(aspects of trauma • a review paper)

Treatment of Distal Tendon Ruptures Benjamin J. Widmer, MD, and Robert Z. Tashjian, MD

Abstract n 1925, Biancheri1 examined nates at the supraglenoid tubercle Distal biceps tendon rupture is the incidence of biceps ten- and traverses the an injury typically reported in the don ruptures and found that before exiting through the later- dominant extremity of middle- 96% ruptured at the long head, al rotator cuff interval. It then aged men. Clinical findings are I 1% proximally at the short head, passes through the intertubercular the mainstay of diagnosis, but 2 magnetic resonance imaging or and 3% distally. In 1941, Dobbie groove into the proximal . The ultrasound imaging can provide specifically examined distal biceps short head takes origin from the additional diagnostic information. injuries and made an early attempt coracoid. The distal biceps ten- Anterior 1- or 2-incision repairs are at a meta-analysis. He reviewed the don inserts into the radial tuberos- commonly used. Various fixation 24 surgically treated cases of distal ity and supinates the and techniques have been reported, biceps injuries previously reported assists with flexion.8 It also all with comparable biomechani- in the literature and sent a ques- functions as a secondary elevator cal results and clinical outcomes. tionnaire to almost 500 active sur- and abductor of the shoulder.9 Complication rates are lower in patients treated closer to time of injury. Tendon retraction associat- ed with chronic ruptures can pre- sent a difficult surgical problem. “Partial ruptures should be treated Advanced soft-tissue imaging adds helpful information about the without surgery initially..” level of biceps tendon retraction Protected and possible reparability. When the tendon can be reapproximated geons. From their replies, he identi- Elbow and forearm position safely at less than 45° to 90° fied 51 new cases of distal biceps has been determined to affect the of elbow flexion, then primary repair may be performed. When injuries repaired with a variety of function of the biceps muscle. reapproximation is not possible, techniques and noted that the “end Electromyograms have demon- options are reconstruction and results as reported are equally satis- strated that the flexion activity of tenodesis. Reconstruction per- factory” independent of technique the biceps is inhibited by forearm formed through 1 or 2 incisions and are “for the most part excel- pronation.10 Maximum supination with either allograft or autograft lent.” He identified only 3 reported strength is achieved with forearm has successfully restored both complications. flexion, and maximum flexion motion and power. Interest in the surgical treatment strength is achieved with forearm of distal biceps injuries has continued supination.11 to grow with the 1961 description by The blood supply to the distal Dr. Widmer is Resident, and Dr. Tashjian Boyd and Anderson3 of a 2-incision biceps tendon is somewhat tenuous. is Assistant Professor, Department of repair technique and more recently The brachial artery provides proxi- Orthopaedics, University of Utah School with several reports4-7 of promis- mal perfusion, and the distal blood of Medicine, Salt Lake City, Utah. ing results with 1-incision repairs. supply stems from the posterior This increased interest is reflected radial recurrent artery and the bra- Address correspondence to: Robert in a “distal biceps tendon ruptures” chial artery. This leaves a watershed Z. Tashjian, MD, University of Utah PubMed search that yielded 46 cita- area approximately 2 cm in length Orthopaedic Center, 590 Wakara Way, tions for calendar year 2007. 1 to 2 cm proximal to the insertion.12 Salt LakeCopyright City, UT 84108 (tel, 801-587- 5457; fax, 801-587-5411; e-mail, robert. More details about the distal [email protected]). Distal Biceps Tendon biceps footprint have been revealed Anatomy in recent years. The biceps ten- Am J Orthop. 2010;39(6):288-296. The biceps muscle has 2 tendinous don occupies 85% of the proximal Copyright Quadrant HealthCom Inc. origins and 1 tendinous insertion. radioulnar joint at the level of the 2010. All rights reserved. The long head of the biceps origi- tuberosity in full pronation and

