Edward W. Kelly
Injury to the biceps tendon encompasses a spectrum from insidious partial tears, complete traumatic tears, to chronic neglected ruptures. Nonoperative treatment was commonly advocated in the past and still plays a role in the elderly or inactive patient. Many surgeons now recognize that early surgical reattachment of the torn tendon to the radial tuberosity will restore function and prevent deformity.
Pathogenesis
Etiology
Chevallier proposed that complete biceps tears occur in two stages; the first is the partial tear, which can be insidious in onset, followed by a complete disruption of the remaining tendon with a sudden traumatic event. Davis and Yassine in 1956 presented two cases, one a partial and one a complete rupture of the distal biceps tendon, which illustrated the degenerative changes that occur in the tendon. In both cases, spurring had occurred at the bicipital tuberosity, which acted as a knife to separate the tendon with supination and pronation. In each case, the disruption occurred in the lateral aspect of the tendon first and progressed medially (Fig. 52-1). The tendon avulsion almost always occurs at the insertion site, and at the time of surgery, the torn tendon end is bulbous and frayed, confirming the degenerative process of this injury.
Epidemiology
The ruptures tend to occur in active, middle-aged men, whereas women rarely present with this injury. In a review of >100 cases of distal biceps injuries surgically repaired at the Mayo Clinic, only one patient was a woman, and her tear was only partial. Distal biceps injuries were once considered uncommon, mostly based on a report by Gilcrest in 1925 in which he stated that only 3 of 100 patients with biceps tendon injuries that he reviewed were at the distal insertion. Currently, greater recognition of this condition has led to more diagnoses.
Classification
Distal biceps tears can be classified into partial or complete tears. Complete tears can be further divided into acute (<10 days from injury), subacute (11 to 21 days), or delayed/chronic (>21 days). The subclassification of the complete tear is important when considering surgical management of the torn tendon. On average, if the patient is operated on ≤10 days of the injury, the retracted tendon is easily identifiable, the tract to the tuberosity is intact, and the tendon can be reapproximated to the tuberosity without significant dissection. If >10 but <21 days have passed since the injury at the time of surgical repair, the scarring makes the surgery more difficult and increases the risk of complications, but the tendon can usually be reapproximated to the tuberosity. At ≥21 days postinjury, primary repair becomes more difficult and a graft may be necessary to restore length.
Diagnosis
Physical Examination and History
Clinical Features
Complete distal biceps tears are most often associated with a sudden traumatic event of forced extension against an actively flexing elbow. Patients present with ecchymosis, pain, swelling, weakness, and a palpable defect of the biceps tendon. The ecchymosis is fairly characteristic, extending along the entire medial aspect of the arm and forearm. The deformity of the retracted biceps is also characteristic with the tendon stump retracted proximally and the Popeye-shaped muscle belly retracted into the upper arm. Initially the patients may complain of pain, but this often subsides by the time they present to the orthopaedist. The patients will be tender in the antecubital fossa and have pain with resisted
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supination and flexion as well as mild to moderate weakness with these resisted motions. In some cases, the lacertus fibrosis may remain intact, making it difficult to palpate the tendon defect. In thin individuals, the diagnosis can be confirmed by comparing the motion of the bicep muscle belly with the elbow flexed 90 degrees while the forearm is passively rotated. While moving the forearm from supination to pronation, the biceps muscle belly should move distally with an intact tendon. In addition, as the examiner grips a patient's right injured forearm with the right arm, he or she should be able to grip the arm above the elbow and place the left thumb under an intact biceps tendon.
