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Single-Incision Distal Biceps Tendon Repair
Single-Incision Distal Biceps Tendon Repair Lindley B. Wall, MD,* and Leesa M. Galatz, MD† Distal biceps ruptures are relatively uncommon injuries. Tears of the distal biceps tendon occur primarily in middle-aged males. Surgical repair can be performed by a single- or double-incision technique. The single-incision technique offers advantages of simple technique, reliable results, low complications, and cosmetic incision. The repair is performed through a small, transverse incision using a variety of fixation devices. We describe the technique using suture anchors. Operative concerns include identification and protection of the lateral antebrachial cutaneous nerve, safe exposure of the bicipital tuberosity, avoiding injury to the radial recurrent vessels, and secure fixation of the tendon at the repair site. Repair typically restores excellent function and pain relief, allowing return to full activity within 3-4 months. This review describes the technique and includes tips and pearls for navigating the procedure and avoiding common complications. Oper Tech Orthop 19:258-263 © 2009 Elsevier Inc. All rights reserved.
D
istal biceps tendon ruptures are uncommon injuries, occurring with an incidence of 1.24 per 100,000 annually.1 However, they are the most common acute tendon injury of the elbow.2 Most distal biceps tendon ruptures occur in individuals of age 40-60 years. The majority of the patients with these injuries are male. The mechanism of injury is classically a forceful contraction against resistance with the elbow in flexion. Most ruptures occur at the bonetendon junction at the radial tuberosity; however, intramuscular and intratendinous ruptures have also been reported.3 Acute, full-thickness tears often result in an audible “pop” and leave a defect just proximal to the antecubital fossa where the biceps is usually subcutaneous. Surgical repair of distal biceps tendon ruptures can be performed by either a single- or double-incision repair technique. Historically, a single-incision was first used. A single anterior incision allowed access to the radius and placement of drill holes through the radius through which suture was threaded to attach the distal tendon stump to the radial tuberosity. Unfortunately, this single-incision technique was often complicated by posterior interosseous nerve (PIN) injuries.4 The high incidence of nerve injury prompted development of a double-incision technique, which remains popular to this day. The double-incision technique involves a
*Department of Orthopedics, Washington University Orthopedics, BarnesJewish Hospital, St Louis, MO. †Shoulder and Elbow Service, Washington University Orthopedics, BarnesJewish Hospital, St Louis, MO. Address reprint requests to Leesa M. Galatz, MD, Department of Orthopedic Surgery, Washington University, Campus Box 8233, 660 South Euclid Ave., St Louis, MO 63110. E-mail: [email protected]
258
1048-6666/09/$-see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2009.09.019
muscle splitting approach dorsolaterally to protect the nerve. However, this approach is not without its own drawbacks; heterotopic ossification and radioulnar synostosis are reported complications not seen with the earlier single-incision technique.4 In the last several years, with an increase in the understanding of surgical anatomy and the advent of modern instrumentation, such as suture anchors, cortical buttons, and interference screws, interest reverted back to the singleincision technique. Single-incision repair has evolved. Optimization of the single-incision technique has decreased the amount of dissection required, limiting the risk to the PIN, and eliminated the exposure of the ulna, thus decreasing the risk of heterotopic ossification and radioulnar synostosis. Consequently, singleincision repair is a safe and viable option in the management of distal biceps tendon ruptures.
Examination and Diagnosis Most distal biceps tendon ruptures can be diagnosed from the patient’s history and physical examination. The typical presentation is in a middle-aged male patient; this injury rarely occurs in females.5 Commonly, the patient will report a forced eccentric contraction incident of the arm, often with no prodromal symptoms. The patient describes a “pop” followed by pain in the antecubital fossa. The biceps muscle contracts proximally, leaving a noticeable defect. Physical examination often reveals a defect in the antecubital fossa; however, an intact bicipital aponeurosis (lacertus fibrosus) can be mistaken for an intact tendon. The biceps muscle belly retracts proximally and can be prominent in a muscular individual. Ecchymosis develops and commonly
Single-incision distal biceps tendon repair tracks medially along the proximal and medial forearm. Mild weakness in flexion may result, but significant weakness in supination is evident. Radiographs are usually normal, though an irregularity can sometimes be seen on the radial tuberosity. Magnetic resonance imaging and ultrasound are the investigative tools of choice to ascertain the diagnosis when history and physical examination are unclear. Soft-tissue imaging is also helpful to differentiate between ruptures at the tendon to bone junction and musculotendinous ruptures. Musculotendinous ruptures are rare, but change the surgical management substantially. Differential diagnosis of a ruptured tendon includes partial tears of the tendinous insertion, tendon degeneration, or cubital bursitis.
