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Distal biceps tendon insertion: An anatomic study
Distal biceps tendon insertion: An anatomic study Hank L. Hutchinson, MD,a David Gloystein, MD,b and Martin Gillespie, MD,c San Antonio, TX, and Tacoma, WA
Knowledge of the exact location of the distal biceps brachii insertion is crucial when performing tendon reconstruction or repair. To quantitatively describe the morphology of the distal biceps brachii insertion, 20 cadaveric arms were examined. Linear and angular measurements, including the footprint dimensions and shape, radial tuberosity dimensions and irregularities, and the rotational position of the tuberosity and footprint, were obtained. The axial and transverse dimensions of the radial tuberosity and distal biceps tendon footprint measured 24.2 x 12 mm and 18.7 x 3.7 mm, respectively. The insertion footprint is on the posterior/ulnar aspect of the radial tuberosity centered at approximately 30 anterior to the lateral/coronal plane with the forearm fully supinated. This explains why any preoperative limitation in supination may make an anatomic repair difficult through a single anterior incision. To our knowledge, this is the first study to quantitatively describe the angular location of the radial tuberosity and the relationship of the distal biceps tendon on the tuberosity. (J Shoulder Elbow Surg 2008;17:342-346.)
R
upture or avulsion of the distal biceps tendon is believed to be a rare injury with a reported incidence of 1.2 per 100,000 patients per year.33 Interest in repair has grown in recent years due to the increased frequency of reported cases and many new techniques for repair that have been developed. The typical injury occurs in the dominant arm of a male in his 40’s to 50’s after a single forceful eccentric load is applied to the flexed elbow of the dominant extremity.27 There is an increased incidence in weightlifters, smokers, and those who use anabolic steroids.27,33 The diagnosis is typically made clinically.32 Magnetic resonance imaging (MRI) or ultrasound can be used From the aDepartment of Orthopaedics, University of Texas Health Science Center-San Antonio, bDepartment of Orthopaedics, Madigan Army Medical Center, and Orthopaedic Associates. Reprint requests: Hank L. Hutchinson MD, Department of Orthopaedics, University of Texas Health Science Center-San Antonio, 7703 Floyd Curl Dr., Mail code 7774, San Antonio, TX 78229 (E-mail: [email protected]). Copyright ª 2008 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2008/$34.00 doi:10.1016/j.jse.2007.05.005
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when the diagnosis is unclear from the clinical picture.7,17,18,26,29,32 MRI is best done with the patient prone, arm overhead, elbow flexed to ninety degrees and forearm fully supinated.18 This position places the tendon under tension and minimizes obliquity.10 Acute repair is indicated for a complete tear in a physiologically young and active patient who will be able to comply with postoperative care and rehabilitation. Nonoperative treatment is considered for older, sedentary individuals who do not require strength and endurance in elbow flexion and supination.6,27,31 Recent literature has also focused more attention on operative treatment of partial ruptures.39 A case report recently described the partial rupture of an anomalous bifurcated distal biceps tendon that was treated operatively with anatomic repair with a good clinical outcome.34 Many techniques have been described to repair complete tears of the distal biceps tendon. All techniques begin with an anterior incision to retrieve the retracted tendon, but differ in how the radial tuberosity is approached and how the tendon is repaired to it. Some authors advocate a 2-incision technique to better visualize the radial tuberosity and minimize the dissection necessary in the antecubital fossa,1,8,27 while other authors feel that the tuberosity can be visualized adequately with a single anterior incision with less risk of heterotopic ossification.3,9,15,25,42 A technique through a single anterior 1.5 cm incision has also been described recently using an endoscope.36 Repair of the tendon to the brachialis muscle and bone using sutures tied over a bony bridge, suture anchors, screw and washer, endobutton, and the use of an interference screw have all been described.6,9,15,25,27,36,37,39,41-43 Whichever technique is chosen, performing an anatomic repair should always be the goal to best restore function.24 Anatomy textbooks provide a vague description of the insertion of the tendon onto the radial tuberosity, but they fail to address the footprint of the tendon on the tuberosity or the rotational position of the tuberosity on the radius. Recent literature has described the footprint’s shape and size;25 however, an extensive literature search failed to locate any quantitative description of the rotational position of the tuberosity and its corresponding biceps tendon insertion angle on the radius. The purpose of this study is to more accurately describe the distal biceps tendon insertion. A clear understanding of these anatomic relationships
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Table I Radial tuberosity and distal biceps brachii tendon insertion data Range Axial dimension of tuberosity Transverse dimension of tuberosity Axial dimension of insertion footprint Transverse dimension of insertion footprint Angular position of borders of radial tuberosity from coronal plane Rotational position of center of radial tuberosity
Figure 1 A cross-section through proximal forearm in full supination showing the axes used for angular measurements and the rotational position of the radial tuberosity.
