Hospital Ortopédico e Medicina Especializada (Home), Servic¸o de Cirurgia de Ombro e Cotovelo, Brasília, DF, Brazil
Introduction
The biceps brachii is the primary supinator and secondary flexor of the forearm.1 Ruptures of the distal tendon of the biceps are rare injuries that usually affect the dominant arm of middle-aged men. The injury typically occurs during resisted contraction, with the elbow at 90 ? of flexion.2 Significant loss of flexion strength and more pronounced loss of supination strength are often associated with chronic ruptures.2 Ruptures are considered chronic 4–6 weeks after the injury.1 In these cases, the muscle-tendon unit retracts and there is formation of fibrosis, which hinders the radial tuberosity repair.3–5 Several procedures have been described to treat chronic ruptures of the distal biceps tendon, including tenodesis in the brachial tendon and the use of tendon graft.3
The authors describe the surgical technique used in a patient who presented chronic retracted rupture of the distal tendon of the biceps brachii, which was reconstructed using double incision with grafting from the distal tendon of the brachial triceps.
Case report
Patient, 51 years, male, taxi driver, right-handed, attended to this service with history of sudden pain and deformity on the anterior aspect of the left arm when attending to lift weights at home five weeks before. He reported having pain and difficulties while driving, which impaired his professional activity. He had no significant history of diseases or previous elbow pain. He did not practice any physical activities. Upon physical examination, evident deformity was observed on the anterior aspect of the left arm, with bulging contour of the biceps muscle belly. He had pain at palpation and absence of the biceps tendon on the anterior aspect of the elbow, in addition to a great strength reduction during supination and pain during flexion. Neurological and vascular status was preserved.
Magnetic resonance imaging disclosed signs of complete rupture of the distal biceps tendons, with 4.4 cm retraction. Surgical technique
The surgical treatment was selected due to the functional demand of the patient’s professional activity (taxi driver), which relies heavily on the movements of the upper limbs. The authors opted for a reconstruction of the distal biceps tendon through the double incision technique described by Boyd and Anderson6 and modified by Morrey et al.5 Tendon graft from the distal triceps was used; this technique has not been described in the literature, but the authors’ literature research7,8 indicated that this procedure would be useful in the present case of a middle-aged patient with high functional demand of the affected limb for his work activities and no sports demand.
The patient was placed on the operating table in the supine position, without tourniquet. A transverse incision of approximately 3 cm was made in the anterior cubital fold. The biceps tendon is easily captured when the skin is retracted proximally, separated from the deep tissues. The most distal portion of the degenerated tendon was resected; the tendon was repaired with Bunnell sutures using nonabsorbable No. 5 thread (Fig. 1).
Then, the radial tuberosity was palpated and a curved Kelly forceps was passed through the biceps tendon tunnel, between the ulna and the radius, and it was advanced until its tip could be palpated on the dorsal aspect of the proximal forearm. A second incision was made over the forceps. The tuberosity was exposed through muscle divulsion with the forearm in maximal pronation (Fig. 2). The radial tuberosity was scarified until bleeding was observed. Two bioabsorbable, double-loaded 2.9-mm anchors were positioned.
Then, the brachial triceps tendon graft was collected, without olecranon bone fragments, through a posterior longitudinal incision and subcutaneous dissection until the tendon was exposed. The authors chose to remove a strip from its middle portion, measuring 1 cm wide and 10 cm long, with
no need to explore the ulnar nerve (Fig. 3). Subsequently, the medial and lateral borders of the removed portion were approximated and the interval was closed.
