Distal Biceps Repair

Steven M. Andelman, MD

Lauren E. Geaney, MD

Robert A. Arciero, MD

Anthony A. Romeo, MD

Augustus D. Mazzocca, MS, MD

Dr. Geaney or an immediate family member serves as a paid consultant to or is an employee of Paragon 28; has received research or institutional support from Arthrex, Inc.; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Foot & Ankle Society and the Connecticut Orthopaedic Society. Dr. Arciero or an immediate family member has stock or stock options held in Biorez; has received research or institutional support from Arthrex, Inc. and DJ Orthopaedics; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports Medicine. Dr. Romeo or an immediate family member has received royalties from Arthrex, Inc.; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, Inc.; serves as a paid consultant to or is an employee of Arthrex, Inc.; has received research or institutional support from Aesculap/B.Braun, Arthrex, Inc., Histogenics, Medipost, NuTech, OrthoSpace, Smith & Nephew, and Zimmer; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such as paid travel) from the Arthroscopy Association of North America, Arthrex, Inc., and MLB; and serves as a board member, owner, officer, or committee member of the American Shoulder and Elbow Surgeons, Atreon Orthopaedics, and Orthopedics Today. Dr. Mazzocca or an immediate family member serves as a paid consultant to or is an employee of Arthrex, Inc. and has received research or institutional support from Arthrex, Inc. Neither Dr. Andelman nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

PATIENT SELECTION

Patients with an acute distal biceps tendon rupture usually describe a specific event of a sudden extension force on a flexed elbow and may report hearing a “pop” at the time of rupture.¹ Initially, the pain is sharp and tearing in the anterior forearm; it evolves into an aching pain persisting for weeks to months. Many have ecchymosis in the antecubital fossa and swelling and tenderness.² Morrey³ described three criteria for diagnosis: (1) a history of a single traumatic event, (2) grossly palpable and visible signs of proximal retraction of the distal end of the biceps, and (3) weakness of flexion of the elbow and supination of the forearm. The O’Driscoll hook test may be used to identify an absence of the distal insertion:⁴ The patient’s arm is flexed to 90°, and the patient supinates the arm. If the distal tendon is intact, the examiner can hook a finger underneath. If absent, there is no structure to hook.

Most patients with an acute complete rupture of the distal biceps tendon should be offered surgery.³ These are most often middle-aged, active men. Patients with significant comorbidities may be poor candidates. A discussion is conducted with all patients involving the risks and benefits of the procedure, and more sedentary patients may opt for nonsurgical treatment. In our practice, these patients are given a trial of physical therapy for 3 to 4 weeks and are encouraged to continue daily activities. If symptoms are unbearable at this time, they may undergo surgery. We recommend initial nonsurgical treatment of partial ruptures. If pain continues despite physical therapy, and weakness is unacceptable to the patient, surgical treatment is undertaken. Patients with chronic symptomatic ruptures are also offered surgery.³

PREOPERATIVE IMAGING

AP and lateral radiographs are obtained to rule out fracture or other pathology. Occasionally, hypertrophy or avulsion of the radial tuberosity can be seen.¹^,⁴^,⁵ Diagnosis is primarily clinical, but MRI may be helpful for confirmation or in the case of partial ruptures. MRI can also help to identify the amount of tendon retraction for preoperative planning² (Figures 1 and 2).

VIDEO 8.1 Cadaveric Demonstration: Distal Biceps Tendon Fixation. Anthony A. Romeo, MD; Augustus D. Mazzocca, MS, MD (32 min)

View Quicktime Video

Video 8.1

PROCEDURE

Special Instruments/Equipment/Implants

Surgical techniques for distal biceps repairs are numerous, and a wide variety of fixation methods may be used. Our preferred method is a combination of a cortical button with interference screw fixation. We usually use an 8- × 12-mm interference screw. Other options include bone tunnels, suture anchors, and either a cortical button or interference screw alone.

Surgical Technique

Repair of the distal biceps may be nonanatomic or anatomic. The nonanatomic technique sutures the biceps tendon to the brachialis, in a simple procedure with limited dissection but which sacrifices supination power.⁶ This is also a possible solution in cases of chronic ruptures where
the tendon is retracted. Anatomic approaches reinsert the tendon to the radial tuberosity, restoring both supination and flexion strength. The initial approach was a single-incision anterior approach. However, a high incidence of nerve injuries was reported.³

FIGURE 1 Sagittal MRI shows a torn biceps tendon (arrow) retracted 6 cm.

In 1961, trying to avoid these complications, Boyd and Anderson⁷ introduced a method for reinserting the distal biceps tendon using a two-incision approach. Although their method reduced nerve injury, a higher rate of heterotopic ossification and radioulnar synostosis was reported.

FIGURE 2 Coronal MRI shows a retracted biceps tendon (arrow) torn from the radial tuberosity (asterisk).

In response, Morrey et al⁸ modified the procedure to avoid subperiosteal elevation and advocated a muscle-splitting approach with copious irrigation to reduce the rates of heterotopic ossification and synostosis. However, complications continued to occur,⁹ prompting the development of new one-incision anterior approaches, avoiding the extensive dissection necessary with two incisions.