Mean +/- 2 SD
20.5-29.9 mm
24.2 +/- 2.5 mm
9.7-15.7 mm
12.0 +/- 1.6 mm
13.9-25.4 mm
18.7 +/- 3.0 mm
1.6-5.3 mm
3.7 +/- 0.9mm
0–34 to 42-80
16.6 +/- 9.4 to 68.6 +/- 9.0
34–51
42.6 +/- 7.89
eral (Figure 1). Degrees increased as the arc progressed anterolaterally.
RESULTS is vital to planning and performing a distal biceps tendon repair, regardless of the technique chosen. METHODS AND MATERIALS From 20 different cadavers, 20 cadaveric radii (14 right and 6 left) were removed from 20 upper extremities, with only the distal one half of the biceps brachii and its insertion remaining attached to the radius.The cadavers were preserved in a mixture of 50% H2O, 30% Isopropyl alcohol, 10% phenol, 8% glycerin, and 2% formaldehyde. Out of 50 available limbs, the 20 radii that were in the best condition were chosen. As these cadavers had been previously dissected by medical students, many of the limbs were not suitable because the distal biceps tendon had been previously cut. Other than condition, no preference was made to which limb was chosen. The age of the cadavers chosen ranged from 57 to 98 years with a mean of 79.3 years and a standard deviation of 11.1 years. All soft tissue, except for the distal one half of the biceps muscle belly and its tendon, was removed. The distal biceps tendon was then removed sharply from its insertion and measurements were then made of the dimensions of the tendon insertion and radial tuberosity. The shape of the insertion and additional features on the radial tuberosity were also noted. All linear measurements were made with a Starrett electronic digital caliper and rounded to the nearest 0.1 mm. All angular measurements were made with a standard goniometer by placing the radii in the position of supination. This position was maintained by resting the radii on Lister’s tubercle and the ulnar aspect of the radius distally. The same position was used for all specimens. All angular measurements were made in reference to the coronal plane. Zero degrees was defined as the medial portion of the line that bisects the center of the radial head from medial to lat-
The insertion footprint was located on the posterior/ulnar aspect of the radial tuberosity and posterior/ulnar to the middle of the tuberosity in all specimens (Table I).Sixteen (80%) of the insertion footprints were semilunar in shape (type I) (Figure 2), following the posterior/ulnar contour of the tuberosity; the remaining 4 (20%) were larger and oval in shape (type II) (Figure 3). An axial ridge, located on the tuberosity and lateral to the footprint, was noted on 8 of the 20 specimens (40%) and measured one to two millimeters in height (Figure 4). Osteophytes located lateral to the insertion on the tuberosity were observed on 3 of the 20 specimens (15%) (Figure 4). Degenerative changes were seen on the distal tendon in locations corresponding to where the osteophytes encountered the tendon in pronation. The osteophytes were 2 to 3 millimeters in height and hemispherical in shape. DISCUSSION Injury to the distal biceps tendon insertion is the most common tendinous injury about the elbow.27 Distal biceps tendon injury is most commonly a complete avulsion from its insertion.27 Other injuries include tearing of the musculotendinous junction and rupture of the tendon itself. Gilcreest has the most comprehensive study of injuries to the entire biceps brachii from origin to insertion. His study of over 100 cases shows that only 6 were of the distal biceps insertion. Of those 6,3 were complete avulsions, 2 were musculotendinous, and 1 was tendon rupture.16
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Figure 4 The common locations of osteophytes and an axial ridge are depicted just anterior and radial to the insertion of the distal biceps tendon.
