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Eight Year Experience with   EndoButton-assisted Repairof Distal Biceps Tendon Ruptures
Eight Year Experience with   EndoButton-assisted Repairof Distal Biceps Tendon Ruptures            C. Noel Henley, MD and ...
Summary of the near future
Summary of the near future• Clinical overview
Summary of the near future• Clinical overview• Study Objective
Summary of the near future• Clinical overview• Study Objective• Materials and Methods
Summary of the near future•   Clinical overview•   Study Objective•   Materials and Methods•   Results
Summary of the near future•   Clinical overview•   Study Objective•   Materials and Methods•   Results•   Conclusion
Summary of the near future•   Clinical overview•   Study Objective•   Materials and Methods•   Results•   Conclusion•   Fu...
Introduction
Introduction• e injury
Introduction• e injury  – 3% of biceps tendon ruptures
Introduction• e injury  – 3% of biceps tendon ruptures  – Complete avulsion from bone
Introduction• e injury  – 3% of biceps tendon ruptures  – Complete avulsion from bone  – Common mechanism(s)
Introduction• e injury  – 3% of biceps tendon ruptures  – Complete avulsion from bone  – Common mechanism(s)  – Examinati...
Introduction
Introduction• Treatment Results  – Nonoperative     • Decreased supination strength     • Decreased supination, exion endu...
Introduction• Treatment Results  – Nonoperative     • Decreased supination strength     • Decreased supination, exion endu...
Introduction
Introduction• Method of repair - history  – Traditional single incision technique     • Extensive volar dissection     • A...
Introduction• Method of repair - history  – Traditional single incision technique     • Extensive volar dissection     • A...
Introduction• Method of repair - history  – Traditional single incision technique     • Extensive volar dissection     • A...
Introduction
Introduction• EndoButton-assisted repair
Introduction• EndoButton-assisted repair   – A titanium button secured with     suture
Introduction• EndoButton-assisted repair   – A titanium button secured with     suture   – Bain, et al: rst report in 2000
Introduction• EndoButton-assisted repair   – A titanium button secured with     suture   – Bain, et al: rst report in 2000...
Study Objective
Study Objective• To report long-term clinical results of  EndoButton-assisted distal biceps tendon repairs,  re ected by b...
Materials and Methods
Materials and Methods• 48 patients identi ed (1996-2004)
Materials and Methods• 48 patients identi ed (1996-2004)• Records reviewed, patients contacted
Materials and Methods• 48 patients identi ed (1996-2004)• Records reviewed, patients contacted• Evaluation  – DASH  – Phys...
Materials and Methods• 48 patients identi ed (1996-2004)• Records reviewed, patients contacted• Evaluation  – DASH  – Phys...
Demographics
Demographics• 17 patients returned for follow up
Surgery Summary
Surgery Summary• Single anterior Henry approach
Surgery Summary• Single anterior Henry approach• Tendon secured with No. 5 suture, threaded  through EndoButton
Surgery Summary• Single anterior Henry approach• Tendon secured with No. 5 suture, threaded  through EndoButton• Button, s...
Surgery Summary• Single anterior Henry approach• Tendon secured with No. 5 suture, threaded  through EndoButton• Button, s...
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Rehabilitation
Rehabilitation• AROM, AAROM, PROM of the elbow begun at  3-4 days postoperatively
Rehabilitation• AROM, AAROM, PROM of the elbow begun at  3-4 days postoperatively• Splinting limits extension to 30°, disc...
Rehabilitation• AROM, AAROM, PROM of the elbow begun at  3-4 days postoperatively• Splinting limits extension to 30°, disc...
Objective Testing
Objective Testing• Range of motion
Objective Testing• Range of motion• Grip strength
Objective Testing• Range of motion• Grip strength• PIN function
Objective Testing•   Range of motion•   Grip strength•   PIN function•   LABCN function
Objective Testing•   Range of motion•   Grip strength•   PIN function•   LABCN function•   Wound evaluation
Objective Testing•   Range of motion•   Grip strength•   PIN function•   LABCN function•   Wound evaluation•   BTE testing...
Heterotopic Ossification
Heterotopic Ossification• Grade 0  – No HO seen
Heterotopic Ossification• Grade 0  – No HO seen• Grade 1  – Slight mushrooming extending anteriorly  – Or small islands of...
