JBJS | Complications of Repair of the Distal Biceps Tendon with the Modified Two-Incision Technique*†

The Journal of Bone & Joint Surgery, Volume 82, Issue 11

Articles | November 01, 2000

Complications of Repair of the Distal Biceps Tendon with the Modified Two-Incision Technique*†

Edward W. Kelly, M.D.‡; Bernard F. Morrey, M.D.‡; Shawn W. O'Driscoll, Ph.D., M.D.‡

Investigation performed at the Department of Orthopedics, Mayo Clinic, Rochester, Minnesota
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Read in part on Specialty Day of the American Shoulder and Elbow Surgeons and at the Annual Meeting of the American Academy of Orthopaedic Surgeons, Anaheim, California, February 8, 1999.
‡Department of Orthopedics, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905. E-mail address for B. F. Morrey: morrey.bernard@mayo.edu. E-mail address for S. W. O'Driscoll: odriscoll.shawn@mayo.edu.

The Journal of Bone & Joint Surgery. 2000; 82:1575-1575

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Abstract

Background: The purpose of this paper is to describe the complications that we encountered after using a muscle-splitting two-incision technique to repair avulsed distal biceps tendons.

Methods: We conducted a retrospective review of the results of seventy-eight consecutive anatomical repairs of the distal biceps tendon performed through a muscle-splitting two-incision technique at our institution between 1981 and 1998. Four of the patients required a graft to restore length. The seventy-four tendons that were repaired primarily through the modified Boyd-Anderson approach were analyzed in detail and form the basis of this report.

Results: Complications developed after twenty-three (31 percent) of the seventy-four repairs. The complications included five sensory nerve paresthesias (three lateral antebrachial cutaneous and two superficial radial nerve paresthesias) in five patients. A temporary palsy of the posterior interosseous nerve developed in one patient; it resolved in six months. Six patients complained of persistent anterior elbow pain. Heterotopic ossification that did not limit forearm rotation developed in four patients, a superficial wound infection developed in three, one tendon reruptured, three patients lost forearm rotation, and reflex sympathetic dystrophy developed in one patient. No radioulnar synostoses were observed in our series. Complications developed after ten (24 percent) of the forty-one acute repairs (performed fewer than ten days after the injury), six (38 percent) of the sixteen subacute repairs (performed ten to twenty-one days after the injury), and seven (41 percent) of the seventeen delayed repairs (performed more than twenty-one days after the injury). The surgeon's experience with this procedure had no apparent effect on complication rates.

Conclusions: Most of the morbidity from repair of the distal biceps tendon can be attributed primarily to a delay in the timing of the repair and secondarily to an extensive anterior exposure. More importantly, radioulnar synostosis is rare following the muscle-splitting modification of the two-incision technique, which can be performed safely even by surgeons with limited experience with this procedure.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Unrepaired avulsion of the distal biceps tendon frequently leaves the patient with substantial weakness of supination and elbow flexion^2,19,23. Excellent subjective and objective results of surgical repair have been reported^{1,7,8,13,17,20}. As a result of these and other reports, most orthopaedic surgeons now advocate early surgical repair, particularly in young, physically active individuals. The issue of surgical approach, however, has been controversial.

The extensive anterior exposure required to reattach the biceps to the radial tuberosity has been associated with several complications, including radial and median nerve palsies^9,11,19. In an attempt to avoid such complications, Boyd and Anderson advocated a two-incision technique to limit the anterior dissection⁶. Recently, concern has developed because of anecdotal reports of complications of the two-incision technique, including the formation of a proximal radioulnar synostosis¹⁰ as well as injury to the posterior interosseous nerve¹⁴. The surgical approach employed at our institution was introduced by Morrey in 1981 and later described in 1985²⁰. Morrey used a muscle-splitting modification of the posterior approach to avoid subperiosteal exposure of the ulna in an attempt to lessen the likelihood of a proximal synostosis.

Several investigators have recently claimed that placement of suture anchors in the radius through an anterior incision, as an alternative to the two-incision approach, limits the risk of a synostosis^{3,12,16,18,24,25}. However, the cost of surgery increases and the strength of the repair decreases¹⁵ with the use of suture anchors. Objective data are required to provide a scientific basis for the selection of one procedure over the other, but such data are not available in the current literature, to our knowledge.

We are not aware of any single report of the complications associated with the surgical repair of an avulsed distal biceps tendon, through any surgical approach, in a large series of patients. The purpose of this paper is to describe the complications resulting from a muscle-splitting two-incision technique for repair of avulsed distal biceps tendons in a large series of patients at our institution.

