Abstract
Background:
A distal biceps repair is performed after a rupture of the distal biceps tendon, an injury that typically affects the dominant arm of middle-aged men, resulting in weakness in supination and elbow flexion. A volar 2-incision technique minimizes skin incision length while optimizing exposure to anatomical structures through proper incision placement for acute repair and chronic reconstruction with graft.
Indications:
Retraction of the distal biceps away from its insertion on the proximal radius in the chronic setting can require a more extensile incision. Two transverse incisions are strategically placed on either side of the antecubital fossa to optimize exposure of the radial insertion site and proximally to retrieve the retracted tendon for either acute or chronic retracted distal biceps tears with or without graft reconstruction.
Technique Description:
A transverse incision is made in the forearm directly over the radial tuberosity. This facilitates direct exposure and drilling of a socket for placement of the distal biceps’ tendon with suture button and interference screw construct. A second proximal transverse incision is made to identify and retrieve the retracted tendon. The tendon is retrieved and prepared or reconstructed with graft for chronic cases with suture. The tendon and graft are tunneled under the skin bridge between the 2 incisions. The sutures are then loaded onto a titanium button, which is deployed onto the far cortex. The tendon is advanced into the tunnel, an interference screw is placed, and the sutures are tied.
Results:
Restoration of anatomy and correct placement of the 2 incisions is facilitated with this approach, restoring distal biceps function without requiring extensile volar exposure of the entirety of the length of the distal biceps tendon.
Discussion/Conclusion:
This technique mitigates the need for extensive dissection. It also facilitates improved visualization of relevant structures for cases with substantial tendon retraction, even in the case of chronic retracted tears requiring allograft reconstruction.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
Distal biceps repair technique utilizes a volar 2-incision technique for both acute and chronic retracted tears and useful also for partial tears.
The authors have nothing to disclose.
A volar 2-incision technique minimizes incision length while optimizing exposure. It is useful in both the acute repair setting and chronic reconstructions with a graft. It is also useful for partial tears. It simplifies mobilization of the tendon in both these scenarios. Two transverse incisions are strategically placed, with the distal incision directly over the radial tuberosity, and the second incision proximal to the antecubital fossa. This allows for the tendon to be retrieved and prepared or reconstructed with a graft. The tendon or the graft is then tunneled underneath the skin bridge between the 2 incisions and finally dual fixation of the distal biceps graft or native tendon is performed with both a suture button and interference screw.
In reviewing the biceps anatomy, the 2 transverse incisions are identified by the cross-hatched line. The distal most incision is created directly over the radial tuberosity, while the more proximal incision is placed over the biceps muscle tendon junction. The distal incision is created between the interval between the brachioradialis and the pronator teres while the more proximal incision, similarly transverse, is more superficial. The establishment of the tract between the proximal and distal incision is done using gentle finger dissection to re-establish the biceps tendon path.
This is a case study of a chronic and failed biceps repair.
The patient is a 47-year-old man with a history of a left traumatic distal biceps tendon rupture. He was originally treated at an outside hospital, and the prior surgeon was unable to perform a repair due to a lack of tendon length and chronicity of the injury. At the time of presentation, the patient rated his elbow function as 30% of normal and had pain with activity that was relatively minor at 3 out of 10. At clinical examination his elbow range of motion was essentially full, but clearly had weakness with resisted forearm supination. The stump of the tendon was not easily palpable proximally, but he had tenderness to palpation over the antecubital fossa. Overall, an absent distal biceps tendon.
Pre-operatively he demonstrated marked weakness with elbow flexion and supination strength.
His x-rays were normal without arthritic changes.
A magnetic resonance imaging (MRI) was obtained which revealed the absence of the distal biceps tendon.
In terms of setup, the patient is placed supine with an arm board and a small C-arm is utilized. Fixation is achieved with a suture button and an interference screw. A distal transverse incision is created directly over the radial tuberosity and a second transverse incision is created more proximally at the biceps’ tendon origin.
The procedure in this particular case utilized a semitendinosus graft placed through the distal biceps’ tendon junction. The graft was doubled over and whipstitched to an appropriate length, such that the arm resting length was 45° from full extension. An 8-mm unicortical drill hole was created with an acorn reamer and verified fluoroscopically. The tendon was shuttled under the skin bridge from proximal to distal.
The biceps button was then loaded with the suture from the tendon graft. The button inserter was then utilized to insert the button through the drill hole and then across to the far cortex. The 2 suture limbs were tensioned to deliver the tendon into the tunnel.
Fluoroscopic verification of deployment of the button was performed. An interference screw is inserted for additional fixation. The tendon reconstruction was tensioned such that the resting length was approximately 45° from full extension. Because the muscle was retracted, 45° of resting length is appropriate as the muscle will eventually lengthen over time and the patient will be able to achieve full extension with restoration of the biceps muscle contour.
Avoiding complications is important and several steps can be taken to mitigate potential problems. Prevention of heterotopic ossification is achieved by avoiding inadvertent dissection of the ulna during exposure. In addition, any bone debris created after drilling must be carefully and entirely removed. Fluoroscopy is recommended to verify the correct incision placement over the radial tuberosity. Fluoroscopy is also checked again prior to drilling the radial drill hole.
Finally, fluoroscopy is used again to verify deployment of the button on the radial cortex to ensure it is not in the tunnel or hung up on dorsal muscle or fascia away from the radial cortex. One must identify and retract the antebrachial cutaneous nerve. One must also use a semitendinosus graft if more than 90° of elbow flexion is required to insert the native biceps into the drill hole.
Postoperatively, management and rehabilitation include a posterior slab splint for 10 days. The patient is then fitted for a hinged elbow brace and allowed progression of elbow range of motion by 20° per week until full motion is achieved, typically over a period of about 6 weeks. The patient may perform active pronation and passive supination. One could consider physical therapy for recovery supervision and adjustment of hinged elbow brace if the graft is placed under tension. Strengthening and resumption of activity is expected between 4 and 6 months after surgery.
At 2 and half year’s post operative, the patient had full range of motion both in pronation and supination and had returned to his employment as a line man.
Thank you.
Footnotes
Submitted May 12, 2022; accepted August 31, 2022.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