288 The American Journal of Orthopedics® B. J. Widmer and R.Z. Tashjian

tinct distal tendons (distal exten- sions of the long- and short-head muscle bellies) were easily identi- fied as receiving equal musculocu- taneous innervation and attaching separately to the . The long-head distal tendon was noted to be crescentic and deep and to insert proximally, whereas the short-head distal tendon was con- sistently oval and superficial and inserted distally14 (Figure 1). The tendon insertion is a mean Figure 3. Lateral antebrachial cutaneous 23 mm distal to the articular mar- nerve just lateral to distal biceps tendon gin, is located on the posterior/ during anterior approach for repair. ulnar aspect of the tuberosity, and is oriented 30° anterior to the coro- Andover, Mass), and so forth—is Figure 1. Anatomy of radial tuberosity nal plane with the arm fully supi- directed slightly radial during inser- insertion of distal biceps tendon. nated.15 With the arm in full supi- tion (Figure 2). nation, the center of the tuberosity 35% in full supination. This repre- is a mean 45° anterior to horizontal Surgical Anatomy sents a 50% reduction in the space in the plane of the forearm, and the An understanding of the relevant available for the tendon during posterior margin of the tuberosity surgical anatomy is essential to safe transition from supination to pro- is a mean 15° anterior to horizontal and efficient distal biceps repair. nation.12 The radial tuberosity has in the plane of the forearm. These The musculocutaneous nerve been found to have 2 distinct por- anatomical properties result in the innervates the biceps and brachialis tions—a rough posterior portion tendon inserting approximately 30° and then continues in the interval for tendon insertion and a smooth, anterior to horizontal in the plane between these 2 muscles as the bursa-covered anterior portion.12 of the forearm (halfway between lateral antebrachial cutaneous The tuberosity is 24 mm proximal the posterior margin andProtected the tuber- (LABC) nerve. This nerve provides to distal and 12 mm medial to lat- osity center) in full supination. sensation to the lateral forearm. eral. The tendon footprint is 19 mm When there is a rotational deficit It should be carefully identified proximal to distal and 4 mm medial limiting full supination, this loca- and protected during distal biceps to lateral.13 Therefore, the tendon tion can make a 1-incision repair repair, as a traction injury can attaches to only approximately one difficult. Similarly, with the 1-inci- result in numbness or paresthe- third of the overall width of the sion technique, a more anatomi- sias along the forearm. The LABC tuberosity (Figure 1). In addition, cal repair can be achieved when nerve is superficial and just lateral an anatomical study demonstrated the fixation instrument—anchors, to the biceps tendon and is easily that, in 10 of 17 specimens, 2 dis- EndoButton (Smith & Nephew, identified during initial exposure (Figure 3). Care should be taken during repair to not reroute the distal biceps anterior to the nerve. The radial nerve runs between the brachialis and the brachiora- dialis and is usually out of the surgical field during dissection. It bifurcates just anterior to the lat- eral epicondyle, and the posterior interosseous nerve courses radially to enter the supinator while the Copyright superficial radial nerve continues distally beneath the brachiora- dialis. Although the nerve is not routinely exposed during surgery, constant awareness of it and its dis- tal posterior interosseous branch is Figure 2. Angulation of radial tuberosity insertion of distal biceps tendon. needed while retractors are being