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Fig. 1:: Graph showing the types of complications and when they developed. All twenty-four complications were present by seven weeks following the surgery.

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Fig. 2:: Two diagrams demonstrating the incorrect path for exposure of the radial tuberosity with the posterior incision. It is important to avoid exposing the ulna either subperiosteally or through Kocher's interval. EDC = extensor digitorum communis, and ECU = extensor carpi ulnaris.

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Fig. 3:: Diagram demonstrating the correct path for exposure of the radial tuberosity through a posterior incision. The preferred path utilizes a muscle-splitting approach through the extensor carpi ulnaris (ECU) and avoids exposure of the ulna. EDC = extensor digitorum communis.

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Table I: Anatomical Findings at the Time of Surgery According to the Timing of the Repair

	Acute Repair	Subacute Repair	Delayed Repair	P Value
Acute vs. Subacute	Acute vs. Delayed	Subacute vs. Delayed
No. of repairs	41	16	17
Small anterior incision	9 (22%)	5 (31%)	0 (0%)	0.5	<0.05	<0.01
Complete tear	36 (88%)	15 (94%)	4 (24%)	0.5	<0.001	<0.001
Complete tear with patent bicipital tunnel	31/36 (86%)	8/15 (53%)	3/4 (75%)	<0.01	0.6	0.4

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Table I: Anatomical Findings at the Time of Surgery According to the Timing of the Repair

	Acute Repair	Subacute Repair	Delayed Repair	P Value
Acute vs. Subacute	Acute vs. Delayed	Subacute vs. Delayed
No. of repairs	41	16	17
Small anterior incision	9 (22%)	5 (31%)	0 (0%)	0.5	<0.05	<0.01
Complete tear	36 (88%)	15 (94%)	4 (24%)	0.5	<0.001	<0.001
Complete tear with patent bicipital tunnel	31/36 (86%)	8/15 (53%)	3/4 (75%)	<0.01	0.6	0.4

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Table II: Complications According to the Timing of the Repair

*The values are given as the average and the standard deviation, with the range in parentheses.†The values are given as the number of repairs.‡The values are given as the number of complications.Â§Lateral antebrachial cutaneous or superficial radial.

	Acute Repair	Subacute Repair	Delayed Repair	P Value
Acute vs. Subacute	Acute vs. Delayed	Subacute vs. Delayed
No. of repairs	41	16	17
Age* (yrs.)	46 ± 8.10 (27-63)	48 ± 11.4 (33-72)	45 ± 8.3 (30-62)	0.5	0.7	0.4
Time to repair* (days)	4 ± 2.3 (0-9)	14 ± 3.4 (10-21)	363 ± 536 (22-1918)
Complications†	10 (24%)	6 (38%)	7 (41%)	0.3	0.2	0.8
Nerve paresthesia‡§	1 (2%)	2 (13%)	2 (12%)	0.1	0.1	0.9
Posterior interosseous nerve palsy‡	1 (2%)	0 (0%)	0 (0%)	0.5	0.5	0.99
Heterotopic ossification‡	3 (7%)	1 (6%)	0 (0%)	0.9	0.3	0.3
Loss of range of motion‡	1 (2%)	2 (13%)	0 (0%)	0.1	0.5	0.1
Rerupture‡	0 (0%)	1 (6%)	0 (0%)	0.1	0.99	0.3
Persistent anterior elbo pain (no. needing reexploration)‡	2 (0) (5%)	0 (0%)	4 (2) (24%)	0.4	<0.05	<0.05
Reflex sympathetic dystrophy‡	1 (2%)	0 (0%)	0 (0%)	0.5	0.5	0.99
Superficial wound infection‡	1 (2%)	0 (0%)	2 (12%)	0.5	0.1	0.2

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Table II: Complications According to the Timing of the Repair