Indications The primary indication for surgical repair of a ruptured distal biceps tendon is the treatment of weakness and pain or to prevent the development of similar chronic symptoms. Supination strength decreases by 50% with tendon rupture and flexion strength decreases by 30%-40%.5,6 However, flexion strength may improve over time with conditioning and compensation by other surrounding muscles.4 A distal biceps repair is indicated in young, active individuals who are involved in high-demand activities, either occupationally or recreationally. This is often an injury occurring in high demand, middle-aged individuals who lift on a repetitive basis. Finally, many patients are bothered by the resulting appearance of their arm and request repair for cosmetic reasons; this is a relative indication for surgery.
Contraindications Surgical repair is not indicated in all patient populations. Individuals who have significant medical comorbidities are contraindicated for the surgery. Nonsurgical treatment may be considered in older individuals who are sedentary, have low-demand occupations, and do not participate in highdemand recreational activities.4,7 Loss of supination strength maybe well tolerated in these certain instances. Every patient should be educated regarding operative and nonoperative options, and allowed to consider lifestyle issues on an individual basis.
Alternative Treatments The most common alternative to surgical repair is nonsurgical treatment. Nonsurgical treatment should be considered when treating an elderly and/or low-demand patient. In contrast, certain individuals may request nonsurgical treatment to avoid a surgical procedure. Patients must be educated in these instances that they can expect to have some loss of supination and flexion strength. In addition, some patients will report fatigability of their elbow function with activity; however, this may not constitute a level of significant disability for individuals who are involved in relatively low-demand activities.
259 A second alternative to single-incision repair is a doubleincision repair technique. This technique minimizes exposure in the antecubital fossa compared with a single-incision approach. Risk to the lateral antebrachial cutaneous nerve is reduced, as the nerve is adjacent to the deep dissection during single-incision exposure. Another advantage to doubleincision repair is the use of a transosseous fixation method, which has been shown to be biomechanically superior to simple single cortical anchoring devices.8 Finally, there is a possible difference in healing of tendon to cancellous bone with double-incision repair versus healing to cortical bone with a single-incision repair. However, certain modern devices allow fixation in a bone tunnel using the single-incision technique, which may obviate these theoretic advantages. Tenodesis of the biceps tendon to the underlying brachialis muscle is another alternative. Tenodesis is ideal for chronic ruptures where the tendon stump is significantly retracted and difficult to mobilize. A chronic ruptured tendon stump is often attenuated and even once mobilized, may not reach the insertion site. A tenodesis does not provide any recovery of supination or flexion strength, but it does help to alleviate the muscle cramps and pain, which can be seen with distal biceps rupture.
Results A number of studies have investigated the outcomes of single-incision distal biceps tendon repairs in the past 10 years (Table 1). These results are comparable to double-incision repair. The most common complications producing an unsatisfactory result is a loss of elbow motion, either supination/ pronation or flexion/extension, and mild residual pain. Though overall, the outcomes are positive with a high satisfaction level.
Technique Instruments Few special equipment are required for the procedure. A variety of instruments, including anchors, cortical buttons, and interference screws can be used. Our preferred technique uses anchors, and is the procedure described. However, the set-up, incision, and surgical approach and postoperative rehabilitation are applicable to the repair, regardless of fixation method. A hand table and a nonsterile tourniquet are required for initial set-up. An assortment of retractors, including self-retaining, right-angled, and small Hohmann retractors facilitate the exposure. A drill is required for insertion of anchors according to individualized manufacturer protocol. Anchors and nonabsorbable suture should be available. Anchors should be small in size to prevent crowding at the radial tuberosity, which could lead to fracture of the radius during insertion. Preferably, nonloaded anchors are available to allow for surgeon preference to dictate the type of suture used for the repair.
260
Table 1 Results of Single-Incision Distal Repair Author (y)
No. Mean Patient Age Mean Follow-up Elbows (y) (range) (mo) (range) 29.1
Fixation Method
Results
Complications
Fenton et al (2009)9 Heinzelmann et al (2009)10 Johnson et al (2008)11 John et al (2007)12
14
39.4 (32-47)
31
48.1 (32-74)
12
49 (SD 10)
53
46.4 (28-73)
McKee et al (2005)13
53
42 (26-64)
29 (6-89)
2 Suture anchors
Balabaud et al (2004)14 Klonz et al (2003)15
9
41 (32-50)
15 (13-16)
6
44 (29-63)
40 (19-107)
2 TOS, 7 patients 2 suture anchors 2 Suture anchors
El-Hawary et al (2003)16
9
47 (37-60)
