Delayed Reconstruction of Distal Biceps Tendon Ruptures

Bernard F. Morrey

Mark Morrey

INTRODUCTION

Frequency of delayed reconstruction appears to be slightly increasing in recent years. As noted in the prior chapter (Chapter 21), if the host tendon can be reattached with the elbow at 90 degrees, this is possible in most instances and is preferable to reconstruction (1). The 90-degree contracture will stretch out to near-normal extension with time, and function is excellent. When the tendon has retracted to the point that it cannot be reattached directly to the tuberosity, augmentation with an Achilles tendon allograft is our technique of choice. However, we have discontinued preserving the fleck of calcaneus and simply embed the allograft tendon as noted below.

INDICATIONS/CONTRAINDICATIONS

Indications for Delayed Reconstructions

Not all with a missed or nonoperated acute injury require reconstruction (2).
However, chronic pain and fatigue do occur if the injury is not addressed (3).
Hence, we offer reconstruction to patients who have chronic pain, sometimes due to tethering of the neurovascular structures or other symptoms such as cramping and fatigue due to the detached distal biceps tendon.
Typically, selective loss of supination strength is the major problem, and rarely is flexion weakness an indication for delayed reconstruction.

PREOPERATIVE PLANNING

I have had one patient 11 months after rupture who had little retraction due to an intact lacertus fibrosis, hence was able to perform a direct reattachment. Because of the uncertainty, prepare the patient for either eventuality—direct reattachment or reconstruction. Final determination is based on findings at surgery (Fig. 22-1). The recoiled tendon may be able to be teased out to a length that allows reattachment. If not, have an allograft tendon available or prep the patient for autograft harvest and reconstruct.

TECHNIQUE

Several authors have reported small series of reconstructions using various tissues including the autologous hamstring (4,5), the flexor carpi radialis (6), and the Achilles tendon allograft (7). The author has used the allograft Achilles tendon almost exclusively for this reconstruction, and the technique currently used is described in this chapter. The technique has been modified from the prior description (7) that called for retaining a fleck of the calcaneal attachment. This is felt to be no longer necessary, and hence, the calcaneus is resected, and the free end of the tubular Achilles tendon is embedded directly into the tuberosity.

Position

The patient is supine on the table, and the arm is placed on an elbow (arm) table.

Exposure

With reconstruction, the anterior exposure must be more extensive since the biceps tendon and muscle must be exposed (Fig. 22-2). We employ a Henry-type skin and deep exposure. After the tendon has been retrieved and it is determined that the biceps tendon is inadequate for reattachment even with the elbow flexed to 90 degrees (Fig. 22-3), the tuberosity is exposed by blunt dissection in the cubital fossa.

Note: This is one of the most important parts of the procedure; the space occupied by the biceps tendon is often scarred. Care must be taken to avoid injury to the radial nerve: