n Feature Article

Biomechanical Comparison of Interference

Screw and Cortical Button With Screw
Hybrid Technique for Distal Biceps Brachii
Tendon Repair
Afshin Arianjam, MD; William Camisa, MSME; Jeremi M. Leasure, MSE; William H. Montgomery, MD

abstract
Full article available online at Healio.com/Orthopedics. Search: 20131021-17

Various fixation techniques have been described for ruptured distal biceps tendons.
The authors hypothesized that no significant differences would be found between
the mean failure strength, maximum strength, and stiffness of the interference screw
and hybrid technique. Fourteen fresh-frozen human cadaveric elbows were prepared.
Specimens were randomized to either interference screw or hybrid cortical button
with screw fixation. The tendon was pulled at a rate of 4 mm/s until failure. Fail-
ure strength, maximum strength, and stiffness were measured and compared. Fail-
ure strength, maximum strength, and stiffness were 294681.9 N, 294682.1 N, and Figure: Illustration of the interference screw tech-
64.4640.5 N/mm, respectively, for the interference screw technique and 3336129 N, nique showing the screw insertion abutting the
3836121 N, and 56.2640.5 N/mm, respectively, for the hybrid technique. No statisti- distal biceps tendon.
cally significant difference existed between the screw and hybrid technique in failure
strength, maximum strength, or stiffness (P>.05). The interference screws primarily
failed by pullout of the screw and tendon, whereas in the hybrid technique, failure oc-
curred with screw pullout followed by tearing of the biceps tendon. The results suggest
that this hybrid technique is nearly as strong and stiff as the interference screw alone.
Although the hybrid technique facilitates tensioning of the reconstructed tendon, the
addition of the cortical button did not significantly improve the failure strength of the
interference screw alone.

The authors are from the San Francisco Orthopaedic Residency Program (AA, WHM) and the Taylor
Collaboration (WC, JML), St Marys Medical Center, San Francisco, California.
The authors would like to thank Hinesh Patel, who helped with portions of the biomechanical testing
with this project. Arthrex (Naples, Florida) provided the implant materials used for this study.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Afshin Arianjam, MD, San Francisco Orthopaedic Residency
Program, St Marys Medical Center, 450 Stanyan St, San Francisco, CA 94117 (arianjam@gmail.com).
doi:10.3928/01477447-20131021-17

