Delayed Reconstruction of Distal Biceps Tendon Ruptures

22
Delayed
Reconstruction
of Distal Biceps
Tendon Ruptures
Bernard F. Morrey and Mark Morrey
INTRODUCTION
Frequency of delayed reconstruction appears to be slightly increasing in recent years. As noted in
the prior chapter (Chapter 21), if the host tendon can be reattached with the elbow at 90 degrees,
this is possible in most instances and is preferable to reconstruction (1). The 90-degree contracture
will stretch out to near-normal extension with time, and function is excellent. When the tendon has
retracted to the point that it cannot be reattached directly to the tuberosity, augmentation with an
Achilles tendon allograft is our technique of choice. However, we have discontinued preserving the
fleck of calcaneus and simply embed the allograft tendon as noted below.
INDICATIONS/CONTRAINDICATIONS
Indications for Delayed Reconstructions
Not all with a missed or nonoperated acute injury require reconstruction (2).
However, chronic pain and fatigue do occur if the injury is not addressed (3).
●● Hence, we offer reconstruction to patients who have chronic pain, sometimes due to tethering
of the neurovascular structures or other symptoms such as cramping and fatigue due to the
detached distal biceps tendon.
●● Typically, selective loss of supination strength is the major problem, and rarely is flexion weakness an indication for delayed reconstruction.
●●
●●
Contraindications
Absence of functional impairment, either pain or weakness, even though the distal biceps tendon
has been completely avulsed
DIAGNOSIS
●●
●●
By definition, reconstruction implies the diagnosis has been made.
Functional impairment is the key, not only to make the diagnosis but to determine whether reconstruction is indicated.
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PREOPERATIVE PLANNING
I have had one patient 11 months after rupture who had little retraction due to an intact lacertus
fibrosis, hence was able to perform a direct reattachment. Because of the uncertainty, prepare the
patient for either eventuality—direct reattachment or reconstruction. Final determination is based
on findings at surgery (Fig. 22-1). The recoiled tendon may be able to be teased out to a length
that allows reattachment. If not, have an allograft tendon available or prep the patient for autograft
harvest and reconstruct.
TECHNIQUE
Several authors have reported small series of reconstructions using various tissues including the
autologous hamstring (4,5), the flexor carpi radialis (6), and the Achilles tendon allograft (7).
The author has used the allograft Achilles tendon almost exclusively for this reconstruction, and
the technique currently used is described in this chapter. The technique has been modified from the
prior description (7) that called for retaining a fleck of the calcaneal attachment. This is felt to be
no longer necessary, and hence, the calcaneus is resected, and the free end of the tubular Achilles
tendon is embedded directly into the tuberosity.
Position
The patient is supine on the table, and the arm is placed on an elbow (arm) table.
Exposure
With reconstruction, the anterior exposure must be more extensive since the biceps tendon and
muscle must be exposed (Fig. 22-2). We employ a Henry-type skin and deep exposure. After the
tendon has been retrieved and it is determined that the biceps tendon is inadequate for reattachment
even with the elbow flexed to 90 degrees (Fig. 22-3), the tuberosity is exposed by blunt dissection
in the cubital fossa.
Note: This is one of the most important parts of the procedure; the space occupied by the biceps
tendon is often scarred. Care must be taken to avoid injury to the radial nerve:
The tuberosity is exposed by blunt dissection.
Tip: Rotation of the forearm allows confirmation of the location of the radial tuberosity. A curved
hemostat is used to identify the site for the forearm incision by sliding this past the tuberosity
between the radius and the ulna (Fig. 22-4).
●●
●●
The tuberosity is exposed by an incision over the proximal forearm. The extensor muscle and the
supinator muscles are split exposing the tuberosity (Fig. 22-5).
FIGURE 22-1
Biceps tendon partially uncoiled in a patient who sustained injury 3 months prior to surgery (A). When restored to present full length, the
tendon is inadequate to allow primary reattachment (B).
