Orthopedics

Review Article 

Diagnosis and Management Strategies for Distal Biceps Rupture

Jarred Holt, DO; Gordon Preston, DO; Koan Heindel, DO; Heather Preston, DO; Gregory Hill, DO

Abstract

Rupture of the distal biceps tendon most commonly is secondary to mechanical overload during eccentric muscle contraction. Due to deficits of strength and endurance, surgical repair usually is recommended. Although both single- and double-incision approaches have been described, double-incision techniques have been shown to better re-create the native anatomic insertion. However, excellent and comparable clinical outcomes have been demonstrated with both techniques. Fixation with a cortical button and interference screw has been shown to be the strongest construct biomechanically; however, several modern constructs provide adequate strength. Surgical technique should focus on restoration of anatomy, early range of motion, and prevention of complications. [Orthopedics. 2019; 42(6):e492–e501.]

Abstract

Rupture of the distal biceps tendon most commonly is secondary to mechanical overload during eccentric muscle contraction. Due to deficits of strength and endurance, surgical repair usually is recommended. Although both single- and double-incision approaches have been described, double-incision techniques have been shown to better re-create the native anatomic insertion. However, excellent and comparable clinical outcomes have been demonstrated with both techniques. Fixation with a cortical button and interference screw has been shown to be the strongest construct biomechanically; however, several modern constructs provide adequate strength. Surgical technique should focus on restoration of anatomy, early range of motion, and prevention of complications. [Orthopedics. 2019; 42(6):e492–e501.]

Distal biceps ruptures are uncommon injuries. Patients and orthopedic surgeons must weigh the pros and cons of operative vs nonoperative intervention. Surgical interventions frequently are offered secondary to a history of improved outcome. For those wishing to undergo operative intervention, a variety of surgical techniques have been proposed. Anatomic and biomechanical factors, risks and benefits of each technique, and avoidance of complications must be considered for optimal management of patients with distal biceps ruptures.

Anatomy

The distal biceps tendon is composed of 2 bands originating from the long and short heads of the biceps brachii muscle.1–4 The bands arise from the musculotendinous junction and course distally along the anterior arm. As a unit, the bands cross the elbow to insert on the posterior ulnar rim of the bicipital tuberosity of the proximal radius approximately 23 mm distal to the radial head articular surface.5 The tendon has an average length and width of 57 mm and 15 mm, respectively.6

The distal biceps tendon attaches to the bicipital tuberosity in a distinct pattern. The band of the long head of the biceps passes deep to the short head and inserts in a more proximal location. This positioning allows the long head to act as a forceful supinator of the forearm, with the short head acting more as a flexor of the elbow.7 The distal biceps tendon insertion site is long, vertical, and semilunar in shape, with a length of 14 to 21 mm and a width of 2 to 10 mm.4

The pattern and location of injury is thought to be, at least in part, secondary to impingement and vascular supply. The vascular supply of the distal biceps is divided into 3 anatomic zones. The proximal zone receives blood exclusively from the brachial artery and is defined as the proximal portion of the biceps tendon that is near the anterolateral brachial artery. The distal zone receives blood exclusively from the posterior interosseous recurrent artery and is defined as the distal portion of the tendon that attaches to the radial tuberosity. The middle zone, which receives contributions from both arteries, is a transitional watershed zone susceptible to hypovascularity and eventual tendon rupture, and is defined as a 2.14-cm zone between the proximal and distal ends of the biceps tendon.8 In the middle zone, there is also evidence for mechanical impingement during forearm rotation. It has been noted that with full pronation of the forearm, the space available for the tendon is diminished. Impingement is maximal in the presence of a prominent axial ridge or with hypertrophic changes.