June 2010 289 Treatment of Distal Biceps Tendon Ruptures

and age-matched cadaveric controls of a variety of ruptured tendons, including the distal biceps. All ruptured tendons were abnormal: 97% demonstrated degenerative changes, and inflammatory find- ings accounted for the other 3%. In the age-matched cadaveric controls, however, degenerative changes were found in only 34% of specimens. Finally, a relatively hypovascular zone of the distal tendon has been Figure 4. Hook test. Patient’s arm is abducted and elbow flexed to 90° with forearm in proposed as a possible predispos- supination; examiner hooks index finger behind distal biceps tendon. ing factor leading to distal biceps tendon ruptures. The hypovascular placed posterolateral to the radial to 39, 0.5 in ages 40 to 49, and 0.7 zone is located within the tendon tuberosity. We prefer to not hook in ages 50 to 59. Ninety-three per- substance distally, not directly at instruments, like Hohman retrac- cent of patients were men, and 50% the tendon insertion. Most ruptures tors, posterior to the but of cases were in patients 30 to 39 are tuberosity avulsions, not mid- rather to use several deep right- years old. The dominant extremity substance ruptures, though muscu- angle retractors for exposure. The was involved in 86% of cases, and lotendinous injuries have also been median nerve courses ulnarly to an eccentric contraction preceded described.12,20 Therefore, given the the brachial artery and along the all injuries. Smokers had more than common location of tendon rup- radial aspect of the pronator teres 7-fold increased risk for rupture. tures, the zone of limited vascular- before diving deep to the flexor ity is unlikely to have a significant digitorum superficialis. Finally, the Etiology effect on the rate of ruptures. lacertus fibrosis extends from the The etiology of distal biceps ten- biceps tendon ulnarly and overlies don injuries is multifactorial and Clinical Evaluation the brachial artery, the bifurca- includes mechanical failure, tendon Distal biceps tendon injuries rep- tion of the brachial artery, and the degeneration, and limitedProtected vascu- resent a spectrum of disease from median nerve. Release of the lacer- larity. Mechanical factors include tendonitis to partial-thickness tears tus is often required to obtain suf- relative interosseous impingement to complete tears. In addition, ficient mobilization of the biceps to caused by full pronation, which intact tendons may become symp- achieve a repair without significant may lead to degeneration from tomatic because of bicipital tendi- tension. repetitive compression.12 In addi- nosis (intrasubstance degeneration) tion, an oblique vector is applied or cubital bursitis. The clinician Epidemiology to the intact tendon with contrac- should be aware of this variety This injury classically has involved tion of the flexor-pronator mass. of pathology and not discount a the dominant extremity of male This contraction increases the possible injury when a complete laborers in the fourth and fifth cross-sectional area of the flexor- rupture is not identified. decades of life. It typically has pronator mass, thereby placing the Partial ruptures present with a been associated with eccentric lacertus fibrosis on tension. The palpable but painful tendon and contraction of the biceps with the tense, medialized lacertus fibrosis are most easily confused with ten- elbow in midflexion.16 Ruptures initiates an oblique force vector dinosis or bursitis. Pain is exacer- have also been described in vari- on the biceps tendon.14 Tendons bated with resisted elbow flexion ous systemic conditions, including perform the worst when obliquely and forearm supination. The hook rheumatoid arthritis, ankylosing loaded during eccentric contrac- test is typically intact but painful.21 spondylitis, gout, systemic lupus tion, thereby potentially predispos- This test is performed with the erythematosus, syphilis, tuberculo- ing the distal biceps to rupture arm abducted to 90° and the elbow sis, malignancy, and end-stage renal compared with tendons having a flexed to 90° with the forearm in disease.17 dissimilar loading pattern.18 supination. The examiner’s finger Copyright17 Safran and Graham more accu- Tendon degeneration has been is then used to “hook” the biceps rately characterized the incidence implicated as a cause for tendon tendon from lateral to medial in of this injury and defined the possi- rupture in numerous anatomical the antecubital fossa (Figure 4). ble role of smoking in predisposing sites, including the distal biceps. When the tendon can be hooked, patients to ruptures. They found an Kannus and Jozsa19 histologically at least some portion of the ten- incidence of 1.5/10,000 in ages 30 analyzed tendon rupture specimens don is intact.21 In a cohort of 45 290 The American Journal of Orthopedics® B. J. Widmer and R.Z. Tashjian

extensor digitorum communis and the supinator was described for complete débridement and refix- ation through transosseous tun- nels.23 Six of 8 patients in the series were “completely satisfied” with their outcome.