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FIGURE 22-2
Unlike the approach for an acute injury
using a limited transverse incision, a
lazy S type of incision is required both
in some instances to find the tendon, but
the proximal arm is always necessary in
order to envelope the biceps muscle with
the Achilles tendon allograft.
FIGURE 22-3
Patient sustained an injury 5 months
prior to surgery. The biceps tendon had
resorbed leaving only a small “nub” of
the original tendon.
FIGURE 22-4
A: A curved hemostat is passed through the anterior incision and is directed around the radius such as to emerge at the dorsal aspect of the
forearm. B: Care is taken not to disturb or violate the ulnar periosteum; hence, the curvature of the instruments should be directed away from
the ulna.
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FIGURE 22-5
An incision is made directly over the hemostat as it tents the skin (A). The tuberosity is exposed by a transmuscular splitting incision (B).
The allograft tendon is inspected, and the length of the circular Achilles tendon is measured such
that once attached to the tuberosity the flare of the aponeurosis coincides with the musculotendinous junction of the host (Fig. 22-6). Two no. 5 nonabsorbable running locked sutures are placed
in the allograft tendon in a running locked pattern as in the acute rupture (Fig. 22-7).
●● The tuberosity is excavated in the typical fashion (Fig. 22-8) (Chapter 21). Three drill holes are
placed in the margin of the tuberosity.
●●
FIGURE 22-6
The allograft is assessed referable to the anatomy. The length of the Achilles biceps tendon “D” required to
attach to the tuberosity and widen at the site of the musculotendinous junction is estimated.
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FIGURE 22-7
A: A running locked suture with a heavy no. 5 nonabsorbable suture is placed at the end of the allograft tendon. As with the acute repairs, we
typically place two such sutures. B: The proper length of the allograft tendon is confirmed prior to attachment of the biceps tendon into the
tuberosity.
FIGURE 22-8
The tuberosity is exposed, and three drill holes are
placed in the margin to secure the allograft tendon.
The excavation is adequate to fully seat the end of the
allograft into the tuberosity.
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Lead sutures are brought through these drill holes, and the lead sutures are used to bring the heavy
no. 5 Ethibond sutures through the holes, thus drawing the distal aspect of the allograft into the
excavated tuberosity (Fig. 22-9).
●● The tendon is then threaded from the anterior exposure into the dorsal forearm incision. This is
facilitated by the sutures that have been placed in the tendon (Fig. 22-10) and allow the tendon to
be drawn from the anterior to the posterior incision.
●● The sutures are firmly tied (Fig. 22-11).
●●
Tip: Supination of the forearm facilitates this step.
The biceps muscle is grasped at the residual portion of the biceps tendon. The muscle is very
aggressively freed both at the subcutaneous surface and its intermuscular fascial surface. All
adhesions must be removed between the brachialis muscle and subcutaneous tissue to allow restoration of the excursion of the muscle.
●● With the elbow flexed to about 90 degrees and with distal tension on the biceps tendon and moderate proximal tension on the attached allograft (Fig. 22-12), a no. 5 nonabsorbable suture is placed
through the Achilles fascia and then through the residual of the biceps tendon (Fig. 22-13).
●●
FIGURE 22-9
Lead sutures are placed in the holes of the tuberosity to
facilitate drawing the attachment sutures into the prepared
radial tuberosity.
FIGURE 22-10
The allograft is then drawn through the
anterior incision and into the dorsal
incision of the forearm. Care is taken to
assure that the allograft slides smoothly
before it is attached into the tuberosity.
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FIGURE 22-11
A: The end of the allograft tendon is observed, and the sutures have been drawn through the bone tunnels. B: Supinating the forearm rolls
the tuberosity in the direction of the allograft. Pulling the sutures draws the allograft into the prepared bed of the tuberosity, and the sutures
are tied. This is the most critical step of the procedure.
FIGURE 22-12
With a secure attachment of the tuberosity,
the allograft tendon is brought under
tension by pulling it proximally. The
elbow is placed at 90 degrees of flexion.