Epidemiology

Distal biceps tendon ruptures occur classically as an avulsion from the bicipital tuberosity in the dominant arms of men in their fifth decade.9–11 Although the majority of these injuries are complete tears from the bony insertion site, partial tears and disruption more proximal to the radius have been described. The mechanism of injury is commonly a rapid, forced hyperextension of the forearm with the elbow flexed to approximately 90°.12 This creates powerful eccentric loading of the tendon. A smaller percentage of injuries occur in women, who more commonly present in their sixth decade with partial tears and may have a more degenerative etiology compared with men.13

Early evidence suggested the incidence of distal biceps tendon ruptures was approximately 1.2 of 100,000 persons per year, representing 3% of all biceps ruptures.1,14 Recent evidence suggests a higher incidence of 2.55 of 100,000 persons per year, representing 10% of all biceps tendon disruptions.15,16 Higher incidences of distal biceps tendon ruptures have been reported in specific populations including weightlifters and smokers, as well as individuals who use anabolic steroids.1,16 Risk factors include anabolic steroids, Cushing syndrome, oral steroids, tobacco use, and the natural aging process.17–19 The natural aging process results in degenerative changes to the tendon via a combination of diminishing structural integrity and irritation by osteophytes.17–20

History and Examination

Patients with distal biceps rupture often present with focal anterior elbow pain. History frequently includes a painful, audible “pop” followed by weakness during elbow flexion and supination. Physical examination findings usually include tenderness of the antecubital fossa, loss of contour of the affected arm, varying degrees of deformity, ecchymosis at the site of tenderness, and weakness that is most pronounced through resisted flexion and supination.

The hook test described by O'Driscoll et al21 is a reliable diagnostic tool. In this maneuver, the patient is instructed to actively fully supinate and flex the elbow to 90° while the examiner palpates the antecubital crease. The index finger is used to “hook” the margin of the cord-like tendon. If the structure is intact, it is readily palpable. A positive test is indicated by an inability to capture the tendon. Caution is advised with this maneuver as the lacertus fibrosus or deep brachialis tendon can be mistaken for an intact tendon. It is recommended to hook the lateral margin of the tendon to avoid false-negative results.

Additional examination maneuvers include the passive forearm pronation test and the distal biceps crease interval.22,23 The passive forearm pronation test is considered positive for a complete tear when there is loss of visible and palpable movement of the biceps tendon with passive pronation after being placed into the supinated position. The biceps crease interval test evaluates the extent of retraction by measuring the distance between the antecubital flexion crease and the terminal stump of the tendon. When used in conjunction with the hook test, the passive forearm pronation test and biceps crease interval have demonstrated 100% sensitivity and specificity for clinical diagnosis of distal biceps avulsion.24

The clinical detection of partial biceps tendon ruptures can be difficult as classic examination findings may not be encountered. In these cases, imaging often is used to confirm clinical suspicion. Radiographs may demonstrate a small avulsion or bony fragmentation from the radial tuberosity. Magnetic resonance imaging (MRI) is considered the study of choice for further evaluation in unclear cases. Festa et al25 reported the diagnostic accuracy of MRI. In their series, MRI was found to be 100% sensitive and 83% specific for complete ruptures, with 59% sensitivity and 100% specificity demonstrated for partial tears. Magnetic resonance imaging also aids significantly in the diagnosis of injury at the musculotendinous junction.26 Ultra-sound has been explored as an adjunct analysis for the integrity of the distal biceps tendon. Lobo et al27 demonstrated 91% accuracy for the diagnosis of complete vs partial distal biceps tendon tears.

Management

Clinical decision-making regarding treatment of distal biceps tendon rupture is guided largely by patient expectations and functional demands. Some older studies advocated for conservative care, citing acceptable results with nonoperative management.28 Recently published studies demonstrate more favorable outcomes with surgical intervention. Studies have identified a loss of 27% to 60% in supination strength and a loss of 21% to 30% in flexion strength for patients treated nonoperatively.10,26,29,30 The role of conservative treatment generally remains reserved for low-demand individuals and those at high risk for surgical complications.

Surgical intervention typically is performed in the acute to subacute setting. However, patients with distal biceps rupture often present several months after the inciting event.29 The impact of surgical timing has been studied previously. Anakwenze et al31 evaluated the influence of the timing of surgery on the outcomes of 18 patients. Disabilities of the Arm, Shoulder and Hand (DASH) scores, range of motion (ROM), and clinical and radiographic complications were compared for surgery performed within 4 weeks of injury (acute) and surgery performed late (>4 weeks from injury). No statistical differences were noted between the groups with respect to DASH scores or ROM in all planes, and all patients returned to their previous level of activity.