Treatment of Figure 5. Skin incision for anterior approach for distal biceps tendon repair 2 finger- Acute Ruptures breadths distal to flexion crease centered over radial tuberosity. The rationale for acute repair of distal biceps ruptures stems pri- patients who underwent surgical palpable distal arm mass associ- marily from 2 studies that found exploration of the distal biceps ated with a palpable defect and persistent weakness and fatigue of tendon, the hook test was 100% an abnormal hook test provides elbow flexion and forearm supina- sensitive and specific in diagnosing evidence confirming the rupture. tion without repair.8,24 Both stud- a complete distal rupture.11 The In these cases, MRI or ultrasound ies evaluated strength with iso- authors reported that sensitivity may be quite helpful in evaluating kinetic dynamometry. In one,24 and specificity were higher for the the level of tendon retraction. An the nonoperative group demon- hook test than for MRI (92% sen- intact lacertus fibrosis can limit strated a 21% loss of strength and sitive, 85% specific) in diagnosing proximal migration of chronical- endurance in elbow flexion, a 27% a complete rupture in their series. ly ruptured tendons. Significant loss of supination strength, and a MRI or ultrasound can be helpful retraction may limit the surgeon’s 47% loss of supination endurance, in identifying abnormal intratendi- ability to perform a direct repair, whereas the operative group dem- nous signal changes associated with leaving a tenodesis to the brachialis onstrated mildly increased levels bicipital tendinosis and tuberosity and a salvage reconstruction using of performance in these trials. edema or partial tendon avulsions a soft-tissue graft as the only pos- The other study8 demonstrated a associated with partial tears. sible surgical options. 30% loss of flexion strength and Musculotendinous junction inju- a 40% loss of supination strength ries are rare; only a few have been Treatment of PaProtectedrtial compared with the contralater- reported.20 Presenting clinical find- Ruptures al extremity in the nonoperative ings are similar to those of tendini- Partial ruptures should be treated group; with anatomical repair, tis and partial rupture. MRI is use- without surgery initially. The vast patients’ strength recovered to ful in differentiating musculotendi- majority of partial ruptures result near normal. nous injuries from partial ruptures. from degenerative changes associ- Patients with musculotendinous ated with a traumatic injury, either Operative Technique injuries typically do very well with single events or smaller, repetitive for Acute Repair nonoperative management.20 insults. Anti-inflammatory medi- Patients with acute ruptures typi- cations can decrease symptoms Two-Incision Technique. In 1961, cally develop distal arm pain and but are unlikely to improve the Boyd and Anderson3 were the swelling associated with ecchymosis underlying pathology. Activity first to describe using a 2-incision and a traumatic event. Range of modification and physical therapy approach for anatomical repair of motion is limited, and there is a are also reasonable nonoperative the distal biceps tendon. This repair palpable defect in the antecubital treatments. has been modified numerous times, fossa; this defect is often exacer- When nonoperative options have but its essential principles remain bated by elbow flexion. The hook been exhausted, the surgical option unchanged. The repair begins with test is often positive. MRI or ultra- of choice is release of the remaining a small transverse incision about 2 sound may be used to confirm the distal biceps tendon, débridement fingerbreadths distal to the antecu- diagnosis and evaluate the level of of the biceps tuberosity, and reat- bital flexion crease (Figure 5). The tendon retraction. tachment. This surgery may be per- track of the biceps tendon is iden- ChronicCopyright ruptures often present formed with an anterior or posteri- tified and explored. The tendon with a history similar to that of or approach. A series of 7 patients is freed of soft-tissue attachments acute ruptures, but on a delayed treated with anterior repair had and scar tissue, and the lacertus basis. After the patient recovers “uniformly good results,” with 2 fibrosis is released. After excursion from the initial pain of injury, supi- patients sustaining transient LABC is sufficient, 2 braided, nonabsorb- nation weakness and early biceps palsies.22 A posterior approach able sutures are placed into the muscle fatigue may persist. A through a longitudinal split in the tendon in running-locking fash- June 2010 291 Treatment of Distal Biceps Tendon Ruptures

medially, laterally, and distally dur- ing the repair. Hohman retractors are avoided to limit placement of retractors posterior to the proximal radius and possible injury to the posterior interosseous nerve. The tendon is then securely fixed with suture anchors or an EndoButton.