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Figure 52-1 The degenerative tear occurs on the deep side of the tendon. Left: drawing demonstrating the appearance of the lesion at surgery, in which the dotted line represents the enlarged bicipital bursa. Right: A cross section of the area of the arm indicated by thestraight line in the left figure. When the arm is pronated (A), the sharp margin of the tuberosity impinges on the tendon; when the arm is supinated (B), the tendon is pulled free. (Reprinted from Davis WM, Yassine Z. An etiological factor in tear of the distal tendon of the biceps brachii: report of two cases. J Bone Joint Surg A. 1956;39:1365–1368 , with permission.) |
In more chronic cases, the ecchymosis and swelling will no longer be apparent; however, the muscle belly will remain retracted and may be atrophic. The retracted tendon is often scarred, fibrosed, and not palpable, and the patient remains weak in flexion and supination. These patients complain more of a “cramping” and weakness rather than a sharp pain with activity.
Unlike the often dramatic and well-characterized presentation of complete distal biceps tendon ruptures, patients with partial tears often fail to describe an acute traumatic event, describing an insidious onset to their symptoms. The tendon is intact anteriorly but tender to palpation. In addition, the bicipital tuberosity is also tender when palpated with the forearm in full pronation. The patients tend to have weakness with resisted supination and flexion but not as marked as with complete tears. A local cortisone and anesthetic injection from a posterior approach to the radial tuberosity may be both therapeutic and diagnostic in these cases. This should be done with the arm in full pronation, aiming the needle at the level of the tuberosity, just between the radius and ulna. The patients should be warned that temporary posterior interosseous nerve palsy may result as the anesthetic diffuses through the surrounding tissues.
Radiographic Features
In acute disruptions, plain radiographs are most often normal; however, they may occasionally demonstrate osteophytic spurring at the level of the radial tuberosity. Although occasionally helpful in the patient with a questionable diagnosis, MRI is often unnecessary. In partial tears, however, MRI evaluation is very helpful is assisting in the diagnosis of these cases. The presence of increased intratendinous signal intensity and abnormal tendon diameter along with fluid around the tendon can confirm the diagnosis (Fig. 52-2).
Treatment
Surgical Indications/Contraindications
Nonoperative treatment of acute, complete distal biceps tears may provide acceptable results in older or more sedentary individuals. The resulting weakness, pain, and deformity, however, have lead many surgeons to recommend surgical reattachment of the avulsed tendon to the tuberosity. The issue of surgical approach, however, has been controversial.
The significant anterior exposure initially required to reattach the biceps to the radial tuberosity was associated with several complications including radial and median nerve palsies. In an attempt to avoid such complications, Boyd and Anderson advocated a two-incision technique. They were able to limit the anterior dissection by exposing the radial tuberosity through a second posterior incision. Although this technique was thought to decrease the
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potential of nerve injury associated with an anterior approach, it was perceived to increase the likelihood of radioulnar synostosis.
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Figure 52-2 Axial MRI image from a patient with a partial distal biceps tendon tear demonstrating increased signal intensity at the tendon insertion site coinciding with the site of the tendon tear on the radial surface of the tendon. (Reprinted from Kelly EW, Steinmann SP, O'Driscoll SW. Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision. J Shoulder Elbow Surg. 2003;12:456–461 , with permission.) |
There have been reports of heterotopic bone formation occurring with the anterior approach and nerve injury occurring with the two-incision approach. Firm evidence is lacking attributing either excess bone formation or nerve injury with either surgical technique.
Surgical Technique
Regardless of whether the surgeon plans on using only a single anterior or a two-incision approach, the patient is placed supine on the operating table with the arm out on a hand table. The arm is then prepped and draped from the wrist to the axilla and a sterile tourniquet is used. The first important task is to milk the muscle belly distally prior to applying the tourniquet (Fig. 52-3A). This maneuver pushes the tendon down toward the antecubital fossa where is can easily be retrieved through the anterior incision.