Surgical Techniques

Satisfactory results have been demonstrated with a variety of operative techniques. A single-incision, extensile, anterior approach coupled with transosseus suture repair initially was the technique of choice. Newer techniques can be categorized based on the surgical approach and tendon-bone fixation technique. Regardless of the surgical method, goals include restoration of the anatomic footprint of the tendon to the radial tuberosity, adequate biomechanical fixation, atraumatic soft tissue handling and dissection, and avoidance of complications.

Single-Incision Technique. An extensile anterior, single-incision approach initially was described as an extension of the classic volar Henry approach. A large, lazy-S type incision centered over the antecubital fossa was made with extensive dissection to expose the radial tuberosity. Although providing excellent exposure, this incision has been associated with a high rate of neurologic complications.32

Newer fixation techniques have led to development of less invasive single-incision approaches. Short longitudinal, isolated transverse, and L-shaped anterior incisions have been developed, with each using an interval between the brachioradialis and pronator teres muscles. These anterior approaches are performed with the forearm in maximal supination. An anterior approach provides adequate surgical exposure, direct access to the biceps tendon and radial tuberosity, and safe protection of the adjacent neurovascular structures. Its utility in restoring an anatomic footprint, however, has been questioned.33,34 Alternative techniques have returned to using a smaller transverse or longitudinal anterior incision combined with a variety of repair constructs.

Double-Incision Technique. Boyd and Anderson15 developed their classic double-incision technique in an attempt to avoid neurologic injury associated with the anterior Henry approach. A similar anterior S-shaped incision or a smaller transverse incision is made to dissect, identify, and prepare the tendon stump. The radial tuberosity is palpated, and a second dorsal counter incision is localized and created. Wide exposure of the dorsal ulna and dorsal radius is performed, allowing for expansive visualization. This technique lends itself well to fixation via sutures passed through transosseous tunnels from volar to dorsal. Although good success was achieved with this procedure, radioulnar heterotopic ossification became a concern. A modification of the dorsal incision was developed by Kelly et al.35 Their technique split the extensor carpi ulnaris, thereby avoiding dissection of the supinator and proximal ulna to prevent adjacent soft tissue trauma. This approach should be performed with the forearm in pronation to protect the posterior interosseous nerve (PIN).

Endoscopic Assistance. Endoscopic techniques have been described both to evaluate the injured tendon and to assist in repair.36,37 Grégory et al38 reported on a series of 23 patients (25 elbows) who were treated surgically via endoscopic-assisted repair of the tendon using suture anchor fixation. At a median follow-up of 26 months, they reported uniformly good outcomes, with only 1 patient demonstrating an unsatisfying result. They noted 20 of 23 patients returned to preinjury activity. Overall good results were noted with regard to ROM and postoperative strength. Only 1 re-rupture and 2 postoperative nerve palsies were identified in their cohort.

Influence of Incision Location on Footprint Restoration

Existing literature suggests double-incision techniques result in more accurate restoration of the distal biceps footprint. Jobin et al39 and Hasan et al33 performed similar studies using 3-dimensional digitizers to evaluate footprint area and location following simulated distal biceps repairs in human cadavers. Hasan et al33 demonstrated that tunnel placement via a single anterior incision was able to, on average, reproduce only 9.7% of the native biceps tendon insertion site. A dual-incision technique using a posterolateral approach significantly improved attachment site location, reproducing 73.4% of the native footprint. Jobin et al39 performed 36 distal biceps repairs on cadaveric specimens comparing single- and double-incision techniques. They demonstrated a statistically more posterior reattachment site for the double-incision group.

Hansen et al40 obtained postoperative computed tomography (CT) scans on 27 patients treated via single anterior incision repair with 2 suture anchors. They evaluated location and angular position of the anchors with respect to the location of the apex of the radial tuberosity. Anchors were placed consistently in a radial position. They concluded reapproximating the tendon to the native footprint via a single anterior incision was unsuccessful in all patients.