Suture Anchors. Two cortical anchors are placed in the tuberos- ity perpendicular to the cortex, 1 Figure 6. Anterior exposure of radial Figure 8. Final repair of 1-incision tech- distally and 1 proximally (Figure tuberosity with 2 anchors in place. nique using anchors. 6). One limb of the braided, non- absorbable No. 2 suture from 1 anchor is then placed into the distal 3 to 4 cm of the tendon in running- locking fashion. One limb of the No. 2 suture from the other anchor is then run in Bunnell fashion into the tendon (Figure 7). The elbow is placed in 30° of flexion, and the suture for the distal anchor is held taut while the proximal suture is tied. The distal suture is then tied (Figures 8, 9).

EndoButton. During instrumenta- Figure 7. Distal biceps tendon with Figure 9. Lateral radiograph of elbow single limb of suture from each anchor shows placement of suture anchors. tion of the radial tuberosity, the sutured into distal tendon (1 with Protectedarm must be maintained in full Krackow suture, 1 with Bunnell suture). supination. The guide pin should a 1-incision anterior approach, it be started centrally in the tuberos- ion. A clamp is placed around the is important to recall that the true ity and aimed 30° ulnarly to avoid tuberosity through the interosseous anatomical insertion is difficult the posterior interosseous nerve.25 membrane while much care is taken to access, even in full supination The guide pin is overdrilled with the not to disturb the ulnar periosteum. (Figure 2). The approach begins appropriate drill provided by the A second dorsal incision is made with a transverse incision 2 finger- device manufacturer. All remain- over the now subcutaneous clamp, breadths distal to the antecubital ing soft tissue is removed from and dissection is carried down to flexion crease. Several large veins the tuberosity. EndoButton sutures the radial tuberosity. A high-speed of the antecubital venous complex are placed in running-locking fash- burr is used to prepare a trough need to be mobilized, and often ion in the distal 3 to 4 cm of in the tuberosity, and 3 transosse- ligated, to gain adequate exposure the tendon. The sutures are tied ous tunnels are placed through the for repair. The distal biceps track over the button, leaving a 3-mm posterior wall of the trough. The and tendon stump are identified, gap between the knot and the but- clamp is then used to deliver the and the tendon is released from ton so it can traverse the far cor- sutures through the interosseous adherent soft tissue and the lacertus tex. The forearm is flexed to 90° membrane into the wound. The fibrosis. Care is taken to avoid exces- and supinated before the guide pin tendon is placed into the trough, sive radial retraction, as this can is used to pass the “kite string” and the sutures are passed through injure the LABC nerve. Blunt dis- sutures through the posterior cor- the transosseous tunnels and tied. section is carried down to the radial tex and soft tissues. The kite-string The Copyrightwounds are then irrigated and tuberosity between the brachiora- sutures are then manipulated to closed. dialis and the pronator teres. The “flip” the button into the trans- One-Incision Technique. One- radial recurrent branches are pre- verse position and lock the tendon incision techniques are also in wide- served, if possible. The radial tuber- into the tuberosity. The kite-string spread use and are gaining popular- osity is identified, and all remaining sutures are then pulled through ity with improvements in implants soft tissue is removed. Deep right- the button and out of the skin4 used for tendon repair. When using angle retractors are used to retract (Figure 10).