FIGURE 22-13
The biceps has been freed of all adhesions, and it is brought as distally as possible. At this point, the allograft is secured to the nub of the
biceps tendon with a heavy no. 5 nonabsorbable suture with the elbow placed in 90 degrees of flexion. Additional stabilizing sutures are
placed between the allograft and the strong tendinous portion of the distal biceps tendon.
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FIGURE 22-14
The allograft is then deployed and wrapped around the biceps muscle. A running locked heavy nonabsorbable suture is used to secure the
aponeurotic portion of the allograft to the muscle of the biceps tendon.
●●
Once the suture has been tied, the tension of the construct has been defined. With the elbow flexed
to take tension off the repair, we then complete the proximal attachment with a running locked
no. 1 nonabsorbable suture placed in the aponeurosis and wrapped around the medial and lateral
margins of the biceps (Fig. 22-14). (Note: Care should be taken to avoid injury to the radial nerve
as the graft is wrapped along the lateral aspect of the biceps muscle.)
The tension on the reconstruction is assessed to determine the initial postoperative amount of
flexion to protect the reconstruction. The closure is routine.
POSTOPERATIVE MANAGEMENT
The patient is placed in a posterior splint. The recovery is delayed somewhat, and the reconstruction
is protected for 3 weeks in a splint. Passive-assisted motion is begun at 3 weeks and continued for
6 weeks. Full extension is then gained from the 6th to the 9th to 10th week. Active motion for activities of daily living is allowed between 6 and 12 weeks. Activity is tolerated and progresses from the
3rd to the 9th month depending upon the circumstances.
COMPLICATIONS
There has been little written on this procedure or any of the described reconstructions, and thus there
is even less regarding the complications. Kelly has pointed out that any procedure done more than
2 to 3 weeks after the original acute injury is associated with a statistically higher complication rate
(8). The main potential problem of course is injury to the radial nerve. Most reports in the literature
have, however, demonstrated good functional and clinical outcomes with the various techniques
described for delayed reconstruction.
THE MAYO EXPERIENCE
We have performed a delayed reconstruction using the Achilles allograft in nine patients to date.
Of these, all nine have expressed satisfaction with the reconstruction.
●● Details are currently under review.
●● None has been reoperated.
●● There were no complications.
●●
●●
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REFERENCES
1. Morrey ME, Abdel MP, Sanchez Sotelo J, et al.: Primary repair of retracted distal biceps tendon ruptures in high flexion.
(Accepted for publication, JSES)
2. Freeman CR, McCormick KR, Mahoney D, et al.: Nonoperative treatment of distal biceps tendon ruptures compared with
a historical control group. J Bone Joint Surg Am 91A(10): 2329–2334, 2009.
3. Nesterenko S, Domire ZJ, Morrey BF, et al.: Elbow strength and endurance in patients with a ruptured distal biceps tendon. J Shoulder Elbow Surg 19(2): 184–189, 2010.
4. Hallam P, Bain GI: Repair of chronic distal biceps tendon ruptures using autologous hamstring graft and the endobutton.
J Shoulder Elbow Surg 13: 648, 2004.
5. Wiley WB, Noble JS, Dunlaney TD, et al.: Late reconstruction of chronic distal biceps tendon ruptures with a semitendinosus
autograft technique. J Shoulder Elbow Surg 15: 440, 2006.
6. Levy HJ, Mashoof AA, Morgan D: Repair chronic ruptures of the distal tendon using flexor carpi radialis tendon graft.
Am J Sports Med 28: 538, 2000.
7. Sanchez-Sotelo J, Morrey BF, Adams RA: Reconstruction of chronic ruptures of the distal tendon with use of an Achilles
tendon allograft. J Bone Joint Surg 84: 999, 2002.
8. Kelly EW, Morrey BF, O’Driscoll SH: Complications of repair of the distal biceps tendon with modified two-incision
technique. J Bone Joint Surg 82: 1575, 2000.
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