NOVEMBER 2013 | Volume 36 Number 11 e1371

n Feature Article
H
istorically, rupture of the distal bi-
ceps brachii tendon was rare.1 Re-
cent literature has shown that this
injury could represent up to 10% of injuries
to the biceps brachii, which translates to 1.2
ruptures per 100,000 per year.2 Although
this injury continues to be more common
in the dominant extremity of active males
in their fourth through sixth decade of life,
it has also been reported among individu-
als of any age or sex.3,4 In athletes, younger
age groups participating in contact sports
and strength training, particularly weight-
lifters, represent the majority of reported
cases, with rare cases involving overhead
athletes.5 The literature has also suggested
that the use of anabolic steroids may con-
tribute to increased stiffness in the tendon,
which may predispose individuals to an
acute tear.6,7 Smokers have also been cited
as having a 7.5-times increased risk for
rupture.2
Distal biceps ruptures are clinically
diagnosed on the basis of history, mecha-
nism of injury, and physical examination.8
Typically, an acute complete distal biceps
rupture follows a traumatic event in which
excessive eccentric tension occurs as the
arm is forced from a flexed to an extend-
ed position. Alternatively, this injury has
been reported with attempts to avoid a
sudden fall.9 Initial complaints include an
audible pop or a snapping sensation fol-
lowed by pain and weakness in the upper
extremity during elbow flexion and wrist
supination. Immediate intense pain often
subsides within a few hours and is fol-
lowed by a dull aching pain that may last
from weeks to months.10,11 The hook test,
with a reported 100% specificity and sen-
sitivity, is performed with the examiners
index finger literally hooking the cord-
like tendon in the antecubital fossa 1 cm
deep to the tendon. If no cordlike struc-
ture is palpated, then the biceps is not in
continuity. Occasionally, radiographs may
show an irregular or avulsed fragment of
bone from the bicipital tuberosity. Mag-
netic resonance imaging and ultrasonog-
raphy have been proven to be more use-
e1372
ful in equivocal cases involving clinically
missed or partial injuries.12-14
Nonoperative management is generally
reserved for the treatment of low-demand
patients in poor health. The superiority of
surgical treatment has shown improved
strength for flexion and supination as well
as increased upper-extremity endurance.15
With brachialis tenodesis resulting in
weakened supination, early anatomic re-
attachment of the tendon in active young
patients is the treatment of choice. Both
extensile Henry single volar and Boyd and
Anderson 2-incision techniques have been
modified to minimize previously pub-
lished risks of neurovascular injury and
heterotopic ossification, respectively.16-20
Regardless of the approach used, recon-
struction techniques aim to minimize soft
tissue dissection and secure initial fixation
to allow for early range of motion.21
Reconstruction of the ruptured distal
biceps brachii tendon remains an area of
biomechanical interest. Previous biome-
chanical investigations have shown that the
cortical button technique exhibits signifi-
cantly higher maximum strength and stiff-
ness when compared with alternatives.22-24
Sethi et al25 and Sethi and Tibone26 showed
that the hybrid technique of cortical but-
Figure 1: Photo-
graph of the test
setup. The speci-
men was mounted
to the table of the
test frame with
the radial tuberos-
ity facing upward
and the linear ac-
tuator pulling in a
direction 90 from
the long axis of
the bone.
1
ton and interference screw provide op-
timal tendon/bone fixation to promote
healing between the tissues, prohibit gap
formation, and allow for more aggressive
rehabilitation schedules. By combining 2
techniques, a hybrid cortical button and
interference screw technique suggests su-
perior failure strength compared with the
standalone button system.
Although several studies have found
maximum failure loads to be significantly
higher for cortical button constructs, no
study to date has evaluated clinically rel-
evant biomechanical failure when com-
paring standard interference screw fixa-
tion with the cortical button combination
technique. Information is lacking regard-
ing the performance of the hybrid system
relative to the standalone screw system.
The goal of this study was to evaluate the
load-to-failure performance of the inter-
ference screw and a hybrid screw-button
system.
Materials and Methods
Fourteen fresh-frozen human cadav-
eric elbows were procured and thawed 24
hours before use. Twelve of the elbows
were match paired. All muscle and adi-
pose tissue except for the biceps tendon
ORTHOPEDICS | Healio.com/Orthopedics