12
2 Suture anchors
8 Satisfied, 1 unsatisfied?
Sotereanos et al (2000)17 Bain et al (2000)18 Woods et al (1999)19
16
43 (30-59)
39 (12-35)
2 Suture anchors
16 Satisfied
4 Heterotopic ossification - loss of ROM in only 1, 1 lateral antebrachial cutaneous nerve palsy 3 Transient lateral antebrachial cutaneous nerve palsies, 1 flexion contracture, 1 heterotopic ossification None
12
38 (24-50)
17 (8-29)
Endobutton
12 Satisfied
1 Late superficial infection
3
37 (29-49)
8 (6-9)
1 Suture anchor
3 Satisfied
None
24 (7-46) 26 (SD 14) 38.1
11 Excellent and 3 good results None
Soft tissue button ⴙ biotenodesis screw 2 Suture anchors
29 Excellent, 2 good and one fair result 10 Satisfied
2 Suture anchors
1 Heterotopic ossification, 2 transient radial nerve palsies 2 Lateral antebrachial cutaneous nerve injury and 35° flexion contracture 46 Excellent and 7 good results 2 Heterotopic ossifications with loss of forearm rotation, 1 transient radial nerve palsy 43 Satisfied, 8 somewhat 1 Wound infection, 2 transient lateral satisfied, 2 dissatisfied cutaneous nerve palsies, 1 transient pin palsy 9 Satisfied None 2 Satisfied, 4 unsatisfied
L. B. Wall and L.M. Galatz
No., number; ROM, range of motion; mo, month; TOS, transosseous suture.
Biotenodesis screw
Single-incision distal biceps tendon repair
261
Figure 1 A transverse incision is made 2-3 cm distal to the antecubital crease. This provides adequate access and a cosmetic result.
Figure 3 The retracted biceps can be retrieved from this incision by sweeping a finger under the proximal skin flap. It is not necessary to extend or create an incision proximally.
Procedure
After the transverse incision, full-thickness skin flaps are made proximally and distally. The biceps tendon is then retrieved. The biceps tendon and the lacertus fibrosus, in its unruptured state, lie superficial in the antecubital fossa. Especially in the acute setting, the torn, retracted tendon can be easily retrieved by gently sweeping the finger under the proximal skin flap (Fig. 3). Blunt finger dissection releases posttraumatic adhesions in the area without causing damage to nearby structures. After the tendon is mobilized, a stay-suture or Allis clamp is placed on the distal tendon stump so the tendon can be easily handled and mobilized. Gentle traction on the stay suture will assist in relaxation of the biceps muscle-tendon unit, regaining length and enabling repair. The distal 2-3 mm of distal tendon is removed to clear the tendon end from hematoma and scar tissue. Two Number 5 nonabsorbable sutures are then placed into the tendon from distal to proximal direction (Fig. 4). Using a Krachow or other
The patient is placed supine on the operating room table with the affected extremity extended laterally on a hand table. A nonsterile tourniquet is placed around the upper arm; if there is a concern for exposure with a shorter or circumferentially larger extremity, a sterile tourniquet can be used. Conventionally, a longitudinal, curvilinear incision across the antecubital fossa was used, allowing for extension proximally or distally to increase exposure. More recently, and in line with current trends toward minimally invasive techniques, a transverse incision is made 2-3 cm distal to the antecubital crease on the volar forearm (Fig. 1). This incision provides adequate exposure and a superior cosmetic result compared with the previously used longitudinal incision. Care must be taken to identify the lateral antebrachial cutaneous nerve, which is consistently seen in the wound during the exposure (Fig. 2). The nerve should be retracted laterally and protected throughout the case.
Figure 2 The lateral antebrachial cutaneous nerve is identified and protected throughout the surgery.
Figure 4 Tendon grasping sutures are placed from distal to proximal on the medial and lateral aspects of the biceps tendon and tied to each other proximally. Long ends are left distally to load into the suture anchors.
L. B. Wall and L.M. Galatz
262 tendon grasping technique, 1 suture is run up the tendon laterally, and the second medially, approximately 3 cm. The ends of the suture are tied together proximally, distal to the musculotendinous junction. Long free ends are left distally, and are clamped temporarily. The native path of the biceps tendon is commonly filled with hematoma and serous fluid, allowing easy identification of the deeper dissection plane. The interval of dissection lies between the brachioradialis, retracted laterally, and the pronator, retracted medially for exposure. Attention is then focused on exposure of the radial tuberosity. After the interval between the brachialis and pronator is completed; the forearm is supinated to provide protection to the PIN, moving it away from the operative field. Supination also brings the radial tuberosity into the surgical field. One should be aware of the location of both the PIN and the radial nerve during the exposure to avoid injury. The radial recurrent vessels are seen deep in the wound distally. If possible, they should be protected, yet they may be ligated with silk ties if they interfere with exposure. It is better to ligate them than to inadvertently tear a vessel with the distal retractor. Retractor placement at this point is critical. One small Hohman retractor is placed medial and 1 lateral to the tuberosity. They must be placed adjacent to the bone to avoid inadvertent injury to the PIN. A deep right angle retractor is placed distally. These 3 retractors, if placed correctly, are all that is needed to complete the repair. The lateral Hohman presses against the lateral antebrachial cutaneous nerve, so the assistant should apply pressure only when exposure is needed, and it is released but kept in place otherwise (ie, loading anchors). After the radial tuberosity is visualized, the biceps insertion should be debrided, removing any remaining soft tissue. The tuberosity does not need to be decorticated for the repair. Two anchors are used for attachment of the tendon to the radial tuberosity. Each anchor is loaded with one of the sutures, which were sutured into the distal tendon stump. Keeping the forearm supinated to assist with exposure, the
Figure 6 Each limb of suture is loaded on to an anchor. The 2 limbs are then tied to each other over a 1-cm bone bridge, reducing the tendon to the bone.
