Blog Elements - Acta of Shoulder and Elbow Surgery

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty

October 10, 2016/0 Comments/in Vol 1| Issue 1| Oct-Dec 2016 /by ASESADMIN2016

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 14-19 | Gregory G Markarian, Aboul Deng Bab, John W Uribe. Authors: Gregory G Markarian [1], Aboul Deng Bab [2], John W Uribe [3] [1] OAN Sportsmedicine, Naperville, Il. [2] Atlantic University, School of Medicine. [3] Professor and Chairman, […]

Intramedullary Cortical Button Fixation of Distal Biceps Tendon Rupture: long-term Patient Outcomes”

October 10, 2016/0 Comments/in Vol 1| Issue 1| Oct-Dec 2016 /by ASESADMIN2016

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 20-26 | Jake J Ni, David M Auerbach. Authors: Jake J Ni [1], David M Auerbach [2] [1] Fellow, Southern California Orthopedic Institute. [2] Attending, Southern California Orthopedic Institute. Address of Correspondence Dr. David M Auerbach, MD 6815 Noble Avenue […]

Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty

October 10, 2016/0 Comments/in Vol 1| Issue 1| Oct-Dec 2016 /by ASESADMIN2016

Intramedullary Cortical Button Fixation of Distal Biceps Tendon Rupture: long-term Patient Outcomes”

October 10, 2016/0 Comments/in Vol 1| Issue 1| Oct-Dec 2016 /by ASESADMIN2016

Full Sized Blog Element (Big Preview Pic)

Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty

October 10, 2016/0 Comments/in Vol 1| Issue 1| Oct-Dec 2016 /by ASESADMIN2016

Authors: Gregory G Markarian [1], Aboul Deng Bab [2], John W Uribe [3]

[1] OAN Sportsmedicine, Naperville, Il.
[2] Atlantic University, School of Medicine.
[3] Professor and Chairman, Department of Orthopaedic Surgery, Herbert Wertheim School of Medicine, Florida International University.

Address of Correspondence
Dr. Gregory G. Markarian, MD, FRCS
OAN Sportsmedicine 10 West Martin Ave Suite 50
Naperville, IL 60540
Email:- drgmark@hotmail.com

Abstract

Introduction: Shoulder arthroplasty utilization worldwide has undergone significant changes in the past two decades. Early on, the procedure volume was relatively small and demonstrated a preference towards hemiarthroplasty. Starting with the new millennium, the overall arthroplasty volume not only drastically increased, but also showed a tendency towards younger patients. Recent reports revealed that more than three quarters of all shoulder arthroplasty procedures are performed as a stemmed total or reverse procedure. Younger patients result in a clear increase in the revision rate across all conventional implant classes as evidenced by arthroplasty registry results. Increased modularity and adaptability of modern stemmed arthroplasty improved the procedure, but remains largely non-anatomic with continued use of spherical humeral head and onlay glenoid components. The purpose of this review is to highlight the technical and clinical advantages of inlay shoulder arthroplasty and to differentiate it from onlay resurfacing procedures and the current trends in shoulder arthroplasty. Resurfacing arthroplasty is an implant class consists of onlay hemi and total resurfacing, partial inlay and total resurfacing. The distinction is important as onlay procedures use spherical humeral head and onlay glenoid components whereas inlay arthroplasty is taking the geometrical humeral head mismatch into consideration and avoids glenoid related joint line changes. In keeping the glenohumeral joint volume near the native conditions, biomechanical and kinematic advantages can be appreciated. Registry results showed the lowest 5 year cumulative revision rate for partial inlay arthroplasty across the treatment spectrum and clinical results from stemless total resurfacing using non-spherical humeral head and inlay glenoid components display great promise for a new path in primary shoulder arthroplasty.

Introduction

Shoulder arthroplasty as a specialty has undergone significant changes in the new millennium (11,19,24,39,44). This did not only cause a marked increase in procedure volume, but also a shift in the use of specific implant classes and age related trends towards younger patients (2,37,43). Combined, these factors have led to a substantial increase in revisions (44) and may have a significant impact on the long term management of shoulder patients. In the context of these developments, contemporary primary shoulder arthroplasty continues to show a disregard for joint preservation and anatomic surface reconstruction with preferential use of stemmed total and reverse procedures (11,35,43,44). Modularity and adaptability are important aspects of modern stemmed procedures (4,16,48); however, with continued use of spherical humeral head and onlay glenoid components, these procedures remain largely non-anatomic. The purpose of this review is to summarize trends in shoulder arthroplasty and present a rational for inlay arthroplasty as a less invasive alternative in primary shoulder replacement.

Morphology and Biomechanics of the Humeral Head
Since the introduction of modern shoulder arthroplasty by Neer (36), evidence on the non-spherical nature of the humeral head (HH) has steadily increased for more than 50 years with reports on biomechanical and morphological data that reference the native shape of the humeral head. In 1955, Neer (36) described the superior edge of the humeral head as somewhat flattened. In 1979, Clarke (8) showed that the best match to the plane of the cross sectioned humerus was in form of an elliptical shape. This was reconfirmed by multiple studies over the following three decades (1,3,6,18,20,21,31,42,49,50). Other studies comparing the major and minor planes of the HH reported a dimensional mismatch with a range from 1.6 to 6.5 mm (8,18,20,21,22,42,49). The principal goal for primary shoulder arthroplasty is to restore normal glenohumeral joint kinematics (23). Jun et al. (22) compared custom non-spherical and commercially available spherical implants to the native humeral head and showed that the non-spherical shape fit the native HH better. The study reported a significant reduction in rotational range of motion for spherical heads (mean 7.6 +/- 8.2 degrees) compared to the native humeral head; no statistical difference in rotational range of motion was found between the non-spherical and native conditions. The authors concluded that the use of non-spherical heads may improve functional results after shoulder arthroplasty by more closely approximating the rotational range of motion and kinematics of the native humeral head as compared to the current spherical prosthetic designs. The kinematical advantages of non-spherical implants were reconfirmed by the authors in their most recent publication: The non-spherical humeral head shape contributed to increased glenohumeral translation whereas the aspherical head shape did not show significant glenohumeral translation during humeral axial rotation, regardless of glenoid conformity (23).

Trends in Shoulder Arthroplasty
Procedure Volume
In 1993, the US shoulder arthroplasty volume included 13837 procedures with a slight preference for hemiarthroplasty (54%) over total shoulder arthroplasty (46%). In 1999, the total volume had increased to 19113 procedures and the preference for hemiarthroplasty remained (56%) (24). Since the start of the new millennium, shoulder arthroplasty experienced a drastic rise. The American Academy of Orthopaedic surgeons (AAOS) reported an absolute increase in primary procedures from 18,621 discharges in the year 2000 to 45,274 discharges in 2011 (2) with other estimates reporting a total of 66,485 for the same year (43). The Australian orthopaedic association’s annual shoulder arthroplasty registry report mirrored this trend. Since 2004, the registry recorded 32,406 shoulder replacement procedures (35). Starting in 2008, the number of shoulder replacement procedures has increased by 88.5%. Dillon et al. published their results on 6,336 primary shoulder arthroplasties recorded from 2005 – 2013 in the Kaiser Permanente shoulder arthroplasty registry (11). Procedures were classified as a total shoulder arthroplasty in 48%, followed by hemiarthroplasty procedures in 34%, reverse total shoulder arthroplasty in15%, and humeral head resurfacing in 3%. Shoulder arthroplasty utilization was based on the following diagnoses: Osteoarthritis (60%), fracture (17%), cuff tear arthropathy (15%), and avascular necrosis (2.6%). The all cause revision rate for elective shoulder arthroplasty was 4%. The most common reason for revision was glenoid wear following hemiarthroplasty or onlay humeral head resurfacing (27% of all revisions) followed by deep infection (20%), instability (18%), rotator cuff tear (17%), and glenoid component failure. Patients less than 60 years of age receiving a hemiarthroplasty had an almost 5 times higher revision risk than those patients who received a TSA.