Mini Two-Incision Technique
When using the two-incision technique, a 3-cm transverse incision is made in the antecubital crease along the flexion lines (Fig. 52-3A). The incision is centered over the bicipital tract just medial to the midline. The lateral antebrachial cutaneous nerve lies just to the lateral aspect of the incision but does not need to be exposed. Just deep to the subcutaneous tissues lies the fascia of the bicipital tunnel, which can be incised with scissors longitudinally. In the acute setting, hemorrhagic fluid is frequently encountered, indicating the correct plane. Blunt digital dissection can now be used to identify the radial tuberosity distally in the tunnel, and proximally to identify the tendon. The tendon may be grasped with an Allis clamp and then pulled out the anterior incision. The bulbous end is then debrided back just a few millimeters and the tendon prepared with a running locking Krackow stitch using a strong nonabsorbable no. 2 suture. This is done twice to provide four strands of suture (Fig. 52-3B).
The bicipital tuberosity of the radius is then palpated from the anterior incision by following the bicipital tunnel. A blunt, curved hemostat is carefully inserted into the space previously occupied by the biceps tendon. The instrument slips past the tuberosity between the radius and ulna and is advanced below the radius past the ulna while pronating the forearm so that its tip may be palpated on the dorsal aspect of the proximal forearm (Fig. 52-4). A second, 4-cm-long incision is made over the instrument, which should be 1 cm anterolateral to the subcutaneous border of the ulna. The tuberosity is exposed by a muscle-splitting incision. The ulna is never exposed. The supinator fascia is identified after splitting through the common extensor muscles. Fibers are then split to expose the bicipital tuberosity, taking care to keep the forearm in maximal pronation to protect the posterior interosseous nerve. Small Hohmann retractors are carefully placed underneath the supinator on the radius. A small round (4 to 5 mm) high-speed burr is used to excavate a trough 1.5 cm long and 5 mm wide in the radial tuberosity. The trough is taken into the medullary canal of the radius. Two or three drill holes are then placed 7 to 8 mm apart and ≥7 mm from the edge of the excavation using a small drill bit or 0.062 K-wire (Fig. 52-5). Copious irrigation is used to remove bone dust at each stage during preparation of the cavity and the suture holes. The sharp leading edge of the radial bone trough should be smoothed off to prevent irritation of the tendon with supination and pronation.
Once the trough is created, the surgeon passes the four strands of suture through the anterior incision and out the posterior incision, taking care to be aware of the tendon's orientation in the tunnel. The strands of suture are then threaded through the bone trough and out the drill holes, one at each of the proximal and distal holes and two out the middle hole (if using three drill holes). A Hewson suture passer is helpful for this step. The tendon is pulled into the bone trough by supinating the forearm and pulling on the sutures. The sutures are tied over the bone bridges. The wound is carefully lavaged and the wound closed in layers. The patient is placed in a posterior plaster splint overnight for comfort.
Single Anterior Incision
If an anterior-only approach is used, the distal portion of a Henry, S-shaped incision is performed with the transverse aspect similar to that described above for the mini two-incision procedure, but with the lateral edge curving distally. The lateral antebrachial cutaneous nerve is identified in the lateral aspect of the incision and protected. The brachioradialis is retracted laterally and the pronator is retracted medially, exposing the radial tuberosity with the forearm in supination. The posterior interosseous nerve is at risk in this exposure but can be kept out of the surgical field by supinating the forearm. The radial tuberosity is debrided of any remaining soft tissue but is not decorticated. Two suture anchors are then placed in the most medial aspect of the radial tuberosity. The tendon is identified and prepared
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as noted above up to the point of placing sutures. One limb of each of the two sutures is then placed in Krackow fashion up the medial or lateral edge of the tendon. The two sutures are then tied to each other proximally. The two free suture ends at the anchors are then tied to each other pulling the tendon to the tuberosity with the arm in full supination and 90 degrees of elbow flexion. The wound is closed in layers and the patient placed in a posterior rigid splint for 7 to 10 days. If using an interference screw, the exposure is the same while the tuberosity is drilled and the screw inserted per the manufacturer's instructions.