anchors are placed as medial as possible on the tuberosity. After 1 anchor is placed (Fig. 5), its suture should be tagged distally to avoid accidental unloading. The second anchor is then placed leaving a 1-cm bone bridge in between. Both sutures are then tightened as the elbow is flexed and the tendon stump is brought down into contact with the tuberosity. The tendon is inspected to insure reduction to the bone and then the sutures are tied together (Fig. 6).
Wound Closure The wound is irrigated extensively and the tourniquet released. Any bleeding should be addressed before wound closure. The subcutaneous tissue is closed in an interrupted fashion with absorbable suture, and then a running subcuticular stitch finalizes the closure. Steri-stips are placed over the closed incision and a sterile dressing is placed over the top. The extremity is splinted in a well-padded posterior splint with the elbow in 90° of flexion and forearm in neutral rotation.
Postoperative Regimen
Figure 5 The long end of the suture is loaded into an anchor. The forearm is supinated, bringing the bicipital tuberosity into the wound. The anchor is inserted in the anatomical position.
Seven to 10 days after surgery, the patient returns for followup. The splint is removed and the incision is inspected. The extremity is placed into a sling, though some individuals may require a molded plastic splint if more protection is needed. At this time, patients begin passive flexion and active-assisted extension of the elbow; extension limited to 30° for the first 2 weeks. Progression to full extension is then encouraged after 2 weeks. The sling is worn at all times for the first 4-5 weeks and is discontinued thereafter. After the sling is discontinued light resistance exercises are initiated, consisting of flexion and supination strengthening with less than 5 lb of resistance. The resistance is increased at 10 weeks and is adjusted according to the demand level of individuals.
Single-incision distal biceps tendon repair
Complications The most serious complication of this procedure is nerve injury. With the recent transition to suture anchor utilization with the single-incision technique, nerve injury is a less frequent complication. Previously, with transosseous suture fixation, the PIN was at a greater risk of injury. The lateral antebrachial cutaneous nerve remains at risk during this surgery and should be identified after initial skin incision and protected throughout the case. Other possible complications include residual weakness, re-rupture of the tendon, continued elbow pain, loss of full motion, and heterotopic ossification. The described transverse incision may limit exposure distally in certain individuals. To achieve adequate exposure, a large distal skin flap should be made and mobilization of underlying soft tissues will assist in exposing the tuberosity. With distal dissection, attention must be paid to the radial recurrent vessels. If ligation is not required for exposure and the vessels are simply retracted, careful inspection after tourniquet release is vital to ensure that there is no excessive bleeding, which could result in a postoperative hematoma. Finally, complications may occur with suture placement and cause repair failure. Strict attention must be paid when placing the suture anchors. A bone bridge of 1 cm is necessary to decrease the risk of weakness of the bone bridge resulting in fracture and consequent pullout of the anchors. Second, when placing the anchors, there is potential for weakening of the suture at the interface between the anchor and bone. To ensure that this aspect of the suture is not involved in the final knot, a more distal part of the suture should be at the level of the anchor during placement and then slide out of the anchor once it is secure, bringing a more proximal undamaged section of the suture into the anchor for knot tying.
Conclusions Distal biceps tendon ruptures are rare injuries, but can be substantially disabling for an individual. Repair is advocated to improve strength and function, and to decrease the probability of chronic pain. A single-incision repair is recommended for treatment of distal biceps tendon ruptures. In review of the current published study, it is evident that complications of single-incision repairs are infrequent and outcomes are positive with a high satisfaction level. The de-
263 scribed surgical technique provides a precise and thorough method for repair.
