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Distal Biceps Tendon Rupture Surgery: Changing Incidence in Finnish and Swedish Men Between 1997 and 2016

Open AccessPublished:October 01, 2020DOI:https://doi.org/10.1016/j.jhsa.2020.07.024

      Purpose

      Distal biceps tendon rupture is a relatively rare injury usually occurring with excess external extension force applied to a flexed elbow. The aim of this study was to examine the incidence of distal biceps tendon rupture surgery in the Finnish and Swedish adult population between the years 1997 and 2016. A secondary aim was to investigate the distal biceps rupture incidence in the Swedish population in 2001 to 2016.

      Methods

      We assessed the number and rate of distal biceps tendon rupture surgery using the Finnish and Swedish Hospital Discharge Register as databases. The study included the entire Finnish and Swedish adult population aged 18 years and older between January 1, 1997 and of December 31, 2016.

      Results

      During the study period, 2,029 patients had a distal biceps tendon rupture in Finland, and the corresponding figure was 2,000 in Sweden. The rate of distal biceps tendon rupture surgery increased steeply, but equally, in both countries, in Finnish men from 1.3 per 100,000 person-years in 1997 to 9.6 in 2016, and in Swedish men from 0.2 in 1997 to 5.6 in 2016. The incidence of distal biceps tendon rupture in Sweden increased in men from 1.6 to 10.0 per 100,000 person-years from 2001 to 2016.

      Conclusions

      There was a 7-fold and a 28-fold increase in the incidence of distal biceps tendon rupture surgery in Finnish and Swedish men during 1997 to 2016. The incidence of distal biceps tendon rupture rose 6-fold in Swedish men in 2001 to 2016.

      Type of study/level of evidence

      Prognostic IV.

      Key words

      Distal biceps tendon rupture is a relatively rare injury, which usually occurs when an excess external extension force is applied to a flexed elbow. The majority of the patients are otherwise healthy middle-aged men.
      • Safran M.R.
      • Graham S.M.
      Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking.
      The clinical signs of the rupture include sudden elbow and forearm pain with weakness in elbow flexion, especially in forearm supination.
      Only a few publications on the incidence of distal biceps tendon rupture exist. Safran and colleagues
      • Safran M.R.
      • Graham S.M.
      Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking.
      published results from a defined group of patients between 1994 and 1998 and reported a rupture incidence of 1.2 per 100,000 person-years in the United States. Most of the patients were men between 30 and 49 years.
      • Safran M.R.
      • Graham S.M.
      Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking.
      A recent publication from Kelly et al,
      • Kelly M.P.
      • Perkinson S.G.
      • Ablove R.H.
      • Tueting J.L.
      Distal biceps tendon ruptures: an epidemiological analysis using a large population database.
      also from United States, showed a surgical rate for distal biceps or triceps ruptures of 2.6 per 100,000 person-years between 2006 and 2010, most of the patients again being men from 35 to 54 years.
      Risk factors for distal biceps rupture have been found to be smoking and elevated body mass index.
      • Safran M.R.
      • Graham S.M.
      Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking.
      • Kelly M.P.
      • Perkinson S.G.
      • Ablove R.H.
      • Tueting J.L.
      Distal biceps tendon ruptures: an epidemiological analysis using a large population database.
      • Del Buono A.
      • Battery L.
      • Denaro V.
      • Maccauro G.
      • Maffulli N.
      Tendinopathy and inflammation: some truths.
      It has been suggested that, as in Achilles tendon injury,
      • Kannus P.
      • Jozsa L.
      Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients.
      a predisposing factor might be a degenerative process in the distal biceps tendon. Diabetes has been shown to be associated with Achilles and rotator cuff tendinopathy.
      • Batista F.
      • Nery C.
      • Pinzur M.
      • et al.
      Achilles tendinopathy in diabetes mellitus.
      ,
      • Titchener A.G.
      • White J.J.
      • Hinchliffe S.R.
      • Tambe A.A.
      • Hubbard R.B.
      • Clark D.I.
      Comorbidities in rotator cuff disease: a case-control study.
      However, it does not seem to increase the risk of the distal biceps tendon rupture.
      • Kelly M.P.
      • Perkinson S.G.
      • Ablove R.H.
      • Tueting J.L.
      Distal biceps tendon ruptures: an epidemiological analysis using a large population database.
      There are no randomized controlled trials (RCTs) comparing surgical and nonsurgical treatment. Instead, the RCTs have assessed the number of incisions (1 or 2 incisions) and the choice of surgical implant.
      • Grewal R.
      • Athwal G.S.
      • MacDermid J.C.
      • et al.
      Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial.
      • Keener J.D.
      Controversies in the surgical treatment of distal biceps tendon ruptures: single versus double-incision repairs.
      • Recordon J.A.
      • Misur P.N.
      • Isaksson F.
      • Poon P.C.
      Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series.
      Thus, the optimal treatment for the distal biceps tendon rupture is unknown, although case series in the literature suggest that patients sustaining this injury might benefit from surgical treatment.
      • Hrubina M.
      • Behounek J.
      • Skotak M.
      • Krumpl O.
      • Mika P.
      • Olgun D.
      The results of primary repair after distal biceps tendon rupture.
      The primary aim of this study was to examine the rate of distal biceps tendon rupture surgery in an adult population between 1997 and 2016. The secondary aim was to determine the distal biceps rupture incidence in 2001 to 2016. The objective of the study was to investigate the incidence of distal biceps tendon rupture in countries with publicly funded and registered health care systems, making the incidence numbers valid because the health care systems encompass the entire country.

