Distal Biceps Tendon Rupture

Epidemiology

 

Dominant arm of middle aged men

- between 40 and 60

 

Aetiology

 

Sudden dramatic event

- sporting / weightlifting injury

- resisting heavy extension load

 

Pathology

 

Degenerative changes seen on histology

 

Types

 

Complete

- retracted / rupture of lacertus fibrosis

- minimally retracted

 

Partial

- small - partial tears of some fibres

- large - near complete avulsion of biceps tendon from radial tuberosity

 

NHx

 

Complete tears / non operative management

- 30% loss of flexion strength

- 50% loss of supination strength

 

Examination

 

Distal Biceps Rupture

 

Acute onset pain / distal swelling / bruising

 

Biceps muscle may bulge proximally

- not always seen as lacertus fibrosis may be intact

 

Hook test

- attempt to hook finger about biceps tendon

- unable to palpate biceps tendon

 

O'Driscoll et al Am J Sports Med 2007

- Hook test negative in partial tears

- but 9/12 painful with this test

 

Biceps Tendon Hook Test

 

Weakness

- supination > flexion

 

Distal Biceps Rupture 1Distal Biceps Rupture 2Distal Biceps Rupture 3

 

X-ray

 

May see bony avulsion from radial tuberosity

 

MRI

 

Confirm diagnosis

 

A.  Complete tear / retracted

- relatively easy to diagnose

 

Distal Biceps Rupture MRI

 

B.  Partial tear

 

Best evaluated on the axial view

- absence of low signal intensity biceps tendon insertion onto tuberosity

- present of soft tissue oedema

 

MRI Biceps Partial TearBiceps Partial tear

 

Festa et al J Hand Surg Am 2010

- MRI 100% sensitive for full thickness tears

- MRI only 59.1% sensitive for partial tears

 

Management

 

Non-operative

 

Indication for complete tears

 

Elderly patients who do not require full strength and endurance

 

Usually lose one grade power with distal avulsion

- decreased strength and endurance 

- supination and flexion

- i.e. labourer might have difficult with inserting screws

 

Operative

 

Indication

 

Young active patients with recent rupture 

- may be more difficult with chronic tears

 

Options

 

Two incision Boyd and Anderson

- anterior incision to retrieve tendon

- posterior incision to attach tendon to radial tuberosity

- associated with radioulnar synostosis

- less risk of inadvertant PIN injury

 

One incision

- single anterior incision

- use suture anchors / endobutton to fix to tuberosity through this incision

- theoretical higher risk PIN injury

- endobutton fixation 2 - 3 x higher strength than suture anchors

 

Operative Technique:  One incision technique with endobutton

 

Set up

- supine, arm board, tourniquet

 

Incision

- longitudinal medially / transverse across cubital fossa / longitudinal mobile wad

- S shaped

 

Find biceps tendon

- proximally above brachialis

- Allis clamp

- mobilise by blunt dissection

- deliver into wound

 

Distal Biceps Repair IncisionDistal Biceps Tendon with EndobuttonDistal Biceps Repair Final

 

Fixation with no 2 Ethibond / Fibre wire

- Krackow suture

- enter lateral aspect tendon proximally

- suture down to distal aspect

- pass around middle two holes of endobutton

- back up medial aspect and tie

- leave 2 mm space between endobutton and distal end of tendon

- allows space for dorsal cortex of radius

 

Insert passing sutures and flipping sutures in lateral holes

- no 2 ethibond to pull through

- 1 vicryl to flip

- different colours to help you tell which is which

 

Dissect down to radial tuberosity

- find and protect LCNFA

- under cephalic vein

- mobile wad laterally with radial nerve

- blunt dissect down to radial tuberosity

 

Prepare radial tuberosity

- forearm fully supinated

- make trough for tendon with burr

- avoid lateral retractors which can inadvertantly injure PIN

 

Pass guide wire through dorsal cortex 

- aim distal and medial

- pass cannulated 4.5 endobutton reamer

- pass beath needle with sutures

- pass and flip endobutton

- check II

 

Distal Biceps Endobutton RepairDistal Biceps Endobutton Repair

 

Post op

- splint for 2 weeks

- then active assist ROM

- no heavy lifting for 8/52

 

Results

 

Greenberg et al J Should Elbow Surg 2003

- endobutton technique

- patients had 97% flexion strength

- 82% supination strength

 

Khan et al Arthroscopy 2008

- suture anchor repair in 17 patients

- 5 degee loss of extension and rotation

- strength 80% other side

 

John et al JSES 2007

- suture anchor repair in 53 patients

- 46 excellent results, 7 good

- HO in 2 patients

 

Chavan et al Am J Sports Med 2008

- systematic review

- endobutton strongest

- increased complications in two-incision techniques

 

Mazzocca et al Am J Sports Med 2007

- biomechanical study

- endobutton (440N) stronger than suture anchors (380N) or bone tunnel (300)

 

Lo et al Arthroscopy 2011

- 11 mm to PIN if aim directly across long axis of radius

- increases to 16 mm if aim 30 degrees to the ulna side

- aiming distally 45 degrees and radially decreased this to 2 mm

 

2 incision Boyd and Anderson Technique

 

Technique

 

Anterior Henry approach as before

 

Passed curved haemostat 

- maximally pronate forearm

- hug border of radius

- avoid periosteum of ulna to prevent synostosis

- palpate tip dorsally in extensor mass

- dissect down to radius

 

Thompson's approach

- line from lateral epicondyle to lister's tubercle

- between EDC and ECRB

- expose supinator

- find and protect PIN

- subperiosteally detach supinator

 

Repair

- performed through bone tunnels

 

Results

 

Greewal et al JBJS Am 2012

- single incision (anchors) v double incision (drill holes)

- RCT 91 patients

- double incision 10% stronger flexion strength

- increased transient neuropraxis LCNF in single incision

- ASES / DASH scores same in each group

- 4 re-ruptures due to lack of complicance

 

Partial Tears

 

Management Options

 

Bain et al Sports Med Arthrosc 2008

- non operative treatment < 50%

- operative treatment for > 50%

 

Surgical Treatment of a Partial Tear

 

Biceps ApproachBiceps Partial TearBiceps Partial Tear 2Biceps Partial Tear 3

 

Repair with suture anchors

 

Biceps Suture Anchor Repair

 

Chronic Tears

 

> 3 weeks old

- harder to repair

- associated with higher complication rates

- have to repair in significant position of flexion

 

Typically run into problems > 6 - 8 weeks

- tendon involutes into biceps

- need either hamstring autograft or allograft reconstruction

- secure to radial tuberosity with endobutton first

- then weave through distal biceps stump

- pulve taft weave through tendon

 

Hamstring autograft biceps reconstruction

 

Biceps reconstruction with tendoachilles allograftDistal biceps reconstruction with allograft

 

Complications

 

Infection

Rerupture

Injury LCNFA

Injury PIN

Loss of extension

- more common with chronic injuries