	Acute Repair	Subacute Repair	Delayed Repair	P Value
Acute vs. Subacute	Acute vs. Delayed	Subacute vs. Delayed
No. of repairs	41	16	17
Age* (yrs.)	46 ± 8.10 (27-63)	48 ± 11.4 (33-72)	45 ± 8.3 (30-62)	0.5	0.7	0.4
Time to repair* (days)	4 ± 2.3 (0-9)	14 ± 3.4 (10-21)	363 ± 536 (22-1918)
Complications†	10 (24%)	6 (38%)	7 (41%)	0.3	0.2	0.8
Nerve paresthesia‡§	1 (2%)	2 (13%)	2 (12%)	0.1	0.1	0.9
Posterior interosseous nerve palsy‡	1 (2%)	0 (0%)	0 (0%)	0.5	0.5	0.99
Heterotopic ossification‡	3 (7%)	1 (6%)	0 (0%)	0.9	0.3	0.3
Loss of range of motion‡	1 (2%)	2 (13%)	0 (0%)	0.1	0.5	0.1
Rerupture‡	0 (0%)	1 (6%)	0 (0%)	0.1	0.99	0.3
Persistent anterior elbo pain (no. needing reexploration)‡	2 (0) (5%)	0 (0%)	4 (2) (24%)	0.4	<0.05	<0.05
Reflex sympathetic dystrophy‡	1 (2%)	0 (0%)	0 (0%)	0.5	0.5	0.99
Superficial wound infection‡	1 (2%)	0 (0%)	2 (12%)	0.5	0.1	0.2

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Table III: Analysis According to the Experience of the Surgeon

	>20 Repairs	<4 Repairs	P Value
No. of repairs	48	26
Age* (yrs.)	46 ± 8.7 (30-72)	47 ± 9.3 (27-71)	0.8
Time to repair* (days)	817 ± 351 (0-1918)	43 ± 143 (1-730)	0.4
Acute repair†	25 (52%)	16 (62%)	0.5
Subacute repair†	12 (25%)	4 (15%)	0.3
Delayed repair†	11 (23%)	6 (23%)	0.99
Complications†	18 (38%)	5 (19%)	0.1
Nerve paresthesia‡§	5 (10%)	0 (0%)	0.1
Posterior interosseous nerve palsy‡	1 (2%)	0 (0%)	0.5
Heterotopic ossification‡	3 (6%)	1 (4%)	0.7
Loss of range of motion‡	2 (4%)	1 (4%)	0.9
Rerupture‡	1 (2%)	0 (0%)	0.5
Persistent anterior elbow pain (no. needing reexploration)‡	4 (2) (8%)	2 (0) (8%)	0.9
Reflex sympathetic dystrophy‡	1 (2%)	0 (0%)	0.5
Superficial wound infection‡	2 (4%)	1 (4%)	0.9

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Table III: Analysis According to the Experience of the Surgeon

	>20 Repairs	<4 Repairs	P Value
No. of repairs	48	26
Age* (yrs.)	46 ± 8.7 (30-72)	47 ± 9.3 (27-71)	0.8
Time to repair* (days)	817 ± 351 (0-1918)	43 ± 143 (1-730)	0.4
Acute repair†	25 (52%)	16 (62%)	0.5
Subacute repair†	12 (25%)	4 (15%)	0.3
Delayed repair†	11 (23%)	6 (23%)	0.99
Complications†	18 (38%)	5 (19%)	0.1
Nerve paresthesia‡§	5 (10%)	0 (0%)	0.1
Posterior interosseous nerve palsy‡	1 (2%)	0 (0%)	0.5
Heterotopic ossification‡	3 (6%)	1 (4%)	0.7
Loss of range of motion‡	2 (4%)	1 (4%)	0.9
Rerupture‡	1 (2%)	0 (0%)	0.5
Persistent anterior elbow pain (no. needing reexploration)‡	4 (2) (8%)	2 (0) (8%)	0.9
Reflex sympathetic dystrophy‡	1 (2%)	0 (0%)	0.5
Superficial wound infection‡	2 (4%)	1 (4%)	0.9

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From October 1976 through December 1997, eighty-eight ruptures of the distal biceps tendon were repaired in a consecutive series of eighty-seven patients (one patient had bilateral rupture) at our institution. The records of these patients were reviewed retrospectively for the timing of the repair, the surgical approach, and any complications. A single anterior approach was employed in ten patients, one of whom required the use of a tendon graft to restore length. Beginning in 1981, a two-incision approach utilizing a muscle-splitting modification of the Boyd and Anderson technique as described by Morrey et al.²⁰ was used in seventy-eight patients. Four of these patients required a tendon graft to restore length. The remaining seventy-four patients had a primary repair through the Morrey modification of the Boyd-Anderson approach, and they were analyzed in detail and form the basis of this report.

Of the seventy-four repairs, forty-eight were performed by the two senior authors (B. F. M. and S. W. O'D.), both experienced elbow surgeons who had performed this particular operation more than twenty times each. Eleven different surgeons performed the remaining twenty-six repairs; each had performed the operation less than four times (an average of 2.4 times).