Figure 2 The transverse and axial dimensions of the radial tuberosity and distal biceps tendon footprint are shown.The shaded area represents the location of the distal biceps insertion footprint with its more common, type I, shape along the posterior ulnar aspect of the tuberosity.
Figure 3 The shaded are represents the less common, Type II, distal biceps tendon footprint with its larger oval shape.
Over 80% of reported cases have involved the right dominant upper limb in a well-developed man.13,30 The average patient age is 47 years with a range of 21 to 70.4,13,33 The patient is typically a wellconditioned male weightlifter. There have recently been reports of older athletic women having complete rupture of the distal biceps tendon.38 In the majority of cases, a single traumatic event with a rapid eccentric load with the elbow at approximately 90 of flexion is the direct cause.4,13,33 Secondary causes related to weakening of the tendon include anabolic steroids, periarticular corticosteroid injections, Cushing’s syndrome, oral steroids, and the effect of aging on tendon strength and integrity.12 Tendon impingement has also been suggested as a contributing factor.35 With pronation, the space available for the tendon is decreased by 50%, and the tendon occupies 85% of the available space.35 Impingement may become more significant in the presence of an axial ridge, osteophytes, or hypertrophy of the tendon. Partial tears, degenerative changes, and a sharp anterior/radial edge on the tuberosity that engages the tendon in supination have also been described as contributing factors to ruptures.35 In addition, the distal tendon may be inherently susceptible to these tears when
high loads are applied because of a hypovascular zone in the middle one third of the purely tendinous portion of the distal biceps tendon.35 Historical data suggest that repair of the distal biceps tendon within the first 7 to 10 days after injury is ideal.4,11,40 Muscle activity through the distal biceps tendon insertion contributes to 40% of supination power and 20% of elbow flexion power.28 A loss of strength and endurance in elbow flexion and supination are noted in higher demand patients when not repaired surgically.21,24,28 Activity related pain and poor cosmesis are also frequent complaints.28 Various methods have been described to surgically treat this injury. For many years, the 2-incision technique originally described by Boyd and Anderson,8 and later modified by Kelly and Morrey,21,27 was considered the standard of care. This belief has been brought into question by several authors recently describing single incision techniques utilizing suture anchors, endobuttons, or interference screws through a single anterior incision.5,9,14,15,19,23–25,37 This was thought to decrease the chances of forming symptomatic heterotopic ossification in the forearm.11 However, there has been a recent case report of symptomatic heterotopic ossification using an endobutton with a single anterior incision.2 A single posterior incision has also been described for surgical treatment of symptomatic partial distal biceps tendon ruptures.22 Ligament augmentation devices and tendinous autografts have been used to reconstruct distal biceps tendon injuries that present later than 4 weeks after the initial injury.20 The goal of any surgical procedure to repair the distal biceps tendon insertion should be restoration of the preinjury anatomy and function as closely as possible. Our observations have shown that the insertion site is typically a thin, semilunar area on the posterior/ulnar aspect of the radial tuberosity. It can be inferred that the radial tuberosity increases the force of supination to the radius by increasing the moment arm through which the biceps tendon applies its force, and acting as a cam when the forearm is in full pronation. If the biceps tendon is not repaired to its anatomic location and is merely inserted into the center of the radial tuberosity, the power of supination may never be restored to preinjury levels.