Grade 0
Grade 0
Grade 1
Grade 1
Heterotopic Ossification
Heterotopic Ossification• Grade 2  – Moderate mushrooming  – Or bone islands < 1 cm dimension
Heterotopic Ossification• Grade 2  – Moderate mushrooming  – Or bone islands < 1 cm dimension• Grade 3  – Large area affect...
Grade 2
Grade 2
Subjective Assessment
Subjective Assessment• DASH questionnaire
Subjective Assessment• DASH questionnaire  – An upper extremity-speci c patient-centered    outcomes instrument
Subjective Assessment• DASH questionnaire  – An upper extremity-speci c patient-centered    outcomes instrument  – Score r...
Subjective Assessment• DASH questionnaire  – An upper extremity-speci c patient-centered    outcomes instrument  – Score r...
Subjective Assessment• DASH questionnaire  – An upper extremity-speci c patient-centered    outcomes instrument  – Score r...
Results
Results• 17 patients examined
Results• 17 patients examined• Mean follow up time = 51 months (4.25 years)  (range = 13 to 130 months)
Results
Results• All incisions well-healed – no wound  complications
Results• All incisions well-healed – no wound  complications• Four patients - persistent numbness of LABCN
Results• All incisions well-healed – no wound  complications• Four patients - persistent numbness of LABCN• Signi cantly l...
Results• All incisions well-healed – no wound  complications• Four patients - persistent numbness of LABCN• Signi cantly l...
Results
Results• DASH scores  – DASH1 reported for all patients  – Mean DASH1 = 9.5  – Mean DASH2 (n = 14) = 5.4  – Mean DASH3 (n ...
Results
Results• Radiographic examination
Results• Radiographic examination  – 2/17 patients had grade 2 HO – no functional    limitation
Results• Radiographic examination  – 2/17 patients had grade 2 HO – no functional    limitation  – 11/17 had grade 1 HO
Results• Radiographic examination  – 2/17 patients had grade 2 HO – no functional    limitation  – 11/17 had grade 1 HO  –...
Results
Results• Work, recreation status  – One patient retired  – One patient (worker’s comp) disabled after several    surgeries...
Conclusions
Conclusions• Technique appears safe  – No motor nerve palsies  – No functionally limiting HO/synostosis
Conclusions• Technique appears safe  – No motor nerve palsies  – No functionally limiting HO/synostosis• EndoButton streng...
Conclusions• Technique appears safe  – No motor nerve palsies  – No functionally limiting HO/synostosis• EndoButton streng...
Future work
Future work• Number of patients  – More to follow up, repeat contacts  – Incentives
Future work• Number of patients   – More to follow up, repeat contacts   – Incentives• Endpoint: longest, largest follow u...
Biceps Tendon Repair - Endobutton
Biceps Tendon Repair - Endobutton
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Biceps Tendon Repair - Endobutton

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In this presentation I summarize research on Endobutton-assisted repair of the distal biceps tendon. Find out more about hand and arm problems at http://www.noelhenley.com

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Biceps Tendon Repair - Endobutton

  1. 1. Eight Year Experience with EndoButton-assisted Repairof Distal Biceps Tendon Ruptures
  2. 2. Eight Year Experience with EndoButton-assisted Repairof Distal Biceps Tendon Ruptures C. Noel Henley, MD and Jeffery A. Greenberg, MD May 18, 2006
  3. 3. Summary of the near future
  4. 4. Summary of the near future• Clinical overview
  5. 5. Summary of the near future• Clinical overview• Study Objective
  6. 6. Summary of the near future• Clinical overview• Study Objective• Materials and Methods
  7. 7. Summary of the near future• Clinical overview• Study Objective• Materials and Methods• Results
  8. 8. Summary of the near future• Clinical overview• Study Objective• Materials and Methods• Results• Conclusion
  9. 9. Summary of the near future• Clinical overview• Study Objective• Materials and Methods• Results• Conclusion• Future work
  10. 10. Introduction
  11. 11. Introduction• e injury
  12. 12. Introduction• e injury – 3% of biceps tendon ruptures
  13. 13. Introduction• e injury – 3% of biceps tendon ruptures – Complete avulsion from bone
  14. 14. Introduction• e injury – 3% of biceps tendon ruptures – Complete avulsion from bone – Common mechanism(s)
  15. 15. Introduction• e injury – 3% of biceps tendon ruptures – Complete avulsion from bone – Common mechanism(s) – Examination • Swelling, ecchymosis if acute • Contour, palpable defect • Weakness in supination • Squeeze test* *Ruland. CORR. 2005.
