Abstract
Background:
Distal biceps tendon injuries typically occur in the dominant arm of men in their fourth decade of life. Surgical repair restores flexion and supination strength, resulting in good functional outcome. The complication profile of each surgical approach and fixation technique has not been widely studied in the literature.
Purpose:
To report the rate of complications after repair of complete distal biceps ruptures, to classify them according to surgical approach and fixation technique, and to analyze risk factors and outcomes of the individual complications.
Study Design:
Systematic review.
Methods:
Studies published in English on primary repair of the distal biceps between January 1998 and January 2019 were identified. Data on complications were extracted and classified as major and minor for analysis. A quantitative synthesis of data was done to compare the complication rates between (1) limited anterior incision, extensile anterior incision, and double incision and (2) 4 fixation methods.
Results:
Seventy-two articles including 3091 primary distal biceps repairs were identified. The overall complication rate was 25% (n = 774). The major complication rate was 4.6% (n = 144) and included a 1.6% (n = 51) rate of posterior interosseous nerve injury; 0.3% (n = 10), median nerve injury; 1.4% (n = 43), rerupture; and a 0.1% (n = 4), synostosis. Brachial artery injury, ulnar nerve injury, compartment syndrome, proximal radius fracture, and chronic regional pain syndrome occurred at a rate of <0.1% each. The majority of nerve injuries resolved with an expectant approach. The minor complication rate was 20.4% (n = 630). The most common complication was lateral cutaneous nerve injury (9.2%, n = 283). An extensile single incision was associated with a higher rate of superficial radial nerve injury when compared to limited single incision(6% vs 2.1%, P = .002). Limited anterior single incision technique had a higher rate of lateral antebrachial cutaneous nerve injury compared to extensile single incision. (9.7% vs 5.2%, P = .03). Synostosis occurred only with double incision. Fixation technique had no significant effect on rerupture rate and posterior interosseous nerve injury rate.
Conclusion:
This is the largest analysis of complications after distal biceps repair, indicating a major complication rate of 4.6%. This study provides valuable data with regard to the choice of technique, surgical approach, and rate of complications, which is essential for surgical planning and patient consent.
Registration:
CRD42017074066 (PROSPERO).
Distal biceps tendon rupture occurs most commonly in the dominant arm of men between 30 and 50 years of age.14,33 Surgical repair of the distal biceps tendon restores supination and flexion strength.6,24 A number of fixation techniques, including bone tunnels, suture anchors, cortical buttons (alone or with interference screws), and screws alone have been used to fix the tendon to its anatomic insertion, the radial tuberosity.2,3,7,9
Biomechanically, all the fixation methods have been proven to be effective. In the clinical setting, there are not sufficient data comparing these methods with reference to rerupture and implant failure. Both the single- and double-incision approaches have been employed to achieve fixation, with extensile and minimally invasive versions of each technique used. More recently, there has been an interest in endoscopic-assisted and all-endoscopic fixation techniques.
Complication rates after surgical repair have been reported up to 24.5%. 34 A number of studies give conflicting evidence on the complication rates of the single- and double-incision methods.12,34 There is no literature on whether an extensile single incision has fewer complications than the limited single incision or double incision. To our knowledge, a comparison of the various fixation methods according to complication profile is also not evident in current literature.
There have been a few comparative studies9,12 and systematic reviews1,5 of surgical repairs of the distal biceps tendon. But complications after each surgical technique and each surgical approach of distal biceps tendon repair have not been systematically evaluated.
The primary aim of this study is to compare the complication rates among fixation methods and surgical approaches while assessing the overall complication rate of surgical repair of a complete rupture of the distal biceps tendon.
Methods
A systematic review was conducted and reported according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). The review was registered on the International Prospective Register of Systematic Reviews following the primary literature search (PROSPERO CRD42017074066).
Search Strategy
The search strategy was developed with the PEO concept (population, exposure, outcomes) and performed by a clinical librarian (T.R.) (Appendix, available in the online version of this article). The search terms distal, biceps, tendon, repair, and reconstruction were applied to the following bibliographic databases on January 14, 2019: Medline, Embase, and Cochrane Database of Systematic Reviews.