2A
Figure 2: The interference screw technique showing the screw insertion abutting the distal biceps tendon.
No penetration of the distal cortex is seen (A). The hybrid technique showing the interference screw com-
bined with a cortical button (B).
3 acorn reamer (Arthrex) was used to ream
Figure 3: Screw pullout with the interference tech-
nique showing visual failure.
were removed from the radii. The proxi-
mal and distal ends of each radius were
embedded in urethane resin (Smooth-Cast
300; Smooth-On, Easton, Pennsylvania)
and secured to the table of a materials test
frame (Instron 8521; Instron, Norwood,
Massachusetts). The long axis of the bone
was oriented parallel to the plane of the
table (Figure 1) with the radial tuberosity
facing upward.
After all 14 specimens were mounted
on the resin, the paired right and left spec-
imens were randomized to 1 of 2 tendon
repair groups. The first group included an
interference screw repair technique, and
NOVEMBER 2013 | Volume 36 Number 11
Interference Screw vs Cortical Button With Screw Hybrid Technique | Arianjam et al
2B
the second group included a hybrid cor-
tical button with interference screw tech-
nique. In both techniques, a #2 polyester
suture (FiberLoop; Arthrex, Naples, Flor-
ida) was used to secure the distal 2.5 cm
of the incised biceps tendon in a locking-
loop fashion. The tuberosity was debrided
of soft tissues if necessary.
The interference screw technique (Fig-
ure 2A) was performed as described by
Idler et al.21 A 2-mm guide pin was placed
in the center of the tuberosity perpendicu-
lar to the long axis of the radius and pen-
etrated only the anterior cortex. An 8-mm
a hole through the cortex to a depth of
15 mm; the posterior wall was not pen-
etrated. One limb of the FiberLoop was
passed through an 8312-mm bioabsorb-
able (polyglycolic acid) tenodesis screw
and screwdriver (Arthrex), thus bringing
the distal end of the tendon to the tip of
the screwdriver, and secured around the
back of the screwdriver. The screw and
tendon were inserted into the hole and
screwed down flush to the tuberosity. The
remaining ends of the suture were then se-
cured by tying them over the screw with
5 square knots. This procedure reinforces
the tendon with both interference of the
bone/tendon and a suture anchor effect.
The hybrid technique (Figure 2B) was
then performed as described by Sethi et
al25 and Sethi and Tibone.26 A 3.2-mm
guide pin was used to drill through the
central aspect of the radial tuberosity from
anterior to posterior, aiming 15 in the ul-
nar direction. The anterior cortex and in-
tramedullary canal were then reamed with
an 8.0-mm cannulated reamer to allow for
flush seating of the end of the distal bi-
ceps tendon. The suture was then threaded
through the biceps button. The first strand
was fed through the right hole and then
back through the left hole. Then, the op-
posite was performed with the other tail
of the same suture. Tension was then held
on all 4 suture limbs as the cortical but-
ton was inserted through both cortices of
the radial tuberosity. The free suture limbs
were then pulled to seat the button against
the radius. A 7310-mm polyetheretherk-
etone tenodesis screw (Arthrex) was then
loaded onto the tenodesis driver (Arthrex),
and 1 suture limb was passed through the
driver. The screw was then inserted on the
radial side of the bone tunnel until it seat-
ed flush with the anterior cortex, pushing
the tendon more ulnar. Once the tendon
was fully seated, a free needle was used
to pass the remaining suture limb through
the tendon to tie a knot over the screw.
In both techniques, the biceps tendon
was then attached to the actuator of the
test frame with a custom fabricated ten-
don clamp and oriented 90 from the long
axis of the bone. The actuator was load
controlled to pull the tendon to a load of
5 N to ensure appropriate tensioning of
the tendon and to establish the data for
strain and stiffness measurements. The
tendon was then pulled in tension at a
rate of 4mm/s until visual failure (Figure
3).21,27,28
Load, displacement, and time were
recorded to determine construct stiffness
and failure strength. Stiffness was defined
as the linear region of the load displace-
ment curve following the initial toe region.
Strength was the maximum load recorded
within the first 12 mm of displacement,
which was defined as clinical failure. The
difference between the failure strength
and maximum strength was established
e1373
n Feature Article
4 5
Figure 4: Graph showing the average maximum
strength for screw and hybrid technique (no sig-
nificant difference: P5.20).
primarily for the hybrid specimens that
continued to resist rupture of the tendon-
suture interface beyond 12 mm of excur-
sion.21 The failure mode of the repaired
tendons was noted. The outcome mea-
sures for testing were stiffness (N/mm),
failure strength at 12-mm excursion (N),
and maximum strength at construct fail-
ure (N). All statistical calculations were
performed with JMP version 5.0 software
(SAS Institute Inc, Cary, North Carolina)
and Excel (Microsoft, Redmond, Wash-
ington). Each outcome measure was com-
pared between the 2 treatment groups by
a 1-way analysis of variance t test for sig-
nificant differences with alpha set to 0.05.
Statistical power was calculated for all
mean comparisons at alpha equal to 0.05.
Results
Mean age of the specimens was 67
years (range, 59-79 years). Six were from
men, and 2 were from women. Each spec-
imen failed distally at the interface be-
tween the implant and tendon, except for
4 specimens. Three specimens repaired
with the hybrid technique failed proxi-
mally at the musculotendinous junction
near the clamp and were not included in
the results. One specimen repaired with
the interference screw technique was not
included in the results because of a tu-
berosity fracture as noted by the surgeon
immediately after implantation and before
testing. The hybrid group failed by 1 of
3 mechanisms: (1) the distal tendon tore
e1374
Figure 5: Graph showing the average failure
strength in the first 12 mm for the screw and hy-
brid technique (no significant difference: P5.57).
out of the tubercle, causing suture fail-
ure with intact screw and cortical button
in 2 specimens; (2) screw pullout failure
with intact cortical button in 1 specimen;
and (3) suture failure in 1 specimen. The
interference screw group failed by 1 of 2
mechanisms: (1) screw pullout failure in
5 specimens; and (2) failure in the distal
biceps tendon in 1 specimen.
Results showed that the screw and hy-
brid techniques had similar stiffness and
strengths. Mean failure strength, maximum
strength, and stiffness were 294681.9 N,
294682.1 N, and 64.4640.5 N/mm, re-
spectively, with the interference screw
technique and 3336129 N, 3836121
N, and 56.2640.5 N/mm, respectively,
with the hybrid technique (Figures 4-6).
The hybrid technique often reached peak
strength after the first 12 mm, whereas the
screw-only system always yielded before
the first 12 mm. Although a trend existed
for higher strengths with the cortical but-
ton, statistically insignificant differences
were observed between the 2 constructs
and all outcome measures (P>.05), in-
cluding failure strength (P5.57), maxi-
mum strength (P5.20), and stiffness
(P5.76). The power of these observations
was 94% for stiffness, 92% for failure
strength, and 77% for maximum strength.
Discussion
The results of this study showed no sig-
nificant difference between mean failure
strength, maximum strength, or stiffness
6
Figure 6: Graph showing the average stiffness for
the screw and hybrid technique (no significant dif-
ference: P5.76).
of the interference screw and hybrid tech-
nique tested. Pulling the repaired tendon
at a rate of 4 mm/s allows differentiation
between failure and maximum strength.
The cadaveric model showed that fail-
ures always occurred within the first 12
mm of displacement for both techniques.
In the hybrid group, the cortical button
remained intact until catastrophic failure
involved tearing of the tendon and suture.
Clinical failure occurs within 12 mm of
translation either stretching the repaired
tendon or displacing it completely from
bone-tendon contact. Nonetheless, the
difference in maximum strength between
the 2 groups was also insignificant. Given
the reported tension (52 N) on the tendon
with active flexion of the forearm against
gravity, one could begin early active range
of motion after interference screw fixation
alone, even without the addition of the
cortical button.29
Several other biomechanical studies
have addressed the failure strengths of
different distal biceps tendon repair tech-
niques.21-23,25,27,28,30,31 However, the results
of cortical button technique and interfer-
ence screw have conflicted because of
the techniques used and the biomechani-
cal testing methodology (Table 1). The
current study aimed to address this dis-
crepancy in methodology and technique.
Unlike previous authors who tested the
cortical button with the #5 polyester su-
ture with a 0.88-mm diameter (Ethibond;
Ethicon, Somerville, New Jersey),23,32,33
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 Interference Screw vs Cortical Button With Screw Hybrid Technique | Arianjam et al