Influence of Incision Technique on Clinical Outcomes

Data regarding clinical outcomes after distal biceps tendon refixation are heterogeneous secondary to the variety of surgical techniques developed (Tables 12). Early studies using the traditional Boyd-Anderson double-incision approach produced excellent clinical outcomes. Baker and Bierwagen30 reported on 10 patients who underwent repair via a double-incision technique with transosseous tunnels. This early study demonstrated return to normal flexion, supination strength, and endurance. However, several other studies demonstrated relatively high complication rates that most commonly included restricted ROM.41–45

Clinical Outcomes Following Double-Incision Repairs

Table 1:

Clinical Outcomes Following Double-Incision Repairs

Clinical Outcomes Following Single-Incision Repairs

Table 2:

Clinical Outcomes Following Single-Incision Repairs

The double-incision muscle-splitting technique was developed in an effort to avoid heterotopic ossification and loss of motion. Hartman et al46 used this approach on 33 elbows and reported excellent restoration of flexion and supination strength along with good motion through supination (mean, 76°) and pronation (mean, 79°). Weinstein et al47 reported comparable results that suggested restoration of strength and motion, as well as high patient satisfaction, can be expected using the double-incision muscle-splitting approach.

Several studies have evaluated clinical outcomes after the more limited single-incision anterior approaches. Bain et al36 and Greenberg et al48 reported excellent clinical results with respect to patient satisfaction and motion using the single-incision technique and a cortical button. Larger studies with greater power have produced similar outcomes with low complication rates. McKee et al,49 in a larger cohort of 53 men treated by a single surgeon using a single-incision suture anchor technique, reported a mean DASH score of 8.2±11.6 at final follow-up. They noted only 4 complications (1 superficial wound infection, 2 transient lateral cutaneous nerve palsies, and 1 PIN palsy), and no patient lost more than 5° of elbow ROM arc in both flexion/extension and rotation.

Data directly comparing the double-incision muscle-splitting technique and limited single anterior incision technique create some controversy regarding the ideal surgical approach.36,48,49 Chavan et al28 performed an excellent systematic review analyzing a total of 19 articles. They identified significantly improved dissatisfaction rates (6% vs 31%) with single-incision techniques compared with double-incision techniques. The odds ratio of an unsatisfactory outcome was 7.6 (95% confidence interval, 3.2–17.7). Although they identified no difference in overall complication rates between the groups, they reported the double-incision cohorts demonstrated greater loss in forearm rotation. Grewal et al50 showed advantage to the double-incision technique vs the single-incision technique when comparing American Shoulder and Elbow Surgeons (ASES) pain, ASES function, and DASH scores. A 10% advantage in final flexion strength was noted in the double-incision group. The single-incision group demonstrated a higher overall complication rate, particularly due to lateral antebrachial cutaneous (LABC) neurapraxia.

Fixation Techniques

Several fixation techniques have been described. Fixation methods include transosseous tunnel suture fixation, suture anchor technique, suspensory button fixation, and intraosseous screw fixation. Fluoroscopy may be used to confirm appropriate placement of the selected implant.

Transosseous Suture Fixation. The bone tunnel technique typically is performed using a double-incision approach to appropriately visualize and pass suture tails at the dorsal cortex of the proximal radius. The tendon stump is identified volar and prepared in routine fashion using a heavy, durable braided suture placed in a locking fashion. The radial tuberosity is identified, and a slot is created in the anterior cortex with the use of a reamer or burr. Two small-diameter holes are created. Sutures are shuttled, and the tendon is delivered into the slot. The sutures are tied over a cortical bridge via the posterior incision.

Suture Anchor Technique. The suture anchor technique uses a single anterior incision to identify and prepare the tendon stump along with identification of the radial tuberosity. The anatomic insertion site is debrided and gently decorticated to create a bony bed for tendon healing. One or 2 suture anchors are placed into the bicipital tuberosity, typically with 1 placed more distally and 1 placed more proximally. The sutures of the anchors are passed through the tendon stump and then tied, proceeding with distal fixation first to restore appropriate tendon length.