Inclusion and Exclusion Criteria
Inclusion criteria were human studies published in English reporting the results of primary distal biceps tendon repair for complete distal biceps rupture between January 1998 and January 2019.
Exclusion criteria were non–peer reviewed articles, review articles without original data, conference abstracts, technical notes, case reports, and studies discussing imaging only. Studies on biomechanics alone and cadaveric studies were also excluded. Reconstruction with grafts and repairs for partial tears were excluded. When the same data were presented in 2 studies, only the data from the most recent study were included.
Abstracts were reviewed for inclusion by 2 authors. Full-text articles were then obtained, and further review was performed independently by the same authors. Any discrepancies were discussed and settled in conjunction with the senior author.
Search Results
The primary search yielded 2371 articles. After screening for duplicates, 802 were excluded. A further 1316 articles were excluded after screening the abstracts according to the exclusion criteria, and 259 full-text articles were retrieved and assessed for eligibility. Of these, 66 articles were deemed suitable for inclusion, and a further 6 studies were identified after a review of the references in the included articles, resulting in 72 suitable studies for inclusion in the final systematic review (Figure 1).
PRISMA (Preferred Items for Systematic Meta-analyses) flow diagram with search results.
Method of Review
Complete journal articles were reviewed for the selected 72 publications and data extracted by 2 authors with a focus on patient demographics, surgical approach, fixation technique, and postoperative complications.
Assessment of Bias, Quality, and Levels of Evidence
This was performed with the Newcastle-Ottawa scale for evaluating the quality of cohort studies and case report series. 35 This utilizes the following domains to assess for study quality and bias: selection (representativeness of the exposed cohort), comparability (quality of study design, analysis, and confounding variables), and outcome (follow-up period and cohort retention). According to this system, the quality of the available studies for review was good (n = 36), fair (n = 32), and poor (n = 4).
The included studies were classified according to Oxford Centre for Evidence-Based Medicine’s levels of evidence. 28 Of the 72 included studies, there were 3 prospective studies and 69 retrospective studies. There were 9 studies of level 3 evidence and 63 of level 4 evidence.
Reporting of Complications
Complications were categorized as major or minor, modifying the initial classification by Cain et al. 4 In addition to Cain’s classification of major complications that included posterior interosseous nerve (PIN) palsy, radioulnar synostosis, and rerupture, our review included all other motor nerve injuries (median, ulnar), vascular injury, compartment syndrome, and deep infections as major complications.
Subgroup Analysis
Fixation Method
The described fixation methods were recorded and compared as transosseous bone tunnels (sutures only), transosseous cortical buttons with and without additional interference screw fixation, suture anchor fixation, and interference screw fixation in isolation.
Surgical Approach
The surgical approaches reported were single incision and double incision. The single-incision approach was subdivided into an extensile single incision and a limited single incision. An extensile single-incision approach was defined as an exposure that crossed the cubital fossa exposing the biceps from the muscle belly to the radial tuberosity as described by Fischer and Shepanek. 11 A limited single incision (transverse or longitudinal) was defined as one where exposure was only performed distal to the cubital fossa without visualization of the whole biceps muscle-tendon unit.
Statistical Methods
Endnote (v 8.0; Clarivate Analytics) was used to manage data and analysis was done with SPSS (v 17.0; IBM). Fischer exact test was performed to assess the statistical significance between the groups. A P value of .05 was considered statistically significant.
Results
Demographic Data
In total 3091 primary distal biceps repairs performed in 3080 patients were reported in the systematic review. Bilateral repairs were performed in 11 patients. There were 2717 men (88.2%) and 43 women (1.4%). Sex was not specified in 320 (10.4%) cases. The mean age was 49.2 years (range, 20-78 years). Age range was not specified in 14 studies (Table 1).
Demographic Data
Follow-up from the index procedure ranged from 1 week to 480 weeks with a weighted mean of 22 weeks. Data on follow-up durations were not specified in 11 studies.