The most distal end of the graft was attached to the tuberosity by four U-shaped sutures with anchor wires (Fig. 4). The other end of the tendon was then passed to the region of the antecubital fossa incision through nonabsorbable No. 5 sutures (Krackow) to pull the tendon through the tunnel previously occupied by the biceps tendon. The biceps was mobilized and then pulled with the use of Allis clamps. The elbow was positioned at 40–60 ? offlexion, with the forearm in full supination. Moderate traction was applied to the graft, while the tendon stump was distally tractioned. The two structures were initially stabilized with non-absorbable No. 5 U-shaped suture; then several single sutures were made at the edges (Fig. 5). Once the reconstruction was completed, the wounds were
closed; compressive dressings were applied, and the limb was immobilized with a brachial splint, maintaining the elbow at 90 ? of flexion and the forearm in mild supination. Immobilization with a sling was maintained for two weeks; thereafter, physical therapy was initiated. Initially, exercises of passive flexion and limited active extension with the forearm in supination were performed, as well as passive supination and active pronation to 50 ?. The limb was immobilized with a sling while outside of physiotherapy. This phase lasted until
the end of the third week, when exercises to increase flexion and active supination without load were initiated; at this phase, the patient was instructed to interrupt the use ofslings. Muscle strengthening exercises were initiated after the sixth week with light loads, which were progressively increased.
Results
Three months after surgery, the patient had full range of motion without pain, but still presented decreased muscle strength. After the fourth month, he was allowed to return to his work activities. At five months post-operative, the patient had recovered full muscle strength and had completely returned to daily activities.
In his last follow-up assessment, six months after surgery, the patient had full range ofmotion: 0 ? extension, 135 ? flexion, 85 ? supination, and 85 ? pronation. At that moment, a digital dynamometer was used; the observed flexion force was 17.35 kgf (19.29 kgf in the contralateral elbow) and the supination force, 7.14 kgf (7.40 kgf in the contralateral). Furthermore, the extension force was 16.25 kgf in the operated elbow vs. 15.45 kgf in the contralateral. The patient’s result is encouraging, with recovery of 90% of the flexion strength and 96% of the supination strength, and maintenance of extension force, even after graft removal.
Discussion
The primary repair of a chronic rupture of the distal brachial biceps is technically challenging. Non-anatomical tenodesis in the brachialis muscle has been proposed as a treatment option. However, despite the high satisfaction rate of the patients who underwent this procedure, Klonz et al.9 observed that half of their patients lost over 50% of the supination strength. The risk of weakness in supination after this technique may be unacceptable for patients with high functional demand.
Several techniques for the reconstruction of the distal biceps tendon have been described; they differ in their approach, the graft choice, and the type of fixation.1–4 Both auto- and allografts have been used for this purpose. Several allografts have been reported in the literature,1,10,11 including the Achilles tendon, semitendinosus, anterior tibial, and gracilis. Regarding autografts,1–4 some studies indicated the use of the fascia lata, semitendinosus, and palmaris longus.
No descriptions of the use of the distal brachial triceps tendon for this purpose were retrieved in the literature. The use of this tendon as an autograft for chronic ruptures of the distal brachial biceps was devised by the authors to avoid the disadvantages observed in the recovery period when the donor area is not located in the same joint as the recipient area. Moreover, other advantages include its presence in every individual, the absence of neurovascular risks during harvesting, and the possibility of variable sizes and lengths, according to the need.
Martin et al.7 assessed the biomechanical characteristics of grafts from the central portion of the triceps brachii, comparing them to those of the long palmar, and concluded that the triceps graft is comparable in ultimate load-to-failure and stiffness with the palmaris longus tendon graft. They also observed that the triceps tendon presents greater deformation than the palmaris longus, but without clinical significance. In another biomechanical study, Baumfeld et al.8 evaluated the properties ofthe medial, central, and lateral strips ofthe distal triceps and concluded that the lateral portion is significantly thinner and less rigid than the central and medial portions, and that the central portion of the triceps brachii presented an ultimate load to failure of 704 N, vs. 357 N for the palmaris longus.
Wiley et al.2 compared two groups of patients with chronic ruptures of the distal biceps; one group was conservatively treated and the other underwent reconstruction with semitendinosus autograft through double incision. They concluded that the patients who underwent reconstruction obtained an improvement in flexion and supination strength when compared to those treated conservatively.
Although there is still debate on the best approach for fixation of distal biceps tendon ruptures, whether double or single incision, recent studies show a negligible difference in results and complications between the two techniques.12,13 The choice of the best approach for these pathologies should be guided by surgeon experience and confidence.
Conflicts of interest
The authors declare no conflicts of interest.
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