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Figure 52-3 A: The tendon stump is milked distally with the tourniquet applied and then expressed through the anterior incision. B:Two running, locking stitches are placed in the tendon stump providing four strands of suture to tie to the radius. (Reprinted from Kelly EW, O'Driscoll SW. Mini-incision for acute distal biceps repair. Techniques Shoulder Elbow Surg. 2002;3[2]:57–62 , with permission.) |
Subacute and Chronic Tears
If the tendon has been torn for >14 days, but <30 days, it is often quite retracted and it is difficult to get the tendon back to the radius without flexing the elbow. If the tendon can be reapproximated with the elbow flexed <90 degrees, a primary repair may be performed with the confidence that the muscle belly will relax within a few days once tension has been restored. Often, however, in the chronic setting, the tendon itself is very atrophic or so scarred that primary repair is not an option. In this situation, a tendon graft is the best option to restore length and contour. The biceps is first exposed through a larger, Henry type of anterior incision taking the smaller transverse incision as described above and carrying it out laterally, then curving proximally as far as necessary to expose the muscle. Care is taken to identify and protect the lateral antebrachial cutaneous nerve. Different types of tendon grafts have been described including semitendinosus, brachioradialis autografts, and Achilles tendon allografts. The latter are ideally suited for chronic biceps reconstructions. The graft has excellent mechanical and physical properties. The aponeurotic portion of the graft is wide and long enough to permit secure suturing to the host biceps muscle, while the distal part of the allograft can be easily trimmed to the appropriate length.
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The wide expansive portion of the Achilles allograft tendon is attached to the biceps muscle belly and tendon stump with multiple no. 2 nonabsorbable sutures (Fig. 52-6). The tendon insertion end is then passed through the bicipital tunnel and out through the posterior incision as described above for the primary repair. The distal end of the allograft can then be trimmed back to create the proper length for tensioning prior to inserting the distal tendon end into the prepared bone trough at the bicipital tuberosity. The sutures are to be tied with the elbow in 60 to 90 degrees of flexion and full pronation. Once the tendon is trimmed to the appropriate length, it is prepared as described for the primary repair above with two no. 2 nonabsorbable sutures in a Krackow fashion providing four suture stands. The repair is then completed as described above using the two-incision technique.
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Figure 52-4 A large blunt curved hemostat is placed through the anterior incision, down the tunnel of the biceps tendon, and between the radius and ulna to identify the site for the posterior incision. (Reprinted from Kelly EW, O'Driscoll SW. Mini-incision for acute distal biceps repair. Techniques Shoulder Elbow Surg. 2002;3[2]:57–62 , with permission.) |
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Figure 52-5 Illustration of the proximal radius describing the position of the holes placed to pass the suture and tie over the bone bridge. The holes should be 7 to 10 mm from the trough edge and 7 to 8 mm apart, creating a very stable bone bridge over which to tie the suture. (Reprinted from Kelly EW, O'Driscoll SW. Mini-incision for acute distal biceps repair. Techniques Shoulder Elbow Surg. 2002;3[2]:57–62 , with permission.) |
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Figure 52-6 The aponeurosis of the Achilles allograft is secured proximally to the muscle belly and remaining tendon stump of the biceps while distally it is prepared with two running, locking sutures to secure the allograft to the radius. |
Partial Tears
For partial repairs that require surgery, the entire repair can be accomplished through a single posterior incision avoiding any anterior dissection. The radial tuberosity is located by palpating the lateral forearm in full pronation, or by measuring down from the olecranon on the lateral preoperative x-ray view. A 4-cm incision is then made centered over the radial tuberosity, 1 cm anterolateral to the subcutaneous border of the ulna. The fascia of the extensor digitorum communis is identified and split longitudinally in line with the skin incision, avoiding the subcutaneous border of the ulna. With the forearm fully pronated to protect the posterior interosseous nerve, the supinator fascia is identified and split longitudinally over the radial tuberosity, exposing the underlying biceps tendon at its insertion on the radius. As the partial tear and pathology occurs on the undersurface of the tendon, which is not exposed, the tendon in the wound often appears normal.