Patient follow-up averaged 2.8 years, with a range of twelve weeks to seventeen years. Sixty of the patients were followed for more than six months. All twenty-four complications identified in our review occurred by seven weeks postoperatively (Fig. 1). The complications were analyzed in relation to the experience of the surgeon performing the repair as well as the timing of the repair.

The interval between the injury and the surgery ranged from zero (the operation was performed on the day of the injury) to more than five years. If the tendon repair was performed fewer than ten days after the injury, it was considered an acute repair; if it was performed between ten and twenty-one days after the injury, it was considered subacute; and if it was performed twenty-two days or more after the injury, it was considered delayed. These timing categories were based on the experience of one of the authors (E. W. K.) at the time of surgery. On the average, if the patient was operated on within ten days after the injury, the retracted tendon was easily identifiable, the track to the tuberosity was intact, and the tendon could be reapproximated to the tuberosity without major dissection.

With use of chi-square analysis or the Student t test for means where appropriate, complication rates were compared between groups that were based on the timing of the repair and the surgeon's experience. Differences between the groups were considered significant at p < 0.05.

Results

Introduction | Materials and Methods | Results | Discussion | References

Of the seventy-four repairs in which the biceps tendon was reattached through the Morrey modification^21,22 of the Boyd-Anderson two-incision technique, seventy-three were performed in men and one was performed in a woman. The average age was forty-six years (range, twenty-seven to seventy-two years). Twenty-six ruptures occurred on the left side and forty-eight, on the right. Fifty of the injuries involved the dominant arm. Fifty-five tendons were completely ruptured, and nineteen were partially ruptured. Partial rupture was suspected on the basis of the history (sudden forced extension of the elbow while it was flexed against resistance) and the findings of the physical examination (pain and weakness on resisted supination and flexion as well as tenderness over the bicipital tuberosity). Later in the series, magnetic resonance imaging showing a gap between the tendon and the site of the insertion on the tuberosity as well as edema around the tendon insertion assisted with the diagnosis. The diagnosis was confirmed by exploration of the tendon.

For sixty of the repairs, a Henry anterior incision was made to identify the torn tendon. For fourteen, only a small (2.5 to 4.0-centimeter) transverse incision was used to find the distal tendon. In all seventy-four repairs, a muscle-splitting posterior incision was utilized to expose the radial tuberosity and a burr was used to create a trough in the bone for insertion of the tendon. Figure 2 demonstrates the incorrect path for exposure of the radial tuberosity through a posterior incision, while Figure 3 shows the correct path.

Four of the tendons that were repaired with the modified Boyd-Anderson technique required augmentation with a graft to restore length. The need for a graft was decided at the time of surgery. If the avulsed tendon stump could be reapproximated to the radial tuberosity without the need to flex the elbow more than 70 degrees, no graft was required and a primary repair was performed. When the tendon could not be repaired primarily, a semitendinosus autograft (one repair), a ligament-augmentation device with a fascia lata graft (two repairs), or an Achilles tendon allograft (one repair) was used. Currently, we prefer to use an Achilles tendon allograft to augment length.

Table I describes the anatomical findings at the time of surgery in the three groups based on the timing of the surgical repair. In the majority of the acute and subacute tendon repairs (88 and 94 percent, respectively), the tear was found to be complete, whereas a complete tear was found in only 24 percent of the delayed repairs (p < 0.001). Analysis of the fifty-five repairs of complete tears revealed that a tunnel to the radial tuberosity was identifiable during significantly more of the acute repairs than the subacute repairs (86 compared with 53 percent, p < 0.01).

Twenty-four complications were identified following twenty-three (31 percent) of the seventy-four repairs. Six patients had a nerve injury; these injuries included three paresthesias of the lateral antebrachial cutaneous nerve (two resolved and one required neurolysis of a neuroma), two paresthesias of the superficial radial nerve (one resolved and the other persisted at the time of the three-year follow-up), and one transient palsy of the posterior interosseous nerve that completely resolved six months following surgery.

Six patients had persistent anterior elbow pain. The pain was attributed to the scarring of the incision in four patients. Two patients had reexploration and were found to have an intact but degenerated tendon. One of these two patients had the tendon debrided and reinserted to the radius, and the other had it sewn to the brachialis. Both noted some decrease in the symptoms following the second surgery. The other four patients had no more surgical procedures.

Small amounts of heterotopic ossification developed in the anterior area of the tendon reinsertion in four patients. None lacked motion or required surgical excision. No radioulnar synostoses developed in this series.

A superficial infection or suture abscesses at the site of the anterior incision developed in three patients. All of these complications resolved with administration of oral antibiotics.