292 The American Journal of Orthopedics® B. J. Widmer and R.Z. Tashjian

cyclic load-displacement testing of various fixation constructs has been performed in cadaver mod- els. Some authors have reported that EndoButton fixation is stron- ger than either suture anchors or tunnels as a biomechanical construct.4,33-36 Other investiga- tors have found interference screw fixation superior to both suture anchors and transosseous tech- niques.37,38 Still others have found Figure 10. Lateral radiograph of elbow Figure 12. Augmentation of distal biceps no meaningful difference between shows placement of EndoButton (Smith tendon with semitendinosus allograft these various fixation methods.39 & Nephew, Andover, Mass). using Pulvertaft weave through distal In a single cadaveric study, biceps tendon stump. Mazzocca and colleagues35 evalu- been recommended for tendons ated various distal biceps repairs, that can be reapproximated with including transosseous tunnels, 45° to 90° of elbow flexion.7,26,27 suture anchors, tenodesis screw fix- When primary repair is not fea- ation, and EndoButton. They found sible, there are 2 surgical options: no significant difference between tenodesis to the brachialis muscle methods in cyclic displacement, and extension of the remaining which ranged from 2.25 to 3.5 mm distal biceps tendon with a tendon in all specimens. They determined graft. Numerous grafting options mean loads to failure to be 439 N and fixation methods have been for EndoButton, 381 N for suture described. Several authors have anchors, 310 N for transosseous had success with use of transosse- tunnels, and 231 N for tenodesis Figure 11. Distal biceps tendon stump ous tunnels, suture anchors, and screw. The EndoButton load to in chronic injury precludes direct repair. EndoButtons in combinationProtected with failure was significantly larger than Achilles allograft, semitendinosus that of all other tested constructs. Treatment of Chronic allograft/autograft, and flexor carpi No other relationships between Ruptures radialis autograft27-31 (Figures 11, constructs reached statistical sig- In the chronic setting (>4 weeks 12). Nonanatomical reconstruction nificance. Although significant from injury), the tendon may by tenodesis to the underlying bra- differences can certainly be dem- retract significantly and require chialis can be clinically successful, onstrated in the laboratory, they grafting for anatomical reconstruc- particularly in recovering flexion may be less relevant in the clinical tion. With advances in surgical strength. It is essential to prop- setting. All techniques are likely technique and fixation implants, erly tension the biceps muscle, or sufficient for early passive motion, anatomical reconstructions aug- pronounced weakness can result. and EndoButton fixation may mented with a graft are becoming Flexion strength with tenodesis allow early active motion.35 Active easier to perform. Nonanatomical has been reported to equal that elbow flexion in cadaveric speci- reconstructions should still be of anatomical repair, but half of mens was shown to require only 25 considered in these cases, with the the patients who undergo tenodesis N for flexion to 30°, 35 N for flex- final decision regarding surgical lose 50% of supination strength. ion to 90°, and 67 N for flexion to treatment based on the individual Endurance in flexion and supina- 130°.4 The largest specimen in this patient’s needs, functional deficits, tion did not differ significantly study required 123 N for full elbow and expectations. Although preop- between acute repair and tenode- flexion.4 Consequently, the loads to erative imaging may aid in the deci- sis.32 failure reported by Mazzocca and sion to perform a primary repair colleagues35 in the weakest con- or reconstruction,Copyright the final deci- Biomecha nics struct still far surpassed the in vitro sion is made during surgery. During Given the numerous fixation forces required for immediate active exposure, the lacertus fibrosis and options, an understanding of the range of motion. any additional soft-tissue restraints biomechanics of various repair The effect of reinsertion location must be released. The feasibility techniques is essential to deter- on ability of a repair to restore of tendon reapproximation is then mining the optimal surgical con- the normal flexion and supination determined. Primary repair has struct. Both load-to-failure and force imparted by the biceps ten-

