89
EEXOT Volume 63, (2): 89-92, 2012
Repair of distal biceps brachii tendon ruptures through a limited anterior approach
ANTONOPOULOS D1, MAVROGENIS A-F2, 2 1 STAVROPOULOS N , SPYRIDONOS S.G 1
ΚDepartment of Hand and Upper Extremity Surgery and Microsurgery, KAT Hospital, Athens Greece First Departments of Orthopaedics, Athens University Medical School, Athens Greece
2
ABSTRACT We present 35 patients with complete rupture of the distal biceps brachii tendon treated with limited anterior approach for anatomical reattachment at the radial tuberosity of the tendon by using suture anchors. Our clinical outcome shows that the limited surgical approach combined with the anatomical reconstruction allows for early mobilization and rapid return of function, providing the excellent long-term results with acceptable complications. We suggest using the limited anterior approach in patients with early (less than 6 weeks) distal biceps brachii tendon rupture. Key words: distal biceps brachii tendon rupture; radial tuberosity; limited anterior approach.
INTRODUCTION Only 3% of biceps tendon ruptures occur at the distal tendon17; 80% of them involve the dominant arm, usually 2,8 of an active adult at an average age of 50 years . The usual mechanism of injury is a single traumatic event during heavy object lifting with the elbow in 90 degrees of flexion, or with the biceps muscle contracting against resistance. Anabolic steroid use in weightlifters accounts for a surprisingly high 17 incidence of the injury in this population .
Mailing address: Andreas F. Mavrogenis, MD First Department of Orthopaedics Athens University Medical School 41 Ventouri Street, 15562 Holargos, Athens, Greece Tel: +30210-6540800 Mobile: +30-697222609 e-mail:
[email protected]
Complete avulsion of the tendon from the radial tuberosity is much more frequent than partial rupture. The most common symptoms of complete distal biceps brachii tendon injury are a sudden, sharp pain followed by discomfort in the cubital fossa or the lower anterior aspect of the arm and absence of the distal biceps muscle contour during elbow flexion. Ecchymosis and tenderness is usually observed at the anterior and medial aspect of the 5,8 cubital fossa . Diagnosis is difficult in patients with partial distal biceps brachii tendon rupture. Signs and symptoms often include pain and weakness of elbow flexion and forearm supination, and crepitus during forearm pronation17 supination; however, the tendon is still palpable . If unclear, magnetic resonance imaging and ultrasonography can be used to confirm the diagnosis distal biceps brachii tendon 1-3,14 . rupture The repair of acute distal biceps tendon rupture by using a single limited anterior approach and suture anchors was 21 described in the past . All patients regained full range of flexion and extension at the elbow and pronation and supination of the forearm, without neurovascular complications. The purpose of our study is to present the limited anterior approach for anatomical reattachment at the radial tuberosity of distal biceps brachii tendon complete rupture using suture anchors. To our opinion, this technique simplifies repositioning of the tendon at its original anatomical insertion with excellent long-term functional and cosmetic results and none complications.
PATIENTS AND METHODS Thirty five consecutive patients admitted to the authors institution over the last 6 years with complete distal biceps
90
E.E.X.O.T., Volume 63, Number 2, 2012
Figure 1. (Α), (Β) magnetic resonance imaging of the left arm of a 45-yearold man with distal biceps tendon rupture.
brachii tendon rupture. All patients were men with a mean age of 42 years (range, 37 to 46 years). Twenty six patients were hand working laborers, four were office workers, and five were non-professional athletes. All patients were informed of the limited anterior approach of the technique presented herein, and gave their informed consent to be included in this study. Diagnosis was obtained in all patients using clinical examination and magnetic resonance imaging (Figure 1). In most patients, surgery was performed within 10 days after the injury. In 12 patients, surgical treatment was performed at 30 and 45 days, respectively because of delayed orthopaedic evaluation and diagnosis. Anatomical reattachment of the tendon at the radial tuberosity was performed through a limited anterior approach to the cubital fossa by using 2 suture anchors (PANALOK ® QUICKANCHORTM PLUS, DePuy Mitek, Inc., Johnson & Johnson). A 3-4cm oblique incision was made at the anterior cubital fossa (Figure 2). Using blunt dissection, the ruptured tendon is located and easily recognized at the anterior cubital fossa or the lower arm (Figure 3). With the forearm in supination, so as to avoid iatrogenic injury of the anterior interosseous nerve, the radial tuberosity is exposed through the common extensor and supinator muscles approximately 1cm to 1.5cm so as to allow the positioning of two suture anchors within 1 cm (Figure 4). In early ruptures the tendosynovial sheath was usually intact. The ulna was not exposed. The suture anchors used were constructed of molded poly-L-lactide polymer. The sutures of the anchors were Ethibond (ETHICON, Inc., Somerville, NJ). After debridement the tendon was reattached to the tuberosity without tension, with the elbow in 90 degrees of flexion and neutral
Figure 2. (Α) Oblique incision (Β) at the medial border of the brachioradialis muscle.
rotation of the forearm. Postoperatively, a brachial arm cast in 90 degrees of flexion and neutral rotation of the forearm was applied for 4 weeks; at this time, passive and active-assisted range of motion gradually begun.
RESULTS The mean follow-up was 18 months (range, 12 months to 3 years). There was minimal surgical wound and the contour of the biceps muscle was restored in all cases (Figure 5). At 3 months, all patients had reached a free range of motion and full strength unlimited recreational and professional activity. Muscle strength of elbow flexion and forearm supination were within normal limits and symmetrical to the opposite side. One patient, a hand working laborer operated within 10 days after the injury, had a posterior interosseous nerve neurapraxia that recovered completely at 2 months. Early complications such as neurovascular injuries and wound healing problems were not observed.
DISCUSSION Depending on patients’ age and activity level, conservative and surgical treatment have been reported for distal biceps 1,4,6,13,17,18 . However, conservative brachii tendon rupture treatment is associated with functional problems, chronic pain in the cubital fossa and proximal forearm, and substantial weakness in forearm supination (45 days from injury day) we suggest tendon reinsertion into the brachialis muscle or direct suturing of the distal biceps tendon to the brachialis muscle tendon in case of operative treatment 12,17 10 days after the injury increases the risk of postoperative complications. When surgical reconstruction is performed within 10 days from the injury, the retracted tendon is easily identifiable, the track to the radial tuberosity is intact, and the tendon can be reattached to the tuberosity without major surgical 12 dissections . Moreover, the secure fixation and limited surgical exposure allow for early mobilization and rapid 13,18 return of function . Anatomical repair of distal biceps brachii tendon rupture through a limited anterior approach using suture anchors is a safe, minimally invasive and reliable technique with minor complications and excellent functional outcome.
Figure 4. (Α) Insertion of two bone anchors at the anatomical insertion of the distal biceps tendon at the bicipital tuberosity of the radius, and (Β) reattachment of the tendon.
92
E.E.X.O.T., Volume 63, Number 2, 2012
Figure 5. Clinical result 6 months postoperatively.
The secure fixation obtained with the suture anchors, the limited surgical approach and the anatomical reconstruction allow for early mobilization and rapid return of function of patients with early (