Three patients lacked greater than 10 degrees of motion at the time of final follow-up. One patient lost 30 degrees of supination, and two patients lost 20 degrees of pronation.

One patient had a rerupture of the biceps tendon two weeks following the repair. At reexploration, it was found that the sutures had pulled out of the tendon. The tendon was reattached with use of a ligament-augmentation device and a fascia lata graft. Eight months after the surgery, the patient was doing well without additional problems.

Reflex sympathetic dystrophy developed in one patient; it resolved at one year.

Table II summarizes the complications in relation to the timing of the repair. The rate of complications increased, although it did not increase significantly, as the repair was delayed. The rate of superficial nerve paresthesia after the subacute repairs or delayed repairs was six times greater than that after the acute repairs. The most significant difference among the three groups was the higher percentage of cases of persistent anterior elbow pain after the delayed repairs.

Table III compares the prevalence of complications after repairs performed by surgeons with substantial experience with the modified Boyd-Anderson technique with the prevalence after repairs performed by surgeons with much less experience. Of the forty-eight repairs done by the senior authors, who had performed this procedure more than twenty times each, eighteen (38 percent) were followed by complications. This complication rate was higher than the complication rate (19 percent; five complications) after the twenty-six repairs done by surgeons with limited experience with the two-incision technique. All of the nerve paresthesias followed repairs done by the experienced surgeons. The prevalences of the rest of the complications were comparable between the two groups. There was no significant difference in the distribution of the timing of the repairs in the two groups that were based on the surgeon's experience.

None of the patients requiring a graft demonstrated a loss of motion, had heterotopic ossification, or complained of anterior elbow pain postoperatively. A superficial wound infection developed in only one of these four patients, all of whom had had a delayed repair (at an average of 220 days [range, forty-five to 652 days] after the injury).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

To our knowledge, Dobbie was the first, in 1941, to describe the results of surgical repair of avulsed distal biceps tendons⁹. Dobbie described nine different surgical techniques that had been utilized by various surgeons to repair fifty-one of these relatively rare injuries. The majority of the surgeons utilized an extensive anterior exposure, whereas only three added a posterior approach to the radial tuberosity. Despite the varying techniques described, 98 percent of the patients had a subjectively good-to-excellent result. However, there is little information in the literature documenting the rate of complications of the procedure. Dobbie expressed concern regarding the many important anatomical structures at risk when the approach is through a large anterior incision, noting two cases of radial nerve paralysis and one case of myositis ossificans. In fact, he concluded that reattachment of the biceps tendon to the radius was dangerous and unnecessary, and he advocated suturing of the tendon to the brachialis instead.

More recently, however, Morrey et al. clearly demonstrated, with objective measurements, that patients who do not have the tendon surgically reattached to the radius have a 30 percent reduction in flexion strength and a 40 percent loss of supination strength²⁰.

To avoid the large anterior incision required to expose the radius, Boyd and Anderson advocated a two-incision technique, in which the bicipital tuberosity is approached through a second, posterior incision near the ulna⁶. The most frequently expressed concern regarding the two-incision approach to the radius is that there is a risk of radioulnar synostosis. A review of the current literature revealed only five cases of radioulnar synostosis occurring after repair of the distal biceps tendon through a two-incision technique^10,17. Failla et al. suggested that the synostosis may be caused by the damaged proximal interosseous membrane and the stimulated ulnar periosteum resulting from a subperiosteal exposure of the ulna¹⁰. In addition, they postulated that the bone dust resulting from the use of a burr to create a trough in the radius might contribute to the development of the synostosis. They recommended avoiding exposure of the ulna by using a muscle-splitting technique and recommended copious irrigation of the wound to remove the bone dust.

In our series of seventy-four repairs with use of the muscle-splitting modification of the two-incision technique, there were no cases of radioulnar synostosis. This was thought to be due, in part, to the avoidance of subperiosteal dissection of the ulna as well as to meticulous irrigation of the wound to eliminate bone dust or fragments. Although small amounts of anterior heterotopic ossification developed in four patients, none experienced a loss of motion or had pain.

Injuries to both the radial^9,11,19,23 and the median nerve have been reported following distal biceps tendon repairs⁵. Most authors have attributed neural injuries to the anterior exposure. In our series, a nerve injury occurred after 8 percent of the repairs through the two-incision approach. The lateral antebrachial cutaneous and superficial radial nerves were the most frequently injured. Both are at risk laterally when a long Henry incision is used anteriorly. Of the seventy-four repairs in which the distal biceps tendon was reattached to the radius, sixty were performed with a long Henry incision anteriorly and fourteen, with only a small (2.5 to 4.0-centimeter) horizontal incision in the antecubital crease. All five of the patients in whom an anterior nerve paresthesia developed and all six of those who complained of anterior elbow pain had a Henry incision anteriorly. None of the patients with a small anterior incision had these complications. One patient had a posterior interosseous nerve palsy that resolved by six months postoperatively. The posterior interosseous nerve may be at risk with any dissection of the radial tuberosity.

