Distal biceps tendon repair

Distal biceps tendon repair refers to the direct surgical fixation of an injured distal biceps tendon to restore elbow flexion and/or supination power and is the surgical procedure of choice in the acute setting. 

Indications

Main indications for distal biceps tendon repair include the following situations ^1-3:

• distal biceps tendon injury involving >50% of the biceps tendon
• feasible anatomical repair

Contraindications

Contraindications to distal biceps tendon repair include significant patient comorbidities precluding surgery and situations rendering a primary repair difficult or unfeasible as delayed diagnosis or the following findings:

• extensive proximal tendon stump retraction >8 cm or a flipped torn tendon
• short and/or degenerated/frayed tendon stumps
• extensive tendon scarring
• fatty infiltration of the biceps muscle and myotendinous junction

Imaging aids in the preoperative assessment. However, the definite decision between primary repair or reconstruction of the distal biceps tendon is made intraoperatively.

Procedure

There are numerous surgical techniques including single-incision, dual-incision and endoscopic approaches, that might vary with different fixation techniques ^1,2,4:

• transosseous suture fixation (involves drilling of a bone tunnel for tensioning and fixation)
• suture anchor technique (good tendon to bone contact and footprint recreation)
• intraosseous screw fixation technique (e.g. with interference screws or bioabsorbable screws)
• suspensory cortical button technique

Complications

Overall complications of distal biceps tendon repair are in the range of 16-18% with lateral antebrachial cutaneous nerve injury being the most common ². Other complications of biceps tendon repair are partially related to the surgical approach and include the following ^1,2: 

• posterior interosseous nerve injury
• superficial radial nerve injury
• heterotopic ossification
• proximal radio-ulnar synostosis
• hematoma
• re-rupture
• infection (cellulitis, abscess, arthritis, osteomyelitis)
• proximal radius fracture (from large bone tunnels)
• suture rupture or suture granuloma

Radiographic features

The cross-sectional area of repaired tendons is larger and more rounded than normal tendons ³.

Plain radiograph

Bone tunnels and some suture devices as radiodense suture anchors and interference screws as well as heterotopic ossifications can be seen on plain radiographs of the elbow ³.

CT

CT can aid in the assessment of heterotopic ossification and visualize radiodense suture devices ¹.

MRI

Postoperative MRI findings after distal biceps tendon repair should depict an intact anastomosis and adequate fiber orientation. The postoperative tendon seems might have a more rounded cross-sectional morphology and might be significantly larger than a normal tendon ³.

Radiological report

Preoperative evaluation

The radiological report of a preoperative evaluation should include a description of the following:

• distal biceps tendon injury category (tendon rupture, partial tear, tendinosis)
• proximal tendon retraction, stump position and length
• distal tendon stump degeneration and/or fraying
• fatty infiltration of the myotendinous junction and the biceps muscle belly
• excessive scarring

Postoperative evaluation

In a postoperative setting the radiological report should include a description of the following ^1-3:

• the integrity of the anastomosis and signs of re-tear
• signs of nerve injury
• postoperative scarring (possibly around the lateral antebrachial cutaneous nerve)
• heterotopic ossification or proximal radio-ulnar synostosis
• proximal radius fracture

Outcome

Postoperative re-rupture is rare with an estimated frequency of 1-2% and usually occurs within three weeks of surgery ³. Overall complications are less frequent than in distal biceps tendon reconstruction and are partially related to the approach and fixation technique ^1,5.

The dual incision approach has been introduced to reduce the risk of injury to the lateral antebrachial cutaneous nerve ² and seems to be associated with a better restoration of the native distal biceps tendon footprint ² but carries a higher risk of posterior interosseous nerve injury ¹. The single incision approach has a decreased risk for heterotopic ossification ¹. There seems to be no clear evidence favoring one surgical technique over the other ¹.