Ortho Oracle - orthopaedic operative atlas
Home » Muscles Tendons » Distal Biceps Tendon Rupture: part two

Distal Biceps Tendon Rupture: part two

- Two Incision Approach (Boyd and Anderson)
    - advantages:
           - two-incision technique to limits the anterior dissection and therefore may limit pain;
           - may reduce injury to the radial nerve, which can occur w/ a one incision technique that incorporates drill holes thru the radius;
           - rerupture is uncommon;
           - following surgical repair, most pts achieve nearly normal isometric strength, & many are capable of relatively normal endurance;
           - allows stronger fixation than the one incision technique:
           - ref: Surgical repair of distal biceps tendon ruptures: a biomechanical comparison of two techniques.
    - disadvantages:
           - supinator may have to be detached from the ulna, which would further weaken supination strength;
           - synostosis (between the radius and ulna) may occur from the following:
                    - from stripping of the aconeus andsupinator muscles;
                    - from having the posterior tunnel directly over the periosteal surface of the ulna;
                    - from disruption of the proximal interosseous membrane and, with subsequent hematoma formation,
                    - from bone dust debris from burring of the radial tuberosity;
    - technique:
           - proximal incision:
                   - 3-cm transverse incision is made over the distal biceps tendon sheath;
                   - care is taken to avoid injury to lateral antebrachial cutaneous nerve (nerve dyesthesia is often most common complications);
                            - avoiding aggressive lateral retraction and toeing "in" the retrator helps avoid this complication;
                   - enter the tendon sheath and identify the tendon stump and then retracted into the wound;
                   - insert a core tendon suture through the end of the tendon;
           - distal incision:
                   - the forearm is maximally pronated (protects the PIN which is not visualized);
                   - a curved hemostat is passed through the biceps tendon sheath and is passed down between the radius and the ulna (along
                           medial border of the radius tuberosity);
                   - it is then passed thru the common extensor muscles until it can be palpated underneath the subcutaneous tissues;
                           - muscle-splitting approach avoids subperiosteal exposure of the ulna in an attempt to lessen the likelihood of a
                                     proximal synostosis;
                           - splits the extensor carpi ulnaris muscle (avoiding supinator which reduces synostosis) 
                   - tip of the hemostat is then palpated on the dorsal surface of the forearm to locate the position of the posterior incision;
                           - it is important that curved hemostat not be passed along ulnar periosteal surface, so as to avoid radial-ulnar synostosis;
                   - 4-cm muscle-splitting incision is made and taken down to the radial tuberosity;
                   - an incision is then made, which allows exposure of the radial tuberosity;
                           - with acute repairs finding the radial tuberosity is usually possible, but the tuberosity is often obscured with delayed repairs;
                   - alternatively use a posterolateral approach to the elbow;
           - anchor the tendon:
                   - small osteotome is used to create a concavity in the tuberosity;
                   - drill holes are made through the radial tuberosity inorder to allow anchoring of the tendon;
                   - frequently irrigate the wound to remove all bone dust (to avoid synostosi);
                   - pass sutures thru the biceps using the weave of choice (Bunnel, Krachow etc...);
                   - the biceps is then retrieved thru the distal incision;
                   - sutures are then passed thru the tuberosity drill holes and is tied down;
                   - ref: The Importance of Preserving the Radial Tuberosity During Distal Biceps Repair
           - post op: consider indomethacin

- Outcomes:
    - in the report EW. Kelly et al (2000), the authors report on a retrospective review of the results of 78 consecutive
           anatomical repairs of the distal biceps tendon performed through a muscle-splitting 2 incision technique between 1981 and 1998;
           - 4 of the 8 required a graft to restore length;
           - complications developed after 23 (31 %) of the 74 repairs;
                  - complications included 5 sensory nerve paresthesias (3 lateral antebrachial cutaneous and 2 superficial radial nerve
                              paresthesias) in 5 patients;
                  - 6 patients complained of persistent anterior elbow pain;
                  - heterotopic ossification that did not limit forearm rotation developed in four patients, a superficial wound infection
                           developed in three, one tendon reruptured, three patients lost forearm rotation, and reflex sympathetic dystrophy
                           developed in one patient.
                  - complications developed after ten (24 %) of the 41 acute repairs (performed fewer than ten days after the injury), 6 (38
                           %) of the 16 subacute repairs (performed ten to 21 days after the injury), and seven (41 %) of 17 delayed repairs
                           (performed more than 21 days after injury).
           - the authors note that most of the morbidity from repair of the distal biceps tendon can be attributed primarily to a delay in the
                      timing of the repair and secondarily to an extensive anterior exposure;
           - the authors note that radioulnar synostosis is rare following the muscle-splitting modification of the two-incision technique;
           - they also noted only one temporary PIN palsy;

           - ref: Complications of repair of the distal biceps tendon with the modified two-incision technique.

- Complications:
   - synostosis: (see HO of elbow)
        - pain and swelling, leading to loss of rotation, esp supination
        - CT scan demonstrates the local of the synostosis;
        - references:
              - Radioulnar synostosis after the two-incision biceps repair: A standardized treatment protocol.
              - Permanent posterior interosseous nerve palsy following a two-incision distal biceps tendon repair.
              - Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique. Report of 4 cases.  
              - A comparison of proximal radioulnar synostosis excision after trauma and distal biceps reattachment
              - Complications of distal biceps tendon repairs.
              - Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: a possible mechanism of palsy after two-incision repair for distal biceps rupture--clinical experience and a cadaveric investigation.
              - Variables Influencing Successful Two-Incision Distal Biceps Repair

Proximity of the Posterior Interosseous Nerve During Cortical Button Guidewire Placement for Distal Biceps Tendon Reattachment

Outcomes of Modified 2-incision Technique With Use of Indomethicin in Treatment of Distal Biceps Tendon Rupture

Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertion--clinical and radiological evaluation after 2 years.

Rupture of the distal tendon of the biceps brachii. A biomechanical study.

Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment.

Distal biceps brachii tendon avulsion: a simplified method of operative repair

Partial rupture of the distal biceps tendon.

Repair of the distal biceps tendon using suture anchors and an anterior approach

Distal biceps brachii repair. Results in dominant and nondominant extremities.

A method for reinsertion of the distal biceps brachii tendon

Repair of avulsion of insertion of biceps brachii tendon.  

Clinical, Functional, and Radiographic Assessments of the Conventional and Modified Boyd-Anderson Surgical Procedures for Repair of Distal Biceps Tendon Ruptures