Patient Age
From 2000 to 2011, the AAOS report (2) showed a 5% increase in total shoulder replacement in patients between 45 – 64 years old (29 –34%), whereas patients 65 – 84 years essentially remained unchanged with a 1% reduction over the same period. The proportion of partial shoulder replacements in middle-aged patients increased by 10% (25 – 35%) (2). US inpatient sample estimates showed that 53% of all patients treated with reverse total shoulder arthroplasty were less than 75 years old. The same applied for 50% of total shoulder arthroplasty (TSA) and 32% of hemiarthroplasty (43).

Procedure Type
Based on current Australian utilization, primary total shoulder replacement is the most common category (71.8%), followed by primary partial (17.9%) and revision procedures (10.3%). The proportion of total shoulder replacement has increased from 57.5% in 2008 to 82.1% in 2015. The majority of this increase has been led by a more than a fourfold increase in reverse total shoulder arthroplasty over this time frame. Between 2008 and 2015, partial shoulder replacement decreased from 32.6% to 7.2% (35). A similar trend towards total shoulder replacement has been reported in the US. Schwartz et al. showed a fivefold increase in primary total shoulder utilization based on a national hospital discharge survey with data from 2001 to 2010 (44). Based on 2011 estimates published by Schairer et al. (43), 32.6% of all procedures were reverse shoulder arthroplasties (RSA), 44.2% were total shoulder replacements, and 23.2% were hemi arthroplasty procedures.

Revision Rates by Age
Shoulder implant classes demonstrate an overall trend towards higher revision rates with younger patient age. The 5 year cumulative percent revision for primary hemi onlay resurfacing in patients under 55 years was 10.4, compared to 8.1 in the 65-74 year old patients and 6.6 in patients over 75 years. Similar 5 year trends were reported for primary stemmed hemiarthroplasty with a revision rate of 13.1 (<55 years) versus 7.0 (>75 years) and 11.0 (<55 years) versus 6.7 (>75 years) for primary stemmed TSA (35).

Hemi versus Total Shoulder Replacement

Several comparative studies support the preference towards TSA. A systematic review and meta- analysis conducted by Bryant et al. (5) compared TSA to hemiarthroplasty (HA) at a minimum of 2 years follow up. A total of 112 patients (62 TSA, 50 HA) were included in the review. The authors concluded that TSA showed better functional improvement than HA and contributed continuous degeneration of the glenoid to the result. In a 10-year update, Sandow et al. showed that 42 percent of the surviving TSA patients rated their shoulders as pain free while none of the HA patients were free of pain at 10 years (41). Radney et al. (40) conducted a systematic review comparing TSA to humeral head replacement (HHR) and concluded that TSA significantly improved pain relief, range of motion and patient satisfaction. TSA also had a significantly lower revision rate (6.5%) compared to patients undergoing HHR (10.2%). Garcia et al. (13) reported on patients with osteoarthritis (OA) who wished to return to sports following a total or hemi shoulder arthroplasty. He found that the rate of return to sports was significantly better after TSA compared with HA. In addition, the HA patients had significantly more pain, worse surgical satisfaction, and a decreased ability to return to high upper extremity use sports.

Inlay Arthroplasty

Shoulder resurfacing as a less invasive alternative to stemmed arthroplasty has been popularized by Copeland and Levy (27-29,34). Despite the inherent advantages from a joint preservation perspective, the use of spherical onlay implants has not been void of criticism. Five year revision rates for hemi onlay resurfacing (10.6%) have been higher than their stemmed counterparts (8.5%) (35). Despite previous reports of overstuffing or varus placement (32,45), underlying reasons are not yet fully understood. Inlay arthroplasty (IA) represents a departure from the use of spherical humeral head configurations. The concept was introduced more than decade ago and started with partial humeral head surface reconstruction, which was expanded in recent years to full head coverage. The system consists of various humeral head diameters ranging from 25 to 58mm. Each diameter has an array of shapes that allows for congruent surface reconstruction within the curvature of the humeral head. The two piece implant consists of a screw that is placed into the center of the defect for the purpose of fixation and surface measurement and an articular component that matches the superior-inferior (SI) and anterior-posterior (AP) curvatures of the surrounding surface. The contour is mapped intraoperative, corresponding surface reamers prepare an implant bed, and the screw and articular component are connected via morse taper. The surgical procedure has been described in detail previously (17,46,47). IA uses anatomic references to reconstruct the native geometry. Neither stemmed procedures, nor onlay resurfacing procedures take the non-spherical humeral head morphology into consideration; however, IA preserves anatomic landmarks for intraoperative measurements and reconstruction thereby keeping soft tissue tension and the moment arms of the shoulder muscles intact. Technical challenges associated with stemmed procedures are avoided by maintaining humeral head height, version, offset, and joint volume. This may not only have positive implications for postoperative recovery and rehabilitation, but also reduces the risk of implant related pressure on the rotator cuff and subscapularis repair following the customary deltopectoral approach. Hemi and total onlay resurfacing procedures using spherical implants reference the implant diameters off the larger superior-inferior humeral head plane to gain complete surface coverage. The non-physiological joint volume increase in the anterior-posterior plane can be avoided by using non-spherical implants that respect the SI – AP mismatch. Similar to onlay total shoulder resurfacing, IA allows for total resurfacing of the glenoid vault using dedicated 30 degree off axis reamers. Following preparation of the humeral head, the glenoid vault is accessed from the front using a circular paddle reamer. Single or double circle inlay glenoid components allow for surface reconstruction without lateralizing the joint line. Keeping glenohumeral volume contributions at their native levels may have positive implications for postoperative pain relief and functional improvements.

Biomechanical Comparison

The concept of inlay glenoid resurfacing has been previously described by Gunther et al. (15). Following cyclic loading to 100,000 cycles, no inlay glenoid components demonstrated signs of loosening. Finite element analysis results indicated that the inset technique achieved up to an 87% reduction in displacement compared with the onlay pegged implant and a 73% reduction compared with the onlay keel implant. Onlay implants exhibited high stress at the implant edges in form of a rocking-horse stress distribution, whereas the inset design did not show the rocking-horse stress distribution. The authors concluded that cyclic loading and finite element analysis support the concept of inset glenoid fixation in minimizing the risk of glenoid loosening. Recently, Gagliano et al. (12) presented their results comparing onlay versus inlay glenoid prosthetic design survivorship characteristics in total shoulder arthroplasty at the 2015 Orthopaedic Research Society Meeting (ORS). The study showed visible loosening in all onlay implants in less than 2000 cycles, whereas none of the inlay components showed signs of loosening following 4000 cycles. A biomechanical study by Hammond et al. (17) reported on the comparison of the intact glenohumeral joint to that following HH inlay arthroplasty and stemmed hemiarthroplasty. IA restored the center of rotation more closely than stemmed hemiarthroplasty and the glenoid had demonstrated less eccentric loading. The authors concluded that IA may provide better functional outcomes for patients as the biomechanics of the joint and the moment arms of the rotator cuff and deltoid more closely resembled the intact condition.

