Table 1 Long-term outcomes of operative and nonoperative treatment for distal biceps tendon tear. ROM, range of motion.
Courtesy of Anna K. Reinholz

AAOS Now

Published 3/25/2022
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Rebecca Araujo

Study: Patient Factors and Long-term Outcomes of Operative and Nonoperative Management of Distal Biceps Rupture

A study presented at the AAOS 2022 Annual Meeting examined the patient profile associated with distal biceps tendon tears and long-term outcomes of treatment for this injury. The findings were shared by Anna K. Reinholz from the department of orthopaedic surgery at Mayo Clinic in Rochester, Minn.

Distal biceps tendon tears can significantly impair elbow mobility. “Although uncommon, these injuries can result in significant pain and functional limitations for patients,” Ms. Reinholz told AAOS Now. “The ramifications beyond time missed from work and long-term physical consequences of sustaining a distal biceps tear are relatively unknown. While much has been published on these injuries, very little is known about long-term outcomes.”

The researchers sought to report updated information regarding patient characteristics associated with distal biceps pathology, along with long-term outcomes of both nonoperative and operative treatment for these injuries. They analyzed imaging data from 158 patients with an MRI-confirmed distal biceps rupture, either partial or full thickness, identified from an institutional database from years 1996 through 2016. Eligible patients had complete medical records and at least five years of clinical follow-up. Exclusion criteria were inflammatory arthritis and enthesitis, polytrauma, or incidental findings without clinical assessment. The baseline patient characteristics studied were demographic information, BMI, smoking status, dominant-handedness, and laborer occupation. Outcomes included severe complications, functional outcomes, and health-related productivity loss.

Patient characteristics
The cohort was predominantly male, with 136 males and only 22 females. The mean age was 51.5 years (range, 44.8–61.2). The average clinical follow-up was 13.7 years (range, 8.4–17.8 years). Forty-seven percent of patients had a complete tear, and 53 percent had a partial tear. Of those with complete tear, 86 percent were treated operatively, compared with 49 percent of partial tears.

“Consistent with previous literature, distal biceps tears were more often male laborers in their early 50s,” said Ms. Reinholz, adding that “tobacco use was common.” Twenty-one percent of patients were current smokers, and one-third were former smokers.

The researchers noted that most injuries occurred in the nondominant arm, “which is a departure from what we have typically known and described in the literature,” she said.

Fifty-two patients were managed conservatively, and 106 underwent surgical treatment. Most surgical cases utilized a double incision technique in the early period following injury, according to Ms. Reinholz.

She noted, “Although most patients in this study underwent double incision with suture through bone tunnel, there remains no consensus on superior surgical technique,” pointing to an area of further research. “One knowledge gap highlighted in this study is a lack of patient-reported outcomes, physical outcomes, and complication rates specifically with different operative modalities.”

Long-term outcomes
Overall, long-term follow-up showed that most patients had improved mobility and were able to return to work after treatment (Table 1). Among the 106 surgically treated patients, over the long-term follow-up period, there were seven reoperations (4 percent) and five reruptures (3 percent). The overall rate of complications in the surgery group was 35 percent. A significant portion of complications were nerve-related with eventual resolution.

There was a high rate of return to work among both groups. Eighty-three percent of patients returned to work without the need for modifications, regardless of treatment type. Longer follow-up showed that patients who were surgically treated were more likely to miss time from work (61 percent versus 12 percent; P <0.001) and missed more days of work (111 days versus 30 days;>P = 0.04) compared with the conservative treatment group.

The researchers reported that most patients regained full range of motion (ROM) after treatment. “Over two-thirds of our cohort was treated operatively; however, nonoperatively managed patients returned to normal ROM and joint strength in a similar capacity to the operative group at long-term follow up,” said Ms. Reinholz. “Nonoperative management showed satisfactory outcomes with the added benefit of less time lost from work, which is useful information for patients who may be good nonoperative candidates”

Notably, there were no significant differences between treatment groups in any of the ROM measurements, including extension, flexion, elbow arc, pronation, and supination. “Although successful outcomes with conservative treatment have been previously reported in the literature, the fact there was no statistically significant deficits in ROM or strength metrics between the two cohorts at final long-term follow-up was interesting,” said Ms. Reinholz. “Lingering functional deficits and residual subjective weakness are historically concerns with nonoperatively managed distal biceps tear.”

Due to these findings, Ms. Reinholz and colleagues suggested that that patient selection and proper counseling of patients on both nonoperative management and surgical repair is of key importance.

Regarding the study’s limitations, the researchers noted the retrospective nature and a paucity of standardized follow-up data. “This study was retrospective in nature with common limitations associated with retrospective research. Additionally, there was a lack of standardized operative approach and postoperative treatment among the entire cohort,” noted Ms. Reinholz. “Lastly, patients were only included with five or more years of clinical follow-up, which may have restricted the cohort size.”

In conclusion, said Ms. Reinholz, “This study is, to our knowledge, one of the first to describe the long-term outcomes for distal biceps tendon tears; it is also one of the largest cohorts of distal bicep tears to date.” For clinicians, she added, “The results of this study aid in some of those discussion points with patients about how this injury is going to impact them in the present, as well as 10 or more years down the road.”

Ms. Reinholz’s coauthors of “Long-term Outcomes of Distal Biceps Injuries: A Comparative Study of Surgical and Nonsurgical Management at a Mean Follow-up of 13 Years” are Sara E. Till, MS; Adam J. Tagliero, MD; Ryan R. Wilbur, BA; Bryant M. Song, MS; Joaquin Sanchez-Sotelo, MD, PhD, FAAOS; Jonathan D. Barlow, MD, FAAOS; and Christopher L. Camp, MD.

Rebecca Araujo is the associate editor of AAOS Now. She can be reached at raraujo@aaos.org.