No consensus exists in the literature on the optimal operative treatment method for distal biceps tendon ruptures. It is our hypothesis that a single-incision technique with a poly-L-lactide Bio-Tenodesis screw (Arthrex, Inc, Naples, Florida) is a safe and effective method for operative management of distal biceps tendon ruptures, with success and complication rates comparable to previous reports in the literature. This article describes a prospective case series of 29 consecutive patients (30 operations) managed by the same surgeon over 34 months. Average follow-up was 19.6 months. Two patients were lost to follow-up. Elbow range of motion (ROM) and strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and SF-12 score were measured at various time points up to 2 years.
All patients had full extension and supination. Supination and flexion strength was at least 4/5 in all patients. Mean DASH, SF-12 Physical Component (PCS), and SF-12 Mental Component (MCS) scores were 5.86 (range, 0-16.67), 50.35 (range, 30.4-60.1), and 57.15 (range, 41.7-64.4), respectively. These scores are comparable to normative values reported by the American Academy of Orthopaedic Surgeons. Complication rates were similar to those previously reported in the literature. This type of fixation allowed for early mobilization of the operative arm. Our study demonstrates that use of a tenodesis screw for distal biceps repair results in DASH and SF-12 scores comparable to the norm for the general population with complications similar to those seen in past studies. In addition, biomechanical studies suggest that the repair is strong enough to allow early ROM, and the fixation technique may allow for more anatomic positioning of the distal biceps along the ulnar border of the bicipital tuberosity.
Complete distal biceps tendon ruptures are uncommon injuries, with an estimated incidence of 1.2 per 100,000 people per year.1 Studies suggest that operative management with anatomic fixation of the distal biceps tendon restores elbow flexion and supination strength and results in superior outcomes when compared to nonoperative treatment.2-7 Overall complication rates with operative management have approached 30%.3,8 These complications include nerve injuries (specifically the radial sensory nerve, the posterior interosseous nerve, and the lateral antebrachial cutaneous nerve), radioulnar synostosis, heterotopic ossification, re-rupture, stiffness, decreased strength, complex regional pain syndrome, infection, and persistent pain.3,8
Operative management is broadly divided into single- versus 2-incision approaches. The single-incision approach is typically associated with an increased risk of nerve injury, while the 2-incision approach is more often associated with synostosis and heterotopic ossification.3,8,9 Fixation options include suturing through bone tunnels, suture anchors, cortical buttons, and tenodesis screws. Each of these options has advantages and disadvantages with regard to technical complexity and strength of fixation.
To our knowledge, there are only 2 reports in the literature that use a tenodesis screw alone for fixation of distal biceps tendon ruptures.10,11 The purpose of this study was to demonstrate that tenodesis screw fixation of distal biceps ruptures through a single-incision approach is a safe and effective method for operative management of distal biceps tendon ruptures, with success and complication rates comparable to those reported in the literature. In addition, screw fixation may provide some biomechanical advantages over other fixation methods, allowing for earlier mobilization and more anatomic positioning of the tendon.
Materials and Methods
This study received IRB approval. The study group comprised 29 consecutive patients presenting to a single surgeon (N.A.D.) from 2005 to 2007. All patients were treated with single-incision Bio-Tenodesis screw (Arthrex, Inc, Naples, Florida) fixation of the distal biceps tendon. A total of 30 surgeries were performed (1 patient ruptured both distal biceps tendons at different times). Two patients were lost to follow-up, leaving 28 operations in 27 patients. Information was collected from initial history and physicals, operative notes, and postoperative clinic notes. Disabilities of the Arm, Shoulder, and Hand (DASH), and SF-12 scores were collected postoperatively. Average follow-up was 19.6 months for DASH and SF-12 data. All patients were men with an average age of 45.8 years (range, 30-65 years). There were 9 right-sided and 19 left-sided injuries. Twenty-one of 27 patients were right hand dominant. Eleven of 28 tears (39.3%) occurred in the dominant arm. All patients were employed at the time of injury. Patient demographics are summarized in Table 1.
On preoperative examination, all but 2 patients had an obvious defect in the antecubital fossa (Figure 1). All but 1 patient had supination weakness, and 17 of 28 had flexion weakness. There was no radiographic evidence of a bony avulsion at the radial tuberosity in any patient. All but 4 patients underwent magnetic resonance imaging (MRI) (Figure 2). Twenty-six were complete ruptures, and 2 were high-grade partial ruptures (Table 2). The average time to surgery from date of injury was 23 days (range, 9-57 days). The average time from initial evaluation to surgery was 9.5 days (range, 3-39 days).
