Table of Contents
The annual incidence of distal biceps tendon ruptures is 1.5 per 10,000 per year. In 93% of cases, men aged 30–59 are involved, mainly in the dominant extremity. Distal biceps tendon ruptures can result in loss of supination and elbow flexion strength, for which surgical repair is often indicated to restore preinjury level of functionality. The distal biceps tendon can be repaired via single- or double-incision techniques using several associated implants, including endobuttons, suture anchors, or interference screws. Here, we present the case of a middle-aged male presenting with an acute distal biceps tendon rupture. The tendon was repaired via a single-incision technique using an endobutton and an interference screw.
Distal biceps repair, single incision, double incision, endobutton, interference screw, suture anchor.
Distal biceps tendon tears have an annual incidence rate of 1.5 per 100,000 people, with the majority occurring in the dominant arm and in males.2 Distal biceps tendon ruptures are typically multifactorial and include tendon degeneration, limited vascularity, and mechanical factors through repetitive trauma or eccentric contracture.3 The short and long head of the biceps comprise the distal biceps tendon attaching to the biceps tuberosity of the radius. The average area of the long head attachment is about 48 mm, and the short head is 60 mm. The primary action of the biceps is forearm supination, while the secondary action is elbow flexion. Thus, a complete distal biceps tear results in loss of supination and elbow flexion strength. Complete distal biceps tendon tears can be indicated for surgical repair in order to restore elbow flexion and forearm supination strength.1
A complete distal biceps tendon tear presents with a sudden onset of sharp pain in the antecubital fossa, often with an audible pop, followed by ecchymosis and alteration in the ability to flex the elbow and supinate the forearm. There may be a history of a sudden eccentric force to a flexed elbow, such as heavy lifting. Unlike a proximal biceps tendon rupture that can result in shortening of the biceps musculature, often referred to as a “Popeye deformity”, a distal biceps rupture may be not as obvious of a shortening or retraction of the biceps muscle because the lacertus fibrosus may maintain continuity with the distal biceps tendon, minimizing tendon retraction.
Findings on physical exam of a complete distal biceps tendon tear include:
Retraction and ecchymosis: On inspection, swelling and ecchymosis are evident in the antecubital fossa, with possible shortening or proximal retraction of the biceps muscle.
Hook test: On palpation, the distal biceps tendon may not be palpable. A useful clinical test is the ‘hook test’ in which the elbow is flexed to 90 degrees, and the forearm is supinated. The examiner’s index finger is placed between the lateral edge of the biceps and brachioradialis (BR) to hook the finger around the tendon. Inability to hook indicates a complete distal biceps tendon tear because the distal brachialis is flat. The hook test is the most sensitive and specific physical examination test in diagnosing a complete distal biceps tendon tear.4 With a partial tendon tear, it may be able to hook the tendon, but it may be more painful.
Weakness: Resisted forearm supination on the injured side will be weaker and painful.
Ruland biceps squeeze test: With the elbow supported in 60–80 degrees of flexion and the forearm pronated, the biceps muscle is squeezed to elicit passive forearm supination. In the case of a rupture, the forearm will not supinate.5
Radiographs are taken to assess bony avulsion and other potential injuries. MRI is highly sensitive and specific in diagnosing a complete tear, with even 92% sensitivity and 85% specificity in diagnosing partial tears. The recommended position for the optimum visualization of the distal biceps tendon is elbow flexion, shoulder abduction, and forearm supination (FABS). In this position, the whole length of the tendon is visualized on a single cut.6 Ultrasound is also effective in diagnosing distal biceps tendon tears.
Non-operative treatment is a reasonable treatment strategy as pain improves after the acute period, but residual loss of forearm supination and elbow flexion strength with altered contours of the biceps musculature will persist. However, the rate of returning to the previous level of strength is greater with a surgical repair.8
Both partial and complete distal biceps tears can be treated non-operatively and operatively. If pain persists, loss of strength is symptomatic, and/or the altered biceps contour is unacceptable, surgical repair can be performed.9
Distal biceps tendon repair can be performed using single- or double-incision techniques. Studies have shown no significant difference in functional outcomes, force, and range of motion between the two techniques. The complication rates are comparable (24% in single-incision vs. 26% in double-incision techniques).10
Options to fixate the distal biceps tendon include suture anchors, buttons, interference screw, and the bone tunnel. Biomechanical studies have shown that button repairs provide the strongest repair compared to the other three, which are comparable. More robust repair and superior load to failure allow an earlier range of motion.10
The primary goal of distal biceps tendon repair is to restore and maximize functional recovery. Biomechanical analysis has demonstrated a 74% and 88% strength of supination and flexion, respectively, compared to the contralateral side following non-operative management.3 Another study has demonstrated that non-operative management of distal biceps tendon rupture results in 50% loss of sustained supination strength, 40% loss of maximal supination strength, 30% loss of flexion strength, and even 15% loss of total grip strength. In general, varying degrees of weakness may persist with non-operative treatment.3
Operative treatment is usually indicated in younger active patients preferring to maximize functional recovery.11 Patients with low physical demands and/or several comorbidities may elect a conservative non-operative approach.