Overview of Complications
The overall complication rate was 25% (n = 774 of 3091). The major complication rate was 4.6% (n = 144), and the minor complication rate was 20.4% (n = 630) (Table 2).
Major and Minor Complication Rates After Distal Biceps Tendon Repair a
CRPS, chronic regional pain syndrome; HO, heterotopic ossification; LABCN, lateral antebrachial cutaneous nerve; PIN, posterior interosseous nerve; SRN, superficial radial nerve.
Major Complications
Nerve Injuries
There were 62 (2%) motor nerve injuries of 3091 repairs. The most common injury was to the PIN (n = 51, 1.6%). Of these, 47 had a full recovery with expectant management at a mean follow-up of 19.4 months (range, 2-120 months). Two cases did not resolve spontaneously and were surgically treated with neurolysis (n = 1) and tendon transfer (n = 1). The outcome of 2 PIN injuries was not specified.
There were 10 median nerve injuries reported (0.3%). Six of these resolved completely with expectant management. One patient had persistent anterior interosseous nerve palsy but opted for nonoperative treatment. Two underwent decompression. One patient had a tardy median nerve palsy 6 months from surgery owing to heterotopic bone, with full recovery after excision. Three ulnar nerve injuries were reported (0.1%): 2 were sensory and details of the other were not specified. Outcome data were unavailable.
Out of all 64 major nerve injuries, 62 involved the motor component, and 2 ulnar nerve injuries affected only the sensory fibers.
Other Major Complications
Rerupture was reported in 43 of 3091 cases (1.4%) (described later). There were 2 brachial artery injuries (0.06%), both of which required vascular repair. There were 3 proximal radial fractures (0.1%), which were all managed nonoperatively and reported to have healed. There was 1 case of compartment syndrome (0.03%) and 4 cases of chronic regional pain syndrome (0.1%). There were no deaths or amputations reported after the procedure, but 1 fasciotomy was performed after the diagnosis of compartment syndrome.
Minor Complications
There were 358 (11.6%) sensory nerve injuries, the most common being the lateral antebrachial cutaneous nerve (LABCN) of the forearm (n = 283 of 3091, 9.2% incidence). Of these, 64% (n = 181 of 283) resolved with expectant treatment. Of 283 cases, 29 (10%) were reported as persisting at final follow-up, and the outcomes of 73 (25.8%) were not specified in the literature.
Superficial radial nerve (SRN) injury occurred in 75 of 3091 cases (2.4%). HO was reported in 123 cases (3.9%). Of these, 62 were classified as mild, and 3 were of moderate severity. Fourteen (11.4%) patients required surgical excision of HO. The degree or management of HO was not reported in 44 (36%) cases.
There were 46 postoperative infections (out of 3091 repairs; 1.5%). Of these, 7 were deep infections and 3 needed surgical debridement. Management of the other 4 deep infections and the remaining 39 superficial infections was not detailed. The rate of HO was less in the group with interference screw and button than with all other techniques. The difference was statistically significant (P < .05) when compared with cortical button but not when compared with screw alone.
Other complications included elbow stiffness unrelated to HO (n = 31 of 3091, 1%), scar numbness (n = 7, 0.3%), and keloid or hypertrophic scar formation (n = 5, 0.2%).
Subgroup Analysis
Fixation Technique
Complications after each surgical approach and fixation technique were separately assessed (Table 3).
Complication of Distal Biceps Repair by Fixation Method a
HO, heterotopic ossification; LABCN, lateral antebrachial cutaneous nerve; PIN, posterior interosseous nerve; R-U, radioulnar; SRN, superficial radial nerve.
The surgical repair was performed with suture anchors (n = 865), cortical buttons (n = 360), cortical button with an interference screw (n = 324), transosseous fixation with bone tunnels (n = 425), and interference screw alone (n = 69).