In an attempt to prevent the complications associated with a two-incision technique and still return the distal biceps tendon to its anatomical position, several investigators have utilized a sole anterior incision and suture anchors^{3,12,16,18,24,25}. A review of the current reports on the use of suture anchors for repair of avulsed biceps tendons identified two nerve paresthesias (one superficial radial and one median nerve) in forty-three patients, a prevalence of 5 percent. These results are similar to those seen in our series of two-incision repairs.

There have been several recent cadaveric biomechanical studies comparing the pull-out strength of various tendon reattachments to the radius^4,15. The results of the studies indicate that the technique of attaching the tendon through a trough in the radius is the most secure. Only one (1 percent) of our seventy-four patients with a repair through the modified Boyd-Anderson approach had a rerupture of the tendon; this disruption occurred at the tendon-suture interface, a finding that supports those of in vitro biomechanical studies. We could not identify any other reports of tendon rerupture or repair failure in the literature for comparison with our results.

Of the seventeen tendons treated with delayed repair, only four were completely torn. These four patients had an average delay until surgery of forty-three days (range, twenty-three to eighty-six days). In comparison, the four patients who required a graft to restore tendon length had the repair at an average of 220 days (range, forty-five to 652 days) following the injury. We believe that when a complete tear is repaired less than two months after the injury, the tendon can be reattached to the tuberosity without the use of a tendon graft. If more than two or three months have passed, however, a tendon graft will likely be necessary.

In patients with a complete tear, the tunnel to the bicipital tuberosity is quickly obliterated as it fills with granulation tissue. In our series, while 86 percent of the patients with an acute repair of a complete tear had an intact tunnel at the time of surgery, only half (53 percent) of those with a subacute repair of a complete tear had a patent tunnel. The loss of the biceps tunnel makes the dissection to the tuberosity more difficult and extensive.

A delay of more than ten days before repair increased the risk of complications; this is an important finding in our study. The overall complication rate after repairs performed fewer than ten days after the injury was lower than that seen after the subacute and delayed repairs (24 percent compared with 38 and 41 percent). We believe that the difference in complication rates between the acute repairs and those performed at least ten days following the tendon rupture can be attributed to the greater anterior dissection that is required to identify the bicipital tunnel and to mobilize the retracted biceps tendon in delayed repairs.

The modified Boyd-Anderson approach is relatively straightforward. The complications relate primarily to the delay in treatment and to the extent of the anterior dissection required. The anterior exposure can be limited to a small incision (2.5 to 4.0 centimeters). The radius is exposed through a posterior muscle-splitting approach that avoids exposing the ulna. Copious irrigation of any bone dust can minimize the risk of radioulnar synostosis. Overall, this two-incision technique is safe and is best performed early with limited anterior dissection.

References

Introduction | Materials and Methods | Results | Discussion | References

Agins, H. J.; Chess, J. L.; Hoekstra, D. V.; and Teitge, R. A.: Rupture of the distal insertion of the biceps brachii tendon. Clin. Orthop.,234: 34-38, 1988.23434 1988 [PubMed]

Baker, B. E. , and Bierwagen, D.: Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J. Bone and Joint Surg.,67-A: 414-417, March 1985.67-A414 1985

Barnes, S. J.; Coleman, S. G.; and Gilpin, D.: Repair of avulsed insertion of biceps. A new technique in four cases. J. Bone and Joint Surg.,75-B(6): 938-939, 1993.75-B(6)938 1993

Berlet, G. C.; Milne, A. D.; Johnson, J. A.; Patterson, S. D.; and King, G. J. W. Distal biceps tendon repair: an in vitro biomechanical study of fixation methods. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, Louisiana, March 20, 1998.

