Abstract
Background:
Distal biceps tendon ruptures commonly present in the middle-aged population resulting in deficits of strength and endurance. Operative management has shown improved functional outcome; however, there is not a clear consensus on an ideal surgical method.
Indications:
Distal biceps tendon repair is indicated for patients with clinical evidence and supporting magnetic resonance imaging confirmation of complete or partial rupture of the biceps tendon. Ideally, surgery is performed within 1 to 2 weeks of the injury to minimize the amount of scar tissue that is formed and the severity of the tendon retraction.
Technique Description:
A single incision is created on the volar surface of the forearm approximately 15 mm distal to the main flexor crease. After dissection to and retrieval of the biceps tendon, a #2 FiberTag stitch is placed distally and secured in a standard looped, locking fashion. An anchor is then placed in the most proximal aspect of the radial tuberosity and preliminarily placed around the tendon. An all-suture intramedullary cortical button is then placed in the distal aspect of the radial tuberosity. The FiberTag sutures are then shuttled through the button and tightened to anatomically reduce the distal biceps. The sutures on the proximal anchor are then used as supplemental fixation.
Results:
An anterior, single incision technique provides exposure necessary for dual anchor fixation and anatomic restoration of the distal biceps tendon. Utilizing this approach, patients are found to have improved flexion and pronation at 1 year, lower rates of heterotopic ossification, and lower rates of reoperation.
Conclusion:
Distal biceps tendon repair through an anterior, single incision provides excellent exposure for surgical repair. Utilizing a dual anchor technique, the distal button allows for anatomic fixation while the proximal suture anchor provides secondary fixation and increases the bone-tendon interface.
Patient Consent Disclosure Statement:
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
In the following video, we will demonstrate our preferred technique for repairing distal biceps tendon ruptures through a single incision using a dual anchor technique.
We will begin with a review of the background surrounding distal biceps tendon ruptures. We will then review a patient case presentation, which will be used to highlight the surgical technique. Afterward, we will discuss tips and tricks, postoperative management, and we will also review patient outcomes that have been reported in the literature.
Distal bicep tendon injuries typically occur in middle age active patients. 2 While operative management has shown improved functional outcomes, there is still no clear consensus on the ideal surgical technique. Both single and dual incision techniques have been described.2,5 In recent years, single incision approaches are gaining popularity as a minimally invasive technique as our fixation devices continue to evolve. In this video, we will demonstrate a single incision technique that utilizes dual anchor fixation.
Our patient is a 45-year-old active right-hand-dominant man who sustained a left distal biceps injury while attempting to lift a refrigerator. He felt an acute pop and noticed a deformity. On examination, he has near full range of motion. He has weakness with elbow flexion and forearm supination, both of which are painful for him. He also has pain with a hook test, and his biceps tendon is not palpable in the normal anatomic location. His examination demonstrates proximal retraction of the biceps muscle belly, and he is currently neurovascularly intact. A magnetic resonance imaging (MRI) confirms a complete rupture of the distal biceps tendon with approximately 25 mm of retraction.
Ideally, surgery is performed within 1 to 2 weeks of the injury to minimize the amount of scar tissue that is formed and the severity of the tendon retraction. For this specific technique, we will utilize an all-suture cortical button, a knotless suture anchor, and a #2 fiber tag on a straight needle. The patient is going to be positioned supine with the arm out on a hand table.
The patient is prepped and draped in the usual sterile fashion. An incision is created over the anterior aspect of the forearm approximately 15 mm distal to the main flexor crease. Blunt dissection is carried out through skin to identify underlying vascular structures. This case is generally performed without a tourniquet so that these structures can easily be identified. Further dissection allows us to identify the ruptured distal biceps tendon.
