Distal biceps tendon reconstruction is an uncommon surgical procedure used to restore elbow flexion and/or supination power in the situation of a chronic distal biceps tendon rupture.
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Indications
The classical indication for distal biceps tendon reconstruction is a chronic biceps tendon injury where anatomical repair of the distal biceps tendon is difficult or no longer feasible. The definite decision between reconstruction or primary repair of the distal biceps tendon is made intraoperatively. However, some pre-operative imaging features might point more towards reconstruction 1:
- extensive proximal tendon stump retraction >8 cm or flipped torn tendon
- short and/or degenerated/frayed tendon stumps
- extensive tendon scarring
- fatty infiltration of the biceps muscle and myotendinous junction
Contraindications
Contraindications of distal biceps tendon reconstruction include distal biceps tendon injuries that are amenable to repair and comorbidities increasing the general surgical risk.
Procedure
Distal biceps tendon reconstruction can be performed utilizing an autograft (e.g. semitendinosus tendon, tensor fasciae latae, palmaris longus, flexor carpi ulnaris), or an allograft 1,2. Surgical techniques usually include a single-incision or dual-incision approach and the following steps 1,3:
- exposure of the bicipital tuberosity
- isolation and retraction of the tendon stump
- recreation of the tendon path
- graft harvesting in case of an autograft
- graft fixation onto the radial tuberosity (different techniques)
- graft tensioning and fixation to the proximal stump
Complications
Complications of biceps tendon reconstruction often include nerve injuries and include the following 1,2:
- lateral antebrachial cutaneous nerve traction injury (common, most resolve within 3 months)
- posterior interosseous nerve traction injury
- superficial radial nerve injury
- heterotopic ossification
- proximal radio-ulnar synostosis
- hematoma
- graft rupture or tear
- infection (cellulitis, abscess, arthritis, osteomyelitis)
- proximal radius fracture (from large bone tunnels)
- suture rupture or suture granuloma
- donor site morbidity in case of autografts
Radiographic features
The cross-sectional area of repaired tendons is larger than normal tendons 1.
Plain radiograph
Bone tunnels and some suture devices as radiodense suture anchors and interference screws can be easily seen on plain radiographs of the elbow 1, 4.
MRI
Illustrations and/or descriptions of postoperative MRI findings after distal biceps tendon reconstruction are rare but should show an intact proximal and distal anastomosis and adequate fiber orientation 1.
T2 hyperintensity alone is considered a normal finding during several following months after surgery indicating graft revascularization and healing 1.
The ideal insertion angle of the reconstructed distal biceps tendon on the coronal plane with the fully supinated forearm is considered to be 30° 1.
Radiological report
Preoperative evaluation
The radiological report of a preoperative evaluation should include a description of the following 1:
- distal biceps tendon injury category (tendon rupture/complete tear, partial tear)
- proximal tendon retraction and stump length
- distal tendon stump degeneration and/or fraying
- fatty infiltration of the myotendinous junction and the biceps muscle belly
- excessive scarring
- flipped proximal tendon stump
Postoperative evaluation
In a postoperative setting the radiological report should include a description of the following 1,2:
- graft integrity including proximal and distal anastomosis
- signs of nerve injury
- postoperative scarring (possibly around the lateral antebrachial cutaneous nerve)
- heterotopic ossification or proximal radio-ulnar synostosis
- proximal radius fracture
- signs of infection
- graft rupture or tear
Outcome
Overall complications are higher than in acute repair but and include nerve injury and heterotopic ossifications. Re-rupture is rare and not significantly more common than in acute repair with an estimated frequency of 1-2%, usually occurring in the postoperative period 1,5. The dual incision approach has been intended to reduce the risk of nerve injury but seems to be also associated with a better restoration of the native distal biceps tendon footprint 1. The single incision approach aims at decreasing the risk for heterotopic ossification 1. Autografts have the advantage of increased tensile strength but the disadvantage of graft harvesting 1. However, there seems to be no clear evidence favoring one surgical technique over the other 1,2.
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