Boucher, P. R., and Morton, K. S.: Rupture of the distal biceps brachii tendon. J. Trauma,,7: 626-632, 1967.7626 1967

Boyd, H. B., and Anderson, L. D.: A method for reinsertion of the distal biceps brachii tendon. J. Bone and Joint Surg.,43-A: 1041-1043, Oct 1961.43-A1041 1961

D'Alessandro, D. F.; Shields, C. L. Jr.; Tibone, J. E.; and Chandler, R. W.: Repair of distal biceps tendon ruptures in athletes. Am. J. Sports Med.,21: 114-119, 1993.21114 1993 [PubMed]

Davison, B. L.; Engber, W. D.; and Tigert, L. J.: Long term evaluation of repaired distal biceps brachii tendon ruptures. Clin. Orthop.,333: 186-191, 1996.333186 1996 [PubMed]

Dobbie, R. P.: Avulsion of the lower biceps brachii tendon. Analysis of fifty-one previously unreported cases. Am. J. Surg.,51: 662-683, 1941.51662 1941

Failla, J. M.; Amadio, P. C.; Morrey, B. F.; and Beckenbaugh, R. D.: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique. Report of four cases. Clin. Orthop.,253: 133-136, 1990.253133 1990 [PubMed]

Friedmann, E.: Rupture of the distal biceps brachii tendon. Report on 13 cases. J. Am. Med. Assn.,184: 60-63, 1963.18460 1963

Gallay, S. H.; Ring, D.; Winston, L.; Jupiter, J. B.; and McKee, M. D. Functional outcome following repair of distal biceps tendon ruptures with suture anchors and a single incision technique. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, Louisiana, March 20, 1998.

Jobe, M. T.; Azar, F. M.; Calandruccio, J. H.; Wright, P. E.; and Achecar, F. A.: Surgical repair of ruptures of the distal biceps. Orthop. Trans.,19: 783, 1996.19783 1996

Katzman, B. M.; Caligiuri, D. A.; Klein, D. M.; and Gorup, J. M.: Delayed onset of posterior interosseous nerve palsy after distal biceps tendon repair. J. Shoulder and Elbow Surg.,6: 393-395, 1997.6393 1997

Klein, D. M.; Ghany, N.; Urban, W. Jr.; and Caruso, S. A. Repair of the distal biceps tendon: suture-to-bone versus suture anchor fixation. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, Louisiana, March 20, 1998.

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Fig. 1:: Graph showing the types of complications and when they developed. All twenty-four complications were present by seven weeks following the surgery.

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Table I: Anatomical Findings at the Time of Surgery According to the Timing of the Repair

	Acute Repair	Subacute Repair	Delayed Repair	P Value
Acute vs. Subacute	Acute vs. Delayed	Subacute vs. Delayed
No. of repairs	41	16	17
Small anterior incision	9 (22%)	5 (31%)	0 (0%)	0.5	<0.05	<0.01
Complete tear	36 (88%)	15 (94%)	4 (24%)	0.5	<0.001	<0.001
Complete tear with patent bicipital tunnel	31/36 (86%)	8/15 (53%)	3/4 (75%)	<0.01	0.6	0.4

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Table I: Anatomical Findings at the Time of Surgery According to the Timing of the Repair

	Acute Repair	Subacute Repair	Delayed Repair	P Value
Acute vs. Subacute	Acute vs. Delayed	Subacute vs. Delayed
No. of repairs	41	16	17
Small anterior incision	9 (22%)	5 (31%)	0 (0%)	0.5	<0.05	<0.01
Complete tear	36 (88%)	15 (94%)	4 (24%)	0.5	<0.001	<0.001
Complete tear with patent bicipital tunnel	31/36 (86%)	8/15 (53%)	3/4 (75%)	<0.01	0.6	0.4

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Table II: Complications According to the Timing of the Repair

	Acute Repair	Subacute Repair	Delayed Repair	P Value
Acute vs. Subacute	Acute vs. Delayed	Subacute vs. Delayed
No. of repairs	41	16	17
Age* (yrs.)	46 ± 8.10 (27-63)	48 ± 11.4 (33-72)	45 ± 8.3 (30-62)	0.5	0.7	0.4
Time to repair* (days)	4 ± 2.3 (0-9)	14 ± 3.4 (10-21)	363 ± 536 (22-1918)
Complications†	10 (24%)	6 (38%)	7 (41%)	0.3	0.2	0.8
Nerve paresthesia‡§	1 (2%)	2 (13%)	2 (12%)	0.1	0.1	0.9
Posterior interosseous nerve palsy‡	1 (2%)	0 (0%)	0 (0%)	0.5	0.5	0.99
Heterotopic ossification‡	3 (7%)	1 (6%)	0 (0%)	0.9	0.3	0.3
Loss of range of motion‡	1 (2%)	2 (13%)	0 (0%)	0.1	0.5	0.1
Rerupture‡	0 (0%)	1 (6%)	0 (0%)	0.1	0.99	0.3
Persistent anterior elbo pain (no. needing reexploration)‡	2 (0) (5%)	0 (0%)	4 (2) (24%)	0.4	<0.05	<0.05
Reflex sympathetic dystrophy‡	1 (2%)	0 (0%)	0 (0%)	0.5	0.5	0.99
Superficial wound infection‡	1 (2%)	0 (0%)	2 (12%)	0.5	0.1	0.2

