Distal Biceps Tendon Repair 24342

distal biceps tendon rupture picture

elbow cross sectional anatomy

distal biceps tendon repair xray

    distal biceps tendon repair xrayBiomet Toggleloc xray

synonyms: distal biceps repair, distal biceps tendon repair

Distal Biceps Repair CPT

Distal Biceps Repair Indications

  • Acute distal biceps tendon rupture
  • Partial distal biceps tendon rupture which has failed to respond to nonoperative management.
  • Chronic distal biceps tendon rupture

Distal Biceps Repair Contraindications

  • Elderly, sedentary patient, or medically unstable for surgery.

Distal Biceps Repair Alternatives

Distal Biceps Repair Pre-op Planning / Special Considerations

  • Fixation options:Biomet ToggleLoc,  Smith&Nephew Endobutton (Bain GI, JSES 2000;9:120), Arthrex Retrobutton, Interference screws, Suture anchors (John CK, JSES, 2007;16:78).  Biomet Toggleloc. 
  • 4mm Kerrison roungeur is helpful to widen cortical hole. 
  • Combined endobutton/interference screw (Mazzocca AD, Tech Should Elbow Surg 2005;6:108).
  • Surgical approaches are based on volar Henry approach to proximal forearm.
  • Delayed Repair: delay in diagnosis results in shortening of the biceps. Extensive mobilization often required and often require some form of graft for repair. Choices: autogenous flexor carpi radialis, semitendinosus, fasica latea, allograft Achilles tendon.
  • Two-incision repair technique wit bone tunnel-suture fixation = statistically higher rates of posterior interosseous nerve palsy, heterotopic bone formation, and re-operation. Single incision, cortical button + interference screw technique = shorter release from medical care.  (Dunphy, TR, ASES 2017 Specialty Day).
  • 2-incision technique is associated with increased loss of forearm rotation and more unsatisfactory clinical results. 
  • 1-incision technique is associated with higher incidence of lateral antebrachial cutaneous neuropathy.
  • Technique Videos: AAOS The Athletes Elbow, Vumedi.

Distal Biceps Repair Technique

  • Sign operative site
  • Pre-operative antibiotics, +/- regional block
  • General endotracheal anesthesia
  • Supine position. All bony prominences well padded.
  • Examination under anesthesia.
  • Prep and drape in standard sterile fashion.
  • Start with nearly transverse incision in antecubital fossa.  Extend lateral extent proximally if needed to find tendon.  Extend medial portion distally for improved tuberosity exposure as needed.
  • Dissect done under 2.5x/3.5x loop magnification, ensure lateral antebrachial cutaneous nerve is protected.
  • Identify proximal stump, debride loose end if indicated. Up to 10mm may be debrided without compromising repair.
  • Interval is between brachioradialis and pronator teres.  Biceps tendon, bicipital aponeuronsis, brachial artery branching into radial and ulnar arteries can be found here.  May need to ligate radial recurrent vessels.
  • supination and slight flexion brings tuberosity into view and protects PIN.  In acute injuries there is often a soft tissue tunnel (biceps tendon sheath) to follow to the tuberosity.  Be careful with retractors to avoid injury to PIN.
  • Endobutton technique: weave two #2 Fiberwire sutures into the tendon with endobutton 5mm from tendon. Knots must be proximal to allow endobutton to flip. Drill Beath pin into the center of the tuberosity. Drill 8mm cannulated reamer through proximal cortex. Drill 4.5mm endobutton reamer through distal cortex. Irrigate entire area to remove any bone fragment. Pass endobutton passing sutures using Beath pin, seat endobutton in standard fashion. Reinforce with interfernce screw. Technique may be done with Arthrex retrobutton in similar fashion.
  • Suture Anchor technique: Place two 2.5mm Statak suture anchors with non-absorbable suture (O or larger) into the tuberosisty in a proximal to distal fashion equal to the width of the tendon.
  • Consider Botox (1vial{100 units} diluted in 10cc saline) injected into biceps muscle belly to protect repair post-op.
  • Irrigate.
  • Close in layers.

Distal Biceps Repair Complications

  • Total major complication rate = 7.5%
  • PIN palsy = 1.9%
  • Distal biceps tendon rerupture=1.5%
  • Proximal radioulnar synostosis = 1.0%;  generally from subperiosteal disssection of the ulna in two incision approaches. Dorsal approaches spliting the extensor carpi ulnaris and extensor digitorum communis without exposing the radius reduce the risk.
  • Symptomatic HO with reoperation=0.8%
  • Deep infection=0.5%
  • CRPS=0.6%
  • Loss of flexion-extension arc ROM with reoperation=0.4%
  • Tendon reruptures occur at a mean of 48 ± 38 postoperative days (7 weeks) after surgery.    (<5%)
  • Overall reoperation rate= 4.5% 
  • Infection
  • Nerve injury (lateral antebrachial cutaneous, radial/posterior interosseous, median), PIN palsy more common after two-incision technique.  Lateral antebrachial cutaneous nerve palsy is most common complication after anterior single incision tears, generally. traction injury which resolves.
  • Bone tunnel fracture
  • Stiffness
  • Anterior elbow pain
  • heterotopic ossification
  • Radial neck fracture
  • Ford S, et al. J Shoulder Elbow Surg. 2018 Oct;27(10):1898-1906.
  • Kelly EW, JBJS, 2000;82A:1575

Distal Biceps Repair Follow-up care

  • Consider HO prophylaxis.
  • Post-op: place in posterior splint with the forearm fully supinated and the elbow flexed to 90°.
  • 7-10 Days: Begin passive flexion and supination exercises with active extension and pronation. May consider light active motion if repair was strong. Avoid forcefull flexion or supination.  Resting splint at 90° with forearm in suppination or hinged elbow brace.  Limit extension as determined at surgery and advance 10° per week until full extension achieved.
  • 6 Weeks: Avoid forceful flexion. Progress with ROM and active flexion and suppination with physical therapy.
  • 3 Months: May start strengthenging / lifting weights.
  • (McKee MD, JSES 2005;14:302).
  • Distal Biceps Repair Rehab Protocol.

Distal Biceps Repair Outcomes

Distal Biceps Repair Review References

  • Yamaguchi K editor, Advanced Reconstuction: Elbow, AAOS 2007
  • Ramsey ML, JAAOS 1999;7:199
  • Orthopaedic Knowledge Update: Shoulder and Elbow, No. 3
  • AAOS Athletes Elbow DVD..
  • Badia A, Sambandam SN, Khanchandani P. Proximal radial fracture after revision of distal biceps tendon repair: a case report. J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):e4-6. Epub 2007 Feb 2.
  • Cohen MS. Complications of distal biceps tendon repairs. Sports Med Arthrosc Rev. 2008 Sep;16(3):148-53. doi: 10.1097/JSA.0b013e3181824eb0.
  • Sutton KM, Dodds SD, Ahmad CS, Sethi PM. Surgical treatment of distal biceps rupture. J Am Acad Orthop Surg. 2010 Mar;18(3):139-48. 
  • Amin NH, Volpi A, Lynch TS, Patel RM, Cerynik DL, Schickendantz MS, Jones MH. Complications of Distal Biceps Tendon Repair: A Meta-analysis of Single-Incision Versus Double-Incision Surgical Technique. Orthop J Sports Med. 2016 Oct 7;4(10). 
  • Ford S, et al. J Shoulder Elbow Surg. 2018 Oct;27(10):1898-1906.