Repair of Distal Biceps Tendon Ruptures

Augustus D. Mazzocca MD

James Bicos MD

Anthony A. Romeo MD

Robert A. Arciero MD

History of the Technique

Ruptures of the distal biceps tendon have received increased attention recently. This trend is probably the result of increased demands placed on the upper extremities as well as increased activity in the middle-aged population. Treatment options have expanded in an effort to use modern fixation methods to return patients to work or athletic activities quicker.

Historically, a single extensile anterior exposure was used to reinsert the avulsed tendon. Boyd and Anderson¹ subsequently described a two-incision technique designed to minimize anterior exposure and limit the risk to neurovascular structures in proximity to the tuberosity. Their two-incision technique introduced heterotopic ossification and proximal radioulnar synostosis as new complications. In 1985, Morrey et al.² modified Boyd’s original approach by splitting the supinator and avoiding subperiosteal dissection. These modifications led to a decrease in the rate of heterotopic bone formation and synostosis.

Modifications in the method of fixation have also been proposed. Single incision techniques have been revived with the advent of suture anchors. These procedures utilize a Henry exposure and secure the tendon to the cortical surface of the tuberosity and not into a tunnel or trough. Benefits of the single incision technique include decreased morbidity as well as technical ease in use of the suture anchors. Biomechanical studies have shown that the suture anchor techniques are not as stiff or strong when compared to fixation over a bone bridge.³ However, in cyclic loading, the suture anchors have performed adequately to allow early passive range of motion (ROM).⁴

In an attempt to combine both a single incision and the use of a tunnel to place the tendon into, Bain et al.⁵ have described a technique using the EndoButton (Smith and Nephew, Hamburg, Germany). Studies evaluating its stiffness and strength are ongoing, but the EndoButton has performed well in other applications. However, potential complications in passing a Beath pin through the radius, approximating the length of the suture loop, and “flipping” of the device on the posterior cortex can make it a challenging technical procedure. Furthermore, cyclic loading early on might lead to pistoning of the tendon in the tunnel and impaired healing.

Bioabsorbable interference screw fixation has become popular, especially around the knee. Multiple studies testing the biomechanical properties of bioabsorbable interference screws have been performed. They have routinely shown that the constructs fail by graft slippage past the screws but at a level equal to or greater than other fixation methods.⁶^,⁷^,⁸ In cyclical loading models, the screws have performed favorably as well. On a histological level, direct tendon healing to bone has been observed with interference screw fixation.⁶^,⁷ A mature fibrocartilage intratunnel, direct ligamentous insertion can be found at 9 to 12 weeks.⁹ When indirect methods of tendon fixation are used, healing progresses via a zone of vascular, highly cellular fibrous tissue that matures through orientation of collagen fibers over a period of 12 to 26 weeks.¹⁰^,¹¹

With the development of new equipment, a bioabsorbable screw can be delivered into a prepared socket without the need for passage of a needle or suture through the socket. The combination of intratunnel fixation, a bioabsorbable device, and a single anterior approach provides an attractive alternative to other techniques. These technical advances provide the surgeon
with yet another useful option for fixation of the avulsed distal biceps tendon.

Stringent anatomical dissection and biomechanical evaluation of the techniques mentioned have pointed to a combination approach for fixation of the distal biceps tendon in a high-demand upper-extremity patient (paraplegic, laborer, and athlete). This chapter will describe the two-incision technique, as well as a technique that uses a single incision, interference screw, and EndoButton, allowing immediate active postoperative motion for early return to activity and a decrease in postoperative stiffness or heterotopic ossification.

Preoperative Evaluation

Patients with complete distal biceps tendon ruptures usually report feeling a sudden, sharp, painful tearing sensation in the antecubital region of the elbow when an unexpected extension force was applied to the flexed/supinated arm. Occasionally, pain is also present in the posterolateral aspect of the elbow. The acute pain subsides in a few hours and is replaced by a dull ache; with chronic ruptures, weakness and fatigue occur with repetitive flexion and supination activities. Physical examination reveals tenderness in the antecubital fossa, and a defect usually can be palpated there. Active flexion of the elbow causes the biceps muscle belly to retract proximally, accentuating the defect in the antecubital fossa. If the biceps tendon can be palpated in the antecubital fossa, a partial rupture of the distal biceps tendon should be considered. Ecchymosis and swelling usually are evident in the antecubital fossa and along the medial aspect of the arm and proximal forearm.

