Distal Biceps Repair

Prevalence of Biceps rupture

• Excessive eccentric tension as arm is forced from flexed to extended position¹
  • weightlifting, wrestling and labor intensive job²
• Greater risk in patients who smoke (7.5 times)^1,3
• Higher BMI³
• Presence of rotator cuff disease⁴

1. Safran MR, Graham SM (2002). Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 404):275-83.
2. Thomas JR, Lawton JN (2017). Biceps and Triceps Ruptures in Athletes. Hand Clin. 33(1):35-46
3. Kelly, M. P., Perkinson, S. G., Ablove, R. H., & Tueting, J. L. (2015). Distal Biceps Tendon Ruptures: An Epidemiological Analysis Using a Large Population Database. The American Journal of Sports Medicine, 43(8), 2012–2017. https://doi.org/10.1177/0363546515587738
4. Vestermark GL, Van Doren BA, Connor PM, Fleischli JE, Piasecki DP, Hamid N (2018). The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture. J Shoulder Elbow Surg. 27(7):1258-1262.

Anatomy of Biceps

• Consisting of 2 muscular heads that gather into a single insertion on the radial tuberosity and the fascia of the forearm
  • long head (caput longum)
  • short head (caput breve)
• Presence of distinct footprint areas
  • Biceps Tendon Footprint

• Biceps Dumbbell Exercises/
• Picture of the Biceps

Biceps Insertion

Area: 108 mm²

Width: 6 – 10 mm (Avg: 7 mm)

Length: 17 – 25 mm (Avg: 21 mm)

Starts 23 mm from the articular margin of the radial head

Primary Acute Repair Technique Complete and Partial

• Complete ruptures should always be treated surgically unless medically not indicated.
• Partial ruptures can be treated conservatively or surgically
  • Surgical repair recommended when patient experiences loss of strength or is symptomatic

Is nonoperative management of partial distal biceps tears really successful?

• 55.7% of patients who tried non-operative treatment ended up undergoing surgery.
• High-need patients (defined by occupation) were more likely to report that they recovered ideally if they underwent surgery (OR: 11.57, p = 0.0138).
• MRI-diagnosed tear of > 50% was predictor of needing surgery.

Methods of Repair – Two Incision Transosseous bone tunnel Repair

Sutures passed and tied across bone bridge, via posterior incisions

Methods of Repair – Single Incision-Suture Anchor Repair

• Double Anchor placement
• Bilateral Krakow Stitching
• Tendon repaired to Tuberosity
• Repair using Hemi-Krackow Suture Technique

Methods of Repair - Interference Screw Fixation

• Bio-absorbable Tenodesis Screw

• Distal biceps repair via Bio-Tenodesis screw

• Unicortical drill hole
• Distal End of Biceps is whipstitched
• Cortical Button with Inference Screw
• Suture threaded through button
• Sutures passed through Endobutton
  and then passed through biceps tendon
• Suture limbs tied over interference Screw

Single vs. Double Incision Techniques

• Overall frequency of reported complications is higher for single-incision repair.
• Frequencies of re-rupture and nerve complications are both higher for single-incision repairs.
• Frequency of heterotopic ossification is higher for double-incision repair.

Outcomes from Distal Biceps Tendon Repairs

• 22 studies, 498 elbows
• Complication rate 25% (122 of 498 elbows)
• No difference:1 & 2 incision techniques
• 26% suture anchors
• 20% bone tunnels
• 45% intraosseous screws
• 0% cortical button fixation
• Most common complication
  • LABC neurapraxia :9.6% across all studies
    • 11.6% for one incision
    • 5.8% for two incisions

Outcomes from Distal Biceps Tendon Repairs

• Primary repair: Good outcomes (strength and function) in majority of patients.
• Low rates of major complications
• Low re-rupture rates.
• No differences between technique/method of repair!

What about Biomechanical Evidence?

• Mean pullout strength of the repair with a Bio-Tenodesis screw was significantly higher, compared to suture anchors.

Suture anchor fixation resulted in greater yield strength compared to bone tunnel fixation.

Suture Anchor Fixation

• Mean failure strength and stiffness: tunnel < interference screw < intact Specimens
• No significant differences between intact a& interference screw
• Interference screw fixation repair is nearly as strong and stiff as the intact tendon and stronger than the bone tunnel repair technique.

• No differences in final displacement between suture anchor group and EndoButton group
  • Comparable fixation strength

• Schema of suture anchor repair
• Schema of EndoButton sutured to tendon

• Greatest Load to FailureEndoButton Repair
• Suture Anchor Repair
• Bone-Tunnel Repair
• Lowest Load to FailureInterference Screw Repair

Bottom Line

• Mixed results in biomechanical studies
• My interpretation: cortical button repair with interference screw superior to any other repair technique.
• Any technique can work if executed well!

Revision/Chronic Biceps Reconstruction Options

Reconstruction with allograft/autograft tissue

• Achilles tendon reconstruction
• Semitendinosus reconstruction

Methods of Repair - Achilles tendon allograft

Case Study - Chronic/Failed Biceps Repairs

Case History

• Patient history
  • 47 yr. old male w/a history of left distal biceps tendon rupture.
  • Originally taken to OR a few months prior but surgeon at the time was unable to preform repair due to short tendon
  • Pt. rates elbow function as 30% and pain as 3/10
• Clinical examination
  • Elbow range of motion is 5-135°
  • 80–80 pronation supination
  • Weakness with resisted forearm supination
  • stump of the tendon is not easily palpable.
  • Tender palpation over the antecubital fossa.
  • Absent distal biceps tendon

Pre-operative motion

Imaging

MRI

My Preferred Setup & Equipment

• Supine with arm board
• Small C-Arm
• Suture button plus PEEK (non-absorbable) interference screw
• Single transverse incision directly over radius
• Optional – second transverse incision biceps tendon origin

Procedure

2.5 Year Outcome

2.5 Year Patient Outcomes

• Pt. reported noticeable improvement in ROM and pain.
• Still some weakness with activity but generally can do most all activities
• SANE 80%, Pain 2-3/10
• Pt. was satisfied with outcomes and reports general improvement in function.
• Returned to work as a laborer

Reconstruction Pearls

• Anticipate tissue loss
• Autograft vs allograft?
• Match the reconstruction with the tissue loss
• With allograft fix with elbow in 45 degree of flexion- will stretch out
• Use fluoroscopy to verify location of incision, drill hole and deployment of button

Pearls of Treatment

• Use small c-arm to localize location of incision, verify location of drill hole and verify deployment of button.
• Beware of the LABC and PIN nerves! Identify and dissect free the LABC & avoid using Homan retractors on radial aspect of radius.
• Use a hinged elbow brace to protect the repair if tension requires more than 30-45 degrees of flexion