strength for the hybrid technique used in

Table 1 the current study (ie, 432 N vs 383 N, re-
Summary of Aggregate Studies in Relation to Cortical Button, spectively). When comparing interference
screw repair techniques, size and diameter
Interference Screw, and Hybrid Technique
also act as additional variables. Kettler et
Interference Hybrid al22 compared a smaller-sized 5.5-mm di-
Study/Method Cortical Button Screwa Techniquea ameter screw; the present study used an
Greenberg et al12 584 N 8-mm diameter screw, resulting in differ-
Failure at unknown rate
ences of 131 N and 294 N, respectively.
Although 1 study recently attempted to
#5 polyester suture
address this variable, the screws com-
Idler et al15 __ 192.1653.1 N __
pared (7- vs 8-mm diameter) showed no
Failure at 4 mm/s 178.0654.5 N
significant difference.30
#2 polyester suture The current study reproduced biome-
8312-mm screw chanical testing of bone-tendon inter-
Spang et al34 274.77698.55 N faces using previously established stan-
Failure at 4 mm/s 249.95686.40 N dards.21,27,28,31 Therefore, the results of
#2 polyester suture this study are directly comparable with
Mazzocca et al20 439.62 N 231.95 N __
a greater number of studies in this field.
By using these standards, this study dif-
Failure at 120 mm/s __ __ __
ferentiates clinical failure strength from
#5 polyester suture
maximum failure strength. However, this
8312-mm screw differentiation ultimately proved inconse-
Kettler et al18 259628 N 131628 N quential because no significant difference
Failure at 4 mm/s __ __ __ was found between any of the parameters
#2 polyester suture tested. Nonetheless, this study further
5.5-mm diameter screw supports prior studies that used this tech-
Sethi et al30 439694 N 4366103 N nique.
One limitation of this study is that the
Failure at 120 mm/s __ __ __
bone mineral density of the cadavers was
#2 polyester suture
unavailable. However, by using matched
Current study __ 294682.1 N 3836121 N
specimens in a randomized fashion, an at-
Failure at 4 mm/s __ 294681.9 N 3336129 N tempt was made to eliminate this variable.
#2 polyester suture With poor bone mineral density, early
8312-mm screw failure by fracture of the radial tuberosity
a
Mean6SD for load to maximum failure (top row) and clinical failure (bottom row). Lemos et was evident in 1 specimen of the interfer-
al19 and Pereira et al27 also used 4 mm/s as the failure rate but did not evaluate interference ence screw technique. A smaller interfer-
screw or cortical button.
ence screw used in coordination with the
cortical button in the hybrid technique
appeared to eliminate this problem, sug-
this study used the #2 polyester suture (Fi- mean failure load (259 N and 274 N) re- gesting that this construct may be better
berLoop) with a 0.69-mm-diameter suture sulted compared with studies that used suited in a population with poor bone min-
in concordance with the hybrid surgical the larger-diameter suture (584 N and 439 eral density. A second limitation is that
technique. Although literature is sparse N).22,23,31,33 In addition, the current study this study had 3 proximal failures in the
on the significance of the difference be- adopted the tension rate of 4 mm/s as op- hybrid technique group, not allowing use
tween suture materials, this variable has posed to 120 mm/s. This allows for the of that data. Nevertheless, this study had
provided conflicting results in studies detection of both clinical failure and ul- high power, indicating that the differences
looking at cortical button-only repairs.34,35 timate tensile load.21,31 Sethi et al25 pulled observed between the 2 constructs were
For instance, when the smaller-diameter the tendon at the faster rate, which can insignificant. Finally, a third limitation
suture was used, a dramatically lower account for the difference in the pullout is that this study had no separate group

