1 General considerations top
Timing of surgery
Reattachment of the distal biceps tendon should be performed within a few days of injury. After three weeks the tendon will have retracted and shortened, and the tendon tract will have begun to scar over.
Indication
Surgery is indicated in patients with functional impairment. If the patient needs strength of elbow flexion and forearm supination, repair is usually advisable.
Approach options
The biceps tendon can be reattached with either a two-incision approach to the proximal radius, or a single anterior approach.
Note
The two-incision approach reduces the risk of radial nerve injury.
2 Option 1: Tendon through bone tunnel (two-incision approach) top
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Preparation for tendon reinsertion
As described in the two-incision approach, the biceps tendon has been identified anteriorly and a tendon suture has been placed.
A soft-tissue tunnel has been prepaired on the medial side of the radius for passage of the tendon.
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The radial tuberosity has been identified through the posterior incision.
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Reattachment preparation
Remove tendon remnants from the bicipital tuberosity to expose bare bone.
Prepare a trough for the tendon. Excavate it with a high-speed burr until it is deepened into a cavity of approximately 10x8mm, and 5 mm deep.
Place three small drill holes on the anterior side of the trough.
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Tendon passage
With its attached sutures, bring the biceps tendon through the soft-tissue tunnel from the anterior incision to the posterior incision.
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Tendon reinsertion
Suture the tendon into the trough in the bicipital tuberosity. The sutures are placed through the prepared holes as shown.
Check tendon reinsertion during supination and pronation.
3 Option 2: Suture anchors (anterior approach) top
Preliminary remark
Alternatively, the biceps tendon can be reinserted into the bicipital tuberosity of the radius with suture anchors through an anterior approach.
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Embedding two suture anchors
Create a shallow trough for tendon reinsertion in the bicipital tuberosity with a high-speed burr to expose bleeding cortical bone. Place two suture anchors into the trough as shown.
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Tendon reinsertion
Trim the end of the tendon to a smooth fresh surface. Weave the anchored sutures securely, but so they will slide, through the tendon end.
Next, advance the tendon end into the excavated tuberosity, such that it contacts the bone well. Tie the sutures with the forearm in neutral position.
Check the reinsertion site during pronation and supination.