  16. 16. Introduction
  17. 17. Introduction• Treatment Results – Nonoperative • Decreased supination strength • Decreased supination, exion endurance
  18. 18. Introduction• Treatment Results – Nonoperative • Decreased supination strength • Decreased supination, exion endurance – Operative • Repair advocated by a majority • Necessary for return of maximum function in active patients
  19. 19. Introduction
  20. 20. Introduction• Method of repair - history – Traditional single incision technique • Extensive volar dissection • Association with PIN, radial nerve palsy
  21. 21. Introduction• Method of repair - history – Traditional single incision technique • Extensive volar dissection • Association with PIN, radial nerve palsy – Boyd, Anderson modi cation = two incisions • Goal to avoid above complications • Reports of HO problems became more frequent
  22. 22. Introduction• Method of repair - history – Traditional single incision technique • Extensive volar dissection • Association with PIN, radial nerve palsy – Boyd, Anderson modi cation = two incisions • Goal to avoid above complications • Reports of HO problems became more frequent – Recent use of single incision method • Possible with anchors, screw, button devices • May minimize problems with earlier techniques
  23. 23. Introduction
  24. 24. Introduction• EndoButton-assisted repair
  25. 25. Introduction• EndoButton-assisted repair – A titanium button secured with suture
  26. 26. Introduction• EndoButton-assisted repair – A titanium button secured with suture – Bain, et al: rst report in 2000
  27. 27. Introduction• EndoButton-assisted repair – A titanium button secured with suture – Bain, et al: rst report in 2000 – Greenberg, et al: biomechanical, anatomic study 2003 • Pullout strength superior to anchors or bone tunnels
  28. 28. Study Objective
  29. 29. Study Objective• To report long-term clinical results of EndoButton-assisted distal biceps tendon repairs, re ected by both patient-centered outcome measures and objective testing
  30. 30. Materials and Methods
  31. 31. Materials and Methods• 48 patients identi ed (1996-2004)
  32. 32. Materials and Methods• 48 patients identi ed (1996-2004)• Records reviewed, patients contacted
  33. 33. Materials and Methods• 48 patients identi ed (1996-2004)• Records reviewed, patients contacted• Evaluation – DASH – Physical examination – BTE (strength, endurance) testing – Radiographs
  34. 34. Materials and Methods• 48 patients identi ed (1996-2004)• Records reviewed, patients contacted• Evaluation – DASH – Physical examination – BTE (strength, endurance) testing – Radiographs• Opposite extremity served as control
  35. 35. Demographics
  36. 36. Demographics• 17 patients returned for follow up
  37. 37. Surgery Summary
  38. 38. Surgery Summary• Single anterior Henry approach
  39. 39. Surgery Summary• Single anterior Henry approach• Tendon secured with No. 5 suture, threaded through EndoButton
  40. 40. Surgery Summary• Single anterior Henry approach• Tendon secured with No. 5 suture, threaded through EndoButton• Button, suture passed through radius
  41. 41. Surgery Summary• Single anterior Henry approach• Tendon secured with No. 5 suture, threaded through EndoButton• Button, suture passed through radius• Button locked on posterior radius
  42. 42. Surgery
  43. 43. Surgery
  44. 44. Surgery
  45. 45. Surgery
  46. 46. Surgery
  47. 47. Surgery
  48. 48. Surgery
  49. 49. Surgery
  50. 50. Surgery
  51. 51. Rehabilitation
  52. 52. Rehabilitation• AROM, AAROM, PROM of the elbow begun at 3-4 days postoperatively
  53. 53. Rehabilitation• AROM, AAROM, PROM of the elbow begun at 3-4 days postoperatively• Splinting limits extension to 30°, discontinued at 4 weeks
  54. 54. Rehabilitation• AROM, AAROM, PROM of the elbow begun at 3-4 days postoperatively• Splinting limits extension to 30°, discontinued at 4 weeks• Full use encouraged at 10-12 weeks after surgery
  55. 55. Objective Testing
  56. 56. Objective Testing• Range of motion
  57. 57. Objective Testing• Range of motion• Grip strength
  58. 58. Objective Testing• Range of motion• Grip strength• PIN function
  59. 59. Objective Testing• Range of motion• Grip strength• PIN function• LABCN function
  60. 60. Objective Testing• Range of motion• Grip strength• PIN function• LABCN function• Wound evaluation