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The insertion angle, regardless of technique, should be along the posterior/ulnar aspect of the radial tuberosity and lie within the posterior/ulnar half of the tuberosity. From our data, this point should be at an angle between the center of the tuberosity (approximately 45 ) and the posterior/ulnar edge of the tuberosity (approximately 15 ). Therefore, it is our conclusion that the ideal insertion angle of the distal biceps tendon is approximately 30 from the coronal plane with the forearm fully supinated. This position should correspond with the posterior/ulnar half of the radial tuberosity. With this in mind, the surgeon must preoperatively assess the patient’s ability to supinate. Any limitation in supination may impede access to the radial tuberosity from an anterior incision. If supination is limited, even with general anesthesia, a 2-incision technique may be needed for better access to the radial tuberosity. Our observations also confirm reports of a ridge forming lateral to the insertion and osteophytes on the tuberosity.25 These structures may contribute to degenerative changes in the tendon and predispose certain individuals to tendon rupture. When surgical repair is performed, it is advisable to inspect the tuberosity for irregularities. If any sharp prominences are noted lateral to the insertion, removing them may decrease the chances of later rerupture. The authors would like to thank Ron Philo, MD, and James Mazzucca of the University of Texas Health Science Center, Department of Cellular and Structural Biology, for their assistance in providing access to the specimens.
REFERENCES
1. Agins HJ, Chess JL, Hoekstra DV, Teitge RA. Rupture of the distal insertion of the biceps brachii tendon. Clin Orthop 1988;234: 34-8. 2. Agrawal V, Stinson MJ. Case report: heterotopic ossification after repair of distal biceps tendon rupture utilizing a single-incision Endobutton technique. J Shoulder Elbow Surg 2005;14:107-9. 3. Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D. Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Shoulder Elbow Surg 2000;9:120-6. 4. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg 1985;67:414-7. 5. Balabaud L, Ruiz C, Nonnenmacher J, Seynaeve P, Kehr P, Rapp E. Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach. J Hand Surg [Br] 2004;9: 178-82. 6. Bell RH, Wiley WB, Noble JS, Kuczynski DJ. Repair of distal biceps brachii tendon ruptures. J Shoulder Elbow Surg 2000; 9:223-6. 7. Belli P, Costantini M, Mirk P, Leone A, Pastore G, Marano P. Sonographic diagnosis of distal biceps tendon rupture: a prospective study of 25 cases. J Ultrasound Med 2001;20:587-95. 8. Boyd HB, Anderson LD. A method for reinsertion of the distal biceps Brachii tendon. J Bone Joint Surg 1961;43:1041-3. 9. Burton KJ, Arciero R. Distal biceps Brachii tendon repair: suture anchor technique. Oper Tech Sports Med 2003;11:47-50.
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10. Chew ML, Giuffre BM. Disorders of the distal biceps brachii tendon. Radiographics 2005:1227-37. 11. Cohen MS, Katolic L. Complications of distal biceps tendon repairs. Oper Tech Sports Med 2003;11:60-6. 12. Davis WM, Yassine Z. An etiologic factor in tear of the distal tendon of the biceps brachii: report of two cases. J Bone Joint Surg 1956;38:1365-8. 13. Dobbie RP. Avulsion of the lower biceps brachii tendon: A report of fifty-one previously unreported cases. Am J Surg 1941;51: 662-83. 14. El-Hawary R, Macdermid JC, Faber KJ, Patterson SD, King GJ. Distal biceps tendon repair: comparison of surgical techniques. J Hand Surg 2003;28:496-502. 15. Fox JA, Fernandez JJ. Single incision technique for distal biceps tendon repair: using the endobutton. Oper Tech Sports Med 2003; 11:42-6. 16. Gilcreest EL. The common syndrome of rupture, dislocatrion and elongation of the head of the biceps brachii, an analysis of one hundred cases. Surg Gynecol Obstet 1934;58:322-40. 17. Giuffre BM, Lisle DA. Tear of the distal biceps branchii tendon: a new method of ultrasound evaluation. Australas Radiol 2005; 49:404-6. 18. Giuffre BM, Moss MJ. Optimal positioning for MRI of the distal biceps brachii tendon: flexed abducted supinated view. AJR Am J Roentgenol 2004;182:944-6. 19. Greenberg JA, Fernandez JJ, Wang T, Turner C. EndoButton-assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 2003;12:484-90. 20. Kaplan FT, Rokito AS, Birdzell MG, Zuckerman JD. Reconstruction of chronic distal biceps tendon rupture with use of fascia lata combined with a ligament augmentation device: a report of 3 cases. J Shoulder Elbow Surg 2002;11:633-6. 