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Table II: Complications According to the Timing of the Repair

	Acute Repair	Subacute Repair	Delayed Repair	P Value
Acute vs. Subacute	Acute vs. Delayed	Subacute vs. Delayed
No. of repairs	41	16	17
Age* (yrs.)	46 ± 8.10 (27-63)	48 ± 11.4 (33-72)	45 ± 8.3 (30-62)	0.5	0.7	0.4
Time to repair* (days)	4 ± 2.3 (0-9)	14 ± 3.4 (10-21)	363 ± 536 (22-1918)
Complications†	10 (24%)	6 (38%)	7 (41%)	0.3	0.2	0.8
Nerve paresthesia‡§	1 (2%)	2 (13%)	2 (12%)	0.1	0.1	0.9
Posterior interosseous nerve palsy‡	1 (2%)	0 (0%)	0 (0%)	0.5	0.5	0.99
Heterotopic ossification‡	3 (7%)	1 (6%)	0 (0%)	0.9	0.3	0.3
Loss of range of motion‡	1 (2%)	2 (13%)	0 (0%)	0.1	0.5	0.1
Rerupture‡	0 (0%)	1 (6%)	0 (0%)	0.1	0.99	0.3
Persistent anterior elbo pain (no. needing reexploration)‡	2 (0) (5%)	0 (0%)	4 (2) (24%)	0.4	<0.05	<0.05
Reflex sympathetic dystrophy‡	1 (2%)	0 (0%)	0 (0%)	0.5	0.5	0.99
Superficial wound infection‡	1 (2%)	0 (0%)	2 (12%)	0.5	0.1	0.2

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Table III: Analysis According to the Experience of the Surgeon

	>20 Repairs	<4 Repairs	P Value
No. of repairs	48	26
Age* (yrs.)	46 ± 8.7 (30-72)	47 ± 9.3 (27-71)	0.8
Time to repair* (days)	817 ± 351 (0-1918)	43 ± 143 (1-730)	0.4
Acute repair†	25 (52%)	16 (62%)	0.5
Subacute repair†	12 (25%)	4 (15%)	0.3
Delayed repair†	11 (23%)	6 (23%)	0.99
Complications†	18 (38%)	5 (19%)	0.1
Nerve paresthesia‡§	5 (10%)	0 (0%)	0.1
Posterior interosseous nerve palsy‡	1 (2%)	0 (0%)	0.5
Heterotopic ossification‡	3 (6%)	1 (4%)	0.7
Loss of range of motion‡	2 (4%)	1 (4%)	0.9
Rerupture‡	1 (2%)	0 (0%)	0.5
Persistent anterior elbow pain (no. needing reexploration)‡	4 (2) (8%)	2 (0) (8%)	0.9
Reflex sympathetic dystrophy‡	1 (2%)	0 (0%)	0.5
Superficial wound infection‡	2 (4%)	1 (4%)	0.9

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Table III: Analysis According to the Experience of the Surgeon

	>20 Repairs	<4 Repairs	P Value
No. of repairs	48	26
Age* (yrs.)	46 ± 8.7 (30-72)	47 ± 9.3 (27-71)	0.8
Time to repair* (days)	817 ± 351 (0-1918)	43 ± 143 (1-730)	0.4
Acute repair†	25 (52%)	16 (62%)	0.5
Subacute repair†	12 (25%)	4 (15%)	0.3
Delayed repair†	11 (23%)	6 (23%)	0.99
Complications†	18 (38%)	5 (19%)	0.1
Nerve paresthesia‡§	5 (10%)	0 (0%)	0.1
Posterior interosseous nerve palsy‡	1 (2%)	0 (0%)	0.5
Heterotopic ossification‡	3 (6%)	1 (4%)	0.7
Loss of range of motion‡	2 (4%)	1 (4%)	0.9
Rerupture‡	1 (2%)	0 (0%)	0.5
Persistent anterior elbow pain (no. needing reexploration)‡	4 (2) (8%)	2 (0) (8%)	0.9
Reflex sympathetic dystrophy‡	1 (2%)	0 (0%)	0.5
Superficial wound infection‡	2 (4%)	1 (4%)	0.9