Treatment

Nonoperative Treatment

In the past, nonoperative management of distal biceps tendon ruptures was popular.2,4,6,7,10-12 Authors of numerous case reports suggested that early motion and strengthening exercises could restore normal strength. Authors of subsequent studies in which they used dynamometers demonstrated the deficits of nonoperative treatment.4,6 They found that patients who were treated nonoperatively for their distal biceps tendon ruptures had weaker supination and flexion than patients who had the ruptured tendon reattached to the bicipital tuberosity.

If supination strength is not important, nonoperative treatment can be considered. A surprising degree of elbow flexion strength can be restored by strengthening the other muscles that cross the anterior aspect of the elbow. If the distal biceps tendon becomes tethered distally, it too may add to the variable elbow flexion strength that develops.

Although the treatment for each patient must be considered individually, nonoperative treatment generally yields unsatisfactory results. Using Cybex testing of nonoperatively treated patients, Baker and Bierwagen demonstrated objective deficits of biceps weakness, with endurance affected more than strength.4 Patients in a study by Morrey et al. noted that, while they did not find their weakness debilitating, they did reach fatigue more easily with repeated, forceful supination activity.6 Muscularly well-developed patients, particularly those involved in body-building competition, may occasionally prefer to be treated nonoperatively to avoid scarring.

Indications for Operative Treatment

The main indication for operative repair is restoration of supination strength. Without an anatomic repair, the arm's twisting motions, such as when using a screwdriver, will be weak. Patients who can effectively meet the demands of daily living without significant disability or restriction do not require surgery.

Another indication for surgery is improvement of the cosmetic appearance of the arm. A completely ruptured distal biceps tendon can cause proximal migration of the muscle belly, giving an unacceptable appearance to the arm. Anatomic restoration restores the normal contour to the arm. In a patient who desires surgery for cosmesis, the incision should not cross the antecubital fossa. Incisions that do so usually widen and are less cosmetic than those that avoid the anterior elbow flexion crease.

Delayed diagnosis can be a relative contraindication to repair.6 Anatomic reattachment to the bicipital tuberos-ity is harder with contracture or scarring of the biceps muscle.7 For such situations, some authors have advocated attachment of the tendon to the brachialis or use of a tendon graft.5-7,13 In our own series, we have found that most delayed repairs can be reattached anatomically, even in patients whose injuries had occurred more than 6 months earlier.14 In some cases, the tendon could only be secured with the elbow flexed 45° to 60°, but full extension was ultimately restored.

Operative Techniques

Repairs of distal biceps tendon ruptures fall into one of two groups: anatomic and nonanatomic. The earlier operations tended to be nonanatomic repairs. This type of repair was favored because of concerns about injury to the vital structures in the region of the antecubital fossa. At that time, surgeons avoided the deeper dissections associated with anatomic repair and secured the ruptured distal biceps tendon to either the lacertus fibrosis or the brachialis.5,15 Authors of the earlier literature suggested that they could obtain a good result by attaching the ruptured tendon to the brachialis muscle. Their conclusions, however, were not based on objective measurements.

Most modern surgeons recommend anatomic reattachment. The differences in modern techniques center around the number of incisions, the site of tendon reattachment, the type of fixation device, and the use of grafts.

Initially, the tendon was reattached through an anterior incision,16,17 but the number of reported neurovas-cular complications dampened the enthusiasm for this approach.5,15 In 1961, Boyd and Anderson reported a method of reattaching the distal end of the ruptured biceps tendon using two approaches.16,18 They used an anterior incision to retrieve the ruptured tendon and a posterior incision to reattach the tendon to the tuberosity. The tendon was passed posteriorly between the radius and ulna and was retrieved through a posterior incision. Silk sutures were passed through the tendon and out the avulsed end. The forearm was pronated to expose the radial tuberosity. A "trap door" was made in the radial tuberosity by elevating the cortex and drilling holes opposite the cortical hinge. The tendon was advanced into the trap door and the sutures tied outside the cortical drill holes. The Boyd-Anderson approach avoided the dangers of deep dissection in the antecubital fossa, but required dissection of the muscles off the lateral aspect of the ole-cranon. Modifications of this approach avoid the ulna by approaching the tuberosity through a posterior muscle-splitting incision and by using a high-speed burr to make the trough.6

The development of suture anchors has rekindled interest in the anterior approach. Le Huec et al.9 and Lint-ner and Fischer19 used a single anterior incision and reat-tached the tendon end with suture anchors placed into the radial tuberosity. The authors of both studies reported excellent results with no nerve injuries.