It is then retrieved out through the wound and clamped with an Allis clamp. After cleaning and debriding the tendon, a #2 FiberTag stitch is placed. It is initially fixed distally and then provisionally clamped proximally. The sharp needle is passed through the tendon and through the most proximal aspect of the fiber tape portion of the suture. The looped suture is then passed through the tape and the tendon in a standard looped, locking fashion. This is continued all the way down to the distal tip of the tendon and the fiber tape. The tendon is then retracted proximally out of the way, and attention is turned to the radial tuberosity.
Bent Hohmann retractors are used to expose the radial tuberosity. Great care must be taken to ensure that the Hohmann retractors are placed immediately adjacent to the bone to prevent a crush injury to any of the surrounding nerves or blood vessels. Once the radial tuberosity is identified, scar tissue and debris can be removed using electrocautery and a curette. This is done with the wrist in maximum supination.
To better illustrate the location of the anchors, here you can see the proximal radius and the radial tuberosity. Our first anchor will go in the proximal aspect of the radial tuberosity. In this window, we can see the full extent of the proximal and distal aspects of the radio tuberosity. A 1.8-mm knotless FiberTak suture anchor is placed in the far proximal aspect of the radial tuberosity. This is angled in a distal direction so that the anchor is secured in an intramedullary position. The suture is then shuttled through the anchor to create a loop. Before the loop is final tensioned, the biceps tendon is passed through this loop. Additional tension is applied but it is not fully tensioned at this stage. It is tagged and laid aside, and attention is then turned to the distal aspect of the radial tuberosity.
At this location, we will place our all-suture intramedullary cortical button. Once again, the drill is angled distally and laterally to ensure that the button is maintained in an intracortical position. The anchor is then impacted into place, and gentle tension is applied to set the anchor in the intramedullary position. The shuttling sutures are then separated, and the first shuttling suture is used to shuttle the first repair stitch from the biceps tendon through the anchor. After it is shuttled, it is set aside. The second shuttle suture from the button is used to shuttle the second repair stitch from the distal biceps tendon. Now both repair stitches are shuttled through the intramedullary button. These are then tensioned and tied.
It can be helpful to do final tying and tightening using an arthroscopic knot pusher. Excess suture is cut and then the more proximal knotless FiberTak anchor is tensioned to provide additional proximal fixation and to increase the surface area of the tendon to bone contact and provide supplemental fixation to the all-suture intracortical button that is distal. Retractors are then removed and the wound is thoroughly irrigated and then closed in layers using a subcuticular stitch in the skin. The patient is placed in a splint with the elbow at approximately 90° of flexion and neutral rotation.
To recap, this technique utilizes 2 anchors. An all-suture intramedullary cortical button is used to anatomically reduce the distal biceps onto its footprint and the distal aspect of the radial tuberosity. Just proximal to this, a knotless all-suture suture anchor is used as supplemental fixation at the proximal aspect of the radial tuberosity.
For the first 2 weeks, the patient is maintained in a splint with no elbow range of motion. The splint is then removed at 2 weeks, and range of motion is progressed as tolerated with the goal of reestablishing full range of motion by 6 weeks postoperative. Beginning at 6 weeks, the patient can lift up to 5 pounds, and then starting at 12 weeks, this is progressed and strengthening can be progressed as tolerated. The goal is to get patients back to all activities in an unrestricted fashion at 4 to 6 months postoperative.
The outcomes of distal biceps tendon repairs have been studied extensively. In a recent meta-analysis of over 2500 patients that compared single to double incision approaches, it was determined that a single incision approach tended to result in improved flexion and pronation at 1 year, lower rates of heterotopic ossification, and lower rates of reoperation. 4 However, single incision approaches tend to be associated with a higher risk of nerve-related complications, the most common of which is a neuropraxia to the lateral antebrachial cutaneous nerve.1,7 In other studies, cortical button fixation is shown to be a reliable fixation technique, and utilization of a proximal suture anchor as a secondary fixation method allows for increased fixation strength while also increasing the tendon to bone contact area.3,6
Footnotes
Submitted December 19, 2022; accepted January 18, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: This study was partially funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases for the Musculoskeletal Research Training Program (T32AR56950). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. 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.
