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December 2008

Distal Biceps Repair
Bernard F. Hearon, M.D.

Distal biceps tendon rupture at the elbow typically occurs in men between 30 and 50 years of age as the result of forceful extension (straightening) of the arm from an initially flexed (elbow bent) position. For example, if two men are carrying a heavy sofa and one man drops his end, the other lifter will experience a sudden heavy load bringing his arm into extension thereby overloading the distal biceps tendon. The tendon may completely rupture and retract upward leading to a noticeable bulge in the biceps muscle or the tendon partially rupture leaving the injured man with pain in the front of his elbow which is aggravated by later lifting activities. Local bruising and swelling may be associated with the injury.

Men sustaining distal biceps injuries are often manual laborers whose jobs require the ability to lift. Since complete rupture of the distal biceps results in a 40% decrease in elbow flexion strength (and thus lifting strength), many men with these injuries will elect to have the ruptured tendon surgically repaired by reattaching the tendon to bone. For many years, the standard surgical repair technique required two incisions - one in front of the elbow to retrieve and suture the ruptured tendon and a second on the outside of the elbow to reattach the tendon to bone. This two-incision technique, though allowing for successful tendon repair, is time-consuming and may be associated with surgical complications.

Recent study of cadaver elbows has led to a better understanding of distal biceps tendon anatomy and its bony attachment point at the radial tuberosity (ref. 1 & 2). A more anatomically precise repair of the distal biceps tendon to the radial tuberosity using just one incision in the front of the elbow has been described (ref. 3). In this new “tension slide” repair, a special suture called a FiberLoop (Fig. 1) is used to create a running suture in the stump of the ruptured tendon (Fig. 2). The sutured tendon is sized or measured and then a drill hole corresponding to the size of the tendon is made at the bony reattachment point (Fig. 3). The suture tails in the tendon are passed through a small metal pulley called BicepsButton (Fig. 4) which is used to secure the tendon in the bony tunnel under the correct tension (Fig. 5). A screw advanced into the tunnel may also be used to reinforce the repair.

Figure 1 FiberLoop	Figure 2 Tendon Preparation
Figure 3 Bony Tunnel	Figure 4 Suture in BicepsButton
Figure 5 Completed Repair

We have been using this new tension slide technique with BicepsButton by Arthrex to repair distal biceps tendon ruptures for about 6 months. We have been favorably impressed with the advantages of this new fixation method. The tension slide technique permits secure fixation of the ruptured tendon to bone under the correct tension through one incision rather than two incisions. The high pull-out strength of this repair technique allows patients to begin early elbow range of motion and to return to their regular activities sooner than with other repair methods.

Want more information online? Go to www.arthrex.com, scroll the New Product Websites list on the home page and click on BicepsButton to view an animation of this new distal biceps repair technique.

References

1. Athwal GS, Steinmann SP, Rispoli DM. The Distal Biceps Tendon: Footprint and Relevant Clinical Anatomy. J Hand Surg, 32-A(8): 1225-1229, October 2007.

2. Eames MH, Bain GI, Fogg QA, van Riet RP. Distal Biceps Tendon Anatomy: A Cadaveric Study. J Bone Joint Surg, 89-A:1044-1049, May 2007.

3. Sethi P, Cunningham J, Miller S, Sutton K, Mazzocca A. Anatomical Repair of the Distal Biceps Tendon Using the Tension Slide Technique. Techniques in Shoulder & Elbow Surg, 9(4): 182-187, December 2008.