In some patients, the distal end of the ruptured distal biceps tendon cannot be brought down easily to the tuberosity. Although such instances are rare, they usually occur in patients who present many months after the complete rupture. In such situations, the distal end of the ruptured biceps tendon may be either extended or augmented with fascia lata or palmaris longus tendon graft.7 If augmentation is not an option, the tendon can be attached to the brachialis muscle.5

Authors' Preferred Technique

The senior author (BML) prefers to use a modified two-incision technique to reattach the ruptured distal biceps tendon to the radial tuberosity. Most of the dissection is done through an anterior incision. A small posterolateral incision is used to tie the knot. The surgeon positions the patient supine on the operating table and extends the patient's upper extremity on a hand table. A pneumatic tourniquet is placed close to the axilla; a sterile tourniquet generally is not needed. A 6- to 8-cm oblique incision is made along the anterior edge of the flexor-prona-tor muscle mass and distal to the elbow flexion crease (Fig. 9.3). Placing the incision medially reduces the possibility of injury to the lateral antebrachial cutaneous

FIGURE 9.3. Distal (oblique) incision along the anterior edge of the flexor-pronator mass and the supplemental proximal incision used for tendon retrieval.

nerve. Dissection is carried down through the subcutaneous tissue to the deep forearm fascia. If the tendon rupture is partial, the tendon may appear intact and course deep toward the radial tuberosity. If the tendon rupture is complete, the tendon may have migrated proximally. If the tendon has migrated proximally, division of the lac-ertus fibrosis facilitates tendon exposure. At times, a swollen, fluid-filled tendon sheath obscures the tendon. Incising the sheath usually releases serosanguineous fluid. If the tendon still is not visible, milking and flexing the arm may advance the tendon into view. Sometimes the tendon can be brought down by inserting a finger proximally and medially in the incision. If the surgeon can palpate the tendon, he or she may be able to expose the end of the tendon with deep retractors and grasp it with a Kocher clamp (Fig. 9.4). Alternatively, the surgeon can make a small incision proximal and medial to the elbow flexion crease to retrieve the tendon (see Fig. 9.3). The tendon then can be passed safely into the distal incision. The use of two separate incisions, rather than a standard S-shaped incision that crosses the anterior elbow, usually provides a more cosmetically pleasing result.

After passing the tendon into the distal incision, a Kocher clamp is placed transversely at the distal end of the ruptured tendon. Traction is applied for a few minutes to overcome muscle contracture and tendinous adhesions. Blunt digital dissection usually is adequate to release the peritendinous adhesions. Two Keith needles are threaded on a no. 5 nonabsorbable suture. The suture is

FIGURE 9.4. The distal end of the ruptured biceps tendon. Note the thickened, swollen, nodular appearance suggestive of chronic inflammation.

passed transversely near the musculotendinous junction. A Bunnell suture is placed with which to grasp the tendon. The needles should be passed simultaneously so that the suture material is not cut (Fig. 9.5). Small cuts on the medial and lateral aspects of the distal end of the ruptured tendon allow the surgeon to pass the Keith needles out of the freshly debrided tendon while still grasping the tendon with the Kocher clamp. After passing the needles and suture through the distal stump, the surgeon can safely divide the residual tendon, which is being held firmly in the Kocher clamp (Fig. 9.6). Unless the Keith needles are swagged onto the suture, small clamps should be kept on the ends of the suture to prevent the needles from sliding off. The Keith needles and suture ends then are wrapped in towels and set aside to prevent accidental puncture of the protective drapes or injury to the operating room personnel.

The next step is exposure of the radial tuberosity. If the tendon sheath is still visible, a Kelly clamp can be passed down the sheath to the tuberosity. Slow, careful dissection about the clamp exposes the radial tuberosity. Frequently, however, the tendon sheath is not visible. In this case, the tuberosity can be exposed safely by dissecting lateral to the midline and close to the extensor muscle mass. Generally, two or three veins and a branch of the recurrent radial artery must be ligated. Once the vessels are ligated, a blunt-tipped cobra retractor can be placed around the radial neck. The cobra retractor is crucial to the exposure of the radial tuberosity because it protects the medial neurovascular structures (Fig. 9.7). If the tissue is dissected lateral to the midline, the median nerve usually cannot be seen. Inadvertent dissection medial to the midline exposes the median nerve. The forearm is supinated, and the radial tuberosity is visualized. Shreds of tendon often still are attached to the tuberosity. If the patient has a partial tear, serosanguineous fluid is released as the tuberosity is approached. Careful inspection of the

FIGURE 9.5. (A) Keith needles are passed simultaneously for placement of the Bunnell suture through the distal end of the biceps tendon. (B) At least three separate passes can be made.

FIGURE 9.5. (A) Keith needles are passed simultaneously for placement of the Bunnell suture through the distal end of the biceps tendon. (B) At least three separate passes can be made.

Keith Needle For Tendon TransferTendond Sutturing

FIGURE 9.6. (A) Suture exiting from the freshly debrided end of distal biceps tendon. (B) Ruptured biceps tendon is brought out through the distal incision. (C) and (D) Lateral views of the tendon with the Bunnell sutures woven through it.

FIGURE 9.6. (A) Suture exiting from the freshly debrided end of distal biceps tendon. (B) Ruptured biceps tendon is brought out through the distal incision. (C) and (D) Lateral views of the tendon with the Bunnell sutures woven through it.

distal attachment can demonstrate nearly complete detachment of the tendon from the tuberosity. If a portion of the tendon is still attached, it generally is attached at the proximal end of the tuberosity. In nearly complete ruptures, the small remaining fibers are divided to facilitate repair.

