Augmentation of Distal Biceps Repair With an Acellular Dermal Graft Restores Native Biomechanical Properties in a Tendon-Deficient Model

Am J Sports Med. 2017 Jul;45(9):2028-2033. doi: 10.1177/0363546517701426. Epub 2017 Apr 19.


Background: The majority of distal biceps tendon injuries can be repaired in a single procedure. In contrast, complete chronic tears with severe tendon substance deficiency and retraction often require tendon graft augmentation. In cases with extensive partial tears of the distal biceps, a human dermal allograft may be used as an alternative to restore tendon thickness and biomechanical integrity.

Hypothesis: Dermal graft augmentation will improve load to failure compared with nonaugmented repair in a tendon-deficient model.

Study design: Controlled laboratory study.

Methods: Thirty-six matched specimens were organized into 1 of 4 groups: native tendon, native tendon with dermal graft augmentation, tendon with an attritional defect, and tendon with an attritional defect repaired with a graft. To mimic a chronic attritional biceps lesion, a defect was created by a complete tear, leaving 30% of the tendon's width intact. The repair technique in all groups consisted of cortical button and interference screw fixation. All specimens underwent cyclical loading for 3000 cycles and were then tested to failure; gap formation and peak load at failure were documented.

Results: The mean (±SD) load to failure (320.9 ± 49.1 N vs 348.8 ± 77.6 N, respectively; P = .38) and gap formation (displacement) (1.8 ± 1.4 mm vs 1.6 ± 1.1 mm, respectively; P = .38) did not differ between the native tendon groups with and without graft augmentation. In the tendon-deficient model, the mean load to failure was significantly improved with graft augmentation compared with no graft augmentation (282.1 ± 83.8 N vs 199.7 ± 45.5 N, respectively; P = .04), while the mean gap formation was significantly reduced (1.2 ± 1.0 mm vs 2.7 ± 1.4 mm, respectively; P = .04). The mean load to failure of the deficient tendon with graft augmentation (282.1 N) compared with the native tendon (348.8 N) was not significantly different ( P = .12). This indicates that the native tendon did not perform differently from the grafted deficient tendon.

Conclusion: In a tendon-deficient, complete distal biceps rupture model, acellular dermal allograft augmentation restored the native tendon's biomechanical properties at time zero. The grafted tissue-deficient model demonstrated no significant differences in the load to failure and gap formation compared with the native tendon. As expected, dermal augmentation of attritional tendon repair increased the load to failure and stiffness as well as decreased displacement compared with the ungrafted tissue-deficient model. Tendons with their native width showed no statistical difference or negative biomechanical consequences of dermal augmentation.

Clinical relevance: Dermal augmentation of the distal biceps is a biomechanically feasible option for patients with an attritionally thinned-out tendon.

Keywords: allografts; augmentation; elbow; repair; tendon-deficient model.

MeSH terms

  • Acellular Dermis*
  • Arm / surgery
  • Biomechanical Phenomena
  • Elbow / surgery
  • Humans
  • Muscle, Skeletal / surgery
  • Orthopedic Procedures
  • Reconstructive Surgical Procedures / methods
  • Rupture / surgery
  • Skin Transplantation / methods*
  • Tendon Injuries / surgery*
  • Tendons / surgery
  • Transplants / surgery