      Materials and Methods

      Our study included both the entire Finnish and the entire Swedish adult populations 18 years and older, between January 1, 1997 and December 31, 2016. The size of the Finnish adult population, according to Official Statistics of Finland, was 4.0 million in 1997 and 4.4 million in 2016. Respective figures for Swedish adult population were 7.0 million in 1997 and 7.9 million in 2016. Surgically treated patients of the study were obtained from an electronic registry, the National Hospital Discharge Register of Finland (NHDR) and the Swedish Hospital Discharge Register (SHDR). They include all patients admitted to any hospital in both Finland and Sweden. Starting from 2001, the SHDR also recorded outpatient visits, which were, however, lacking from the Finnish NHDR. However, all day-surgery operations are included in the NHDR.
      The coverage and accuracy of the NHDR and SHDR have been shown to be excellent.
      • Huttunen T.T.
      • Kannus P.
      • Lepola V.
      • Pihlajamaki H.
      • Mattila V.M.
      Surgical treatment of clavicular fractures in Finland—a register based study between 1987 and 2010.
      • Huttunen T.T.
      • Kannus P.
      • Rolf C.
      • Fellander-Tsai L.
      • Mattila V.M.
      Acute Achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012.
      • Mattila V.M.
      • Sihvonen R.
      • Paloneva J.
      • Fellander-Tsai L.
      Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden.
      • Sumrein B.O.
      • Huttunen T.T.
      • Launonen A.P.
      • Berg H.E.
      • Fellander-Tsai L.
      • Mattila V.M.
      Proximal humeral fractures in Sweden-a registry-based study.
      In both countries, public health care, including surgical treatment, is equally available for all citizens. Contribution of data to NHDR and SHDR is mandatory for all hospitals, both public and private.
      • Sund R.
      Quality of the Finnish Hospital Discharge Register: a systematic review.
      ,
      • Ludvigsson J.F.
      • Andersson E.
      • Ekbom A.
      • et al.
      External review and validation of the Swedish National Inpatient Register.
      The NHDR and the SHDR datasets contain information on patients’ age, sex, place of residency, length of hospitalization, diagnoses, and surgical procedures performed during the hospital visit. The 10th revision of the International Classification of Diseases (ICD-10) has been in use in Finland since 1996 and in Sweden since 1997.
      The primary outcome variable in this study was the rate (per 100,000 person-years) of surgical treatment of patients with a diagnosis of distal biceps tendon rupture. Only the first procedure for each individual was recorded. The ICD-10 codes used solely for distal biceps rupture were S46.2 in Finland and S46.8 in Sweden (injury of biceps muscle or tendon, excluding S42.1—Injury of long head of biceps). Corresponding NOMESCO (Nordic Medico-Statistical Committee) classification for surgical procedure codes used for biceps operations in Finland and Sweden were NBL19, NBL30, NBL68, NBL99, NCL19, NCL20, NCL32, NCL40, and NCL64.
      NOMESCO
      Classification of Surgical Procedures version 1.16. 2011.
      The patients selected for the final analysis had to have both the pertinent ICD-10 diagnosis and NOMESCO procedural codes.
      The secondary outcome measure was the total incidence of the distal biceps rupture, as a primary or secondary diagnosis, in the hospital or as outpatients in Sweden. This secondary outcome was possible to assess in Sweden because, since 2001, outpatient visits have also been recorded by the SHDR.

