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Delayed posterior interosseous nerve palsy caused by bicortical suture button nerve entrapment following distal biceps tendon repair: case report and multi-institution outcomes assessment of PIN and LABCN injury following distal biceps repair.
Fraser J. Leversedge, MD
1, Emma Judge, BA
2, Byron Ward, BA
3, Sean Higinbotham, MS
3; Alex Lauder, MD
3(1)University of Colorado, Aurora, CO, (2)University of Colorado, Centennial, CO, (3)Denver Health Medical Center, Denver, CO
Aims: (1) To describe a unique case of delayed postoperative PIN palsy caused by implant entrapment of the PIN during forearm motion for rehabilitation following a bicortical distal biceps suture button repair technique. (2) To present a retrospective multi-center outcomes analysis of bicortical suture button technique for distal biceps repair and incidence of PIN and lateral antebrachial cutaneous nerve (LABCN) injury.
Methods: (1) Case report: A 63-year-old male presented 6-weeks following distal biceps tendon repair with a bicortical suture button technique with a 1-week onset of progressive PIN weakness, progressing to complete palsy by 3 months, despite normal post-operative nerve function. Nerve exploration at 3.5 months following biceps repair revealed that the PIN was entrapped, coursing deep to a limb of the suture button. Suture button removal and neurolysis was performed and PIN recovery gradually recovered to normal function at 15 months post-operatively. (2) A multi-center 1,2, retrospective chart review of patients undergoing distal biceps repair using a bicortical suture button between 2016-24 was conducted at the authors' institutions to assess the incidence, timing, severity, and treatment of potential PIN and LABCN injury associated with the biceps repair.
Results: 721 patients undergoing distal biceps tendon repair using a bicortical suture button repair were identified. 6 / 721 (0.8%) sustained a PIN palsy of which 4/6 had full PIN recovery and 2 patients had incomplete PIN recovery at 3-month follow-up. LABCN injuries were noted in 143 / 721 (19.8%) of patients with persisting numbness / sensory disturbance at final follow up (Range: 13-1226 days).
Conclusions: (1) Timing of post-operative nerve deficit following bicortical suture button use for distal biceps tendon repair is an important consideration for determining mechanism of injury and treatment; (2) Subacute or delayed PIN palsy may be associated with nerve capture / entrapment by the suture button during post-operative rehabilitation and nerve exploration may be indicated; (3) As direct and indirect nerve injury may be associated with bicortical suture button use, decreased risk may be realized with a unicortical button technique; (4) Nerve injury (PIN and LABCN) following distal biceps tendon repair is likely under-reported in the peer-reviewed literature.
Figure Legend: (1) Intraoperative photo of the PIN trapped deep to the bicortical tendon repair button; (2) Intraoperative photo following suture button removal with intact PIN; (3) Illustration of probable mechanism of PIN entrapment by the bicortical implant during forearm rotation.
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