Approach Considerations
Most surgeons agree that the vast majority of bicipital tendon ruptures benefit from early surgical repair. Indications for surgical intervention include a complete tendon rupture, with or without lacertus fibrosus rupture, in an otherwise healthy, cooperative, and active individual. In a systematic review and meta-analysis comparing the clinical and functional outcomes of operative treatment and nonoperative treatment in patients with distal biceps tendon ruptures, Looney et al found that surgical management resulted in superior elbow and forearm strength and endurance, as well as better Disabilities of the Arm, Shoulder, and Hand (DASH) score and Mayo Elbow Performance Score (MEPS). [31]
Acute ruptures are best treated early, within 8 weeks of the injury. Chronic injuries may necessitate reconstruction or augmentation of the tendon, a much more complicated procedure. [4] A systematic review by Bajwa et al found that surgical management of chronic distal biceps ruptures led to improvement in outcomes (including pain reduction and functional ability). [32]
Partial tears are often treated with a period of nonoperative management, followed by surgery if symptoms remain, but the efficacy of nonoperative management in this setting has not been conclusively established. [33] A 2022 review of current evidence by Hamoodi et al stated that partial tears of the distal biceps tendon involving less than 50% of the tendon could be successfully treated by nonoperative means. [34]
Surgical repair of a bicipital tendon rupture has few contraindications. Contraindications include the presence of little functional impairment from the injury, medical contraindications for a surgical procedure, and a sedentary or uncooperative patient. A relative contraindication is chronic disruption. Because of tendon retraction and muscle contraction, it is difficult or impossible to reattach the tendon anatomically to the radial tuberosity. In these situations, delayed reconstruction using autograft or allograft tissue is commonly required, and the outcome is less dependable. In some cases, it may be possible to unfold a severely retracted tendon and repair it primarily. [35]
With early repair, success rates with either the two-incision or the one-incision technique (see Surgical Therapy) are high. The use of multiple drill holes instead of a high-speed burr to excavate the radial tuberosity should improve outcomes by decreasing the incidence of synostosis. The one-incision approach will continue to advance with the development of more anatomic repair techniques. In theory, a greater emphasis on anatomic repair of the distal biceps tendon to the bicipital tuberosity may improve supination, endurance strength testing, and functional outcomes.
Surgical Therapy
Early surgical intervention for complete ruptures provides the best results. Two techniques are commonly used: the two-incision (modified Boyd-Anderson) technique and the one-incision technique. [5, 36, 37]
The two-incision technique, which Boyd and Anderson described in 1961, is the one more commonly employed; however, with the advent of suture anchors, the single-incision technique is becoming more popular. An advantage of the two-incision technique is potentially stronger fixation to the radial tuberosity. The most common complication is heterotopic bone, which can create a mechanical block to motion. As a result, this bone may have to be removed surgically. Another reported complication is injury to the posterior interosseous branch of the radial nerve. [38]
The one-incision technique has the obvious advantage of involving fewer incisions. Fixation usually is achieved with suture anchors, cortical buttons, or interference screws placed into the radial tuberosity. The most common complication with the current one-incision technique is lateral antebrachial nerve neurapraxia.
A clinical trial comparing the single- and double-incision techniques showed no significant difference in outcomes between the two types of surgery. [39]
Preparation for surgery
A thorough history, physical examination, and radiographic workup should be completed prior to surgery. Range of motion (ROM) and stability of the elbow should be assessed.
Operative details
Examination with the patient under anesthesia is essential to surgery in any extremity. Surgery should be performed by using a tourniquet placed as high on the arm as possible. After standard sterile preparation and draping, the limb is exsanguinated and the tourniquet inflated.
Two-incision technique
With the two-incision technique, a small (~3-4 cm) incision in the antecubital fossa is made in the flexion crease. Dissection is taken through the fascia, and the biceps tendon is easily identified. Sometimes, a "milking" maneuver must be performed to deliver the tendon into the wound. Once the tendon is identified, it is prepared for fixation. The tendon invariably has bulbous degeneration at the rupture site. Once the bulbous degeneration is resected, two nonabsorbable braided 5-0 sutures are placed in a Bunnell or Krakow fashion to secure the tendon.
A curved Kocher or Kelly clamp is used to mark the second incision. The clamp is placed through the sheath of the biceps tendon and curved toward the radius with the forearm in supination. To prevent synostosis, great care is taken not to disturb the periosteum of the ulna. The clamp is used to tent the skin dorsally after it passes by the radial tuberosity. Once the clamp is past the tuberosity, the forearm is placed in pronation so as to protect the radial nerve.
A 4- to 6-cm incision is made over the tip of the clamp. The dissection is taken down through the fascia of the common extensor and supinator and down to the radial tuberosity, which is cleared of overlying soft tissue. The tuberosity can be excavated with a high-speed burr. D'Arco et al described a better technique in 1998. [6] In their method, the radial tuberosity is prepared with multiple drill holes in an oval fashion and then excavated with small, curved curettes. This approach avoids creating the bone dust from the burr that may lead to synostosis.