21. Kelly EW, Morrey BF, O’Driscoll SW. Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg 2000;82:1575-81. 22. 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;12:456-61. 23. Khan W, Agarwal M, Funk L. Repair of distal biceps tendon rupture with the Biotenodesis screw. Arch Orthop Trauma Surg 2004;124:206-8. 24. Klonz A, Loitz D, Wohler P, Reilmann H. Rupture of the distal biceps brachii tendon: isokinetic power analysis and complications after anatomic reinsertion compared with fixation to the brachialis muscle. J Shoulder Elbow Surg 2003;12:607-11. 25. Mazzocca AD, Alberta FG. Single incision technique using an interference screw for the repair of distal biceps tendon ruptures. Oper Tech Sports Med 2003;11:36-41. 26. Miller TT, Adler RS. Sonography of tears of the distal biceps tendon. AJR Am J Roentgenol 2000;175:1081-6. 27. Morrey BF. Biceps tendon injury. AAOS Instruct Course Lect 1999; 48:405-10. 28. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg 1985;67:418-21. 29. Pereira DS, Kvitne RS, Liang M, Giacobetti FB, Ebramzadeh E. Surgical repair of distal biceps tendon ruptures: a biomechanical comparison of two techniques. Am J Sports Med 2002;30:432-6. 30. Postacchini F, Puddu G. Subcutaneous rupture of the distal biceps brachii tendon; a report on seven cases. Am J Sports Med 1975; 15:81-90. 31. Rantanen J, Orava S. Rupture of the distal biceps tendon. A report of 19 patients treated with anatomic reinsertion, and a metaanalysis of 147 cases found in the literature. Am J Sports Med 1999;27:128-32. 32. Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis of distal biceps tendon ruptures. Clin Orthop 2005;437: 128-31.
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33. Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop 2002; 404:275-83. 34. Sassmannshausen G, Mair SD, Blazar PE. Rupture of a bifurcated distal biceps tendon. A case report. J Bone Joint Surg 2004;86: 2737-40. 35. Seiler JG, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA. The distal biceps tendon. Two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg 1995;4:149-56. 36. Sharma S, MacKay G. Endoscopic repair of distal biceps tendon using an EndoButton. Arthroscopy 2005;21:897. 37. Sotereanos DG, Pierce TD, Varitimidis SE. A simplified method for repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 2000;9:227-33. 38. Toczylowski HM, Balint CR, Steiner ME, Boardman M, Scheller AD. Complete rupture of the distal biceps brachii tendon
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39.
40. 41. 42.
43.
in female patients: a report of 2 cases. J Shoulder Elbow Surg 2002;11:516-8. Vardakas DG, Musgrave DS, Varitimidis SE, Goebel F, Sotereanos DG. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg 2001;10:377-9. Vidal AF, Drakos MC, Allen AA. Biceps tendon and triceps tendon injuries. Clin Sports Med 2004;23:707-22. Ware HE, Nairn DS. Repair of the ruptured distal tendon of the biceps brachii. J Hand Surgery [Br] 1992;17:99-101. Woods DA, Hoy G, Shimmin A. A safe technique for distal biceps repair using a suture anchor and a limited anterior approach. Injury 1999;30:233-7. Yu CO, Caputo AE. Single incision, transosseous suture repair technique for acute distal biceps tendon rupture. Oper Tech Sports Med 2003;11:51-4.
Knowledge of the exact location of the distal biceps brachii insertion is crucial when performing tendon reconstruction or repair. To quantitatively describe the morphology of the distal biceps brachii insertion, 20 cadaveric arms were examined. Linear and angular measurements, including the footprint dimensions and shape, radial tuberosity dimensions and irregularities, and the rotational position of the tuberosity and footprint, were obtained. The axial and transverse dimensions of the radial tuberosity and distal biceps tendon footprint measured 24.2 x 12 mm and 18.7 x 3.7 mm, respectively. The insertion footprint is on the posterior/ulnar aspect of the radial tuberosity centered at approximately 30 anterior to the lateral/coronal plane with the forearm fully supinated. This explains why any preoperative limitation in supination may make an anatomic repair difficult through a single anterior incision. To our knowledge, this is the first study to quantitatively describe the angular location of the radial tuberosity and the relationship of the distal biceps tendon on the tuberosity. (J Shoulder Elbow Surg 2008;17:342-346.)