Clinical Results

The Australian Shoulder Arthroplasty Registry has been reporting on inlay arthroplasty since 2010. While the procedure volume has remained low, the revision rate (RR) has shown dramatic differences comparing partial inlay arthroplasty to other implant classes. In the 2016 report (35), the 5 year cumulative RR of partial inlay arthroplasty was 1.5%. No other implant class showed comparable registry results. As an implant class, hemi onlay resurfacing at 5 years had a cumulative revision rate of 10.6%, which was highest with Global CAP implants (12.8%, primary diagnosis OA), followed by Copeland (9.1%, primary diagnosis OA), and Aequalis (9.0%, primary diagnosis OA). These results highlight the importance of differentiating among inlay and onlay surface reconstruction methods. When addressing the glenoid as well, the 5 year cumulative revision rate of total onlay resurfacing was lowered to 7.3%. For comparison, the 5 year RR for stemmed hemiarthroplasty was 8.5%, for stemmed total shoulder arthroplasty 8.1%, and for total reverse arthroplasty 4.6%. It remains important to view registry and literature reports in the context of patient age and clinical exit opportunities. Procedures that are amenable for younger patients will be subject to higher demands and increased RR as reported earlier. End stage procedures such as stemmed total shoulder replacement and reverse arthroplasty face increasing technical demands when revision procedures become necessary. The management of patient expectation is generally more restrictive in these arthroplasty solutions when compared to less invasive alternatives and may impact the patients’ desire to undergo further surgery. Therefore, end stage procedures may show a false positive revision rate due to the lack of treatment alternatives. Advanced stages of osteonecrosis of the Humeral Head (ONHH) with separation of the subchondral bone or contour collapse are typically managed with arthroplasty. Uribe et al. reported on the use of partial inlay arthroplasty for advanced stage ONHH (47). The consecutive series of 12 shoulders (9 female, 2 male, one bilateral, mean age 56 years) was staged according to the Cruess classification and included five Stage III, 6 Stage IV, and one Stage V. All procedures were performed on an outpatient basis. The average procedure time was 41 minutes (range 23 to 62 min), blood loss was less than 100ml, no patient required transfusions peri-operatively and no complications were encountered. At an average follow up of 30 months, all patients reported significant pain relief. Visual analogue scales improved from 75 to 16 at the time of final evaluation. The mean Western Ontario Osteoarthritis of the Shoulder index score significantly improved from 1421 preoperatively to 471 postoperatively. The mean Shoulder Score Index score improved from 24 preoperatively to 75 postoperatively. The mean Constant score improved from 23 preoperatively to 62. Forward elevation improved from a mean of 94° to 142° (P < .001). External rotation improved from a mean of 28° to 46° (P < .001). All postoperative radiographs showed solid fixation of both implant components and no evidence of periprosthetic loosening, osteolysis, or device migration. In a retrospective case series of 19 patients (16 men, 3 women, 20 shoulders), Sweet et al. (46) reported their findings on inlay arthroplasty in young patients (average age of 48.9 years). Preoperative diagnoses included osteoarthritis in 16 shoulders and osteonecrosis in 4. At a mean follow-up of 33 months (range, 17-66 months), the mean American Shoulder and Elbow Surgeons score improved from 24.1 to 78.8, the mean Simple Shoulder Test score improved from 3.95 to 9.3, the mean visual analog scale score was reduced from 8.2 to 2.1, mean forward flexion improved from 100 degrees to 129, and the mean external rotation changed from 23 to 43 degrees (P<.001 for all). Radiographic examination showed no evidence of periprosthetic fracture, component loosening, osteolysis, or device failure. The overall patient shoulder self assessment was 90% poor prior to the procedure and improved to 75% good to excellent at final follow-up; 90% of patients were satisfied with the choice of the procedure. Three patients experienced postoperative complications unrelated to the prosthesis, that included a partial rotator cuff tear treated with physical therapy, a pre-existing glenoid wear which was effectively addressed with arthroscopic debridement and microfracture, and one infection that was complicated by a subscapularis rupture requiring several subsequent surgical interventions but with retention of the implant. The authors concluded that inlay arthroplasty is effective in providing pain relief, functional improvement, and patient satisfaction and called it a promising new direction in primary shoulder arthroplasty for younger and active patients with earlier stage disease. Since 2007, several authors advocated the use of IA in patients with Hill-Sachs lesions (7,10,14,25,26,33,38). Potential advantages were attributed to the anatomically contoured surface reconstruction, minimizing soft-tissue disruption, individual sizing, avoiding the limitations of autograft tissue, conservation of bone stock, short operative time, no associated graft resorption and subsequent hardware removal, and lack of disease transmission. Moros and Ahmad presented a case report with 2 years follow-up and reported full arm function with no pain, instability, clicking, catching, or dislocation. Range of motion was without limitations and the patient had returned to full work duties as a porter (33). In 2015, McKenna et al. (30) published their rational for outpatient treatment of compensated cuff arthropathy using inlay arthroplasty with subscapularis preservation. Using strict early disease stage selection criteria and addressing all primary and secondary pain generators, the authors concluded that the use of humeracromial IA in compensated cuff arthropathy has distinct advantages as the technique preserves the glenohumeral joint and avoids the bone loss and complications associated with stemmed arthroplasty. A deltoid splitting approach may reduce the risk of iatrogenic muscle imbalance leaving the subscapularis tendon intact. The outpatient procedure enabled patients to undergo an accelerated recovery and rehabilitation with emphasis on the deltoid driven functional compensation. Detailed results on their first 50 subjects treated since 2007 are pending to date. Most recently, Davis et al. (9) published their series of 9 patients treated with total shoulder arthroplasty combined with inlay glenoid components for glenoid deficiency. Four glenoids were classified as Walch type A2, 2 as type C, and 3 were unable to be classified. At a 34 month follow-up, seven patients (4 female and 3 male patients; 9 shoulders) with a mean age of 66 years showed a statistically significant increase in range of motion, decrease in pain scores (8 points to 1 point), and improvement in Single Assessment Numeric Evaluation scores (31.7% to 89.4%). The mean patient satisfaction score was 8.6 points on a 10-point scale. The authors concluded that management of the glenoid with severe retroversion or medial bone loss remains a challenging procedure at all levels of surgical expertise. Based on their 2-year follow-up, total shoulder arthroplasty with a mini glenoid component may be an option to address a glenoid deficiency and offer adequate pain relief and functional results.
Our own experience with stemless total shoulder arthroplasty using non-spherical humeral head resurfacing and inlay glenoid replacement has been very encouraging. In the ongoing prospective study, a total of 70 patients (74 shoulders) were treated for advanced glenohumeral arthritis. 38 reached their 2 year follow-up mark. Of those, 2 have been lost to follow-up and 2 did not consent to participate further. Thus 34 patients (36 shoulders, 20 male, 14 female) have reached a mean follow-up of 30 months (24-39 months). Their mean age was 65.9 years (range 45 – 81 years). All clinical outcomes scores showed statistically significant improvements (p<0.001): The mean ASES Score improved from 27.9 – 75.4, the Constant Score improved from 26.9 – 73.0, and the WOOS Index improved from 29.2 – 82.9. Range of motion improved in all dimensions particularly for forward flexion from 102° to 155° and internal rotation from the hip pocket to L3. The VAS Pain Score improved from 7.8 to a mean of 1.4. Patient satisfaction at last follow-up was excellent. All surgeries were performed on an outpatient or 23 hour admission basis. No patient required a transfusion. One patient suffered from a deep infection resulting in glenoid component loosening which was removed. Aside from this complication, radiographs showed no evidence of component loosening or migration. A subset of these patients demonstrated remarkable functional performance at a competitive level of bodybuilding or powerlifting. Five male athletes with an average age of 45.6 years (range 25-57) were prospectively followed. All had advanced glenohumeral arthritis and expressed a strong desire to continue their sport. All were treated utilizing stemless non-spherical resurfacing of the HH combined with an inlay glenoid. There were no blood transfusions and all cases were performed on an outpatient patient basis. The mean follow-up was 31 months (range, 16 – 51). The average ASES score improved from 26 to 93. The mean WOOS score improved from 18 to 87. The mean VAS pain score went from 9 to 1, mean forward flexion increased from 115° to 135°, mean external rotation from 30 ° to 60°; the preoperative internal rotation allowed patients to reach sacrum levels which improved to lumbar level 3 post-surgery. Four out of five patients assessed their shoulder as poor prior to surgery which improved to good to excellent in all subjects at follow-up. Radiographic assessment revealed no evidence of component loosening, glenoid migration, or evidence of device failure. All patients were satisfied with the choice of the procedure with 4 of the 5 reported to have returned to at least moderate weight lifting activities. One patient required an arthroscopic capsular release for arthrofibrosis which significantly improved function. In this difficult patient population, stemless non-spherical humeral head resurfacing along with an inlay glenoid has been a reliable and effective option for the management of symptomatic osteoarthritis and allowed athletes to return to their sport. The risk for future prosthetic problems or other complications appears less likely than with standard TSA although longer follow-up is necessary.