After the tuberosity is prepared, three drill holes are made along the lateral margin of the tuberosity. The tendon is then delivered from the anterior wound to the tuberosity. This step can be expedited by placing a passing stitch when the curved clamp is removed from the biceps tendon sheath. The tendon is delivered into the tuberosity, and the sutures are tied, securing the tendon. Finally, the wound is closed in layers.
One-incision technique
Single-incision techniques through an anterior approach have become increasingly popular. With such techniques, a larger, anterior incision may be necessary to safely expose the bicipital tuberosity and avoid neurovascular injury.
Care is taken to avoid excessive retraction on the surrounding neurologic structures, specifically the posterior interosseous nerve (PIN) and the lateral antebrachial cutaneous nerve. If a nerve palsy of the PIN develops, it is usually traction-related and resolves with time. [40] The distal biceps tendon can be secured to the bicipital tuberosity from the anterior incision with different types of fixation devices.
The following types of fixation devices have been successfully used to repair biceps tendon injuries with the one-incision technique:
Anchors are inserted into the radial tuberosity, and sutures from an eyelet on the anchor are passed into the biceps tendon. With cortical-button and interference-screw techniques, the tendon stump is delivered into a bone trough. The screw provides fixation with interference fit of the tendon and the surrounding bony socket, whereas the cortical button provides fixation over a bone bridge on the opposing cortical bone. When the cortical button is used, care must be taken to avoid drilling distal and radial to minimize risk of injury to the PIN. [44]
In a retrospective study of 14 patients with complete distal biceps tendon ruptures, Micheloni et al found that a tension-slide technique using cortical button fixation combined with an interference screw (BicepsButton; Arthrex, Naples, FL) was safe, reliable, and reproducible and yielded excellent clinical, functional, and radiologic outcomes. [45]
Lacertus fibrosus transfer
Caputo et al published a case series of 12 patients with distal biceps tendon injuries who were treated with an operative approach that used a transfer of the lacertus fibrosus to augment the tendon repair. [46] The authors concluded that in cases of distal biceps tendon injuries where operative management is indicated and the lacertus fibrosus intact, this approach can yield predictable outcomes without the complications associated with autograft or allograft tendon reconstruction.
Adjunctive botulinum toxin
The use of botulinum toxin A as an adjunct to repair of distal biceps tendon ruptures has been described. In a retrospective review of 14 patients who underwent 15 distal biceps tendon repairs (12 acute, 2 chronic, 1 chronic partial), all of whom were injected intraoperatively with a mixture of 100 U of botulinum toxin and 10 mL of normal saline, Khalil et al reported no intraoperative complications. [47] All patients were discharged home on the day of surgery, and the average DASH score at latest follow-up (mean follow-up, 32.9 months) was 4.9 (range, 0.0-12.5). In all cases, return of function of paralyzed muscle was noted before final follow-up.
Postoperative Care
Whether the two-incision or the one-incision technique is used, the elbow should be immobilized in 90° of flexion and slight supination for 7-10 days for the patient's comfort. Outpatient physical therapy begins with gentle ROM. A hinged ROM brace can help initially block the terminal 30° of flexion to protect the repair. This angle is gradually increased to full extension. Pronation and supination should be initiated early in therapy.
Complications
The most common complication from a two-incision approach is heterotopic ossification. This complication can be minimized by avoiding use of a burr to excavate the radial tuberosity, decreasing the amount of bone dust created. In addition, by avoiding disruption of the ulnar periosteum, the risk of radioulnar synostosis can be minimized.
The most common complication from a one-incision approach is nerve palsy. [48] Most of these palsies are transient in nature and completely resolve. They are best avoided by minimizing traction on the nerve.
Proponents of the one-incision technique argue that there is a lower risk of radioulnar synostosis and heterotopic ossification. Proponents of the two-incision technique argue that there is a lower risk of neurovascular injury and that a more anatomic repair of the biceps to the radial tuberosity is possible.
Cadaveric studies have shown that a two-incision technique restores the original footprint more adequately than a one-incision technique does. [49] Postoperative magnetic resonance imaging (MRI) has shown that single-incision techniques can cause anterior tendon reattachment, which can be associated with a decrease in supination strength. [50]
There are complications specific to the newer types of fixation. Potapov et al observed high rates of bone resorption with bioabsorbable screws made out of poly-L-Lactide (PLLA), though there was no correlation with clinical outcomes. [51] Transient PIN palsy, persistent radial nerve palsy, disengagement of the button, and heterotopic ossification have been reported with the use of cortical-button fixation. [52]
Long-Term Monitoring
Unrestricted motion can usually be achieved by 6-8 weeks after surgery. Full, unrestricted resistance activities should be delayed at least 4 months.
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Biceps muscle and tendons.