The rerupture rate after suture anchor repair was 1.7% (n = 15 of 865). Cortical button fixation (n = 3 of 360, 0.8%) had the lowest rate, but this difference was not statistically significant. Cortical button and screw fixation had a rerupture rate of 0.9% (n = 3 of 324), and interference screw alone had a rerupture rate of 1.5% (n = 1 of 69). Rerupture rate with transosseous fixation was 1.2% (n = 5 of 425). There was no statistically significant difference in the rerupture rate according to any of the fixation techniques or when transosseous fixation techniques were compared with onlay techniques (suture anchors).
There were reported cases where the use of an interference screw was associated with severe osteolysis of the proximal radius, 29 1 with screw breakage, 29 and a proximal radius fracture. 21
Posterior interosseous nerve injury was the most common major complication with every fixation method. The incidence of PIN injury after suture anchor repair and when fixed with cortical button was 1.7% and 2.2%, respectively. This difference was not statistically significant.
Cortical button fixation had the highest rate of LABCN injury (n = 67 of 360, 18.6%), which was significantly higher than that with suture anchor repair (n = 67 of 865, 7.7%; P < .001) and transosseous fixation (n = 25 of 425, 5.9%; P = .001).
Radioulnar synostosis (n = 4 of 425, 1%) was exclusively reported with transosseous suture fixation following a 2-incision approach.
Surgical Approach
Complications of the various surgical approaches are presented in Table 4.
Complications of Distal Biceps Repair by Surgical Incision a
HO, heterotopic ossification; LABCN, lateral antebrachial cutaneous nerve; PIN, posterior interosseous nerve; R-U, radioulnar; SRN, superficial radial nerve.
An extensile single incision was used in 233 patients, a limited single incision in 814, and a double incision in 411. Another 1021 patients were operated with a single-incision approach without detail regarding incision size.
Radioulnar synostosis (n = 4 of 411, 1%) was reported only with the double incision, and HO was most commonly identified with the double incision (n = 24 of 411, 5.8%). The lowest reported incidence was with the limited anterior incision (n = 28 of 814, 3.4%), but this difference was not statistically significant. Rerupture rate was noted to be significantly higher with standard single incision (n = 7 of 233, 3.0%) as compared with limited single incision (n = 4 of 814, 0.5%; P = .003) and double incision (n = 2 of 411, 0.5%; P = .01).
The incidence of LABCN injury was higher after a single-incision repair as compared with a double-incision repair but was not statistically significant (n = 144 of 2068 [7%] vs n = 20 of 411 [n = 4.9%], P = .10). Among the single-incision repairs, the rate of LABCN injury with limited anterior incision (n = 79 of 814, 9.7%) was significantly greater than with an extensile single incision (12 of 233, 5.2%; P = .03).
Injury to the superficial branch of the radial nerve was significantly higher with an extensile single incision (n = 14 of 233, 6%) as compared with a limited anterior incision (n = 17 of 814, 2.1%; P = .002).
Reoperation Rate
The reoperation rate was 1% (32 cases). HO accounted for 43% (n = 14) and rerupture or implant failure for 31% (n = 10). Three needed surgical debridement for infections. The other 5 reoperations were for nerve injuries (Table 5).
Reoperations After Distal Biceps Repair
Discussion
Overall Complication Rates
The primary aim of this study was to provide a comprehensive evidence-based summation of the complication rates after primary distal biceps tendon repair. For the 3091 repairs included, the overall complication rate was 25%, and the major complication rate was 4.6%. Other authors have reported similar overall complication rates of between 20% and 28% albeit in studies with far fewer numbers of cases and where the focus was not necessarily on complications alone.1,5,34 Nevertheless, this relatively consistent rate of overall complications suggests that it is not decreasing with time or the evolution of technique.
Cain et al 4 classified complications according to major and minor with rates of 6% and 24%, respectively, among 119 acute tears. Their study had a slightly higher reported rate of major complications because, in contrast to our review, they included HO in this category. We revised their classification of major and minor complications (Table 2) to include all motor nerve injuries and limb-threatening injuries such as vascular compromise and compartment syndrome. Also, we included symptomatic HO as a major complication, only because the majority of cases are actually asymptomatic. In addition, deep infections and proximal radius fractures were included in the major category.
