- The study evaluated the outcomes of 17 patients who underwent distal biceps tendon repair using an EndoButton technique with an average follow-up of 4.25 years. - Results found no wound complications, nerve palsies, or functionally limiting heterotopic ossification. Patients regained near normal elbow range of motion and strength on objective testing. - Subjective outcomes using DASH scores averaged 9.5, indicating minimal disability, and 14 of 15 patients returned to pre-injury recreational activities. The study concluded the EndoButton technique provides a safe and effective repair allowing early motion and return to normal upper extremity function.

1. Eight Year Experience with
EndoButton-assisted Repair
of Distal Biceps Tendon Ruptures

2. Eight Year Experience with
EndoButton-assisted Repair
of Distal Biceps Tendon Ruptures
C. Noel Henley, MD and
Jeffery A. Greenberg, MD
May 18, 2006

3. Summary of the near future

4. Summary of the near future
• Clinical overview

5. Summary of the near future
• Clinical overview
• Study Objective

6. Summary of the near future
• Clinical overview
• Study Objective
• Materials and Methods

7. Summary of the near future
• Clinical overview
• Study Objective
• Materials and Methods
• Results

8. Summary of the near future
• Clinical overview
• Study Objective
• Materials and Methods
• Results
• Conclusion

9. Summary of the near future
• Clinical overview
• Study Objective
• Materials and Methods
• Results
• Conclusion
• Future work

10. Introduction

11. Introduction
• e injury

12. Introduction
• e injury
– 3% of biceps tendon ruptures

13. Introduction
• e injury
– 3% of biceps tendon ruptures
– Complete avulsion from bone

14. Introduction
• e injury
– 3% of biceps tendon ruptures
– Complete avulsion from bone
– Common mechanism(s)

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. Introduction

17. Introduction
• Treatment Results
– Nonoperative
• Decreased supination strength
• Decreased supination, exion endurance

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. Introduction

20. Introduction
• Method of repair - history
– Traditional single incision technique
• Extensive volar dissection
• Association with PIN, radial nerve palsy

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. 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. Introduction

24. Introduction
• EndoButton-assisted repair

25. Introduction
• EndoButton-assisted repair
– A titanium button secured with
suture

26. Introduction
• EndoButton-assisted repair
– A titanium button secured with
suture
– Bain, et al: rst report in 2000

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. Study Objective

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. Materials and Methods

31. Materials and Methods
• 48 patients identi ed (1996-2004)

32. Materials and Methods
• 48 patients identi ed (1996-2004)
• Records reviewed, patients contacted

33. Materials and Methods
• 48 patients identi ed (1996-2004)
• Records reviewed, patients contacted
• Evaluation
– DASH
– Physical examination
– BTE (strength, endurance) testing
– Radiographs

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. Demographics

36. Demographics
• 17 patients returned for follow up

37. Surgery Summary

38. Surgery Summary
• Single anterior Henry approach

39. Surgery Summary
• Single anterior Henry approach
• Tendon secured with No. 5 suture, threaded
through EndoButton

40. Surgery Summary
• Single anterior Henry approach
• Tendon secured with No. 5 suture, threaded
through EndoButton
• Button, suture passed through radius

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. Surgery

43. Surgery

44. Surgery

45. Surgery

46. Surgery

47. Surgery

48. Surgery

49. Surgery

50. Surgery

51. Rehabilitation

52. Rehabilitation
• AROM, AAROM, PROM of the elbow begun at
3-4 days postoperatively

53. Rehabilitation
• AROM, AAROM, PROM of the elbow begun at
3-4 days postoperatively
• Splinting limits extension to 30°, discontinued at
4 weeks

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. Objective Testing

56. Objective Testing
• Range of motion

57. Objective Testing
• Range of motion
• Grip strength

58. Objective Testing
• Range of motion
• Grip strength
• PIN function

59. Objective Testing
• Range of motion
• Grip strength
• PIN function
• LABCN function

60. Objective Testing
• Range of motion
• Grip strength
• PIN function
• LABCN function
• Wound evaluation

61. Objective Testing
• Range of motion
• Grip strength
• PIN function
• LABCN function
• Wound evaluation
• BTE testing for strength, endurance
– Flexion
– Supination

62. Heterotopic Ossification

63. Heterotopic Ossification
• Grade 0
– No HO seen

64. Heterotopic Ossification
• Grade 0
– No HO seen
• Grade 1
– Slight mushrooming extending anteriorly
– Or small islands of bone < 1 cm dimension

65. Grade 0

66. Grade 0

67. Grade 1

68. Grade 1

69. Heterotopic Ossification

70. Heterotopic Ossification
• Grade 2
– Moderate mushrooming
– Or bone islands < 1 cm dimension

71. Heterotopic Ossification
• Grade 2
– Moderate mushrooming
– Or bone islands < 1 cm dimension
• Grade 3
– Large area affecting functional forearm rotation

72. Grade 2

73. Grade 2

74. Subjective Assessment

75. Subjective Assessment
• DASH questionnaire

76. Subjective Assessment
• DASH questionnaire
– An upper extremity-speci c patient-centered
outcomes instrument

77. Subjective Assessment
• DASH questionnaire
– An upper extremity-speci c patient-centered
outcomes instrument
– Score range = 0-100 (DASH1)

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. 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. Results

81. Results
• 17 patients examined

82. Results
• 17 patients examined
• Mean follow up time = 51 months (4.25 years)
(range = 13 to 130 months)

83. Results

84. Results
• All incisions well-healed – no wound
complications

85. Results
• All incisions well-healed – no wound
complications
• Four patients - persistent numbness of LABCN

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. 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. Results

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. Results

91. Results
• Radiographic examination

92. Results
• Radiographic examination
– 2/17 patients had grade 2 HO – no functional
limitation

93. Results
• Radiographic examination
– 2/17 patients had grade 2 HO – no functional
limitation
– 11/17 had grade 1 HO

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. Results

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. Conclusions

98. Conclusions
• Technique appears safe
– No motor nerve palsies
– No functionally limiting HO/synostosis

99. Conclusions
• Technique appears safe
– No motor nerve palsies
– No functionally limiting HO/synostosis
• EndoButton strength allows early motion

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. Future work

102. Future work
• Number of patients
– More to follow up, repeat contacts
– Incentives

103. Future work
• Number of patients
– More to follow up, repeat contacts
– Incentives
• Endpoint: longest, largest follow up of
EndoButton-assisted repairs