      Statistical analysis

      When calculating the binational sex- and age-specific rates of distal biceps tendon rupture surgery and national distal biceps rupture incidence in Sweden, the annual midyear populations were obtained from the Official Statistics of Finland and Sweden, the statutory, computer-based population registers maintained by the 2 countries. Because the incidences were calculated using the entire adult population instead of a cohort or sample, no statistical probability estimation methods were used. This was in full accordance with our previous nationwide studies.
      • Sumrein B.O.
      • Huttunen T.T.
      • Launonen A.P.
      • Berg H.E.
      • Fellander-Tsai L.
      • Mattila V.M.
      Proximal humeral fractures in Sweden-a registry-based study.
      ,
      • Mattila V.M.
      • Huttunen T.T.
      • Sillanpaa P.
      • Niemi S.
      • Pihlajamaki H.
      • Kannus P.
      Significant change in the surgical treatment of distal radius fractures: a nationwide study between 1998 and 2008 in Finland.
      • Huttunen T.T.
      • Kannus P.
      • Pihlajamaki H.
      • Mattila V.M.
      Pertrochanteric fracture of the femur in the Finnish National Hospital Discharge Register: validity of procedural coding, external cause for injury and diagnosis.
      • Mattila V.M.
      • Huttunen T.T.
      • Haapasalo H.
      • Sillanpaa P.
      • Malmivaara A.
      • Pihlajamaki H.
      Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study.

      Results

      During the study period between 1997 and 2016, 2,029 patients were operated on for a distal biceps tendon rupture in Finland, and the corresponding figure in Sweden was 2,000. The annual number of operations increased steadily in both countries, in Finland from 26 patients in 1997 to 215 in 2016, and in Sweden from 12 patients in 1997 to 228 in 2016. The majority of the patients were men (n = 1,972, 97% in Finland; n = 1,943, 97% in Sweden). The mean (SD) age of the patients by country and year is shown in Table 1.
      Table 1Mean Age (SD) of Patients Treated Surgically for a Distal Biceps Tendon Rupture, Divided by Country and Year
      19972016
      Male Finland45.8 (SD, 8.2)47.1 (SD, 9.7)
      Female Finland46
      Only 1 female was operated in 1997; SD not available.
      40 (SD, 7.1)
      Male Sweden48 (SD, 14.1)46 (SD, 9.2)
      Female Sweden56 (SD, 14.8)60 (SD, 8.4)
      Only 1 female was operated in 1997; SD not available.
      The rate of distal biceps tendon rupture surgery increased steeply, but equally, in both countries, in Finnish men from 1.3 (per 100,000 person-years) in 1997 to 9.6 in 2016 (Fig. 1), and in Swedish men from 0.2 in 1997 to 5.6 in 2016 (Fig. 2). In women, the corresponding figures were low without a clear change (0.1 in 1997 and 0.3 in 2016 in Finland, and 0.2 in 1997 and 0.2 in 2016 in Sweden).
      Figure thumbnail gr1
      Figure 1Rate of surgical treatment (per 100,000 person-years) of distal biceps tendon rupture in Finland between 1997 and 2016.
      Figure thumbnail gr2
      Figure 2Rate of surgical treatment (per 100,000 person-years) of distal biceps tendon rupture in Sweden between 1997 and 2016.
      During the period between 2001 and 2016, 4398 patients were diagnosed with distal biceps tendon rupture in Sweden. The annual number was 55 in 1997 and it increased to 420 in 2016. Thus, the incidence increased during the study period; in men, the increase was 6-fold from 1.6 to 10.0 per 100,000 person-years from 2001 to 2016. Respective figures for women were 0.06 and 0.6 (Fig. 3). The mean age of the male patients diagnosed with biceps rupture was 46 years (SD, 12.4) in 2001 and 47 years (SD, 11.7) in 2016. Corresponding figures for women were 58 years (SD, 13.4) in 2001 and 62 years (SD, 17.7) in 2016.
      Figure thumbnail gr3
      Figure 3Incidence of distal biceps tendon rupture (per 100,000 person-years) in Sweden between 2001 and 2016.
      Combining the Swedish data from incidence and rate of surgery was possible between the years 2001 and 2016. Figure 4 shows the increased and symmetrical trend from both per 100,000 person-years.
      Figure thumbnail gr4
      Figure 4Incidence rate and rate of surgical treatment of distal biceps tendon ruptures (per 100,000 person-years) in Sweden between 2001 and 2016.