Nerve Injuries
Of all the complications, the rate, distribution, and outcome of nerve injuries were of greatest interest because of the morbidity and anxiety that they may cause patients and surgeons alike.
The overall motor nerve injury rate was 2%. This mainly includes the PIN, with an incidence of 1.6% (n = 51). This is comparable to the existing literature where PIN injury is reported between 0% and 3.2% in studies with far fewer patients.20,23,27
The current impression is that PIN injuries will resolve without intervention in the majority of patients. 27 This is consistent with our findings where 92% of the reported PIN injuries resolved without intervention. Of the 2 cases that did not resolve, 1 underwent neurolysis and the nerve was found to be in continuity, whereas the other required tendon transfers. The first case, which had a neuroma, was after a suture anchor fixation with an extensile single incision, and the second case, which was not explored but had a tendon transfer, was after a cortical button repair with a limited single incision. Although it was our intention to better understand the time frame for recovery, this was difficult to ascertain accurately because of the variability in follow-up reported after PIN injury (range, 4-480 weeks). Nigro et al 27 noted a mean 86 days (range, 41-145 days) to resolution in 9 cases, all of which completely resolved.
Other authors have analyzed the association between surgical approach and PIN injury.1,27 Amin et al 1 attributed a higher rate of injury to a single-incision approach as compared with a double-incision technique (2.7% vs 0.2%) but did not compare fixation techniques. In the study by Nigro et al, 27 the rate of injury was 3.2% (n = 9 of 280), and all were treated with a single-incision approach. However, they drew no conclusions regarding the fixation method or chronicity of tears.
Two likely mechanisms of PIN injury are direct injury from radially based levered retractors, transcortical wires, or drills (especially if angled radially or distally) and through prolonged traction on the PIN. 19 Our results collated the largest number of PIN injuries reported and did not demonstrate a significantly higher rate of PIN injury according to either surgical approach or fixation technique, although the trend was higher in the cortical button group, as in the study by Nigro et al. 27 The results would suggest that an expectant approach for the first 3 months is possible after PIN injury regardless of technique or approach used. However, Mokhtee et al 25 reported 2 cases where the PIN had neuromas as a result of a suture entangling the nerve, which was managed with excision and grafting. Another study reported an incident of a cortical button deployed exactly onto the nerve, which needed revising the procedure. 32
Of 10 median and anterior interosseous nerve palsies that occurred, 6 resolved and 3 needed surgical exploration. The studies included in this review did not clearly mention the risk factors for median nerve injuries. It was noted that 6 of 10 median nerve injuries followed a single-incision repair. In 2 cases, the surgical approach was not specified. One followed endoscopic repair and was due to late scar tissue formation. Two cases needed only decompression when explored. One anterior interosseous nerve injury resulted in subtle deficiencies on discharge after a mean follow-up of 133 days. With these data, it is not possible to ascertain the mechanism of injury to the median nerve. But the ones that were explored show that the nerve was in continuity, needing decompression only.
Expectant management led to a successful outcome in 90.3% of cases in motor nerve injuries after the index procedure. The 4 cases where nerve exploration was done (3 median nerve and 1 PIN) needed only decompression for the median nerve and neurolysis for the PIN. Therefore, it is justifiable to propose that complete injury to any motor nerve is unlikely during this procedure.
The overall rate of sensory nerve injury was 11.6% (n = 359 of 3091). This includes LABCN injury (n = 283 of 3091), SRN injury (n = 75 of 3091), and 1 case of medial antebrachial cutaneous nerve numbness. This was the highest single complication reported in this study.
This review demonstrated that the rate of sensory nerve injuries was significantly higher in the single-incision group (9.3%) as compared with the double-incision group (5.8%), which is consistent with other studies.1,34 However, we also compared the incidence of nerve injury between limited and extensile anterior single-incision approaches. This revealed a higher incidence of LABCN injury in limited single-incision approaches, which may be attributable to the greater traction and less tendency to directly identify the LABCN in a limited single-incision approach. To our knowledge, this has not been previously reported. The fact that 64% of these injuries resolved completely is consistent with a traction mechanism. Ten percent of patients had a persistent deficit related to the LABCN, while the outcome was unspecified in 25.8%. These figures are consistent with smaller studies.4,17 One study found an increased rate of LABCN injury in more chronic injuries. 4 Although this was not possible to corroborate with our data, it has been our clinical experience that chronicity of tear is associated with scarring and tethering of the LABCN to the biceps muscle belly, which is the likely cause for a higher incidence in chronic injuries.
