s00167-013-2590-0 16) Sutton KM, Dodds SD, Ahmad CS, Sethi PM. Surgical Treatment of Distal Biceps Rupture. J. Am. Acad. Orthop. Surg. 2010 Mar 1;18(3):139–148. 17) Watson JN, Moretti VM, Schwindel L, Hutchinson MR. Repair techniques for acute distal biceps tendon ruptures: a systematic review. J. Bone Joint Surg. Am. 2014 Dec 17;96(24):2086–2090. doi:10.2106/JBJS.M.00481

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