Conclusion

Current trends in shoulder arthroplasty have marginalized joint preservation despite a significant increase in volume and a tendency towards younger patients. The predominant use of non-spherical, non-anatomic solutions with stemmed total and reverse shoulder arthroplasty combined with a lack of distinction between inlay and onlay resurfacing procedures turned the specialty away from individual patient decisions and created a conventional treatment spectrum. Inlay arthroplasty shows great promise both from a biomechanical and clinical perspective to offer an individual alternative in primary arthroplasty. Patients may benefit from tissue preservation and a less invasive procedure that avoids the risks, and technical challenges associated with stemmed procedures. Respecting the humeral head geometry mismatch and avoiding glenohumeral joint volume alterations, inlay arthroplasty may become a new path for high demand and sedentary patients alike. However, larger procedure volumes have to be validated through registry and literature reports in order substantiate the presumed advantages.

References

1. Amstutz HC, Sew Hoy AL, Clarke IC (1981)’UCLA anatomic total shoulder arthroplasty. ‘ Clin Orthop Rel Re,s 155, pp. 7-20.
2. Annual Incidence of Common Musculoskeletal Procedures and Treatment. Department of Research and Scientific Affairs. American Academy of Orthopaedic Surgeons (AAOS 2014) http://www.aaos.org/research/stats/CommonProceduresTreatments-March2014.pdf
3. Boileau P, Walch G (1997) ‘The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design.’ J Bone Joint Surg, 79B(5), pp. 857- 865.
4. Boileau P, Sinnerton RJ, Chuinard C, Walch G (2006) ‘Arthroplasty of the shoulder.’ J Bone Joint Surg Br, 88(5), pp. 562-575.
5. Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A (2005) ‘Acomparison of pain, strength, range of motion, and functional outcomes afterhemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis.’ J Bone Joint Surg Am, 87(9), pp. 1947-1956.
6. Büchler P, Farron A (2004) ‘Benefits of an anatomical reconstruction of the humeral head during shoulder arthroplasty: a finite element analysis.’ Clin Biomech Bristol, 19(1), pp. 16-23.
7. Bushnell BD, Creighton RA, Herring MM (2008) ‘Bony instability of the shoulder.’ Arthroscopy, 24(9), pp. 1061-73.
8. Clarke IC, Gruen TAW, Sew Hoy A, Hirschowitz D, Maki S, Amztutz HC (1979) “Problems in gleno-humeral surface replacements- real or imagined?’ Eng Med, 8, pp. 161- 175.
9. Davis DE, Acevedo D, Williams A, Williams G (2016)0’ Total shoulder arthroplasty using an inlay mini-glenoid component for glenoid deficiency: a 2-year follow-up of 9 shoulders in 7 patients.’ J Shoulder Elbow Surg, 25(8), pp. 1354-1361.
10. Dawson CK, Rolf RH, Holovacs T (2008) ‘Management of localized humeral head defects in the athlete. ‘Oper Tech Sports Med, 16, pp. 14-20.
11. Dillon MT, Ake CF, Burke MF, Singh A, Yian EH, Paxton EW et al (2015) ‘The Kaiser Permanente shoulder arthroplasty registry: results from 6,336 primary shoulder arthroplasties.’ Acta Orthop, 86(3), pp. 286-292.
12. Gagliano JR, Sarah M, Helm SM, Colbath GP, Przestrzelski BT, Desjardin JD et al. (2015) ‘Comparison of Onlay vs. Inlay Glenoid Prosthetic Design Survivorship Characteristics in Total Shoulder Arthroplasty.’ Annual Meeting, Orthopaedic Research Society.
13. Garcia GH, Liu JN, Mahony GT, Sinatro A, Wu HH, Craig EV, Warren RF et al. (2016) ‘Hemiarthroplasty Versus Total Shoulder Arthroplasty for Shoulder Osteoarthritis: A Matched Comparison of Return to Sports.’ Am J Sports Med. pii: 0363546516632527. [Epub ahead of print]
14. Grondin P, Leith J (2009) ’Case series: Combined large Hill-Sachs and bony Bankart lesions treated by Latarjet and partial humeral head resurfacing: a report of 2 cases.’ Can J Surg, 52(3), pp. 249-54.
15. Gunther SB, Lynch TL, O’Farrell D, Calyore C, Rodenhouse A (2012) ‘Finite elementanalysis and physiologic testing of a novel, inset glenoid fixation technique.’ J Shoulder Elbow Surg, 21(6), pp. 795-803.
16. Habermeyer P, Ebert T(1999)’ Current status and perspectives of shoulderreplacement.’ Unfallchirurg, 102(9), pp. 668-683.
17. Hammond G, Tibone JE, McGarry MH, Jun BJ, Lee TQ (2012) ‘Biomechanical comparison of anatomic humeral head resurfacing and hemiarthroplasty in functional glenohumeral positions.’ J Bone Joint Surg Am, 94(1), pp. 68-76.
18. Harrold F, Wigderowitz C. (2012) ‘A three-dimensional analysis of humeral head retroversion.’ J Shoulder Elbow Surg 21, pp. 612-617.
19. Hawi N, Tauber M, Messina MJ, Habermeyer P, Martetschläger F (2016) ‘Anatomicstemless shoulder arthroplasty and related outcomes: a systematic review.’ BMC Musculoskelet Disord. 17(376), pp. 1-10.
20. Hertel R, Knothe U, Ballmer FT (2002) ‘Geometry of the proximal humerus and implications for prosthetic design.” J Shoulder Elbow Surg 11, pp. 331-318.
21. Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S (1992) ‘The normal glenohumeral relationships.’ J Bone Joint Surg, 76A(4), pp. 491-500.
22. Jun B-J, Iannotti JP, McGarry MH, Yoo JC, Quigley RJ, Lee TQ. (2013) ‘The effects of prosthetic humeral head shape on glenohumeral joint kinematics: a comparison of non-spherical and spherical prosthetic heads to the native humeral head.’ J Shoulder Elbow Surg, 22, pp. 1423-1432.
23. Jun BJ, Lee TQ, McGarry MH, Quigley RJ, Shin SJ, Iannotti JP (2016) ‘The effects of prosthetic humeral head shape on glenohumeral joint kinematics during humeral axial rotation in total shoulder arthroplasty. ‘J Shoulder Elbow Surg, 25(7), pp. 1084-1093.
24. Kim SH, Wise BL, Zhang Y, Szabo RM (2011) ‘Increasing incidence of shoulderarthroplasty in the United States.’ J Bone Joint Surg Am, 21,93(24), pp. 2249-2254.
25. Kösters C, Schliemann B, Raschke M. Endoprothetik nach Trauma (2010) Trauma Berufskrankh, 12, pp. 47–52.
26. Lenarz C, Shishani Y, Gobezie R (2011) ‘Surface Replacement: The Hemicap Solution.’ Semin Arthro, 22, pp. 10-13.
27. Levy O, Copeland SA (2001) ‘Cementless surface replacement arthroplasty of the shoulder. 5- to 10-year results with the Copeland mark-2 prosthesis.’ J Bone Joint Surg Br, 83(2), pp. 213-221.
28. Levy O, Copeland SA (2004) ‘Cementless surface replacement arthroplasty (Copeland CSRA) for osteoarthritis of the shoulder. ‘J Shoulder Elbow Surg, 13(3), pp. 266-271.
29. Levy O, Tsvieli O, Merchant J, Young L, Trimarchi A, Dattani R et al. (2015) ‘Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up.’ J Shoulder Elbow Surg, 24(7), pp. 1049-1060.
30. McKenna RW, Chandler T (2015) ‘Outpatient Treatment of Compensated Cuff Arthropathy Using Inlay Arthroplasty with Subscapularis Preservation.’ Tech Shoulder Elbow Surg, 16(4), pp. 115-125.
31. McPherson EJ, Friedman RJ, An, YH, Chokesi R, Dooley L (1994) ‘Anthropometric study of normal glenohumeral relationships.’ J Shoulder Elbow Surg, 6, pp. 105-112.
32. Mechlenburg I, Amstrup A, Klebe T, Jacobsen SS, Teichert G, Stilling M (2013) ‘The Copeland resurfacing humeral head implant does not restore humeral head anatomy. A retrospective study.’ Arch Orthop Trauma Surg, 133(5), pp. 615-619.
33. Moros C, Ahmad CS (2009)’ Partial humeral head resurfacing and Latarjet coracoid transfer for treatment of recurrent anterior glenohumeral instability.’ Orthopedics, 32(8), pp. 602-605.
34. Mullett H, Levy O, Raj D, Even T, Abraham R, Copeland SA (2007) ‘Copeland surface replacement of the shoulder. Results of an hydroxyapatite-coated cementless implant in patients over 80 years of age.‘ J Bone Joint Surg Br, 89(11), pp. 1466-1469.
35. National Joint Replacement Registry, The Australian Orthopaedic Association. Hip, Knee and Shoulder Arthroplasty, Supplementary Report 2016 https://aoanjrr.sahmri.com/annual-reports-2016.
36. Neer CS (1955) ‘Articular replacement of the humeral head.’J Bone Joint Surg, 37A(2), pp. 215-228.
37. Padegimas EM, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S (2015) ‘Future patient demand for shoulder arthroplasty by younger patients: national projections.’ Clin Orthop Relat Res, 473(6), pp. 1860-1867.
38. Patel RV, Apostle K, Leith JM, Regan WD (2008) ‘Revision arthroscopic capsulolabral reconstruction for recurrent instability of the shoulder.’ J Bone Joint Surg Br, 90(11), pp.1462-7.
39. Pinkas D, Wiater JM, Spencer EE Jr, Edwards TB, Uribe JW, Declercq G, Murthi AM, Hertel R (2015) ‘Shoulder prosthetic arthroplasty options in 2014: what to do and when to do it.’ Instr Course Lect, 64, pp. 193-202.
40. Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU, Ahmad CS (2007) ‘Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: A systematic review.’ J Shoulder Elbow Surg 16, pp. 396–402.
41. Sandow MJ, David H, Bentall SJ (2013) ‘Hemiarthroplasty vs total shoulder replacement for rotator cuff intact osteoarthritis: how do they fare after a decade?’ J Shoulder Elbow Surg, 22(7), pp. 877-885.
42. Sarrafian SK (1983) ‘Gross and functional anatomy of the shoulder.’ Clin Orthop, 173, pp. 11-19.
43. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. (2015) ‘National utilization of reverse total shoulder arthroplasty in the United States.’ J Shoulder Elbow Surg, 24(1), pp. 91-97.
44. Schwartz BE, Savin DD, Youderian AR, Mossad D, Goldberg BA (2015) ‘National trends and perioperative outcomes in primary and revision total shoulder arthroplasty: Trends in total shoulder arthroplasty.’ Int Ortho,p 39(2), pp. 271-276.
45. Stilling M, Mechlenburg I, Amstrup A, Soballe K, Klebe T (2012) ‘Precision of novel radiological methods in relation to resurfacing humeral head implants: assessment by radiostereometric analysis, DXA, and geometrical analysis.’ Arch Orthop Trauma Surg, 132(11), pp. 1521-1530.
46. Sweet SJ, Takara T, Ho L, Tibone JE (2015) ‘Primary partial humeral head resurfacing:outcomes with the HemiCAP implant.’ Am J Sports Med, 43(3), pp. 579-587.
47. Uribe JW, Botto-van Bemden A (2009) ’Partial humeral head resurfacing forosteonecrosis.’ J Shoulder Elbow Surg, 18(5), pp. 711-716.
48. Walch G, Boileau P (1999) ‘Prosthetic adaptability: a new concept for shoulder arthroplasty.‘ J Shoulder Elbow Surg, 8(5), pp. 443-451.
49. Wataru S, Kazuomi S, Yoshikazu N, Hiroaki I, Takaharu Y, Hideki Y (2005) ‘Three-dimensional morphological analysis of humeral heads.’ Acta Orthopedica, 76(3), pp. 392-396.
50. Zumstein V, Kraljevic´ M, Hoechel S, Conzen A, Nowakowski AM, Müller-Gerbl M (2014) ‘The glenohumeral joint—a mismatching system? A morphological analysis of the cartilaginous and osseous curvature of the humeral head and the glenoid cavity. ’ J Orthop Surg Res, 9,34, pp. 1-6.