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Figure 1: Patient presenting with asymmetry and defect in his antecubital fossa. Figure 2: MRI demonstrating retraction after a complete distal biceps rupture.
All patients received general anesthesia. Regional blocks were not used. With the patient supine, the injured arm was positioned supine on a hand table. All patients received preoperative antibiotics and were prepped in a standard fashion. Tourniquet was not used. A 6-cm longitudinal incision was made from the elbow flexion crease distally, following a Henry approach. Any crossing veins were coagulated, and the radial tuberosity was exposed with the forearm in full supination. The biceps tendon was identified proximally, and the tendon was debulked and whipstitched so that it fit through a 7-mm sizing block. A mark was made 15 mm from the free end of the tendon.
Holding the forearm in full supination, an 8-mm reamer was used to make a tunnel 15 mm in depth in the radial tuberosity. A beath pin was aimed in a slightly ulnar direction and used to pass the stitches in the tendon out the dorsal aspect of the forearm. With the elbow at approximately 60° of flexion, 15 mm of tendon was seated along the ulnar side of the tunnel and an 8×12-mm Bio-Tenodesis screw was inserted until it was almost flush with the radial cortex (Figures 3, 4). The stitches were cut and the wound was irrigated and closed with Monocryl (Ethicon, Inc, Somerville, New Jersey). The operative arm was placed in a splint at 90° with neutral forearm rotation.
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Figure 3: Distal biceps tendon reattachment via a single-incision approach. Figure 4: Bio-Tenodesis screw.
One week postoperatively, the splint was removed, and patients were allowed to start full range of motion (ROM). No lifting >1 lb was allowed for 8 to 12 weeks. Physical therapy was initiated 4 to 6 weeks postoperatively if patients were not approaching full ROM at that time. Patients were transitioned back to all activities of daily living over 3 to 6 months postoperatively.
Patients were seen at regular postoperative intervals for 6 months. Longer follow-up was conducted in the office, through telephone interviews, and via DASH and SF-12 questionnaires sent through the mail. Two of 30 patients were lost to follow-up. At an average of 1 year, all patients had full ROM. There were no radioulnar synostoses. All patients had at least 4/5 strength with resisted supination and flexion. One patient had an MRI-confirmed partial re-rupture 6 months postoperatively while sustaining an eccentric load to his arm. He had mildly limited ROM and some pain with lifting but elected to be managed nonoperatively and continued to work full-time as a butcher. One patient developed calcific tendonitis in the midsubstance of the tendon between 3 and 6 months postoperatively that resolved by 18 months postoperatively. One patient developed complex regional pain syndrome and was managed by a pain specialist, but was lost to longer follow-up. One patient had undergone a total knee arthroplasty shortly before completing his DASH and SF-12, and this was reflected with an elevated DASH score and decreased SF-12 score.
There were no posterior interosseous nerve injuries. At 6-week follow-up, 42.3% of patients had numbness in the distribution of the radial sensory nerve, and 30.7% had numbness in the distribution of the lateral antebrachial cutaneous nerve. At last follow-up, 7.1% continued to have radial sensory nerve numbness, and 0% had continued lateral antebrachial cutaneous nerve numbness.
The outcomes measures and longest follow-up for each patient are summarized in Table 3. The mean DASH, SF-12 Physical Component (PCS), and SF-12 Mental Component (MCS) scores were 5.86 (range, 0-16.67), 50.35 (range, 30.4-60.1), and 57.15 (range, 41.7-64.4), respectively. Scores for each measure were found to improve as follow-up time increased. Normative values for the general population as reported by the American Academy of Orthopedic Surgeons are: DASH, 10.10±14.68; SF-12 PCS, 51.2; SF-12 MCS, 50.7.12,13
Nonoperative management of distal biceps tendon ruptures often results in permanent elbow flexion and supination strength deficits.2 This can be debilitating, particularly in the active middle-aged men who typically sustain this injury. Classically, distal biceps tears have been repaired through a 2-incision approach, popularized by Boyd and Anderson14 and modified by Morrey et al.5 This technique relies on suture fixation through bone tunnels. Complication rates with this procedure have approached 30%, with the most worrisome being nerve injury, radioulnar synostosis, and loss of ROM.3,8,9,15 In the past, concerns about fixation strength required a period of postoperative immobilization, which likely contributed to elbow stiffness.