      Discussion

      This population-based analysis relied on the single-payer medical system, in which all citizens are publicly covered with free-of-charge health care. Previous analyses have been subpopulations in contrast to the present study that shows whole binational results for distal bicep injury and surgery. The main finding of our study was the 7-fold and 28-fold increase in rate of the surgery for distal biceps tendon rupture in Finnish and Swedish men during the 20-year study period from 1997 to 2016. Interestingly, the actual incidence of distal biceps rupture seemed to increase in Sweden as well. The reasons for this increasing incidence of rupture are not known but a similar phenomenon has been seen in the Achilles tendon.
      • Huttunen T.T.
      • Kannus P.
      • Rolf C.
      • Fellander-Tsai L.
      • Mattila V.M.
      Acute Achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012.
      In the literature, there are only a few publications concerning the incidence of distal biceps rupture and the rate of surgery.
      • Safran M.R.
      • Graham S.M.
      Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking.
      ,
      • Kelly M.P.
      • Perkinson S.G.
      • Ablove R.H.
      • Tueting J.L.
      Distal biceps tendon ruptures: an epidemiological analysis using a large population database.
      In 2002, Safran and Graham
      • Safran M.R.
      • Graham S.M.
      Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking.
      reported a rupture incidence of 1.2 per 100,000 persons in the United States (in an area defined by zip code). In 2015, Kelly et al
      • Kelly M.P.
      • Perkinson S.G.
      • Ablove R.H.
      • Tueting J.L.
      Distal biceps tendon ruptures: an epidemiological analysis using a large population database.
      reported a surgery rate of 2.55 per 100,000 U.S. persons from a national database containing both public and private insurance patients. The observed surgery rates in our study conducted in Finland and Sweden are markedly higher. The reason for the difference is not known, but most likely, the differences between the insurance (single-payer and multipayer) and health care systems between the regions (Scandinavia and North America) are, at least partly, responsible.
      The overall incidence of distal biceps tendon rupture seems to have reached a plateau in Sweden during the last years studied; however, this needs further research. Even though the total incidence of rupture remained at the same level during the last years, surgery in Sweden continued to rise. This might be due to the better availability of magnetic resonance imaging and improved surgical techniques.
      There are several possible reasons for the increased incidence in ruptures and surgical treatments of the distal biceps tendon. First, the accuracy of diagnosis, and especially the accessibility of modern imaging technology, may have made the diagnosis easier and most likely decreased the delay between the injury and the diagnosis. Imaging is performed often and magnetic resonance imaging has replaced ultrasound as the gold standard. Second, current patients might be more demanding and more interested in full recovery, and therefore, the surgical options may be more likely to be offered by attending surgeons. Public perception toward surgical treatment is often positive, although the evidence for the superiority of surgical treatment is often lacking.
      • Haeberle H.S.
      • Bartschat N.I.
      • Navarro S.M.
      • et al.
      Hip arthroscopy: a social media analysis of patient perception.
      Third, increased physical activity among middle-age people (often with degenerative tendinopathy) may have resulted in a greater total number of ruptures in the general population leading to increased surgical activity. These phenomena have been suggested to explain the increase in Achilles tendon ruptures, and possibly supraspinatus tendon rupture surgery in the shoulder.
      • Huttunen T.T.
      • Kannus P.
      • Rolf C.
      • Fellander-Tsai L.
      • Mattila V.M.
      Acute Achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012.
      ,
      • Judge A.
      • Murphy R.J.
      • Maxwell R.
      • Arden N.K.
      • Carr A.J.
      Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England.
      ,
      • Paloneva J.
      • Lepola V.
      • Aarimaa V.
      • Joukainen A.
      • Ylinen J.