Cortical Suspensory Button Technique. Initially described using the EndoButton (Smith & Nephew, Andover, Massachusetts), the cortical suspensory button technique relies on a small suture button placed through drill holes over the dorsal cortex.36 This technique can be performed via a single- or double-incision approach. In extramedullary button fixation, the tendon is prepared using heavy strength suture. Suture limbs are passed through the holes of the button according to the manufacturer's specific techniques. A cortical window or slot is created using a cannulated reamer or burr at the proposed fixation site. The button is passed from the volar ulnar side of the radial tuberosity using a Beath pin or manufacturer-specific device and then flipped, locking it to the cortex. The tendon is delivered into the window, and sutures are tied over the button. Fluoroscopy may be used to confirm appropriate “flipping” of the device.

A modification of the original cortical button technique, termed the tension-slide technique, was described in 2008.51 An adjustable length loop cortical button is used, obviating the need for a second dorsal incision to tension the repair. The button is easily flipped, then using alternating pulls on the suture strands previously placed through the stump, the tendon is delivered into a socket. The use of the adjustable length button avoids the need to predetermine the length of suture between the button and the biceps tendon stump, helps to eliminate suture diastasis, and avoids technical concern regarding button flipping on the dorsal cortex.

The intramedullary suspensory button technique uses 2 single-loaded cortical buttons.52 Buttons are placed 12 mm apart and flipped within the medullary canal of the radius, avoiding the potential complication of PIN entrapment and preventing dorsal cortical perforation. Biomechanical studies support the effectiveness of both single and double intramedullary cortical button fixation.52,53 Early results are encouraging, but the technique has not gained widespread acceptance and requires further investigation.54

Interference Screw Technique. In this technique, the tendon is prepared in routine fashion using heavy duty suture, and the radial tuberosity is exposed. A guide pin is placed into the fixation site, and an appropriately sized socket or tunnel is created with a cannulated reamer. The suture is passed through the screw and accompanying screwdriver, and the construct is delivered into the tunnel and tensioned. After tensioning the tendon within the socket, the interference screw is driven flush to the tuberosity and the remaining suture tails are tied, reinforcing the implant-tendon interface. Bioabsorbable or permanent screws may be used.

Biomechanics of Fixation Construct

Several biomechanical studies have been performed comparing the strength of fixation constructs (Table 3). The mean failure strength of the native tendon is 204.3 N, with a maximum native strength of 221.7 N (±65.9 N). Transosseous bone tunnel fixation is the standard by which most distal biceps repairs are measured. Hybrid fixation using both cortical suspension and interference fixation provides the greatest single load to failure (383 to 432 N) and ultimate tensile load during cyclic testing.55,56 To the current authors' knowledge, there has not been a study demonstrating clinical superiority among any of the current fixation techniques. It is recommended that treating surgeons should focus on anatomic tendon restoration along with prevention of complications. Future studies to elicit the most cost-effective surgical procedure for tendon reapproximation would be beneficial.

Biomechanics of Fixation Devices for Distal Biceps Tendon Repair

Table 3:

Biomechanics of Fixation Devices for Distal Biceps Tendon Repair

Complications

Several complications related to surgical repair of the distal biceps have been reported. A large meta-analysis demonstrated the overall complication rate to range from 16% to 18%, depending on surgical technique.16 In some smaller studies, complication rates have been reported to be as high as 36%.57 The most common complication reported is transient palsy of the LABC nerve, often secondary to vigorous retraction during surgery. Grewal et al50 reported a statistically significant increased risk of transient neurapraxia with single-incision repair compared with double-incision repair (19 of 47 vs 3 of 43, respectively). Injury to the PIN and radial nerve also has been reported; however, these neurapraxias are usually self-limited. Posterior interosseous nerve incarceration resulting in complete loss of digit and thumb extension requiring surgical exploration and release also has been described.58

Dunphy et al12 performed a review of 784 cases of surgically treated distal biceps tendon ruptures via both single-and double-incision repairs. As in other studies, the most common complication encountered was LABC nerve palsy (24.4%). The single-incision cohort demonstrated a statistically higher rate of overall nerve injury; however, when LABC nerve injury was excluded, there was no significant difference between the 2 techniques. The authors also noted no patient demonstrated persistent sensory deficits at final follow-up. In addition, the double-incision technique resulted in higher rates of PIN palsy, heterotopic ossification, and reoperation.