R
upture or avulsion of the distal biceps tendon is believed to be a rare injury with a reported incidence of 1.2 per 100,000 patients per year.33 Interest in repair has grown in recent years due to the increased frequency of reported cases and many new techniques for repair that have been developed. The typical injury occurs in the dominant arm of a male in his 40’s to 50’s after a single forceful eccentric load is applied to the flexed elbow of the dominant extremity.27 There is an increased incidence in weightlifters, smokers, and those who use anabolic steroids.27,33 The diagnosis is typically made clinically.32 Magnetic resonance imaging (MRI) or ultrasound can be used From the aDepartment of Orthopaedics, University of Texas Health Science Center-San Antonio, bDepartment of Orthopaedics, Madigan Army Medical Center, and Orthopaedic Associates. Reprint requests: Hank L. Hutchinson MD, Department of Orthopaedics, University of Texas Health Science Center-San Antonio, 7703 Floyd Curl Dr., Mail code 7774, San Antonio, TX 78229 (E-mail: [email protected]). Copyright ª 2008 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2008/$34.00 doi:10.1016/j.jse.2007.05.005
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when the diagnosis is unclear from the clinical picture.7,17,18,26,29,32 MRI is best done with the patient prone, arm overhead, elbow flexed to ninety degrees and forearm fully supinated.18 This position places the tendon under tension and minimizes obliquity.10 Acute repair is indicated for a complete tear in a physiologically young and active patient who will be able to comply with postoperative care and rehabilitation. Nonoperative treatment is considered for older, sedentary individuals who do not require strength and endurance in elbow flexion and supination.6,27,31 Recent literature has also focused more attention on operative treatment of partial ruptures.39 A case report recently described the partial rupture of an anomalous bifurcated distal biceps tendon that was treated operatively with anatomic repair with a good clinical outcome.34 Many techniques have been described to repair complete tears of the distal biceps tendon. All techniques begin with an anterior incision to retrieve the retracted tendon, but differ in how the radial tuberosity is approached and how the tendon is repaired to it. Some authors advocate a 2-incision technique to better visualize the radial tuberosity and minimize the dissection necessary in the antecubital fossa,1,8,27 while other authors feel that the tuberosity can be visualized adequately with a single anterior incision with less risk of heterotopic ossification.3,9,15,25,42 A technique through a single anterior 1.5 cm incision has also been described recently using an endoscope.36 Repair of the tendon to the brachialis muscle and bone using sutures tied over a bony bridge, suture anchors, screw and washer, endobutton, and the use of an interference screw have all been described.6,9,15,25,27,36,37,39,41-43 Whichever technique is chosen, performing an anatomic repair should always be the goal to best restore function.24 Anatomy textbooks provide a vague description of the insertion of the tendon onto the radial tuberosity, but they fail to address the footprint of the tendon on the tuberosity or the rotational position of the tuberosity on the radius. Recent literature has described the footprint’s shape and size;25 however, an extensive literature search failed to locate any quantitative description of the rotational position of the tuberosity and its corresponding biceps tendon insertion angle on the radius. The purpose of this study is to more accurately describe the distal biceps tendon insertion. A clear understanding of these anatomic relationships
Hutchinson, Gloystein, and Gillespie
J Shoulder Elbow Surg Volume 17, Number 2
343
Table I Radial tuberosity and distal biceps brachii tendon insertion data Range Axial dimension of tuberosity Transverse dimension of tuberosity Axial dimension of insertion footprint Transverse dimension of insertion footprint Angular position of borders of radial tuberosity from coronal plane Rotational position of center of radial tuberosity
Figure 1 A cross-section through proximal forearm in full supination showing the axes used for angular measurements and the rotational position of the radial tuberosity.