References 1. Safran MR, Graham SM: Distal biceps tendon ruptures: Incidence, demographics and the effect of smoking. Clin Orthop Relat Res 404:275283, 2002 2. Morrey BF: Biceps tendon injury. Instr Course Lect 48:405-410, 1999 3. Belli P, Costantini M, Mirk P, et al: Sonographic diagnosis of distal biceps tendon rupture: A prospective study of 25 cases. J Ultrasound Med 20:587-595, 2001 4. Bernstein AD, Breslow MJ, Jazrawi LM: Distal biceps tendon ruptures: A historical perspective and current concepts. Am J Orthop 30:193200, 2001 5. Morrey BF, Askew LJ, An KN, et al: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 67:418421, 1985 6. Nesterenko S, Domire ZJ, Morrey BF, et al: Elbow strength and endurance in patient with a ruptured distal biceps tendon. J Shoulder Elbow Surg (in press) 7. Ramsey ML: Distal biceps tendon injury: Diagnosis and management. J Am Acad Orthop Surg 7:199-207, 1999 8. Berlet GC, Johnson JA, Milne AD, et al: Distal biceps brachii tendon repair: An in vitro biomechanical study of tendon reattachment. Am J Sports Med 26:428-431, 1998 9. Fenton P, Qureshi F, Ali A, et al: Distal biceps tendon rupture: A new repair technique in 14 patients using the biotenodesis screw. Am J Sports Med 37:2009-2015, 2009 10. Heinzelmann AD, Savoie FH, Ramsey JR, et al: A combined technique for distal biceps repair using a soft tissue button and biotenodesis interference screw. Am J Sports Med 37:989-994, 2009 11. Johnson TS, Johnson DC, Shindle MK, et al: One-versus two-incision technique for distal biceps tendon repair. HSSJ 4:117-122, 2008 12. John CK, Field LD, Wesis KS, et al: Single-incision repair of acute distal biceps ruptures by use of suture anchors. J Shoulder Elbow Surg 16: 78-83, 2007 13. McKee MD, Hirji R, Schemitsch EH, et al: Patient-oriented functional outcome after repair of distal biceps tendon ruptures using a singleincision technique. J Shoulder Elbow Surg 14:302-306, 2005 14. Balabaud L, Ruiz C, Nonnenmacher J, et al: Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach. J Hand Surg 29B:178-182, 2004 15. Klonz A, Loitz D, Wohler P, et al: 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 12:607-611, 2003 16. El-Hawary R, MacDermid JC, Faber KJ: Distal biceps tendon repair: Comparison of surgical techniques. J Hand Surg 28A:496-502, 2003 17. Sotereanos DG, Pierce TD, Varitimidis SE: A simplified method for repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 9:227233, 2000 18. Bain GI, Prem H, Heptinstall RJ, et al: Repair of distal biceps tendon rupture: A new technique using the Endobutton. J Shoulder Elbow Surg 9:120-126, 2000 19. Woods DA, Hoy G, Shimmin A: A safe technique for distal biceps repair using a suture anchor and a limited anterior approach. Injury 30:233237, 1999
D
istal biceps tendon ruptures are uncommon injuries, occurring with an incidence of 1.24 per 100,000 annually.1 However, they are the most common acute tendon injury of the elbow.2 Most distal biceps tendon ruptures occur in individuals of age 40-60 years. The majority of the patients with these injuries are male. The mechanism of injury is classically a forceful contraction against resistance with the elbow in flexion. Most ruptures occur at the bonetendon junction at the radial tuberosity; however, intramuscular and intratendinous ruptures have also been reported.3 Acute, full-thickness tears often result in an audible “pop” and leave a defect just proximal to the antecubital fossa where the biceps is usually subcutaneous. Surgical repair of distal biceps tendon ruptures can be performed by either a single- or double-incision repair technique. Historically, a single-incision was first used. A single anterior incision allowed access to the radius and placement of drill holes through the radius through which suture was threaded to attach the distal tendon stump to the radial tuberosity. Unfortunately, this single-incision technique was often complicated by posterior interosseous nerve (PIN) injuries.4 The high incidence of nerve injury prompted development of a double-incision technique, which remains popular to this day. The double-incision technique involves a
*Department of Orthopedics, Washington University Orthopedics, BarnesJewish Hospital, St Louis, MO. †Shoulder and Elbow Service, Washington University Orthopedics, BarnesJewish Hospital, St Louis, MO. Address reprint requests to Leesa M. Galatz, MD, Department of Orthopedic Surgery, Washington University, Campus Box 8233, 660 South Euclid Ave., St Louis, MO 63110. E-mail: [email protected]
258
1048-6666/09/$-see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2009.09.019
muscle splitting approach dorsolaterally to protect the nerve. However, this approach is not without its own drawbacks; heterotopic ossification and radioulnar synostosis are reported complications not seen with the earlier single-incision technique.4 In the last several years, with an increase in the understanding of surgical anatomy and the advent of modern instrumentation, such as suture anchors, cortical buttons, and interference screws, interest reverted back to the singleincision technique. Single-incision repair has evolved. Optimization of the single-incision technique has decreased the amount of dissection required, limiting the risk to the PIN, and eliminated the exposure of the ulna, thus decreasing the risk of heterotopic ossification and radioulnar synostosis. Consequently, singleincision repair is a safe and viable option in the management of distal biceps tendon ruptures.