Radioulnar synostosis, with or without loss of ROM, is a well-documented complication following distal biceps refixation. Synostosis tends to present in earlier stages of healing with persistent pain and swelling. Loss of supination may become notable, although diminished arc of motion also has been reported without evidence of heterotopic ossification. Radiographs and CT may be obtained to evaluate the degree and location of aberrant ossification. These studies are integral to preoperative planning if proceeding with excision and contracture release. In addition to loss of supination, flexion contracture also may occur.

Other potential complications following repair of the distal biceps tendon include infection, re-rupture, and compartment syndrome. Several small volume case series have shown re-rupture to be rare.14,15,59 Hinchey et al60 reviewed a cohort of 190 distal biceps repairs performed via modified 2-incision technique and found a 1.5% (3 of 190) rate of repeat tendon tear; each of these occurred within 3 weeks of the index procedure. Dunphy et al12 reported a 1.6% re-rupture rate in those treated with single-incision technique vs a 2.8% rate with double incision. Acute compartment syndrome following the initial injury has been reported as well.

Authors' Preferred Technique

The extremity is prepared and draped in the usual fashion, and a sterile tourniquet is applied. A single transverse incision with longitudinal extension just radial to the expected location of the biceps rupture is created (Figure 1). A full-thickness skin flap is developed. A combination of blunt and sharp dissection is performed with gentle soft tissue retraction to identify the ruptured stump of the biceps tendon (Figure 2). If necessary, large traversing vessels are ligated and cauterized; however, care is taken to not unduly disturb the local vascular anatomy. A hematoma or seroma often is encountered, providing a guide to identify the tendon stump.

Photograph showing the authors' preferred positioning for prepping, draping, and incision for distal biceps repair. A sterile tourniquet is placed on the arm prior to final extremity drape application and hidden beneath a stockinette.

Figure 1:

Photograph showing the authors' preferred positioning for prepping, draping, and incision for distal biceps repair. A sterile tourniquet is placed on the arm prior to final extremity drape application and hidden beneath a stockinette.

Intraoperative photograph showing the tendon stump, which is dissected free from adhesions and delivered into the wound for preparation prior to repair.

Figure 2:

Intraoperative photograph showing the tendon stump, which is dissected free from adhesions and delivered into the wound for preparation prior to repair.

Following tendon identification, the stump is mobilized and dissected free of adhesions. Remaining portions of intact lacertus fibrosus also are released to allow for adequate tendon excursion. The tendon is whip stitched in locking fashion using a no. 2 FiberLoop (Arthrex Inc, Naples, Florida) (Figure 3) and sized.

Intraoperative photograph showing the tendon stump after being prepared using a locking loop stitch configuration. The suture tails often are used as counter-tension to complete proximal soft tissue release, allowing for adequate excursion and anatomic repair.

Figure 3:

Intraoperative photograph showing the tendon stump after being prepared using a locking loop stitch configuration. The suture tails often are used as counter-tension to complete proximal soft tissue release, allowing for adequate excursion and anatomic repair.

After tendon preparation, attention is turned to the insertion site. Blunt digital dissection is used to identify the radial tuberosity while maintaining full supination of the forearm. Meticulous subperiosteal elevation of the supinator from the tuberosity is completed to visualize the entire biceps tuberosity. Blunt retractors are placed around the radial and ulnar aspects of the bone, taking care to avoid adjacent soft tissue and potential nerve damage. The distal border of the tuberosity is marked, and a guide pin is drilled bicortically. A cannulated reamer of the same size as the tendon is passed in unicortical fashion, creating a bone socket. The wound is irrigated thoroughly to remove bony debris.

An adjustable-length loop biceps button (Arthrex Inc) (Figure 4) is prepared. Free limbs of the previously whipstitched tendon are passed to allow the button to slide freely. With the elbow in flexion and using the accompanying inserter, the biceps button is placed through the previously established bicortical tunnel and flipped. Using gentle, alternating tension on the suture limbs, the tendon is delivered into the socket. After appropriate tension is confirmed, a static locking knot is tied.