Plain radiographs generally do not show any bony changes, although irregularity and enlargement of the radial tuberosity and avulsion of a portion of the radial tuberosity have been reported with complete ruptures of the distal biceps tendon. Magnetic resonance imaging (MRI) can be helpful to distinguish complete from partial ruptures and to differentiate partial rupture from tendinosis, tenosynovitis, hematoma, and brachialis contusion.

Indications and Contraindications

Operative and nonoperative treatment courses are always presented to the patient. Nonoperative treatment involves pain control and introduction of early range of motion when able. Once full range of motion is established, strengthening begins concentrating on supination. The University of Connecticut uses an isokinetic dynamometer to establish strength deficits at the initiation of rehabilitation and at the end. Patients are counseled that they will lose approximately 25% to 35% of their supination strength. They are also instructed to perform all activities that are important to them. If they are unable to perform any of these functions, operative treatment is once again strongly recommended.

The indications for operative fixation of an acute distal biceps tendon rupture are in patients who cannot tolerate a loss of supination strength. These patients are counseled on the risks and benefits of operative treatment, which include but are not limited to infection, nerve damage, wound breakdown, stiffness, heterotopic ossification, and continued pain. The pre-, intra-, and postoperative course is explained in detail to the patient. The timing of the procedure is also a factor. We do not urgently operate on these cases. With this procedure a safe single incision without the necessity of tendon graft or augmentation can be executed between 1 and 4 weeks. If the patient is outside of this time period, consent and the operative plan should include the potential for tendon graft or augmentation.

Surgical Technique

Anesthesia

The surgical technique to restore the distal biceps does not present any unique problems for the anesthesiologist. We prefer laryngeal mask airway (LMA) as it provides excellent coverage without having the incidence of nausea and vomiting associated with general endotracheal anesthesia. Due to our concern for the neurovascular structures, we prefer to place a nerve block for postoperative pain control after the procedure and after the first postoperative neurovascular examination. This is generally an outpatient procedure, and the patient is sent home to recover after initial stabilization.

Approaches

Two main approaches to the operative procedure exist: The two-incision (modified Boyd-Anderson) and one incision volar approach. Most fixation techniques can be used for each of the approaches described without difficulty.

Modified Boyd-Anderson Approach (Azar Technique)

The Boyd-Anderson surgical approach has been described multiple times in the literature.¹^,² A transverse 3- to 4-cm incision is made over the anterior aspect of the elbow along the flexion crease. The deep fascia is incised, with care taken to identify and protect the lateral antebrachial cutaneous nerve, which lies lateral to the distal biceps tendon. Usually, it is retracted 5 to 7.5 cm proximal to the elbow. A heavy no. 5 or no. 2 nonabsorbable suture is passed through the tendon so that its
ends emerge on the avulsed surface. Then a curved Kelly clamp is used to locate the tunnel between the radius and ulna through which the tendon originally passed, taking care not to violate the ulnar periosteum. The elbow is flexed and a second incision is made on the posterolateral aspect of the elbow for the Boyd approach. The interval is developed between the lateral border of the ulna and the anconeus and extensor carpi ulnaris. The anconeus is stripped from the bone subperiosteally. The dissection is deepened to the interosseous membrane, and the supinator muscle overlying the radial head is sharply incised, exposing the radial head. Pronation of the forearm protects the deep branch of the radial nerve as it enters the forearm in the substance of the supinator muscle and brings the radial tuberosity into view. A 0.25-inch osteotome or small bur is used to create a trough in the radial tuberosity and two to three holes are drilled in the margin. With a curved Kelly clamp, the ends of the sutures in the tendon are passed between the radius and ulnar and are brought out through the second incision. Traction on the sutures will advance the tendon into the posterolateral incision. The ends of the sutures are brought out through the holes in the tuberosity and, with the elbow flexed, are securely tied over the bony bridge between the holes. Reinforcing sutures can be placed through the tendon into the adjacent soft tissues if necessary. The two incisions are closed in routine fashion and the elbow is immobilized in a posterior plaster splint with the elbow flexed to 100 degrees and the forearm supinated 45 degrees.

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