In contrast to the LABCN, it was apparent that SRN injury rate was significantly higher in the extensile single-incision approaches (limited single incision, 2.1%; extensile single incision, 6%; P = .003). This may be related to the greater dissection and exposure of the SRN, which would be protected beneath the brachioradialis in a limited approach. In addition to the literature included in this review, there was no further evidence on this to comment on the mechanism of injury. Of the 75 SRN injuries, 30 (40%) were permanent, and 18 (32.1%) were not specified. Permanent SRN symptoms may indicate that it is due to neuroma formation rather than traction injury. This could explain the reason for its high prevalence in the extensile single-incision group. This finding, to our knowledge, is not reported in the literature. However, we are unable to comment on the timeline before it was concluded permanent.
Rerupture and Implant Complications
Much attention in the literature has been given to the relative biomechanical strengths of each fixation technique, with cortical button fixation appearing to have the highest load to failure. Other authors have contested that suture anchor fixation and transosseous fixation without buttons have sufficient load to failure to allow tendon healing and early loading.16,18,22 The overall incidence of rerupture in this study was 1.4%. To our knowledge, no single series has reported >5 reruptures; hence, very little attention has been given to this complication and its risk factors in the existing literature. Hinchey et al 15 reported 3 reruptures, all within 3 weeks of the index surgery, in a group of 190 patients treated with a double-incision approach. Rashid et al 30 reported 5 revision biceps repairs, all revised for gapping of a previous suture anchor repair. They concluded that suture anchor was a risk factor for this mode of failure, although they had no comparative data to report from other techniques. We were able to identify 43 reported reruptures (overall rate, 1.4%), and there was a trend toward lower failure rates with cortical buttons as compared with suture anchors (0.8% vs 1.7%). The numbers were too low to statistically support the notion that the rerupture rate is higher after suture anchor fixation. What is evident is that regardless of technique and rehabilitation, the incidence of rerupture is low.
Radial tuberosity osteolysis was reported exclusively with bioabsorbable interference screws. 29 Radial neck fracture was also reported in relation to interference screws. Use of an interference screw requires creation of a substantially sized bone tunnel in the radial tuberosity, and given that (1) the results of this review show no clinical benefit to using an interference screw in terms of rerupture rate and (2) biomechanical data show that cortical button fixation without a screw has equivalent load to failure, it may be prudent to avoid large bone tunnels in the tuberosity and the use of interference screws. 31
Interestingly, the rerupture rate appeared higher in the standard single-incision approach. We believe that this is likely because of the older techniques, implants, and propensity for onlay fixation with this approach, which is related to these cases being historically earlier. Second, the reason to perform a more extensile approach may be attributed to a more retracted tear, which may influence the rerupture rate.
Radioulnar Synostosis and HO
In this study, HO was more commonly identified in double-incision approaches, and radioulnar synostosis was exclusive to the double-incision approach. This is consistent with the findings of Amin et al 1 in their meta-analysis of 87 publications. In the literature, it is evident that rates of radioulnar synostosis are 1% to 8% with the Boyd and Anderson technique.8,10,26 Morrey modification has lessened the number of this complication but not eradicated it.10,26 The single incision approach caused far fewer cases of radioulnar synostosis and symptomatic HO.
In contrast to radioulnar synostosis, HO is often an incidental diagnosis on radiograph and not functionally disabling. The incidence of HO was similar for all fixation techniques other than the group where an interference screw and cortical button were used. The reason may be that the screw plugs egress of bone debris or blood from the drill hole; however, it must be noted that the rate of HO was higher when a screw alone was used. This suggests that this result may be spurious and confounded by the fact that not all authors perform radiographs postoperatively or report the rate of HO.
