Repair of distal biceps tendon rupture with the Biotenodesis screw
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- Khan, W., Agarwal, M. & Funk, L. Arch Orthop Trauma Surg (2004) 124: 206. doi:10.1007/s00402-004-0639-8
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Distal biceps tendon ruptures are uncommon injuries with only around 300 cases reported in the literature. Current management tends to favour anatomical reinsertion of the tendon into the radial tuberosity, especially in young and active individuals. These injuries are commonly repaired using either a single anterior incision with suture anchors or the Boyd-Anderson dual incision technique.
We report the use of a bioabsorbable interference screw for the repair of distal biceps tendon rupture using a minimal incision technique. In this technique the avulsed tendon and a bioabsorbable screw are secured in a drill hole on the radial tuberosity using whip stitch and fibre wire sutures according to Biotenodesis system guidelines.
The technique described requires minimal volar dissection that is associated with a reduced number of synostosis and posterior interosseous nerve injuries. The bioabsorbable interference screw has all the advantages of being biodegradable and has been shown to have greater pullout strength than suture anchors. It is also a reasonable alternative to titanium screws in terms of primary fixation strength. The strong fixation provided allows early active motion and return to previous activities as seen in our case.
KeywordsDistal biceps tendon ruptureBioabsorbableInterference screwMinimal incision
Rupture of the distal biceps tendon is a relatively uncommon injury with the first known diagnosis reported by Starks in 1843 . The traditional techniques for the repair of this tendon are the single anterior incision technique frequently using suture anchors and the dual incision technique. The Biotenodesis screw (Arthrex Ltd., Sheffield, UK) is an interference screw with a pretensioning insertion device. It has been used successfully with good clinical results for proximal biceps tendon repair  and cruciate ligament repair in the knee [11, 18, 19]. It has the advantages that it can be inserted through a smaller incision and allows the tendon to be inserted into the bone via the interference screw allowing for better pretensioning of the tendon. It has advantages over the suture anchors in terms of greater pullout strengths and the use of a biodegradable material . This is the first documented case of its use in a distal biceps tendon repair. We describe a novel method of using this device for the fixation of the distal biceps tendon through a minimal incision technique.
A 57-year-old male manual worker injured his left arm while working in the fire station storeroom as he reached out to catch a falling heavy nitrogen cylinder. He attended the accident and emergency department the same day. On clinical examination he was found to have ecchymosis over the proximal aspect of his forearm and elbow. A proximally retracted bicepital tendon was palpable 4 cm proximal to the elbow flexion crease. Resisted flexion and supination of the forearm was painful and weak. Radiographs of the affected extremity revealed no fractures. A diagnosis of a complete distal bicepital tendon rupture was made and the management options were discussed with the patient. The patient was in an active occupation and enjoyed playing musical instruments socially. Therefore, surgical repair was offered and planned.
On the 1st day postoperatively the patient was placed in a hinged brace from 30–130° for 6 weeks. Return to unrestricted activity, including lifting, was allowed over the next 6 weeks. There were no postoperative complications and he regained full range of motion and strength by 3 months.
Rupture of the distal biceps tendon is a relatively uncommon injury and only around 300 cases have been reported in the literature . The rupture typically occurs at the tendon insertion into the radial tuberosity in an area of pre-existing tendon degeneration .
Surgical intervention has been reported to achieve better results, especially with restoring supination power. Current management tends to favour anatomical reinsertion to the radial tuberosity in complete injuries, especially in active and compliant young individuals desiring maximum return of elbow supination and flexion power and endurance [1, 4, 12, 13, 14, 17, 20, 21, 22].
The surgical management options include the single incision technique frequently associated with suture anchor attachment [1, 9, 20, 24] and the Boyd and Anderson double incision technique [6, 7]. The use of suture anchor attachment through a single limited anterior incision has been shown not to be as stiff or strong as bone tunnel repairs in cyclic loading and load-to-failure testing in vitro [3, 15].
The minimal volar dissection needed for a limited anterior approach has been associated with the reduced number of complications of synostosis and posterior interosseous nerve injury [20, 22]. Bioabsorbable interference screws have been shown to be a safe and nonreactive alternative to traditional metal interference screws for ACL graft fixation [11, 18, 19] and have been shown to have a greater pullout strength when compared to suture anchors. This absorbable screw is a valuable tool for the surgeon as it minimises the problems of fixation loosening, migration, interference with imaging studies and the potential requirement for later removal [2, 8]. In terms of primary fixation strength, the biodegradable interference screws have been shown to be strong enough to allow accelerated rehabilitation and a reasonable alternative to titanium interference screws [18, 19].
A limited single anterior incision with Biotenodesis screw fixation is a safe and effective alternate surgical option in the treatment of distal bicepital tendon avulsions. The system allows for insertion via a limited exposure and provides a strong fixation allowing early active motion and return to previous activities as seen in our case.