June 2010 293 Treatment of Distal Biceps Tendon Ruptures

don was also examined in a cadaver of 0° to 141°, pronation-supina- Outcomes of Chronic Injuries model.39 In the native state, the tion of 74° to 75°, and a mean As already mentioned, significant radial tuberosity acts as a cam to DASH score of 3.6.40 Both isomet- delays in treatment typically pre- increase supination torque. When ric and dynamic flexion strength dispose patients to increased risk the tendon is not reinserted ana- improved to mildly better than for postoperative complications.41,43 tomically into the posterior tuber- that of the normal side, whereas However, surgically treated chron- osity, loss of the cam effect theoret- isometric and dynamic supination ic ruptures can show significant ically could result. In that cadaveric returned to within 11% of the improvements in function and study,39 1 elbow specimen from a normal side. In another series, all strength. In a series of patients matched pair underwent a 1-inci- 45 patients treated with the 2-inci- evaluated a mean of 119 days after sion anterior repair with transos- sion technique regained “without injury, those treated without sur- seous fixation while a 2-incision a complication” normal motion gery demonstrated a persistent repair into the posterior tuberos- and neurologic function, accord- 20% loss of forearm supination ity with transosseous tunnels was ing to retrospective review.41 A and elbow flexion strength, and performed on the opposite elbow. review of 13 patients documented those treated with semitendinosus

“...significant delays in treatment typically predispose patients to increased risk for postoperative complications.”

No significant difference was found that flexion strength of 91% and autograft augmented reconstruc- between groups in either forearm supination strength of 84% of the tion regained normal supination supination torque or elbow flexion contralateral side were regained.42 and flexion strength compared force with a similar load applied Mean motion loss of 3° pronation, with a group of uninjured con- to the biceps muscle. These results 8° supination, and 6° extension trols. Neither group demonstrated suggest that whether the tendon was reported. a change in endurance strength.31 is reinserted anatomically into the Other investigators have report- footprint or into the anterior aspect Rehabilitation ed similar encouraging results for of the tuberosity, the functional dif- Early, protected passiveProtected motion reconstruction of chronic rup- ferences are likely to be minimal. traditionally has been used after tures.27,30 Supination and flex- repair. Recently, several authors ion strength typically recovered Functional Outcomes and have challenged this idea with to 80% to 90% of normal, and Complications the institution of more aggressive motion recovered to near normal. postoperative therapy protocols Supination strength in chronic rup- Outcomes of Acute Injuries that include early active motion. tures that were primarily repaired Recent reports have described suc- Cheung and colleagues42 used a was mildly decreased compared cess in using the 1-incision ante- postoperative protocol beginning with supination strength in chronic rior approach in restoring patient with immediate passive motion in ruptures that underwent recon- function and minimizing complica- a hinged brace limited between struction with a graft. tions. A single-surgeon series of 53 full flexion and 60°. The extension acute repairs with suture anchors block was increased by 20° every Complications found restoration of normal motion 2 weeks until full extension was Several authors have reported com- to within 5° in all parameters.6 achieved. No reruptures or compli- plications after acute repair with Disabilities of the Arm, Shoulder, cations were reported. Cil and col- a 1-incision technique. In a single- and (DASH) scores were not leagues40 advocated a more aggres- surgeon series of 53 cases, patients significantly different from those of sive protocol in which no exten- sustained 1 wound complication, 2 normal controls. No reruptures or sion block is required. Twenty-one transient paresthesias of the LABC heterotopic ossification was report- patients underwent 2-incision nerve, and 1 posterior interosse- ed. Another single-surgeon series repair; after surgery, they were ous nerve palsy that resolved in withCopyright suture anchors found 7 good treated with a sling for 1 to 2 days 6 weeks.6 In another series of 53 and 46 excellent results according and then allowed full active motion patients, no infections or reruptures to Andrews-Carson scores.5 No with daily activities and a 1-pound were reported, but mild motion patients reported fair or poor results. weight restriction for 6 weeks. At limitation due to heterotopic ossifi- A series of 21 patients treated minimum 2-year follow-up, there cation was found in 4% of patients, with a 2-incision technique dem- were no clinical disabilities or ten- and a transient radial nerve palsy onstrated mean flexion-extension don ruptures. occurred in 2% of patients.5