In this review, 50.4% (n = 62 of 123) of HO was considered mild and asymptomatic. Many studies and senior authors’ clinical practice is not to radiograph patients to diagnose HO unless the patient is symptomatic. This may have led to reduced sensitivity in identifying the true number of HO cases.
Of the 123 patients with HO, only 14 had surgery for excision of HO. HO also occurred mostly with double incision (5.8%) and extensile single incision (5.2%). In a randomized clinical trial by Grewal et al, 12 the rate of HO was 2% for single and double incisions, which contrasts our findings. Prophylactic indomethacin was prescribed to patients in the Grewal et al study. Only 1 study specified the number of patients who had taken prophylactic indomethacin in our review. 13 Hence, prophylactic indomethacin may be associated with reduced rates of HO, but we are unable to comment on that.
Other measures discussed in the literature to reduce the rates of HO are to reduce bleeding by use of tourniquet and irrigation. The literature included in this study did not assess the outcomes of these measures. There is further scope to assess methods to reduce the incidence of HO.
Limitations
An inherent limitation of systematic reviews is the reliance on the quality of data included. The majority of studies included were level 4 quality, which limits the value of drawing comparisons among groups. However, by performing such a study, we were able to collate the biggest cumulative series of primary distal biceps repairs ever reported. The inclusion of a large number of patients with the aim being to collate all complications, rather than focus on complications related to a particular aspect of biceps repair, is less likely to skew the complication rates, particularly of complications with a low overall rate of occurrence. This included identification of cases of major vascular injury and compartment syndrome, which would otherwise be unrecognized as potential complications after biceps repair. A possible limitation is the inclusion of studies without a minimum follow-up period. The rationale for this was to allow capture of the highest number of complications possible. In particular, nerve injuries and reruptures occur early; hence, an arbitrary minimum follow-up time would have excluded some of these serious complications. Conversely, some complications that take time to develop, such as HO or synostosis, may be underreported because of the heterogeneous follow-up time included. We sought to provide rates of complications from the published literature for the purposes of consent and patient counseling. Although the rates of complication cannot be completely accurate, as not all surgeons publish their results, we believe these data provide the most expansive and accurate data currently available. Furthermore, we acknowledge that the rate of complications reported in this study may be an underestimation because of the tendency to underreport complications in the literature. Hence, we believe that the rates reported in this study should be regarded as the minimum rate of complications. This is also the first study to report the reoperation rate (1%) after distal biceps repair.
Conclusion
This study provides data regarding complication rates on the largest cumulative series of primary distal biceps repairs. The major complication rate including motor nerve injuries was 4.6%, although the majority of nerve injuries resolve without surgical exploration. While some complications have an association with particular approaches or techniques, the outcomes appear equivalent across the range of techniques. Hence, surgeons should be familiar with the complication profile of each technique and choose their fixation method accordingly.
Supplemental Material
DS_10.1177_0363546519899933 – Supplemental material for Complications After Distal Biceps Tendon Repair: A Systematic Review
Supplemental material, DS_10.1177_0363546519899933 for Complications After Distal Biceps Tendon Repair: A Systematic Review by Melanie Amarasooriya, Gregory Ian Bain, Tom Roper, Kimberley Bryant, Karim Iqbal and Joideep Phadnis in The American Journal of Sports Medicine
Footnotes
Submitted June 4, 2019; accepted November 18, 2019.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
An online CME course associated with this article is available for 1 AMA PRA Category 1 Credit™ at 
. In accordance with the standards of the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The American Orthopaedic Society for Sports Medicine that authors, editors, and planners disclose to the learners all financial relationships during the past 12 months with any commercial interest (A ‘commercial interest’ is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients). Any and all disclosures are provided in the online journal CME area which is provided to all participants before they actually take the CME activity. In accordance with AOSSM policy, authors, editors, and planners’ participation in this educational activity will be predicated upon timely submission and review of AOSSM disclosure. Noncompliance will result in an author/editor or planner to be stricken from participating in this CME activity.
References
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