Clinical management of distal biceps tendon ruptures vary based on whether the tear is complete or partial and the patient's desired functionality outcomes. However, several studies supported surgical intervention because of increased supination and flexion strength.3,6,10 Treatment of partial tears may include activity modification, physical therapy, and anti-inflammatory medications to decrease symptoms.
In the presented case, the distal biceps tendon was repaired through a single incision. A longitudinal anterior incision is made at the flexion crease and distally following the medial border of the BR. The lateral antebrachial cutaneous nerve is identified and protected, lying over the fascia and in proximity to the cephalic vein. The ruptured biceps tendon can be located within the antecubital fossa or retracted proximally.
Once identified, the distal degenerated portion of the tendon is debrided, and a whip stitch suture is passed through the distal 2–3 cm of the tendon stump. The distal end of the tendon is debrided to fit the tunnel's diameter, which is ideally 7–8 mm in diameter. The distal 1 cm of the tendon is marked to help estimate the length of the docked tendon in the tunnel. A 2-0 silk shuttle loop is passed proximal to this marking to facilitate later shuttling of the suture to reinforce the repair. The free ends of the whip stitch are each passed through one eye of the endobutton and out the other. The tendon is now ready to be delivered into the tunnel.
The bicipital tuberosity of the proximal radius is exposed by fully supinating the forearm after cauterizing or ligating the deep venous leash. With the forearm held in full supination, a guidewire aiming ulnarly to avoid the posterior interosseous nerve (PIN) is placed bicortically, and its position is confirmed on fluoroscopy. Next, a unicortical 7.5-mm drill hole is made over the guidewire. The bone debris should be irrigated thoroughly before the repair to lower the chance of heterotopic ossification. The button is passed through the tunnel with the insertion jig, deployed across the tunnel, and flipped on the far cortex by tensioning the suture limbs. The sequential pull of the two suture limbs delivers the tendon into the tunnel. This step is done with slight elbow flexion and full forearm supination until the marked line on the tendon disappears. One of the limbs is shuttled via the prepared shuttling silk suture and tied to itself, thereby securing the tendon in position. The tendon is reinforced within the tunnel by placing an interference screw across one suture limb. The suture limbs are tied once more over the interference screw. This repair construct includes three fixation points, endobutton repair, interference screw, and the final knot. The wound is irrigated and closed, and hemostasis is ensured. A posterior elbow splint is applied with the elbow at 90 degrees of flexion and the forearm supinated. Alternatively, a sling in 90-degree elbow flexion may also be sufficient. Postoperatively, the patient is started on protected range of motion and progressive strengthening on a graded basis. Unrestricted lifting can generally be permitted by three months postoperatively.12
A randomized controlled study that compared single-incision and double-incision techniques on acute distal biceps tendon tears found that both methods provided similar results in terms of pain, function, isometric extension, pronation, supination strength, and patient-rated elbow evaluation (PREE) score.13 Another study found that a double-incision technique resulted in 10% increased isometric flexion strength in comparison to the single-incision technique.14 Although complications are rare, one study with 53 patients reported one wound complication, two transient paresthesia of the lateral antebrachial cutaneous nerve, and one PIN palsy that resolved within six weeks.15 The overall prognosis after biceps tendon rupture repair is satisfactory.16 Factors such as comorbid disorders, concomitant injuries, age, and time from injury to surgery all play a role in outcomes and complications.
Measures of surgical efficacy can vary and may include:
- Time from injury to surgery
- Muscle force
- Grip strength
- Elbow flexion-extension
- Forearm supination-pronation
- Elbow stiffness
- Heterotopic ossification with or without synostosis
- Nerve injuries
This equipment used in this procedure includes an Arthrex® button fixation system using the 12-mm BicepsButton™ from Arthrex® and #2 FiberLoop® with a straight needle and a PEEK Tenodesis Screw, 7 mm x 10 mm (Arthrex Inc, Naples, Florida).
