Distal Biceps Tendon Rupture: part two : Wheeless' Textbook of Orthopaedics

- 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;