As fixation options improved, the single-incision technique was developed in an effort to avoid some of these complications. Initially, suture anchors were used and, more recently, cortical buttons and tenodesis screws. The surgical approach is more difficult technically but carries a lower risk of synostosis.9,15 The risk of sensory nerve injury, in particular to the radial sensory and lateral antebrachial cutaneous nerves, appears to be higher with the single-incision approach.9,15 Some studies using suture anchors demonstrate postoperative decreases in ROM comparable to those seen with the earlier 2-incision approaches. This is most likely related to the length of postoperative immobilization.16,17 Two recent studies have demonstrated that 2-incision repairs with bone tunnels appear to be safe and consistently result in full or near full ROM.18,19
Multiple biomechanical studies have investigated the strength of the various fixation techniques.7,9,20-23 Pereira et al7 compared bone tunnels to suture anchors in a cadaveric model and concluded that the bone tunnel method was both stiffer and stronger than the anchors. Idler et al20 compared bone tunnels and interference screws to intact tendons in a cadaveric model and concluded that tenodesis screw fixation was significantly stronger than the bone tunnel technique and comparable to the intact tendon. Deirmengian et al9 reached similar conclusions. Mazzocca et al22 compared bone tunnels, suture anchors, interference screws, and cortical buttons and concluded that a cortical button had the highest load to failure and interference screws were best at resisting cyclic loading.
Most clinical studies published in the literature have shown good or excellent results in a majority of patients, regardless of the approach or fixation method used.10,15-17,24-26 In addition to 1 case report,10 a recent 14-patient case series describes the use of the Bio-Tenodesis screw alone in which all patients had a good or excellent result.11 The Bio-Tenodesis screw offers the advantages of the single-incision approach and a strong biomechanical construct allowing for early ROM.
The Mayo Clinic experience with distal biceps ruptures, published in 2000, suggested that delayed repair (>10 days after injury) was associated with higher complication rates.3 The average time to surgery after injury in our series was 23 days (range, 5-57 days). Only 3 patients were operated on within 10 days of injury, primarily because they were not seen and evaluated in the office quickly. In evaluating the 11 patients who had radial sensory nerve deficits 6 weeks postoperatively, the average time to surgery was 25.3 days, whereas the average time to surgery in the group without postoperative radial sensory nerve deficits was 21.5 days. The 8 patients who had lateral antebrachial cutaneous nerve symptoms at 6 weeks had an average time to surgery of 26.38 days, and those without had an average of 22 days to surgery. Our experience suggests that it may be possible to delay surgery >10 days from injury and still achieve good results.
Cadaveric anatomic studies have demonstrated that the distal biceps inserts like a ribbon along the ulnar border of the bicipital tuberosity.27-29 By positioning the tendon along the ulnar side of the tunnel prior to screw insertion, our technique may allow for a more anatomic repair than the other fixation methods available.
Only 38.5% of the tears in our series were in the patient’s dominant arm. This is in contrast to the series by Safran and Graham1 that describes dominant arm tears in 86% of patients.
Our study demonstrates that use of a tenodesis screw for distal biceps repair results in DASH and SF-12 scores comparable to the norm for the general population, with complications similar to that seen in past studies. In addition, biomechanical studies suggest that the repair is strong enough to allow early ROM, and the fixation technique may allow for more anatomic positioning of the distal biceps along the ulnar border of the bicipital tuberosity.
- Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002; (404):275-283.
- Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am. 1985; 67(3):414-417.
- Kelly EW, Morrey BF, O’Driscoll SW. Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am. 2000; 82(11):1575-1581.
- Meherin JM, Kilgore ES Jr. The treatment of ruptures of the distal biceps brachii tendon. Am J Surg. 1960; (99):636-640.
- Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg Am. 1985; 67(3):418-421.
- Norman WH. Repair of avulsion of insertion of biceps brachii tendon. Clin Orthop Relat Res. 1985; (193):189-194.
- Pereira DS, Kvitne RS, Liang M, Giacobetti FB, Ebramzadeh E. Surgical repair of distal biceps tendon ruptures: a biomechanical comparison of two techniques. Am J Sports Med. 2002; 30(3):432-436.
- Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal biceps rupture using the modified two-incision technique. J Shoulder Elbow Surg. 2008; 17(1 Suppl):67S-71S.