How to Cite this article: Markarian GG, Bab AD, Uribe JW. Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):14-19

(Abstract Full Text HTML) (Download PDF)

Intramedullary Cortical Button Fixation of Distal Biceps Tendon Rupture: long-term Patient Outcomes”

October 10, 2016/0 Comments/in Vol 1| Issue 1| Oct-Dec 2016 /by ASESADMIN2016

Authors: Jake J Ni [1], David M Auerbach [2]

[1] Fellow, Southern California Orthopedic Institute.
[2] Attending, Southern California Orthopedic Institute.

Address of Correspondence
Dr. David M Auerbach, MD
6815 Noble Avenue
Van Nuys CA 91405
Emial: dauerbach@scoi.com

Abstract

Introduction: No consensus exists for optimal distal biceps rupture fixation. Dorsal cortical button (DCB) and dual incision transosseous (DITO) provide the greatest biomechanical load-to-failure, permitting earlier mobilization to prevent arthrofibrosis. Both methods have complications, restricted range of motion (ROM) from heterotopic ossification and proximal radioulnar synostosis for DITO while DCB has increased cutaneous and posterior interosseous nerve (PIN) injuries. The intramedullary cortical button (ICB) fixation limits PIN palsy risk, decreases implant costs and provides strong tendon-bone fixation.
Methods: 21 patients with ICB fixation of chronic and acute distal biceps ruptures at >1 year postoperatively completed a satisfaction survey and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. ROM, neuropraxia and other complications obtained from chart.
Results: At 4 years average (1.3-7.4) 81% were extremely and 10% very satisfied with their overall outcome. 81% reported no strength or ROM limitations, 76% had pain-free activity, 86% and 81% were extremely satisfied with postoperative elbow ROM and forearm ROM respectively. The mean DASH and sports DASH score were 3.52 and 2.5. 52% had cutaneous deficits, 38% lateral antebrachial cutaneous nerve (LABCN) and 19% superficial radial nerve (SRN). No biceps re-ruptures or PIN palsies were observed.
Conclusion: The ICB technique provides secure distal biceps tendon fixation with excellent long-term patient satisfaction and comparable functional outcomes with restoration of normative DASH scores. The cutaneous nerve complication rate was comparable to other single incision studies and no observed PIN palsies or wound complications while decreasing implant costs.
Keywords: Distal biceps, Tendon repair; Single incision, Endobutton, Intramedullary fixation, Patient reported outcomes.