Photograph showing the cortical button (left) and the supplementary Biotenodesis interference screw (right) used for tendon reinsertion (Arthrex Inc, Naples, Florida).

Figure 4:

Photograph showing the cortical button (left) and the supplementary Biotenodesis interference screw (right) used for tendon reinsertion (Arthrex Inc, Naples, Florida).

Following insertion, back-up fixation using a biotenodesis interference screw (Arthrex Inc) is used. Line-to-line sizing of the screw is selected to ensure security of the tendon in the socket. A free limb of the tendon suture is passed through the tenodesis screwdriver, and the screw is delivered and inserted into the radial side of the socket. The screw is buried until flush with bone. A final simple stitch is placed into the tendon with the remaining free suture limbs. The elbow is taken through gentle ROM while visualizing the repair to confirm secure fixation. The wound is copiously irrigated and closed in a layered fashion.

Conclusion

Distal biceps ruptures are uncommon injuries. There is still much controversy regarding the ideal treatment strategy for these ruptures. There are many benefits and potential complications associated with the single-incision technique, double-incision technique, and endoscopically assisted technique. Treating orthopedic surgeons should be aware of all of these techniques so they can tailor their treatment to each specific patient.

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Clinical Outcomes Following Double-Incision Repairs

Study (Year)No. of PatientsFixationResultsComplications
Baker and Bierwagen30 (1985)10Transosseous tunnelsFull ROM 90%, repair 13% stronger, 32% more endurance than contralateral1 HO
Leighton et al44 (1995)9Transosseous tunnelsMinimal loss supination ROM, full return strength1 synostosis, 3 HO not affecting ROM
Davison et al17 (1996)8Transosseous tunnelsROM within 5° of contralateral elbow, full flexion/extension strength6 with significant supination weakness (24% to 83%)
Karunaker et al43 (1999)21Transosseous tunnelsMean 130° flexion/extension, mean DASH 5248% with supination strength deficits, 3 HO (motion affected in 2), 1 LABC paresthesia
Bell et al29 (2000)21Transosseous, suture anchors, screwsFlexion/extension normal in 20, normal flexion/supination endurance, slight loss of flexion strength13 HO, 1 synostosis
Moosmayer et al45 (2000)9Transosseous tunnelsSatisfaction VAS 8.5/10, 13% flexion, 19% supination strength deficit7 loss of forearm ROM (5°–45°), HO, 2 transient PIN palsies
El-Hawary et al32 (2003)10Transosseous tunnelsMean arc 7°–131°, 97% flexion, 85% supination strength1 HO affecting motion, 3 transient LABC paresthesias
Cheung et al16 (2005)13Transosseous tunnelsMean DASH 43, 91% flexion, 89% supination strength, mean 6° loss elbow extension1 LABC neuritis
Hartman et al46 (2007)33Transosseous tunnelsMean arc 0°–126°, MEPS 96.5 (acute), 95 (delayed)1 HO
Weinstein et al47 (2008)32Suture anchorsMean arc 0°–145°, all strength measures within 5% of uninvolved side2 transient LABC paresthesias
Cil et al1 (2009)21Transosseous tunnelsMean arc 0°–141°, mean DASH 21, 12% increase flexion, 11% loss supination2 HO not affecting motion (radiographs not routine postoperative)
Grewal et al50 (2012)40Transosseous tunnelsMean ASES function 34.6, mean DASH 5.5 (no difference in outcome scores for single vs double incision), mean flexion strength 104%, mean flexion/extension 1.9°–131.8°Lower overall rate compared with single incision, 2 transient LABC palsies, 1 re-rupture, 1 HO (not affecting ROM)
Anakwenze et al31 (2013)18Transosseous tunnelsMean DASH 4.4, mean flexion/extension 0°–153°, pronation/supination 79°–79°, no difference for acute (<4 wk) vs chronic repairsNone reported
Shields et al61 (2015)21Transosseous tunnelsMean DASH 5.7, mean flexion/extension 131.9°–7.6°1 superficial radial nerve palsy, 2 HO (both without clinical consequence)