  61. 61. Objective Testing• Range of motion• Grip strength• PIN function• LABCN function• Wound evaluation• BTE testing for strength, endurance – Flexion – Supination
  62. 62. Heterotopic Ossification
  63. 63. Heterotopic Ossification• Grade 0 – No HO seen
  64. 64. Heterotopic Ossification• Grade 0 – No HO seen• Grade 1 – Slight mushrooming extending anteriorly – Or small islands of bone < 1 cm dimension
  65. 65. Grade 0
  66. 66. Grade 0
  67. 67. Grade 1
  68. 68. Grade 1
  69. 69. Heterotopic Ossification
  70. 70. Heterotopic Ossification• Grade 2 – Moderate mushrooming – Or bone islands < 1 cm dimension
  71. 71. Heterotopic Ossification• Grade 2 – Moderate mushrooming – Or bone islands < 1 cm dimension• Grade 3 – Large area affecting functional forearm rotation
  72. 72. Grade 2
  73. 73. Grade 2
  74. 74. Subjective Assessment
  75. 75. Subjective Assessment• DASH questionnaire
  76. 76. Subjective Assessment• DASH questionnaire – An upper extremity-speci c patient-centered outcomes instrument
  77. 77. Subjective Assessment• DASH questionnaire – An upper extremity-speci c patient-centered outcomes instrument – Score range = 0-100 (DASH1)
  78. 78. Subjective Assessment• DASH questionnaire – An upper extremity-speci c patient-centered outcomes instrument – Score range = 0-100 (DASH1) – Higher scores suggest greater disability – 2 subscores (DASH2 and DASH3) • Work • Recreational activities
  79. 79. Subjective Assessment• DASH questionnaire – An upper extremity-speci c patient-centered outcomes instrument – Score range = 0-100 (DASH1) – Higher scores suggest greater disability – 2 subscores (DASH2 and DASH3) • Work • Recreational activities – Recent correlation with SF-36
  80. 80. Results
  81. 81. Results• 17 patients examined
  82. 82. Results• 17 patients examined• Mean follow up time = 51 months (4.25 years) (range = 13 to 130 months)
  83. 83. Results
  84. 84. Results• All incisions well-healed – no wound complications
  85. 85. Results• All incisions well-healed – no wound complications• Four patients - persistent numbness of LABCN
  86. 86. Results• All incisions well-healed – no wound complications• Four patients - persistent numbness of LABCN• Signi cantly less supination in injured extremity (5.3° less, p = 0.034)
  87. 87. Results• All incisions well-healed – no wound complications• Four patients - persistent numbness of LABCN• Signi cantly less supination in injured extremity (5.3° less, p = 0.034)• No other signi cant differences in ROM, strength, endurance between dominant- nondominant or injured-uninjured sides
  88. 88. Results
  89. 89. Results• DASH scores – DASH1 reported for all patients – Mean DASH1 = 9.5 – Mean DASH2 (n = 14) = 5.4 – Mean DASH3 (n = 12) = 10.4
  90. 90. Results
  91. 91. Results• Radiographic examination
  92. 92. Results• Radiographic examination – 2/17 patients had grade 2 HO – no functional limitation
  93. 93. Results• Radiographic examination – 2/17 patients had grade 2 HO – no functional limitation – 11/17 had grade 1 HO
  94. 94. Results• Radiographic examination – 2/17 patients had grade 2 HO – no functional limitation – 11/17 had grade 1 HO – Remainder (4) had no HO
  95. 95. Results
  96. 96. Results• Work, recreation status – One patient retired – One patient (worker’s comp) disabled after several surgeries – Of 15 patients giving a history of pre-surgical recreational activity, 14 patients returned to that activity
  97. 97. Conclusions
  98. 98. Conclusions• Technique appears safe – No motor nerve palsies – No functionally limiting HO/synostosis
  99. 99. Conclusions• Technique appears safe – No motor nerve palsies – No functionally limiting HO/synostosis• EndoButton strength allows early motion
  100. 100. Conclusions• Technique appears safe – No motor nerve palsies – No functionally limiting HO/synostosis• EndoButton strength allows early motion• Return to normal upper extremity functional level is a reasonable expectation – DASH scores approach normals for a non-clinical population* *Jester, A., et al. J Hand Surg [Am], 2005. 30(5): p. 1074 e1-1074 e10.
  101. 101. Future work
  102. 102. Future work• Number of patients – More to follow up, repeat contacts – Incentives
  103. 103. Future work• Number of patients – More to follow up, repeat contacts – Incentives• Endpoint: longest, largest follow up of EndoButton-assisted repairs

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