Introduction

Distal biceps tendon injuries are uncommon with an incidence of 1.2 per 100,000, affecting the dominant arm of males, 86% and 97% respectively, with 98% presenting in their 4th and 5th decades after a forced eccentric elbow extension(7,13,17,29,34,40). Suspected etiologies include a hypovascular zone and mechanical tendon impingement during full pronation(35). Cigarette smoking carries a 7.5x greater risk(29). Non-operative management is possible in low demand patients but anatomic repair restores the strength/endurance loss of 30%/40% for forearm supination and 20%/30% for elbow flexion(1,25,29,30). Fixation methods include dorsal cortical button (DCB), interference screw (IS) and suture anchor (SA) through a single anterior incision which decreases stiffness risk from heterotopic ossification (HO) and proximal radioulnar synostosis (PRUS) from the second posterior incision necessitated by the dual incision transosseous (DITO) technique developed by Boyd and Anderson (2,4,7). The Morrey modification decreases HO and PRUS risk by dissecting through the extensor carpi ulnaris (ECU) and avoiding ulna exposure. (22,30) DCB had the highest load-to-failure (LTF) in biomechanical studies but to date has not demonstrated clinical superiority over DITO(7,15,23,27,37,39). 30-50% incidence of cutaneous sensory nerve deficits (CSN) and a 1-15% incidence of posterior interosseous nerve (PIN) palsies have been reported with the DCB fixation, attributed to radial retraction at the radial tuberosity plus guide pin and cortical button location(13,40). PIN palsies have been noted after all techniques but are most frequently associated after the DCB(6,16,31). PIN palsies cause significant patient concern and disability despite spontaneous resolution, in a majority of cases, within 3-5 months(6,31). Tendon transfer for a permanent PIN injury has been reported(31). A distally or radially directed guide pin exits within 1-2mm of the PIN with 30% in direct nerve contact(13,26,31). Nerve injury risk remains despite techniques limiting PIN injury during guide pin advancement by altering pin trajectory to an AP direction with 0-30° ulnar angulation, tapping guide pin through the posterior soft tissues and intraoperative fluoroscopy to assess for soft tissue interposition between the DCB and cortex(6,21,26). In the ICB method, the cortical button is intramedullary, underneath the radial tuberosity as shown in Figure 1 a-b, eliminating PIN injury from the guide pin and cortical button. Two biomechanical studies have validated the load-to-failure strength of this method and a small three patient case series has demonstrated good short-term results(27,39,38). In contrast to the technique by Seibenlist(38), the senior author’s ICB technique utilizes a single intramedullary cortical button securing the biceps stump with two high-strength braided sutures. This article demonstrates the long-term clinical outcomes of this novel technique.

Methods

This institution’s research ethics board approved of this study. The study was a retrospective case series of consecutive patients undergoing a distal biceps tendon repair by the senior author. Patients were identified by CPT code search from January 2009 through April 2016. The exclusion criteria included minors, prior/current legal action with the author’s orthopedic group, and transfer of care in a worker’s compensation setting. Inclusion criteria included ICB repair of acute or chronic ruptures without allograft and greater than 1 year follow-up. A total of 32 distal biceps tendon ruptures were identified in 31 patients. 21 (68%) completed a Disabilities of the Arm Shoulder and Hand (DASH) and sports DASH plus a satisfaction questionnaire. Chart and radiographs were reviewed for ICB location, chronicity of injury, time to surgery, presence of wound complications, motor or sensory nerve deficits with resolution timeframe, ROM, and re-rupture.

Surgical technique and postoperative protocol
The ICB technique utilizes a 4cm transverse anterior incision 2cm distal to the distal antecubital flexion crease with dissection between the brachioradialis and pronator teres. The biceps tendon stump is mobilized as necessary for tendon excursion. The biceps tuberosity is prepared with a curette or high-speed burr creating a clean, bleeding bony surface. A #2 high-strength braided suture is threaded through the toggle hole at both ends of a Smith and Nephew EndobuttonTM.

A needle and suture passes one suture pair into the 4.7mm hole and out the 2mm hole drilled with mild convergence in the distal and proximal tuberosity footprint separated by a 1.5cm bony bridge. This suture pair shuttles the EndobuttonTM into the intramedullary canal with both limbs of each suture exiting their respective hole. Figure 2 a-h illustrates the technique. One limb from each suture is whipstitched proximally and back distally. Tensioning the free suture limb exiting the 2mm hole and tying to its free suture pair compresses the biceps stump against the radial tuberosity and secures the EndobuttonTM against the intramedullary cortex at the 2mm hole. Finally the free suture limb exiting the 4.7mm hole is tensioned and tied with its suture pair limb, evenly distributing the tendon compression over the entire tuberosity footprint.

Figure 3 a-e depicts the tendon reduction and fixation. Intraoperative photographs are shown in Figure 4 a-g. No postoperative HO prophylaxis is routinely used. Postoperatively, a soft dressing and a posterior long-arm splint with the elbow at 90° flexion and forearm maximally supinated is applied. At 1 week, if a tension free biceps tendon repair was possible without elbow flexion, gentle elbow and forearm motion is permitted in a hinged elbow brace limiting the terminal 30° of extension. If elbow flexion is necessary to achieve a tension-free repair, elbow ROM is delayed for 4 weeks in a long-arm cast at 90° elbow flexion and full supination before transitioning to a hinged elbow brace permitting motion except for the terminal 30° of extension. For all patients, the brace is fully unlocked at 6 weeks, allowing full elbow ROM and the brace is discontinued at 8 weeks. The patient begins formal physical therapy at 8 weeks for ROM and strengthening at 12 weeks. The patient is cleared for full activities at 6 months.

Result

All patients were male, averaging 49 years (30-60) and involved the dominant arm in 52% (15/28). 10% (3/31) had bilateral ruptures, the senior author operated bilaterally on one. Former or current smokers comprised 32% (10/31) of patients, including 2 of 3 bilateral ruptures. There were 2 (6.5%) diabetic patients in this study, one who ruptured both distal biceps tendons. 68% (21/31) completed questionnaires at 4 years on average (range 1.3 to 7.4 years), 71% (15/21) also completed the sports DASH. The mean DASH and sports DASH score was 3.52 and 2.5 respectively. 81% (17/21) were extremely satisfied with their overall outcome and 10% (2/21) very satisfied. The mean DASH and sports DASH scores improved to 0.93 and 1.04 respectively with 93% (14/15) extremely satisfied after excluding WC patients. 81% (17/21) reported no motion or strength activity limitations. 76% (16/21) had no pain with any activity. 86% (18/21) and 81% (17/21) of patients are extremely satisfied with postoperative elbow ROM and forearm ROM respectively. 67% (14/21) of patients are extremely satisfied with elbow flexion and forearm supination strength. See Table 1 for summary of results.

Complications

No incidences of PRUS were noted and only 6.5% (2/31) developed HO. All regained full elbow ROM at 20 weeks average (range 4-40 weeks). 9.5% (2/21) lacked more than 50° and 19% (4/21) lacked more than 20° of total forearm rotation at final clinic follow-up, with the two HO patients losing 20° and 40°. Both regained full forearm rotation at 2 and 4 years during re-examination while completing the questionnaire. The EndobuttonTM was located on the intramedullary radial tuberosity footprint in all repairs except 9.5% (2/21) were angled 10-15 degrees towards the proximal drill hole. Nerve injuries were noted in 52% (11/21) of patients, consisting of 66% (38% 8/21) LABCN and 36% (19% 4/21) SRN. At the last clinic follow up visit, 19 weeks average, 50% of both (4/8) LABCN and (2/4) SRN deficits spontaneously resolved. At time of study, another 50% had resolved with only minimal deficits remaining in 25% of the initial (2/8) LABCN and (1/4) SRN injuries. No patients in the study re-ruptured their repaired biceps tendon, developed a PIN palsy or experienced a wound infection.