NOVEMBER 2013 | Volume 36 Number 11 e1375

n Feature Article
of specimens for cortical button alone.
However, given the direct comparison of
the methodology of this study with prior
studies using this technique, sufficient
literature shows the mean failure load for
this group.22,31 In addition, the superiority
of the interference screw with minimized
gap formation in cyclical loading has al-
ready been established.25 Therefore, it was
not necessary to include this additional
arm in the study.
Although prior studies suggest bio-
mechanical superiority of the hybrid cor-
tical button-screw technique when com-
pared with the interference screw alone,
the results of this study suggest that they
are similar. Although one study found no
significant difference in the maximum
strength of the hybrid cortical button-
screw technique vs the cortical button
alone, this study did not use previously
established biomechanical testing tech-
niques.25 It also could not account for
failure strength with the novel method-
ology. Only case reports exist of cortical
button techniques in the literature, with
the exception of one study that evaluated
tendon-to-tendon repair.36 Desai et al37
reported a 44-year-old right-handdomi-
nant man who had failure at the suture
and cortical button interface 7 days post-
operatively while attempting to prevent
a fall on ice. Naidu38 reported on failure
of technique with a cortical button and
interference screw backing out within
6 days postoperatively in a 40-year-old
man. Given that only case reports of
failed repair techniques exist, the lack
of significant differences between failure
strengths of these techniques suggest that
the surgeon should take into consider-
ation factors beyond biomechanical fail-
ure when choosing the most appropriate
repair technique. These factors and areas
of future clinical research may include
surgeon experience, ease of surgical
technique with tensioning of the biceps
tendon, patient bone mineral density,
cost of implants, and/or complications
associated with surgical approach.
e1376
Conclusion
The current cadaveric study showed
that biceps tendon repair via an interfer-
ence screw provided mean failure strength,
maximum strength, and stiffness that were
not significantly different with the addi-
tion of a cortical button. This study used
established biomechanical testing proto-
cols, which allow the results to be directly
comparable. Although the tension slide
technique facilitates seating of the distal
biceps tendon, the addition of the cortical
button may not significantly increase fail-
ure strength in techniques with interfer-
ence screw alone. However, when using a
cortical button-only technique, prior stud-
ies have shown that the addition of an in-
terference screw would decrease gap for-
mation and improve tissue integration.25,30
A thoughtful postoperative rehabilitation
protocol, which includes early active
range of motion, can be initiated immedi-
ately with the interference screw-only
technique.
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