Delayed Repair of Distal Biceps Tendon

You may have heard of (or even seen) the Popeye deformity that occurs when the biceps tendon ruptures or pulls away from the inside of the elbow. The tendon retracts (coils away) from the bone, leaving the muscle bunched up and looking like Popeye's big bicep in his skinny arm. Popeye was a famous cartoon character (a sailor) shown on television in the 1950s and early 60s.

Distal biceps rupture isn't rare, but it doesn't happen very often. Middle-aged men lifting weight beyond their strength are affected most often. Tobacco use seems to be a major risk factor. Besides the obvious Popeye deformity, the patient reports elbow pain with activity, weakness, and loss of motion.

The mechanism of injury is usually a violent, eccentric contraction. An eccentric contraction occurs when an already fully contracted muscle starts to lengthen. With a biceps tendon rupture, this means the biceps tendon was contracted putting the elbow in a position of flexion. Then as the elbow extended, the biceps lengthened. Sudden extension, especially with a weight in the hand can result in this type of biceps rupture.

This type of injury usually requires surgery right away. The surgeon finds the retracted tendon, pulls it back down, and reattaches it to the radial tuberosity. The radial tuberosity is the bony bump on the radius bone of the forearm where it meets the humerus (upper arm bone) to form the elbow. That's the site of the original distal biceps insertion.

This procedure is considered an anatomical repair because it restores the tendon to its original site. If the surgery is delayed for a long period of time (18 months or more), then an anatomical repair may not be possible. The tendon retracts too far and then gets bound down in scar tissue.

In chronic cases of this type, the surgeon performs reconstructive surgery. A graft is used to make up the distance between the stump (end) of the retracted tendon and the elbow where it is reattached. The surgeon must carefully remove scar tissue from around the tendon and nerve in the forearm, and then gently stretch the tendon as far as it will go before attaching the graft. The graft comes from the hamstring or Achilles tendon. It can be an autograft (taken from the patient's own body) or an allograft (someone else's tissue from a donor bank).

In this article, surgeons specializing in sports injuries report on one case of a distal biceps reconstruction performed four years after the injury. The patient was in his late 30s and injured himself lifting weights.

He didn't have the surgery at first because he wasn't bothered by the injury. But over time, the pain with daily activities and loss of function, strength, and endurance brought him in to see the sports specialists.

The surgeons described their findings and surgical technique. A single S-shaped incision was used. They found a mass of scar tissue around the retracted biceps tendon and next to the lateral antebrachial cutaneous nerve (nerve along the front and side of the elbow). The surgeons harvested a hamstrings graft from the patient, wove it in with the biceps stump, and used an EndoButton to hold the graft in place. Fluoroscopy (a special type of imaging) showed that the EndoButton fixation was in the right place for optimal results.

The outcome was so good, the patient opted to have the other arm repaired as well. He was pain free, regained his strength, and improved his motion (especially elbow flexion) to normal. At the end of one year, his biceps strength for elbow flexion and forearm supination (palm up motion) was about 86 to 87 per cent of normal.

There have been other reports of delayed surgery for this type of injury. But this was the first published so long after the initial injury (four years). The surgeons conclude that although there are many different ways to perform this operation, the reconstructive technique described here is very successful and therefore recommended.

References: L. Pearce McCarty, III, MD, et al. Reconstruction of a Chronic Distal Biceps Tendon Rupture 4 Years After Initial Injury. In American Journal of Orthopedics. November 2008. Vol. 37. No. 11. Pp. 579-582.