Discussion

No consensus exists regarding the optimal fixation technique for distal biceps tendon, with common techniques utilizing DCB, SA, or IS fixation through a single incision or a DITO repair. Each has advantages and disadvantages with no clear superiority demonstrated consistently in the literature. DCB and DITO fixation have the greatest biomechanical load-to-failure strength but have respective complications of PIN palsy and decreased ROM from HO and PRUS. The ICB technique’s rationale is decreased cost in comparison to double SA, minimize PIN injury risk of the DCB by eliminating dorsal radius cortical violation and cortical button placement near the PIN while creating a strong tendon-bone interface to aid biologic healing to prevent recurrent rupture and permit early ROM to prevent arthrofibrosis. Patients reported high satisfaction rates and comparable DASH scores to studies utilizing different fixation methods. 91% of patients were either extremely (81%) or very satisfied (10%) with their overall outcome. These satisfaction rates were similar those observed by Cohen(9) with 89% either extremely (72%) or very satisfied (16%) and McKee (28) with 81% very satisfied as shown in Table 2. The high overall satisfaction rates were also reflected in the restoration of normative DASH scores equivalent to the general population(18,19). Our observed mean DASH score of 3.52 was comparable to recent studies, see Table 2, with values from 3.1 to 10.3 and within the minimal clinical important difference (MCID) of 9.6 to 15(1,5,9,14,16,18,28,32,36). Only 4% (1/21) had >50° and 19% (4/21) had >20° loss of total supination/pronation at time of this study at 20 months average. A prospective randomized study of SA versus DITO fixation by Grewal(16) noted no significant difference in patient reported outcomes including DASH, ASES, PREE, and VAS at 2 years postoperatively. The authors did note a significant difference of 10% greater elbow flexion strength in DITO but no difference in ROM was noted with a mean supination of 64° and pronation of 77° for SA fixation. There were 6 worker’s compensation (WC) patients, shown to have worse outcomes overall, included in this study with only half extremely satisfied with worse mean DASH scores of 10 and 8.33(24). Atanda(1) examined WC’s effect on distal biceps tendon repair outcomes and noted statistically significant worse mean DASH and sports DASH scores in WC patients of 3.35 and 0.2 versus 0.4 and 0.1 for non-WC patients. Slower return to full duty of 4 months compared to 1.4 months in non-WC patients was also noted. McKee(28) also observed a statistically significant difference in mean DASH scores of 5.5 in non-WC versus 16.9 in WC patients(28). We observed a similar trend with a mean DASH of 10 in WC patients versus 0.93 for non-WC patients. Similarly, the percentage of extremely satisfied patients improved to 93% from 85%. Besides obtaining good patient outcomes and satisfaction, limiting postoperative complications is important with published studies reporting an increased incidence of CSN deficits after a single anterior incision compared to DITO(16). The most common CSN injury is the LABCN estimated at 5%-57% followed by SRN at 5%-10%(8,11,13,15,16,20,31,33,36,41). Grewel (16) noted a 40% (19/47) incidence of LABCN sensory deficits in SA versus (2/47) 4.3% in DITO. All but 3 had resolved spontaneously by 6 months and 2 remaining at 2 years. Cusick (10) noted complete resolution of all 22 sensory nerve deficits at 8 months including 10% (17/170) LABCN, 1.5% (2/170) SRN, and 2.3% (3/170) local incisional numbness, see Table 3. Motor nerve palsies have been noted with PIN palsies, occurring in 1%-10% and believed to be more prevalent after DCB fixation but has been observed after all techniques(13,31). Nigro(31) reported a 3.2% incidence of PIN neuropraxias in a literature review. Patients had a good prognosis overall with spontaneous recovery at an average of 86 days in a large majority of patients. Cusick(10) noted a 2.3% (3/170) incidence of PIN neuropraxia with spontaneous recovery after combination DCB and IS fixation. The PIN is believed to be at greatest risk during DCB fixation as the guide pin exits the dorsal cortex as close as 2mm on average to the PIN nerve with distal and radial direction of the guide pin. A transverse incision in the antecubital flexion crease is cosmetic, but its location ~2cm proximal to the tuberosity will push the guide pin’s trajectory distally, therefore increasing PIN injury risk. An anterior-posterior (AP) and ulnarly deviated direction increases the guide pin to PIN distance to 11mm-16mm. (26) However, directing the path too ulnarly risks ulna penetration or ulna-implant impingement in full supination. The ICB technique moves the incision 2cm distally, placing it directly over the biceps tuberosity, allowing AP drilling in the biceps footprint and minimizes PIN nerve injury risk as the dorsal cortex is not violated by the guide pin or EndobuttonTM. Other sources of PIN injury include placement of retractors radially on the radius and excessive radial soft tissue retraction(13,31). Many cases of HO are asymptomatic with rates ranging from 0%-25% and found on radiographs while others decrease ROM and, along with PRUS, cause decreased forearm rotation(6,13,40). Studies of the Boyd-Anderson DITO report an incidence of 15% HO and 5% PRUS(12,13). The decrease in incidence of symptomatic HO and PRUS is due to the increasing popularity of single incision fixation, the Morrey modification that dissects through the ECU, avoids interosseous membrane violation and ulna periosteal stripping, see Table 3 (2,22).
We noted no PRUS and 2 cases (9.5%) of HO noted on postoperative radiographs. Both had full elbow ROM but the first had 40° loss of total forearm rotation with 60° of supination at 10 months while the second had 20° of total forearm rotation at 7 ½ months. However on re-examination at time of study, both patients had full symmetric bilateral forearm rotation with 85° of supination and 90° pronation. This suggests that patients with limited forearm rotation at up to 10 months can continue to see improvement over time and achieve full ROM. There were no observed re-ruptures in this study with the reported rate in the literature ranging from 0-5.6%(7,13,16,29,40). However, this study may not have been powered to capture a re-rupture and patients followed a protective postoperative protocol. Grewal(16) noted a 4.4% re-rupture rate in 91 patients treated with either SA or DITO repairs. All 4 occurred during the early postoperative period due to non-compliant activities. Wang(40) reported a 5.4% re-rupture rate, with a non-significant trend towards higher rates in chronic tears. Citak(8) noted a 5.6% re-rupture rate in 54 patients undergoing SA repair with Titan Corkscrew, Super Quick Anchor Plus or DITO. All the ruptures occurred in the Super Quick Anchor Plus suture anchor group. Reliable tendon-bone healing requires rigid fixation with both high LTF and low cyclical displacement. The highest LTF of common fixation methods in biomechanical testing was the DCB as described by Bain(2,16). In testing by Siebenlist(27), the LTF of ICB not statistically different at 275N compared to 305N for DCB despite a thinner biceps tuberosity cortex but both values were significantly less than the LTF of an intact biceps tendon. In comparison to a double suture anchor fixation method, Siebenlist(38) reported a non-significant trend towards less displacement under cyclical loading of a double ICB construct, which doubles the button/bone contact surface area with identical suture/tendon fixation as the single ICB.

Conclusion

ICB fixation provides biomechanically solid bone-tendon fixation performed through a single anterior incision to minimize symptomatic HO and PRUS risk, yielding comparable cutaneous nerve complications rates to other single anterior incision fixation methods while minimizing the PIN neuropraxia risk observed with DCB fixation. Patient satisfaction rates, DASH scores and ROM are comparable to studies utilizing other fixation methods. Patients with decreased forearm motion at up to 10 months postoperatively can continue to improve their motion and achieve symmetric motion with time. The paper’s strengths includes long-term clinical follow-up, validated patient reported outcome questionnaire, single surgeon with a single technique, and no exclusion for chronic tears or allograft use. The weaknesses include limited patient follow-up leading to selection bias and underestimation of complications and poorer outcomes, low number of objective patient physical examinations, retrospective nature of study, and no cohort comparison with alternative repair method.