- Deirmengian GK, Beredjiklian PK, Getz C, Ramsey ML, Bozentka DJ. Distal biceps ruptures: one vs two incision techniques. Tech Shoulder Elbow Surg. 2006; (7):61-71.
- Khan W, Agarwal M, Funk L. Repair of distal biceps tendon ruptures with Biotenodesis screw. Arch Orthop Trauma Surg. 2004; 124(3):206-208.
- Fenton P, Qureshi F, Ali A, Potter D. Distal biceps tendon rupture: a new repair technique in 14 patients using the biotenodesis screw. Am J Sports Med. 2009; 37(10):2009-2015.
- Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American academy of orthopaedic surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002; 84(2):208-215.
- Ware JE, Kosinski M, Keller SD. SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales. 2nd ed. Boston, MA: The Health Institute; 1995.
- Boyd HB, Anderson LD. A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am. 1961; (43):1041-1043.
- Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: a systematic review. Am J Sports Med. 2008; 36(8):1618-1624.
- John CK, Field LD, Weiss KS, Savoie FH III. Single-incision repair of acute distal biceps ruptures by use of suture anchors. J Shoulder Elbow Surg. 2007; 16(1):78-83.
- Khan AD, Penna S, Yin Q, Sinopidis C, Brownson P, Frostick SP. Repair of distal biceps tendon ruptures using suture anchors through a single anterior incision. Arthroscopy. 2008; 24(1):39-45.
- Cheung EV, Lazarus M, Taranta M. Immediate range of motion after distal biceps tendon repair. J Shoulder Elbow Surg. 2005; 14(5):516-518.
- Cil A, Merten S, Steinmann SP. Immediate active range of motion after modified 2-incision repair in acute distal biceps tendon rupture. Am J Sports Med. 2009; 37(1):130-135.
- Idler CS, Montgomery WH III, Lindsey DP, Badua PA, Wynne GF, Yerby SA. Distal biceps tendon repair: a biomechanical comparison of intact tendon and 2 repair techniques. Am J Sports Med. 2006; 34(6):968-974.
- Krushinski EM, Brown JA, Murthi AM. Distal biceps tendon rupture: biomechanical analysis of repair strength of the Bio-Tenodesis screw versus suture anchors. J Shoulder Elbow Surg. 2007; 16(2):218-223.
- Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA, Arciero RA. Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair. Am J Sports Med. 2007; 35(2):252-258.
- Spang JT, Weinhold PS, Karas SG. A biomechanical comparison of EndoButton versus suture anchor repair of distal biceps tendon injuries. J Shoulder Elbow Surg. 2006; 15(4):509-514.
- McKee MD, Hirji R, Schemitsch EH, Wild LM, Waddell JP. Patient-oriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique. J Shoulder Elbow Surg. 2005; 14(3):302-306.
- Greenberg JA, Fernandez JJ, Wang T, Turner C. EndoButton-assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg. 2003; 12(5):484-490.
- Hartman MW, Merten SM, Steinmann SP. Mini-open 2-incision technique for repair of distal biceps tendon ruptures. J Shoulder Elbow Surg. 2007; 16(5):616-620.
- Athwal GS, Steinmann SP, Rispoli DM. The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am. 2007; 32(8):1225-1229.
- Eames MH, Bain GI, Fogg QA, van Riet RP. Distal biceps tendon anatomy: a cadaveric study. J Bone Joint Surg Am. 2007; 89(5):1044-1049.
- Hutchinson HL, Gloystein D, Gillespie M. Distal biceps tendon insertion: an anatomic study. J Shoulder Elbow Surg. 2008; 17(2):342-346.
Drs Silva, Eskander, and DeAngelis are from the Department of Orthopedics, University of Massachusetts Medical School, Worcester, Massachusetts; and Dr Lareau is from Rhode Island Hospital, Providence, Rhode Island.
Drs Silva, Eskander, Lareau, and DeAngelis have no relevant financial relationships to disclose.
The authors thank Patricia Franklin, MD, and Janel Milner for their help with study design and statistical analysis; Douglass Weiss, MD, Ethan Healy, MD, and Jessica Pelow, MD, for their help with presentation and editing; and Jared Leone from Arthrex, Inc.
Correspondence should be addressed to: Mark S. Eskander, MD, Department of Orthopedics, University of Massachusetts Medical School, 119 Belmont St, Worcester, MA 01605 (firstname.lastname@example.org).