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am. 1985;67:414–417.
- Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002;(404):275-283.
- Alentorn-Geli E, Assenmacher AT, Sánchez-Sotelo J. Distal biceps tendon injuries: a clinically relevant current concepts review. EFORT Open Rev. 2017 Mar 13;1(9):316-324. doi:10.1302/2058-5241.1.000053.
- O'Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med. 2007;35(11):1865-1869. doi:10.1177/0363546507305016.
- Hsu D, Anand P, Mabrouk A, Chang K. Biceps Tendon Rupture. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513235/.
- Schmidt CC, Styron JF, Lin EA, Brown BT. Distal biceps tendon anatomic repair. JBJS Essent Surg Tech. 2017;7(4):e32. doi:10.2106/JBJS.ST.16.00057.
- 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. doi:10.1016/j.jse.2007.04.008.
- Wiley WB, Noble JS, Dulaney TD, Bell RH, Noble DD. Late reconstruction of chronic distal biceps tendon ruptures with a semitendinosus autograft technique. J Shoulder Elbow Surg. 2006;15(4):440-444. doi:10.1016/j.jse.2005.08.018.
- Morrison KD, Hunt TR. Comparing and contrasting methods for tenodesis of the ruptured distal biceps tendon. Hand Clin. 2002;18(1):169-178. doi:10.1016/s0749-0712(02)00009-4.
- Watson JN, Moretti VM, Schwindel L, Hutchinson MR. Repair techniques for acute distal biceps tendon ruptures: a systematic review. J Bone Joint Surg Am. 2014;96(24):2086-2090. doi:10.2106/JBJS.M.00481.
- Yao C, Weng W, Zhou X, et al. Individual treatment of delayed distal biceps tendon rupture: case report and literature review. Ann Plast Surg. 2019 Mar;82(3):277-283. doi:10.1097/SAP.0000000000001624.
- Cil A, Merten S, Steinmann SP. Immediate active range of motion after modified 2-incision repair in acute distal biceps tendon rupture. Am J Sport Med. 2009;37(1):130-135. doi:10.1177/0363546508323749.
- Lang NW, Bukaty A, Sturz GD, Platzer P, Joestl J. Treatment of primary total distal biceps tendon rupture using cortical button, transosseus fixation and suture anchor: a single center experience. Orthop Traumatol Surg Res. 2018 Oct;104(6):859-863. doi:10.1016/j.otsr.2018.05.013.
- Grewal R, Athwal GS, MacDermid JC, et al. Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am. 2012;94(13):1166-1174. doi:10.2106/JBJS.K.00436.
- El-Hawary R, Macdermid JC, Faber KJ, Patterson SD, King GJ. Distal biceps tendon repair: comparison of surgical techniques. J Hand Surg Am. 2003;28(3):496-502. doi:10.1053/jhsu.2003.50081.
- 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. doi:10.1016/j.jse.2004.09.007.
Cite this article
Appiakannan HS, Kachooei AR, Ilyas AM. Biceps tenodesis for distal biceps tendon repair. J Med Insight. 2023;2023(335). doi:10.24296/jomi/335.
Table of Contents
- Identification and Preservation of Lateral Antebrachial Nerve
- Whip Stitches Through Tendon
- Debride Distal End of Tendon Stump
- Confirm Tendon Sizing
- Mark Distal Centimeter of Tendon Stump
- Place Shuttle Stitch
- Place Limbs of Whip Stitch Through Distal Biceps Tendon Button
- Place Button on Insertion Device
- Deep Dissection to Proximal Radius
- Sharp Excision of Tendon Remnant from Footprint
- Decortication of Radial Tuberosity Footprint
- Unicortical Placement of Guidewire in Radial Tuberosity
- Confirm Guidewire Placement via Fluoroscopy
- Advance Guidewire Through Second Cortex
- Place 7.5-mm Acorn Reamer over Guidewire and Across First Cortex
- Irrigation to Remove Bone Shavings
- Place Biceps Button Through Both Cortices
- Deliver Tendon Through Bone Tunnel
- Deliver Second Limb of FiberWire Through Tendon via Previously Prepared Shuttle Stitch
- Tie Two Ends Together to Lock Distal Biceps Tendon in Bone Tunnel
- Examine First Point of Fixation
- 7-mm Tenodesis Screw Placement for Second Point of Fixation
- Tie Two Limbs of FiberWire Together for Third Point of Fixation
The incision is marked out just distal to the antecubital fossa and slightly radial in order to both access the retracted distal biceps tendon stump as well as the proximal radius site for repair. Alternatively, a transverse incision can also be placed. Occasionally in cases with a very retracted distal biceps tendon stump or contracted biceps muscle, proximal dissection is necessary, and the incision can be extended as shown here, proximally across the lateral border of the biceps musculature.