References

1. Atanda A Jr, O’Brien D, Kraeutler M, Rangavajjula A, Lazarus M Ramsey ML et al. Outcomes after distal biceps repair in patients with workers’ compensation claims. J Shoulder Elbow Surg. 2013; 22(3):299-304.
2. Bain G, Prem H, Heptinstall R, Verhellen R & Paix D. Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Shoulder Elbow Surg. 2000; 9(2):120-126.
3. Baker B & Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am. 1985; 67(3):414-417.
4. Boyd H & Anderson LA. method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am. 1961; 43(7):1041-1043.
5. Caekebeke P, Corten K & Duerinckx J. Distal biceps tendon repair: comparison of clinical and radiological outcome between bioabsorbable and nonabsorbable screws. J Shoulder Elbow Surg. 2016; 25(3):349-354
6. Cain R, Nydick J, Stein M, Williams B, Polikandriotis J & Hess A. Complications following distal biceps repair. J Hand Surg Am. 2012; 37(10):2112-2117.
7. Chavan P, Duquin T & Bisson L. Repair of the ruptured distal biceps tendon: a systematic review. Am J Sports Med. 2008; 36(8):1618-1624.
8. READ Citak M, Backhaus M, Seybold D, Suero E, Schildhauer T & Roetman B. Surgical repair of the distal biceps brachii tendon: a comparative study of three surgical fixation techniques. Knee Surg Sports Traumatol Arthrosc. 2011;19(11):1936-41.
9. Cohen S, Buckley P, Neuman B, Leland J, Ciccotti M & Lazarus M. (2016) A functional analysis of distal biceps tendon repair: single-incision Endobutton technique vs. two-incision modified Boyd-Anderson technique. Phys Sports med. 2016; 44(1):59-62.
10. Cusick M, Cottrell B, Cain R & Mighell M. Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw. J Shoulder Elbow Surg. 2014; 10:1532-1536.
11. Eardley W, Odak S, Adesina TS, Jeavons R & McVie J. Bioabsorbable interference screw fixation of distal biceps ruptures through a single anterior incision: a single-surgeon case series and review of the literature. Arch Orthop Trauma Surg. 2010; 130(7):875-881.
12. Failla J, Amadio P, Morrey BF & Beckenbaugh R. Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique. Report of four cases. Clin Orthop Relat Res. 1990; 253:133-136.
13. Garon M & Greenberg J. Complications of Distal Biceps Repair. Orthop Clin North Am. 2016; 47(2):435-444.
14. Giacalone F, Dutto E, Ferrero M, Bertolini M, Sard A & Pontini I. Treatment of distal biceps tendon rupture: why, when, how? Analysis of literature and our experience. Musculoskelet Surg. 2015; 99 Suppl 1:S67-73.
15. Greenberg J, Fernandez J, Wang T & Turner C. EndoButton-assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg. 2003; 12(5):484-490.
16. Grewal R, Athwal G, MacDermid J, Faber K, Drosdowech D, 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; 94(13):1166-1174.
17. Hinchey J, Aronowitz J, Sanchez-Sotelo J & Morrey BF. Re-rupture rate of primarily repaired distal biceps tendon injuries. J Shoulder Elbow Surg. 2014; 23(6):850-854.
18. Hudak P, Amadio P & Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand). The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996; 29(6):602-608.
19. Hunsaker F, Cioffi D, Amadio P, Wright J & Caughlin B. The American academy of orthopaedic surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002; 84-A(2):208-215.
20. Read Johnson T, Johnson D, Shindle M, Allen A, Weiland A, Cavanaugh J, et al. One versus two-incision technique for distal biceps tendon repair. HSS J. 2008; 2:117-122.
21. Karunakar M, Cha P & Stern P. Distal biceps ruptures. A followup of Boyd and Anderson repair. Clin Orthop Relat Res. 1999; 363:100-107.
22. Kelly E, Morrey BF & O’Driscoll SW. Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am. 2000; 82-A(11):1575-1581.
23. Kettler M, Lunger J, Kuhn V, Mutschler W & Tingart M. Failure strengths in distal biceps tendon repair. Am J Sports Med. 2007; 35:1544-1548.
24. Koljonen P, Chong C & Yip D. Difference in outcome of shoulder surgery between workers’ compensation and nonworkers’ compensation populations. Int Orthop. 2009; 33(2):315-320.
25. Legg A, Stevens R, Oakes N & Shahane S. A comparison of nonoperative vs. Endobutton repair of distal biceps ruptures. J Shoulder Elbow Surg. 2016; 25(3):341-348.
26. Lo E, Li C & Van den Bogaerde J. The effect of drill trajectory on proximity to the posterior interosseous nerve during cortical button distal biceps repair. Arthroscopy. 2011; 27(8):1048-54.
27. Mazzocca A, Burton K, Romeo A, Santangelo S, Adams D & Arciero R. Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med. 2007; 35(2):252-258.
28. McKee M, Hirji R, Schemitsch E, Wild L & Waddell J. Patient-oriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique. J Shoulder Elbow Surg. 2005; 14(3):302-306.
29. Miyamoto R, Elser F & Millett P. Distal biceps tendon injuries. J Bone Joint Surg Am. 2010; 92(11):2128-2138.
30. Morrey B, Askew L, An K & Dobyns J. Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg Am. 1985;67(3):418-421.
31. Nigro P, Cain R & Mighell M. Prognosis for recovery of posterior interosseous nerve palsy after distal biceps repair. J Shoulder Elbow Surg. 2013; 22(1):70-73.
32. Olsen J, Shields E, Williams R, 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 Elbow Surg. 2014; 23(11):1607-1611.
33. Recordon JA, Misur PN, Isaksson F & Poon P. Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series. J Shoulder Elbow Surg. 2015; 24(6):928-933.
34. Safran M & Graham S. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002; 404:275-83.
35. Seiler J 3rd, Parker L, Chamberland P, Sherbourne G & Carpenter W. The distal biceps tendon. Two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. Shoulder Elbow Surg. 1995; 4(3):149-156.
36. Shields E, Olsen J, Williams R, Rouse L, Maloney M & Voloshin I. Distal biceps brachii tendon repairs: a single-incision technique using a cortical button with interference screw versus a double-incision technique using suture fixation through bone tunnels. Am J Sports Med. 2015; 43(5):1072-1076.
37. Siebenlist S, Buchholz A, Zapf J, Sandmann GH, Braun K, Martetschläger F. Double intramedullary cortical button versus suture anchors for distal biceps tendon repair: a biomechanical comparison. Knee Surg Sports Traumatol Arthrosc. 2015; 23(3):926-933.
38. Siebenlist S, Elser F, Sandmann GH, Buchholz A, Martetschläger F, Stöckle U et al. The double intramedullary cortical button fixation for distal biceps tendon repair. Knee Surg Sports Traumatol Arthrosc. 2011; 19(11):1925-1929.
39. Siebenlist S, Lenich A, Buchholz A, Martetschläger F, Eichhorn S, Heinrich P et al. Biomechanical in vitro validation of intramedullary cortical button fixation for distal biceps tendon repair: a new technique. Am J Sports Med. 2011;39(8):1762-1768.
40. Wang D, Joshi N, Petrigliano F, Cohen J, Lord E, Wang J et al. Trends associated with distal biceps tendon repair in the United States, 2007 to 2011. J Shoulder Elbow Surg. 2016; 25(4):676-680.
41. Watson J, Moretti V, Schwindel L & Hutchinson M. Repair techniques for acute distal biceps tendon ruptures: a systematic review. J Bone Joint Surg Am. 2014; 96(24):2086-90.
42. Weinstein D, Ciccone W 2nd, Buckler M, Balthrop P, Busey T & Elias J. Elbow function after repair of the distal biceps brachii tendon with a two-incision approach. J Shoulder Elbow Surg. 2008; 17(1 Suppl):82S-86S.

How to Cite this article: Ni JJ, Auerbach DM. Intramedullary Cortical Button Fixation of Distal Biceps Tendon Rupture: long-term Patient Outcomes”. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):20-26

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty

Intramedullary Cortical Button Fixation of Distal Biceps Tendon Rupture: long-term Patient Outcomes”

Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty

Intramedullary Cortical Button Fixation of Distal Biceps Tendon Rupture: long-term Patient Outcomes”

Full Sized Blog Element (Big Preview Pic)

Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty

Authors: Gregory G Markarian [1], Aboul Deng Bab [2], John W Uribe [3]

Abstract

Introduction

Hemi versus Total Shoulder Replacement

Inlay Arthroplasty

Biomechanical Comparison

Clinical Results

Conclusion

References

(Abstract Full Text HTML) (Download PDF)

Intramedullary Cortical Button Fixation of Distal Biceps Tendon Rupture: long-term Patient Outcomes”

Authors: Jake J Ni [1], David M Auerbach [2]

Abstract

Introduction

Methods

Result

Complications

Discussion

Conclusion

References

(Abstract Full Text HTML) (Download PDF)

ASES License

Contact

Important Links

Publisher