Examination and Diagnosis Most distal biceps tendon ruptures can be diagnosed from the patient’s history and physical examination. The typical presentation is in a middle-aged male patient; this injury rarely occurs in females.5 Commonly, the patient will report a forced eccentric contraction incident of the arm, often with no prodromal symptoms. The patient describes a “pop” followed by pain in the antecubital fossa. The biceps muscle contracts proximally, leaving a noticeable defect. Physical examination often reveals a defect in the antecubital fossa; however, an intact bicipital aponeurosis (lacertus fibrosus) can be mistaken for an intact tendon. The biceps muscle belly retracts proximally and can be prominent in a muscular individual. Ecchymosis develops and commonly
Single-incision distal biceps tendon repair tracks medially along the proximal and medial forearm. Mild weakness in flexion may result, but significant weakness in supination is evident. Radiographs are usually normal, though an irregularity can sometimes be seen on the radial tuberosity. Magnetic resonance imaging and ultrasound are the investigative tools of choice to ascertain the diagnosis when history and physical examination are unclear. Soft-tissue imaging is also helpful to differentiate between ruptures at the tendon to bone junction and musculotendinous ruptures. Musculotendinous ruptures are rare, but change the surgical management substantially. Differential diagnosis of a ruptured tendon includes partial tears of the tendinous insertion, tendon degeneration, or cubital bursitis.
Indications The primary indication for surgical repair of a ruptured distal biceps tendon is the treatment of weakness and pain or to prevent the development of similar chronic symptoms. Supination strength decreases by 50% with tendon rupture and flexion strength decreases by 30%-40%.5,6 However, flexion strength may improve over time with conditioning and compensation by other surrounding muscles.4 A distal biceps repair is indicated in young, active individuals who are involved in high-demand activities, either occupationally or recreationally. This is often an injury occurring in high demand, middle-aged individuals who lift on a repetitive basis. Finally, many patients are bothered by the resulting appearance of their arm and request repair for cosmetic reasons; this is a relative indication for surgery.
Contraindications Surgical repair is not indicated in all patient populations. Individuals who have significant medical comorbidities are contraindicated for the surgery. Nonsurgical treatment may be considered in older individuals who are sedentary, have low-demand occupations, and do not participate in highdemand recreational activities.4,7 Loss of supination strength maybe well tolerated in these certain instances. Every patient should be educated regarding operative and nonoperative options, and allowed to consider lifestyle issues on an individual basis.
Alternative Treatments The most common alternative to surgical repair is nonsurgical treatment. Nonsurgical treatment should be considered when treating an elderly and/or low-demand patient. In contrast, certain individuals may request nonsurgical treatment to avoid a surgical procedure. Patients must be educated in these instances that they can expect to have some loss of supination and flexion strength. In addition, some patients will report fatigability of their elbow function with activity; however, this may not constitute a level of significant disability for individuals who are involved in relatively low-demand activities.
259 A second alternative to single-incision repair is a doubleincision repair technique. This technique minimizes exposure in the antecubital fossa compared with a single-incision approach. Risk to the lateral antebrachial cutaneous nerve is reduced, as the nerve is adjacent to the deep dissection during single-incision exposure. Another advantage to doubleincision repair is the use of a transosseous fixation method, which has been shown to be biomechanically superior to simple single cortical anchoring devices.8 Finally, there is a possible difference in healing of tendon to cancellous bone with double-incision repair versus healing to cortical bone with a single-incision repair. However, certain modern devices allow fixation in a bone tunnel using the single-incision technique, which may obviate these theoretic advantages. Tenodesis of the biceps tendon to the underlying brachialis muscle is another alternative. Tenodesis is ideal for chronic ruptures where the tendon stump is significantly retracted and difficult to mobilize. A chronic ruptured tendon stump is often attenuated and even once mobilized, may not reach the insertion site. A tenodesis does not provide any recovery of supination or flexion strength, but it does help to alleviate the muscle cramps and pain, which can be seen with distal biceps rupture.
Results A number of studies have investigated the outcomes of single-incision distal biceps tendon repairs in the past 10 years (Table 1). These results are comparable to double-incision repair. The most common complications producing an unsatisfactory result is a loss of elbow motion, either supination/ pronation or flexion/extension, and mild residual pain. Though overall, the outcomes are positive with a high satisfaction level.
Technique Instruments Few special equipment are required for the procedure. A variety of instruments, including anchors, cortical buttons, and interference screws can be used. Our preferred technique uses anchors, and is the procedure described. However, the set-up, incision, and surgical approach and postoperative rehabilitation are applicable to the repair, regardless of fixation method. A hand table and a nonsterile tourniquet are required for initial set-up. An assortment of retractors, including self-retaining, right-angled, and small Hohmann retractors facilitate the exposure. A drill is required for insertion of anchors according to individualized manufacturer protocol. Anchors and nonabsorbable suture should be available. Anchors should be small in size to prevent crowding at the radial tuberosity, which could lead to fracture of the radius during insertion. Preferably, nonloaded anchors are available to allow for surgeon preference to dictate the type of suture used for the repair.