After exsanguination of the limb and elevation of the sterile tourniquet to 250 mmHg, the incision is placed.
Blunt dissection is then performed down to the antebrachial fascia. The first structure to be identified is the lateral antebrachial cutaneous nerve. The dotted line next to the incision is the anticipated location of this nerve.
Once the dissection is taken deeper, the lateral antebrachial nerve should be identified and carefully mobilized and subsequently retracted radially.
Once mobilized and retracted, dissection can then be performed to identify the distal biceps tendon stump. Often, with blunt use of your finger alone, the tendon end can be identified loose within the soft tissue proximally and then can be retracted out into the wound and tagged with an Allis clamp.
Once retrieved and mobilized, the distal biceps tendon is then tagged. Often, the tendon can be retracted, and to help mobilize the tendon, blunt dissection between the biceps and the brachialis can be performed with one's finger. Moreover, the lacertus fibrosus can also be released if necessary. Care must be taken, however, to avoid injury to any neurovascular structures during such a release. Broadly speaking, there are a number of ways to classify distal biceps tendon repair techniques. The first distinction is whether a one-incision or a two-incision technique is being utilized. In this case, a single-incision Arthrex BicepsButton fixation system will be utilized, which involves placement of a trough within the proximal radius to dunk the biceps tendon, followed by tensioning of the biceps tendon within the proximal radius using a BicepsButton, followed by interference fixation of the biceps tendon using an interference screw. This system provides three points of fixation to maximize repair strength of the distal biceps tendon, as will be shown. The repair is initiated by placing a whip stitch around the distal biceps tendon, as being illustrated here, using a number 2 FiberWire suture. At least three to four whip stitches are placed through the distal biceps tendon prior to freshening up the distal biceps tendon for repair.
The very distal end is sharply debrided in order to provide a clean stump for repair. In order to improve ease of placement and sliding of the distal biceps tendon within the tunnel in the proximal radius to be made, all loose ends and frayed ends are sharply debrided away as to not obstruct placement within the tunnel.
Since the manufacturer's technique utilizes a 7-mm tenodesis screw, the tendon is then debrided down to ideally a 7-mm or 8-mm width so that a 7.5-mm bone tunnel can be created. Here, the tendon is shown to comfortably fit within a 7-mm sizer.
To aid in confirming that adequate amount of distal biceps tendon has been dunked into the trough of the proximal radius, the distal centimeter of the tendon is marked.
Next, in order to aid in the first point of fixation of the distal biceps tendon once docked in the tunnel and tensioned, a shuttle stitch is placed one centimeter proximal to the distal biceps tendon stump as shown here to deliver the second limb of the FiberWire suture and then repair of the tendon to the proximal radius. The shuttle stitch consists of an 0 Vicryl suture with the needle cut off, both limbs are placed through a free needle and then run through the proximal biceps tendon stump. The looped end is run through, and the tails are left behind and then tagged as shown here for later shuttling of one limb of the FiberWire once the biceps tendon is inserted.
Attention is now turned back to the distal biceps tendon stump and its whip stitch with the number 2 FiberWire. The loop is cut, and the freed Keith needle is then used to pass each limb of the whip stitch through the distal biceps tendon button as shown here. With the aid of the Keith needle, each limb of the FiberWire is placed through the Biceps Button but in an opposite direction. The entrance of one side represents the exit of the other side. This will provide the necessary relationship for the Biceps Button to slide once tensioned on the other side of the proximal radius.
Lastly, the Biceps Button is placed on its insertion device for later insertion into the second cortex of the proximal radius, as shown here.