Using a rongeur, the surgeon removes bursal and tendinous tissue from the radial tuberosity. Next, he or she makes a trough in the radial tuberosity either with a power burr or with drill holes. Because burrs usually have small shanks, I prefer to use drill bits. An awl is used to make two or three holes in a straight line over the tuberosity. The distance between the awl holes should be approximately \ in., which is usually the diameter of the largest drill bit that can be inserted comfortably into the tuberos ity. Any bridging bone between the holes can be removed with a rongeur, creating a trough that comfortably contains the end of the distal biceps tendon. The surgeon secures the biceps tendon in the trough by making two holes in the posterior cortex.

The drill holes in the posterior cortex of the radial neck are made with 0.062 smooth Kirschner wires (K-wires). The K-wires are directed posteriorly and aiming toward the posterior edge of the extensor muscle mass. This edge is one or two fingerbreadths anterior to the posterior edge of the subcutaneous proximal ulna. While maintaining a finger over the posterior edge of the extensor muscle mass and holding the patient's arm in full supination, the surgeon makes a hole in the posterior cortex with a 0.062 smooth K-wire. Directing the wire toward the postero-

FIGURE 9.7. (A) Placing the cobra retractor around the medial aspect of the proximal radius protects the medial neurovascular structures and exposes the radial tuberosity. (B) The biceps tendon is retracted. Note that the frayed shreds of biceps tendon are still attached to the tuberosity.

FIGURE 9.7. (A) Placing the cobra retractor around the medial aspect of the proximal radius protects the medial neurovascular structures and exposes the radial tuberosity. (B) The biceps tendon is retracted. Note that the frayed shreds of biceps tendon are still attached to the tuberosity.

lateral edge of the proximal ulna helps to avoid injury to the more anterior posterior interosseous nerve. The K-wire is left in place as a directional guide. A similar wire is placed more distal following the general direction of the first wire, but converging posteriorly (Fig. 9.8). The holes generally are placed proximally and distally in the posterior cortex to provide an adequate bony bridge. The K-wires are removed, and a Keith needle is passed

FIGURE 9.8. (A) The trough has been created in the tuberosity, and the first 0.062 K-wire is in place. (B) Note the distance between the K-wires and the convergence posteriorly.

FIGURE 9.8. (A) The trough has been created in the tuberosity, and the first 0.062 K-wire is in place. (B) Note the distance between the K-wires and the convergence posteriorly.

through each drill hole and pushed posteriorly through the soft tissues (Fig. 9.9).

The sutures are retrieved by flexing the patient's elbow and making a small incision over the protruding Keith needles. The incision only needs to be large enough to allow the surgeon to retrieve the sutures and tie a knot. The needles are removed and traction is applied to the sutures, bringing the tendon end into the bony trough (Fig. 9.10). While the patient's elbow is flexed and supinated, the sutures are tied. No attempt is made to dissect down to the posterior cortex of the radius. The sutures are tied directly over the posterior muscle mass. Most of the time, the end of the tendon lies within the intramedullary cavity of the radius; however, sometimes it rests at the entrance to the trough. Either position is acceptable and has not been shown to affect the clinical outcome.

After tying the sutures, the surgeon should measure the passive elbow range of motion. Full pronation and supination and full flexion should be expected. However, flexion contractures of 20° to 30° are relatively common. With delayed repairs, the flexion contracture may be more than 45°. The degree of contracture should be noted because it affects postoperative mobilization.

The anterior and posterior wounds are closed. A longarm splint is applied with the patient's forearm in supination and elbow flexed slightly more than the recorded flexion contracture.

Table 9.1 outlines the postoperative regimen.20-23 At 7 to 10 days after surgery, the sutures are removed and a long-arm cast is applied with the patient's arm in a posture similar to that of the postoperative splint. The cast is removed at 3 to 4 weeks after surgery, and the elbow

Bicep Brachii Cross Section

FIGURE 9.9. (A) Passage of the Keith needles through the skin posteriorly. (B) Cross-sectional anatomy in the region of the tuberosity shows the course of the K-wires in relation to the surrounding vital structures. Note proximity of the posterior interosseous nerve. (C) Drawing demonstrates the close association between the distal biceps tendon and nearby vital structures.

FIGURE 9.9. (A) Passage of the Keith needles through the skin posteriorly. (B) Cross-sectional anatomy in the region of the tuberosity shows the course of the K-wires in relation to the surrounding vital structures. Note proximity of the posterior interosseous nerve. (C) Drawing demonstrates the close association between the distal biceps tendon and nearby vital structures.

Distal Bicep Nerve Concern
FIGURE 9.10. The tendon end is drawn into the bony trough with distal traction on the posterior sutures.

is gently put through a range of motion. At this point, patients usually demonstrate a slight loss of supination and continue to demonstrate a loss of elbow extension. The arm then is placed in a hinged brace with an extension stop at the degree of terminal elbow extension noted at the 3- to 4-week visit. The extension stop is decreased gradually until full extension is reached. The patient begins isotonic and isokinetic strengthening exercises 8 weeks after surgery. Return to all activities is allowed at 12 to 16 weeks after surgery.

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