Mean +/- 2 SD
20.5-29.9 mm
24.2 +/- 2.5 mm
9.7-15.7 mm
12.0 +/- 1.6 mm
13.9-25.4 mm
18.7 +/- 3.0 mm
1.6-5.3 mm
3.7 +/- 0.9mm
0–34 to 42-80
16.6 +/- 9.4 to 68.6 +/- 9.0
34–51
42.6 +/- 7.89
eral (Figure 1). Degrees increased as the arc progressed anterolaterally.
RESULTS is vital to planning and performing a distal biceps tendon repair, regardless of the technique chosen. METHODS AND MATERIALS From 20 different cadavers, 20 cadaveric radii (14 right and 6 left) were removed from 20 upper extremities, with only the distal one half of the biceps brachii and its insertion remaining attached to the radius.The cadavers were preserved in a mixture of 50% H2O, 30% Isopropyl alcohol, 10% phenol, 8% glycerin, and 2% formaldehyde. Out of 50 available limbs, the 20 radii that were in the best condition were chosen. As these cadavers had been previously dissected by medical students, many of the limbs were not suitable because the distal biceps tendon had been previously cut. Other than condition, no preference was made to which limb was chosen. The age of the cadavers chosen ranged from 57 to 98 years with a mean of 79.3 years and a standard deviation of 11.1 years. All soft tissue, except for the distal one half of the biceps muscle belly and its tendon, was removed. The distal biceps tendon was then removed sharply from its insertion and measurements were then made of the dimensions of the tendon insertion and radial tuberosity. The shape of the insertion and additional features on the radial tuberosity were also noted. All linear measurements were made with a Starrett electronic digital caliper and rounded to the nearest 0.1 mm. All angular measurements were made with a standard goniometer by placing the radii in the position of supination. This position was maintained by resting the radii on Lister’s tubercle and the ulnar aspect of the radius distally. The same position was used for all specimens. All angular measurements were made in reference to the coronal plane. Zero degrees was defined as the medial portion of the line that bisects the center of the radial head from medial to lat-
The insertion footprint was located on the posterior/ulnar aspect of the radial tuberosity and posterior/ulnar to the middle of the tuberosity in all specimens (Table I).Sixteen (80%) of the insertion footprints were semilunar in shape (type I) (Figure 2), following the posterior/ulnar contour of the tuberosity; the remaining 4 (20%) were larger and oval in shape (type II) (Figure 3). An axial ridge, located on the tuberosity and lateral to the footprint, was noted on 8 of the 20 specimens (40%) and measured one to two millimeters in height (Figure 4). Osteophytes located lateral to the insertion on the tuberosity were observed on 3 of the 20 specimens (15%) (Figure 4). Degenerative changes were seen on the distal tendon in locations corresponding to where the osteophytes encountered the tendon in pronation. The osteophytes were 2 to 3 millimeters in height and hemispherical in shape. DISCUSSION Injury to the distal biceps tendon insertion is the most common tendinous injury about the elbow.27 Distal biceps tendon injury is most commonly a complete avulsion from its insertion.27 Other injuries include tearing of the musculotendinous junction and rupture of the tendon itself. Gilcreest has the most comprehensive study of injuries to the entire biceps brachii from origin to insertion. His study of over 100 cases shows that only 6 were of the distal biceps insertion. Of those 6,3 were complete avulsions, 2 were musculotendinous, and 1 was tendon rupture.16
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Figure 4 The common locations of osteophytes and an axial ridge are depicted just anterior and radial to the insertion of the distal biceps tendon.
Figure 2 The transverse and axial dimensions of the radial tuberosity and distal biceps tendon footprint are shown.The shaded area represents the location of the distal biceps insertion footprint with its more common, type I, shape along the posterior ulnar aspect of the tuberosity.
Figure 3 The shaded are represents the less common, Type II, distal biceps tendon footprint with its larger oval shape.