      • Mattila V.M.
      Increasing incidence of rotator cuff repairs—a nationwide registry study in Finland.
      We found that surgical activity is higher in Finland than in Sweden. Increased surgical activity of degenerative diseases in Finland has been previously published with respect to degenerative knee arthroscopy and Achilles tendon rupture surgery, showing the same difference toward a more conservative approach in Sweden.
      • Huttunen T.T.
      • Kannus P.
      • Rolf C.
      • Fellander-Tsai L.
      • Mattila V.M.
      Acute Achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012.
      ,
      • Mattila V.M.
      • Sihvonen R.
      • Paloneva J.
      • Fellander-Tsai L.
      Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden.
      ,
      • Mattila V.M.
      • Huttunen T.T.
      • Haapasalo H.
      • Sillanpaa P.
      • Malmivaara A.
      • Pihlajamaki H.
      Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study.
      The reason for this phenomenon is not known, even though the health systems and training are equal in both countries.
      The NHDR and SHDR databases have been proven to be accurate with excellent coverage.
      • Sumrein B.O.
      • Huttunen T.T.
      • Launonen A.P.
      • Berg H.E.
      • Fellander-Tsai L.
      • Mattila V.M.
      Proximal humeral fractures in Sweden-a registry-based study.
      ,
      • Sund R.
      Quality of the Finnish Hospital Discharge Register: a systematic review.
      ,
      • Huttunen T.T.
      • Kannus P.
      • Pihlajamaki H.
      • Mattila V.M.
      Pertrochanteric fracture of the femur in the Finnish National Hospital Discharge Register: validity of procedural coding, external cause for injury and diagnosis.
      A strength of the present study is also the combination of 2 national registers (altogether a population of 12 million) in Nordic countries with public, and essentially free, health care. In addition, both registers also include the private sector health care along with the public one. The SHDR contains both inpatient and outpatient diagnoses, and hence, the total incidence of diagnosed distal biceps tendon rupture could be determined at a national level.
      The weakness of the study is the unknown number of patients who incurred rerupture of the distal biceps tendon. However, although the literature on reruptures is scarce, rates of rerupture appear to be low and, therefore, would not be expected to have a major effect on our main results. Another weakness of the present study is that the coding of the injuries was done by the treating physicians (eg, primary care physicians and not necessarily an orthopedic surgeon), and therefore, the accuracy of injury coding is dependent on the clinical diagnosing skills of the treating physician. In addition, for the same reason, partial ruptures and complete ruptures may not have been differentiated in the data.
      The efficacy of surgical treatment compared with nonsurgical treatment in the distal biceps tendon ruptures has never been tested in a randomized study. High-quality RCTs on the treatment of trauma, and most orthopedic conditions, are needed to identify optimal treatment. Similar phenomena have previously been seen in Achilles tendon and degenerative meniscus ruptures.
      • Mattila V.M.
      • Huttunen T.T.
      • Haapasalo H.
      • Sillanpaa P.
      • Malmivaara A.
      • Pihlajamaki H.
      Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study.
      ,
      • Soroceanu A.
      • Sidhwa F.
      • Aarabi S.
      • Kaufman A.
      • Glazebrook M.
      Surgical versus nonsurgical treatment of acute achilles tendon rupture: a meta-analysis of randomized trials.
      ,
      • Sihvonen R.
      • Paavola M.
      • Malmivaara A.
      • et al.
      Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear.
      In conclusion, we observed 10.0 per 100,000 person-years incidence of distal biceps tendon rupture for Swedish men in 2016 (a 6-fold increase from 2001), and the 7-fold and 28-fold increases in the distal biceps tendon rupture surgery in Finnish and Swedish men, respectively, between 1997 and 2016. The exact reasons for the rises are unknown, but improved imaging of the rupture, increased physical activity, rising demands of middle-aged people for treatment, and increased surgical activity in general may play a role.

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