To expose the tendon and explore the pathology, the tendon needs to be pulled out of the wound and probed. To accomplish this, a stay suture is placed in the most proximal portion of the biceps that is visible in the wound and the tendon pulled down and out of the wound. This same maneuver is repeated two or three times with the elbow flexed, each time placing a new stay suture more proximal in the tendon to pull more tendon out of the wound. With 2 to 3 cm of biceps tendon pulled out through the posterior wound, the undersurface of the tendon can be inspected and probed to reveal the defect in the undersurface of the tendon. Once the pathology has been confirmed, the remaining portion of the intact tendon can be detached while the tendon is held securely with the stay sutures to prevent retraction into the wound. The degenerative and frayed end of the tendon is sharply debrided, cutting back a few millimeters into healthier tendon. The tendon is then made to retract between the radius and ulna by extending the elbow while the stay sutures permit it to be brought back posteriorly after preparation of the bicipital tuberosity. The trough
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in the radial tuberosity is created and the tendon prepared and secured to the radius as described above in the two-incision technique.
Results and Outcome
The results for primary repair of avulsed distal biceps tendon in the acute or subacute setting (<30 days) are uniformly excellent. Numerous reports, regardless of the technique used, have demonstrated return of function, contour, and strength by 6 months. The results from partial repairs are similar but much less commonly reported. Pain relief can be achieved in 90% of patients with the posterior-only incision. The results from chronic repairs using a tendon graft are also limited in number but similarly acceptable with 90% of patients satisfied and few complaints of pain. The restoration of objective strength, however, has not been well documented.
Postoperative Management
Having full confidence in the strength of a repair using a bone trough and transosseous sutures, immobilization of the elbow can be limited to only the first night and rehabilitation of the tendon can be started the day after surgery in the setting of acute, chronic, or partial repairs. The patients are instructed to begin gravity-assisted extension exercises with active-assisted and passive flexion the day they are removed from the postoperative dressing. The sling is worn for comfort the first 6 weeks to prevent a constant gravitational pull on the tendon. As their initial postoperative pain subsides, they are instructed to “use no more force than would be required to lift a glass of water or a telephone receiver” for 6 weeks, then to “use common sense” and avoid heavy force (e.g., getting a window unstuck, and so on) until 3 months. From 3 to 6 months postoperatively, they are simply advised to avoid violent force such as occurs in contact sports but can work against unlimited resistance. They can begin a self-directed strengthening program with light weights. Formal physical therapy is rarely indicated. Unlimited activities are permitted after 6 months in all patients.
Suggested Readings
Boyd HB, Anderson LD. A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg. 1961;43A:1041–1043.
Chevallier CH. Sur un cas de desinsertion au tendons bicipital in terieur. Mem. Acad Chir. 1953;79:137.
Davis WM, Yassine Z. An etiological factor in tear of the distal tendon of the biceps brachii: report of two cases. J Bone Joint Surg, 1956;39A:1365–1368.
Failla JM, Amadio PC, Morrey BF, et al. Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique. Report of four cases. Clin Orthop. 1990;253:133–136.
Gilcrest EL. Rupture of muscle and tendons. JAMA 1925;84:1819.
Kelly EW, Morrey BF, O'Driscoll SW. Complications of distal biceps tendon repairs. J Bone Joint Surg. 2001;82-A:1575–1581.
Kelly EW, Steinmann S, O'Driscoll SW. Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision. J Shoulder Elbow Surg. 2003;12:456–461.
Le Huec JC, Moinard M, Liquois F, et al. Distal rupture of the tendon of biceps brachii. Evaluation by MRI and the results of repair. J Bone Joint Surg. 1996;78B:767–770.
Morrey BF. Distal biceps tendon rupture. In: Morrey BF, ed. The Elbow. 2nd ed. New York: Raven Press; 2002:173–191.
Morrey BF. Tendon injuries about the elbow. In: Morrey BF, ed. The Elbow and Its Disorders. 3rd ed. Philadelphia: WB Saunders; 2000:468–479.