Over 80% of reported cases have involved the right dominant upper limb in a well-developed man.13,30 The average patient age is 47 years with a range of 21 to 70.4,13,33 The patient is typically a wellconditioned male weightlifter. There have recently been reports of older athletic women having complete rupture of the distal biceps tendon.38 In the majority of cases, a single traumatic event with a rapid eccentric load with the elbow at approximately 90 of flexion is the direct cause.4,13,33 Secondary causes related to weakening of the tendon include anabolic steroids, periarticular corticosteroid injections, Cushing’s syndrome, oral steroids, and the effect of aging on tendon strength and integrity.12 Tendon impingement has also been suggested as a contributing factor.35 With pronation, the space available for the tendon is decreased by 50%, and the tendon occupies 85% of the available space.35 Impingement may become more significant in the presence of an axial ridge, osteophytes, or hypertrophy of the tendon. Partial tears, degenerative changes, and a sharp anterior/radial edge on the tuberosity that engages the tendon in supination have also been described as contributing factors to ruptures.35 In addition, the distal tendon may be inherently susceptible to these tears when
high loads are applied because of a hypovascular zone in the middle one third of the purely tendinous portion of the distal biceps tendon.35 Historical data suggest that repair of the distal biceps tendon within the first 7 to 10 days after injury is ideal.4,11,40 Muscle activity through the distal biceps tendon insertion contributes to 40% of supination power and 20% of elbow flexion power.28 A loss of strength and endurance in elbow flexion and supination are noted in higher demand patients when not repaired surgically.21,24,28 Activity related pain and poor cosmesis are also frequent complaints.28 Various methods have been described to surgically treat this injury. For many years, the 2-incision technique originally described by Boyd and Anderson,8 and later modified by Kelly and Morrey,21,27 was considered the standard of care. This belief has been brought into question by several authors recently describing single incision techniques utilizing suture anchors, endobuttons, or interference screws through a single anterior incision.5,9,14,15,19,23–25,37 This was thought to decrease the chances of forming symptomatic heterotopic ossification in the forearm.11 However, there has been a recent case report of symptomatic heterotopic ossification using an endobutton with a single anterior incision.2 A single posterior incision has also been described for surgical treatment of symptomatic partial distal biceps tendon ruptures.22 Ligament augmentation devices and tendinous autografts have been used to reconstruct distal biceps tendon injuries that present later than 4 weeks after the initial injury.20 The goal of any surgical procedure to repair the distal biceps tendon insertion should be restoration of the preinjury anatomy and function as closely as possible. Our observations have shown that the insertion site is typically a thin, semilunar area on the posterior/ulnar aspect of the radial tuberosity. It can be inferred that the radial tuberosity increases the force of supination to the radius by increasing the moment arm through which the biceps tendon applies its force, and acting as a cam when the forearm is in full pronation. If the biceps tendon is not repaired to its anatomic location and is merely inserted into the center of the radial tuberosity, the power of supination may never be restored to preinjury levels.
J Shoulder Elbow Surg Volume 17, Number 2
The insertion angle, regardless of technique, should be along the posterior/ulnar aspect of the radial tuberosity and lie within the posterior/ulnar half of the tuberosity. From our data, this point should be at an angle between the center of the tuberosity (approximately 45 ) and the posterior/ulnar edge of the tuberosity (approximately 15 ). Therefore, it is our conclusion that the ideal insertion angle of the distal biceps tendon is approximately 30 from the coronal plane with the forearm fully supinated. This position should correspond with the posterior/ulnar half of the radial tuberosity. With this in mind, the surgeon must preoperatively assess the patient’s ability to supinate. Any limitation in supination may impede access to the radial tuberosity from an anterior incision. If supination is limited, even with general anesthesia, a 2-incision technique may be needed for better access to the radial tuberosity. Our observations also confirm reports of a ridge forming lateral to the insertion and osteophytes on the tuberosity.25 These structures may contribute to degenerative changes in the tendon and predispose certain individuals to tendon rupture. When surgical repair is performed, it is advisable to inspect the tuberosity for irregularities. If any sharp prominences are noted lateral to the insertion, removing them may decrease the chances of later rerupture. The authors would like to thank Ron Philo, MD, and James Mazzucca of the University of Texas Health Science Center, Department of Cellular and Structural Biology, for their assistance in providing access to the specimens.
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