260
Table 1 Results of Single-Incision Distal Repair Author (y)
No. Mean Patient Age Mean Follow-up Elbows (y) (range) (mo) (range) 29.1
Fixation Method
Results
Complications
Fenton et al (2009)9 Heinzelmann et al (2009)10 Johnson et al (2008)11 John et al (2007)12
14
39.4 (32-47)
31
48.1 (32-74)
12
49 (SD 10)
53
46.4 (28-73)
McKee et al (2005)13
53
42 (26-64)
29 (6-89)
2 Suture anchors
Balabaud et al (2004)14 Klonz et al (2003)15
9
41 (32-50)
15 (13-16)
6
44 (29-63)
40 (19-107)
2 TOS, 7 patients 2 suture anchors 2 Suture anchors
El-Hawary et al (2003)16
9
47 (37-60)
12
2 Suture anchors
8 Satisfied, 1 unsatisfied?
Sotereanos et al (2000)17 Bain et al (2000)18 Woods et al (1999)19
16
43 (30-59)
39 (12-35)
2 Suture anchors
16 Satisfied
4 Heterotopic ossification - loss of ROM in only 1, 1 lateral antebrachial cutaneous nerve palsy 3 Transient lateral antebrachial cutaneous nerve palsies, 1 flexion contracture, 1 heterotopic ossification None
12
38 (24-50)
17 (8-29)
Endobutton
12 Satisfied
1 Late superficial infection
3
37 (29-49)
8 (6-9)
1 Suture anchor
3 Satisfied
None
24 (7-46) 26 (SD 14) 38.1
11 Excellent and 3 good results None
Soft tissue button ⴙ biotenodesis screw 2 Suture anchors
29 Excellent, 2 good and one fair result 10 Satisfied
2 Suture anchors
1 Heterotopic ossification, 2 transient radial nerve palsies 2 Lateral antebrachial cutaneous nerve injury and 35° flexion contracture 46 Excellent and 7 good results 2 Heterotopic ossifications with loss of forearm rotation, 1 transient radial nerve palsy 43 Satisfied, 8 somewhat 1 Wound infection, 2 transient lateral satisfied, 2 dissatisfied cutaneous nerve palsies, 1 transient pin palsy 9 Satisfied None 2 Satisfied, 4 unsatisfied
L. B. Wall and L.M. Galatz
No., number; ROM, range of motion; mo, month; TOS, transosseous suture.
Biotenodesis screw
Single-incision distal biceps tendon repair
261
Figure 1 A transverse incision is made 2-3 cm distal to the antecubital crease. This provides adequate access and a cosmetic result.
Figure 3 The retracted biceps can be retrieved from this incision by sweeping a finger under the proximal skin flap. It is not necessary to extend or create an incision proximally.
Procedure
After the transverse incision, full-thickness skin flaps are made proximally and distally. The biceps tendon is then retrieved. The biceps tendon and the lacertus fibrosus, in its unruptured state, lie superficial in the antecubital fossa. Especially in the acute setting, the torn, retracted tendon can be easily retrieved by gently sweeping the finger under the proximal skin flap (Fig. 3). Blunt finger dissection releases posttraumatic adhesions in the area without causing damage to nearby structures. After the tendon is mobilized, a stay-suture or Allis clamp is placed on the distal tendon stump so the tendon can be easily handled and mobilized. Gentle traction on the stay suture will assist in relaxation of the biceps muscle-tendon unit, regaining length and enabling repair. The distal 2-3 mm of distal tendon is removed to clear the tendon end from hematoma and scar tissue. Two Number 5 nonabsorbable sutures are then placed into the tendon from distal to proximal direction (Fig. 4). Using a Krachow or other
The patient is placed supine on the operating room table with the affected extremity extended laterally on a hand table. A nonsterile tourniquet is placed around the upper arm; if there is a concern for exposure with a shorter or circumferentially larger extremity, a sterile tourniquet can be used. Conventionally, a longitudinal, curvilinear incision across the antecubital fossa was used, allowing for extension proximally or distally to increase exposure. More recently, and in line with current trends toward minimally invasive techniques, a transverse incision is made 2-3 cm distal to the antecubital crease on the volar forearm (Fig. 1). This incision provides adequate exposure and a superior cosmetic result compared with the previously used longitudinal incision. Care must be taken to identify the lateral antebrachial cutaneous nerve, which is consistently seen in the wound during the exposure (Fig. 2). The nerve should be retracted laterally and protected throughout the case.
Figure 2 The lateral antebrachial cutaneous nerve is identified and protected throughout the surgery.
Figure 4 Tendon grasping sutures are placed from distal to proximal on the medial and lateral aspects of the biceps tendon and tied to each other proximally. Long ends are left distally to load into the suture anchors.
