No Significant Difference Between Intramedullary and Extramedullary Button Fixation for Distal Biceps Brachii Tendon Rupture After Cyclic Loading in a Cadaver Model

PURPOSE: To biomechanically compare intramedullary (IM) versus extramedullary (EM) distal biceps button fixation under cyclic loading conditions, which is most representative of postoperative physiologic status. METHODS: This controlled laboratory study used 13 fresh-frozen matched paired cadaver elbows. One specimen from each pair was randomized to either IM (unicortical) or EM (bicortical) distal biceps button fixation via onlay technique. A servohydraulic actuator was used to cycle each specimen from full extension to 90° of flexion at 0.5 Hz for 3,000 cycles. All specimens were subsequently loaded to failure to simulate an acute postoperative load. RESULTS: During cyclic loading, the mean change in force from cycle 5 to cycle 3000 was 2.1 ± 3.2 N for the IM group and 0.6 ± 4.2 N for the EM group (P = .19). The increase in tendon gap for the IM group was 1.02 mm and for the EM group was 1.83 mm (P = .37). During failure loading, the IM group had a mean failure load of 154.9 ± 44.5 N and the EM group a mean failure load of 191.1 ± 62.6 N (P = .16). CONCLUSIONS: No significant differences exist between the IM and EM techniques in loss of force and tendon gap formation under cyclic loading or load to failure conditions. Thus, IM fixation may adequately facilitate optimal bone-tendon apposition, with less risk of iatrogenic injury to the posterior interosseous nerve that can be seen with bicortical extramedullary fixation. CLINICAL RELEVANCE: The most common major complication following distal biceps repair is PIN palsy. IM fixation may be sufficient in facilitating optimal bone-tendon apposition and healing with onlay technique, while minimizing risk of iatrogenic PIN injury associated with EM fixation.