Next, once the distal biceps tendon stump has been prepared for insertion and repair into the proximal radius, deep dissection can now be performed down to the proximal radius. Often, a pseudotendon, or a stump, of the distal biceps tendon may be identified in the wound. This is very helpful, as it can be followed down to the level of the proximal radius to identify the footprint for repair of the distal biceps tendon back down to the radial tuberosity of the proximal radius. To aid in visualization, the camera angle has been changed. The hand is now pointed towards the top of your screen and the shoulder towards the bottom of your screen. During deep dissection as well as preparation of the proximal radial tunnel through the radial tuberosity, the forearm must be kept in maximal supination at all times to deliver the radial tuberosity footprint, as well as to keep the posterior interosseous nerve away from the surgical site. With the radius kept supinated, the distal biceps tendon cyclops lesion, or pseudotendon, is being carefully dissected down to the footprint of the proximal radius at the level of the radial tuberosity.
Once careful blunt dissection down to the radial tuberosity of the proximal radius has been confirmed and the footprint palpable, sharp dissection of the remnants of the distal biceps tendon, or the pseudotendon, can be sharply elevated off with a blade as shown here. It is typical to encounter veins crossing the surgical field, which represent the recurrent leash of Henry. These vessels can either be retracted, cauterized, tied off, or hemoclipped as needed to aid in exposure of the radial tuberosity.
Next, again, with the radius maximally supinated, the radial tuberosity is prepared. First, it is decorticated of any residual soft tissue to aid an exposure of the footprint.
Next, with the radial tuberosity exposed and the radius held in maximal supination, the step guidewire for the tenodesis set is positioned. The guidewire should be placed directly over the radial tuberosity but angled slightly ulnar to avoid injury to the posterior interosseous nerve. First, only a unicortical placement of the guidewire is placed to confirm position before accessing the second posterior cortex of the proximal radius.
Intraoperative fluoroscopy can then be used to confirm appropriate position of the guidewire within the radial tuberosity of the proximal radius before proceeding with bicortical placement of the guidewire.
One satisfied, the guidewire can then be advanced across the second cortex, again, making sure to angle just slightly ulnar while placing this guidewire.
Next, the 7.5-mm acorn reamer from the tenodesis set is placed over the guidewire and advanced across only the proximal cortex, not bicortically.
The bone shavings are aggressively washed away to remove all shavings, which could potentially be a nidus for heterotopic bone or a synostosis formation.
With the bone tunnel established within the proximal radius, the distal biceps tendon is now dunked through the tunnel using the BicepsButton insertion guide as shown here. The BicepsButton should be placed bicortically and disengaged from the insertion device until satisfied that it has crossed the far second cortex of the radius. It can help to place a hand on the other side of the forearm to feel the biceps tendon penetrate the second cortex of the radius.
Next, with the BicepsButton deployed on the far side of the radius, the elbow is slightly flexed and sequentially tensioning the two limbs of the FiberWire, the distal biceps tendon is then delivered within the bone tunnel.
Once satisfied that the distal biceps tendon has been adequately dunked within the proximal radius bone tunnel, and with one limb of the FiberWire under tension, the second limb is then delivered through the distal biceps tendon through the shuttle stitch previously prepared, as shown here.
Now with one limb serving as a post through the second cortex of the proximal radius, and the second limb now running through the distal biceps tendon, the two ends are then sewn together to lock the distal biceps tendon within the proximal radius bone tunnel as shown here.
At this point, the distal biceps tendon has been repaired within the proximal radius, and this represents the first point of fixation. You will know that the distal biceps tendon will be under tension when manipulated.
Next, the second point of fixation is achieved with the 7-mm tenodesis screw. a Nitinol loop is then used to deliver one limb of the FiberWire stitch across the insertion device for the Tenodesis Screw as shown here. With only a short length of the FiberWire emanating from the Nitinol loop to maintain enough length to come across the insertion device, the Nitinol loop is pulled, and the FiberWire limb is then brought through the insertion device and tensioned on the backside. Next, the insertion device is seated within the radial tunnel along the radial border of the distal biceps tendon. Once adequately seated, the paddle is held steady, downward pressure is applied, and the Tenodesis Screw is advanced within the radial tunnel until adequately countersunk. The interference screw fixation represents the second point of fixation of the distal biceps tendon.
The final and third point of fixation is then sewing the two limbs of the FiberWire together, one limb is outside the tenodesis screw, and the second limb is through the tenodesis screw.
Once satisfied, closure is undertaken after copiously washing the wound again, the skin is closed in a layered fashion. No deep closure is required. With the wound closed, a posterior splint can be applied if desired. The elbow is held in 90 degrees, and the forearm supinated. This can be removed at the first postoperative visit. Thank you.