L. B. Wall and L.M. Galatz
262 tendon grasping technique, 1 suture is run up the tendon laterally, and the second medially, approximately 3 cm. The ends of the suture are tied together proximally, distal to the musculotendinous junction. Long free ends are left distally, and are clamped temporarily. The native path of the biceps tendon is commonly filled with hematoma and serous fluid, allowing easy identification of the deeper dissection plane. The interval of dissection lies between the brachioradialis, retracted laterally, and the pronator, retracted medially for exposure. Attention is then focused on exposure of the radial tuberosity. After the interval between the brachialis and pronator is completed; the forearm is supinated to provide protection to the PIN, moving it away from the operative field. Supination also brings the radial tuberosity into the surgical field. One should be aware of the location of both the PIN and the radial nerve during the exposure to avoid injury. The radial recurrent vessels are seen deep in the wound distally. If possible, they should be protected, yet they may be ligated with silk ties if they interfere with exposure. It is better to ligate them than to inadvertently tear a vessel with the distal retractor. Retractor placement at this point is critical. One small Hohman retractor is placed medial and 1 lateral to the tuberosity. They must be placed adjacent to the bone to avoid inadvertent injury to the PIN. A deep right angle retractor is placed distally. These 3 retractors, if placed correctly, are all that is needed to complete the repair. The lateral Hohman presses against the lateral antebrachial cutaneous nerve, so the assistant should apply pressure only when exposure is needed, and it is released but kept in place otherwise (ie, loading anchors). After the radial tuberosity is visualized, the biceps insertion should be debrided, removing any remaining soft tissue. The tuberosity does not need to be decorticated for the repair. Two anchors are used for attachment of the tendon to the radial tuberosity. Each anchor is loaded with one of the sutures, which were sutured into the distal tendon stump. Keeping the forearm supinated to assist with exposure, the
Figure 6 Each limb of suture is loaded on to an anchor. The 2 limbs are then tied to each other over a 1-cm bone bridge, reducing the tendon to the bone.
anchors are placed as medial as possible on the tuberosity. After 1 anchor is placed (Fig. 5), its suture should be tagged distally to avoid accidental unloading. The second anchor is then placed leaving a 1-cm bone bridge in between. Both sutures are then tightened as the elbow is flexed and the tendon stump is brought down into contact with the tuberosity. The tendon is inspected to insure reduction to the bone and then the sutures are tied together (Fig. 6).
Wound Closure The wound is irrigated extensively and the tourniquet released. Any bleeding should be addressed before wound closure. The subcutaneous tissue is closed in an interrupted fashion with absorbable suture, and then a running subcuticular stitch finalizes the closure. Steri-stips are placed over the closed incision and a sterile dressing is placed over the top. The extremity is splinted in a well-padded posterior splint with the elbow in 90° of flexion and forearm in neutral rotation.
Postoperative Regimen
Figure 5 The long end of the suture is loaded into an anchor. The forearm is supinated, bringing the bicipital tuberosity into the wound. The anchor is inserted in the anatomical position.
Seven to 10 days after surgery, the patient returns for followup. The splint is removed and the incision is inspected. The extremity is placed into a sling, though some individuals may require a molded plastic splint if more protection is needed. At this time, patients begin passive flexion and active-assisted extension of the elbow; extension limited to 30° for the first 2 weeks. Progression to full extension is then encouraged after 2 weeks. The sling is worn at all times for the first 4-5 weeks and is discontinued thereafter. After the sling is discontinued light resistance exercises are initiated, consisting of flexion and supination strengthening with less than 5 lb of resistance. The resistance is increased at 10 weeks and is adjusted according to the demand level of individuals.
Single-incision distal biceps tendon repair
Complications The most serious complication of this procedure is nerve injury. With the recent transition to suture anchor utilization with the single-incision technique, nerve injury is a less frequent complication. Previously, with transosseous suture fixation, the PIN was at a greater risk of injury. The lateral antebrachial cutaneous nerve remains at risk during this surgery and should be identified after initial skin incision and protected throughout the case. Other possible complications include residual weakness, re-rupture of the tendon, continued elbow pain, loss of full motion, and heterotopic ossification. The described transverse incision may limit exposure distally in certain individuals. To achieve adequate exposure, a large distal skin flap should be made and mobilization of underlying soft tissues will assist in exposing the tuberosity. With distal dissection, attention must be paid to the radial recurrent vessels. If ligation is not required for exposure and the vessels are simply retracted, careful inspection after tourniquet release is vital to ensure that there is no excessive bleeding, which could result in a postoperative hematoma. Finally, complications may occur with suture placement and cause repair failure. Strict attention must be paid when placing the suture anchors. A bone bridge of 1 cm is necessary to decrease the risk of weakness of the bone bridge resulting in fracture and consequent pullout of the anchors. Second, when placing the anchors, there is potential for weakening of the suture at the interface between the anchor and bone. To ensure that this aspect of the suture is not involved in the final knot, a more distal part of the suture should be at the level of the anchor during placement and then slide out of the anchor once it is secure, bringing a more proximal undamaged section of the suture into the anchor for knot tying.
Conclusions Distal biceps tendon ruptures are rare injuries, but can be substantially disabling for an individual. Repair is advocated to improve strength and function, and to decrease the probability of chronic pain. A single-incision repair is recommended for treatment of distal biceps tendon ruptures. In review of the current published study, it is evident that complications of single-incision repairs are infrequent and outcomes are positive with a high satisfaction level. The de-
263 scribed surgical technique provides a precise and thorough method for repair.
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