Clinical Outcomes Following Single-Incision Repairs

Study (Year)No. of PatientsFixationResultsComplications
Bain et al36 (2008)12Cortical buttonAll patients satisfied, restored 5/5 strength; mean ROM 5°–146°No neurovascular or synostosis reported
Greenberg et al48 (2003)14Cortical buttonSatisfactory return to preinjury activity and occupation; mean ROM arc 141°, 97% flexion and 82% supination strength1 flexion contracture 30°
El-Hawary et al32 (2003)9Suture anchor8 satisfactory; significant SF-36 improvement1 case HO resulting in loss of supination
McKee et al49 (2005)53Suture anchorMean DASH score 8.2, mean flexion 96%, supination 93%4 of 53 (7.5%): 1 infection, 2 superficial paresthesias, 1 PIN palsy
Fenton et al62 (2009)14Tenodesis screw11 excellent, 3 good results; mean MEPS 96.8, 96% flexion strengthNone noted
Peeters et al63 (2009)23Cortical buttonMean MEPS 94; mean flexion strength 80%, supination 91%2 asymptomatic, 3 EndoButton disengagement, 1 EndoButton required removal
Heinzelmann et al64 (2009)32Hybrid (button + interference screw)Mean Andrews-Carson 196 (29 excellent, 2 good, 1 fair); >90% resumed normal activity within 6 weeks; majority grade 5/5 flexion, supination strength (28 flexion, 30 supination)1 HO associated with loss of ROM; 2 transient superficial radial nerve palsies; no re-ruptures
Grewal et al50 (2012)43Suture anchorsMean ASES function score 32.6, mean DASH 7.8 (no differences in outcome scores in single vs double incision), 94% flexion strength, mean flexion/extension arc 3°–134°Higher overall rate compared with double (19 transient LABC palsies, 3 symptomatic >6 months); 3 re-ruptures; 1 case mild HO
Olsen et al65 (2014)37Suture anchor vs cortical buttonMean DASH 4.5 (CB), 10.3 (SA); mean VAS 0.79 (CB), 1.8 (SA); motion excellent in all patients2 superficial infections, 5 superficial radial nerve palsies, 3 LABC palsies, 1 ulnar nerve palsy, 1 hematoma
Hansen et al40 (2014)21Suture anchorMean DASH 10; 17 returned to work with minimal restriction; 9 reported some inability to return to preinjury physical activity level; flexion strength equal, mean supination; work diminished compared with uninvolvedNone reported
Siebenlist et al53 (2014)49Suture anchors86% highly satisfied or satisfied; Mean QuickDASH 7.9, mean Morrey Elbow Score 97.2; 39 excellent, 9 good, 1 fair, no poor outcomes; mean supination strength loss 36.4% of uninvolved side39% HO (none contributing to loss in ROM); 10.2% rate hardware complications; 3 transient LABC nerve palsies, 2 PIN palsies; 1 deep wound infection, 3 superficial infections

Biomechanics of Fixation Devices for Distal Biceps Tendon Repair

Fixation MethodSingle Load to Failure Testing, Mean Ultimate Tensile Load, NCyclic Testing

Ultimate Tensile Load, NDisplacement, mm
Transosseous tunnel125–21066–68195–31013,69,703.5570
Suture anchors57–26368,70209–38170,712.06–2.3870,71
Extramedullary cortical button259–38956,67249–44070,712.58–3.4256,70,71
Intramedullary cortical button
  Single button27552
  Double button45552312722.172
Interference screw131–29455,66,67232702.1570
Hybrid (cortical button+interference screw)383–43255,56439561.2556
Authors

The authors are from the Department of Orthopedic Surgery, Western Reserve Hospital, Cuyahoga Falls, Ohio.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Gordon Preston, DO, Department of Orthopedic Surgery, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH 44223 ( gpreston@westernreservehospital.org).

Received: July 21, 2018
Accepted: December 12, 2018
Posted Online: July 29, 2019

10.3928/01477447-20190723-05

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