294 The American Journal of Orthopedics® B. J. Widmer and R.Z. Tashjian

cation rate, but the authors who to 86°, and pronation to 65°. These compared operative and nonop- range-of-motion values were found erative treatment reported no infec- to be no different from those for tions, radial nerve palsies, hetero- acute repair controls. topic ossification, or ruptures in the 7 patients treated surgically.31 In a Conclusions series of 4 patients who underwent Distal biceps tendon rupture is a Achilles tendon allograft recon- relatively unusual injury typically struction, no complications were reported in the dominant extrem- noted at a mean follow-up of 3 ity of middle-aged men. Clinical years.30 One in a series of 7 patients findings are the mainstay of diag- with Achilles allograft reconstruc- nosis, but MRI or ultrasound Figure 13. Anterior heterotopic bone tion developed heterotopic ossifica- imaging can provide additional formation after 1-incision repair with tion that did not limit motion.27 No information. Either an anterior EndoButton (Smith & Nephew, Andover, other complications were encoun- 1-incision approach or a 2-incision Mass). tered in the series. These studies approach is acceptable for repair. imply a complication profile lower Various fixation techniques have A series of 74 patients treated than that found in acute repairs, been reported, all with comparable with a 2-incision, transosseous tun- but it is important to note that these biomechanical results and clinical nel technique and not stratified by chronicity revealed a complication “ rate of 31%.43 Six patients had per- Either an anterior 1-incision sistent anterior elbow pain, 5 had approach or a 2-incision approach is sensory paresthesias, 4 had hetero- topic bone formation, 3 had loss acceptable for repair.” of rotation, and 3 had superficial infections. In addition, 1 patient small series of reconstructions are a outcomes. Complication rates are had a rerupture, and 1 developed fraction of the size of most series lower in patients treated closer complex regional pain syndrome. published on acute repairs. to time of injury. Tendon retrac- When stratified by chronicity, the Protectedtion associated with chronic rup- overall complication rate was 24% Heterotopic Ossification tures can present a difficult surgi- in acute ruptures (<10 days), 38% Although relatively uncommon, cal problem. Advanced soft-tissue in subacute ruptures (10-21 days), radioulnar heterotopic ossification imaging adds helpful information and 41% in delayed ruptures (>21 with or without synostosis is one about the level of biceps tendon days). It should be noted that other of the most frustrating and dif- retraction and possible reparabil- investigators typically do not report ficult postoperative complications ity. When the tendon can be reap- persistent anterior elbow pain as a to manage for both patient and proximated safely at less than 45° complication. Another study, of 45 surgeon (Figure 13). In a series of 8 to 90° of elbow flexion, then pri- cases, found that 27% of patients patients who developed radioulnar mary repair may be performed. had 12 complications: 7 nerve heterotopic ossification after 2-inci- When reapproximation is not pos- complications, 3 functional synos- sion repair, motion was severely lim- sible, options are reconstruction toses, 1 rerupture, and 1 case of ited.44 All patients had been treated and tenodesis. Reconstruction per- complex regional pain syndrome.41 with primary repair within 14 days formed through 1 or 2 incisions Patients treated within 14 days of of injury. Flexion ranged from 115° with either allograft or autograft injury had a 20% complication to 135°, and rotation averaged 25° has successfully restored both rate, and patients treated 15 days and was absent in 2 patients. All motion and power. or more after injury had a 40% patients underwent open resection complication rate. Although the of heterotopic ossification a mean Authors’ Disclosure trend toward fewer complications of 6 months after primary repair. Statement in interventions performed within Treatment after resection includ- The authors report no actual or the firstCopyright 2 weeks is not significant, ed immediate continuous passive potential conflict of interest in rela- the authors found the procedure motion, 700-cGy external beam tion to this article. technically much easier to perform radiation on postoperative day 1, within 14 days of injury. and use of oral indomethacin for 3 References The increased complexity of weeks. Testing performed a mean of 1. Biancheri TM. Sulla rottura sottocutanea del bicipite brachiale. Chir Organi Mov. operative intervention for chronic 57 months after resection revealed 1925;9:580-602. ruptures suggests a higher compli- mean flexion to 135°, supination 2. Dobbie RP. Avulsion of the lower biceps

June 2010 295 Treatment of Distal Biceps Tendon Ruptures

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