Review Question - QID 219503

Distal Biceps Avulsion Techniques Anterior Single-Incision Technique QID: 219503 (OBQ23.76)

QID 219503 (Type "219503" in App Search)

A 56-year-old man presents to the clinic with pain and weakness after feeling a pop in his elbow while grabbing a railing to prevent a fall down three stairs. On exam, there is bruising in the area of the antecubital fossa and notable weakness with supination compared to the contralateral side. An MRI is obtained, and notable for the finding in Figure A. The patient undergoes surgical repair at four weeks after the injury. At his first clinical visit after surgery, he reports an altered sensation along the lateral aspect of the forearm on the operative side. Which aspect of treatment most likely contributed to this postoperative sequela?

Type & Select Correct Answer

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Dual-incision approach

60/795

Intraosseous screw fixation

14/795

Single-incision approach

86%

685/795

Suture anchor fixation

8/795

Timing of surgical intervention

21/795

Select Answer to see Preferred Response

The patient sustained a distal biceps tendon rupture, treated with surgical repair, and presented postoperatively with symptoms of lateral antebrachial cutaneous (LABC) nerve injury. This is the most common complication after distal biceps surgical repair, with a higher incidence when single-incision techniques are utilized.

Distal biceps tendon ruptures are rare injuries often caused by a sudden, forceful eccentric contraction of the biceps brachii. These injuries can be managed operatively or nonoperatively depending on patient and injury factors. Surgical repair can be performed through either single-incision or dual-incision approaches. Comparing these two approaches, single-incision techniques are associated with a higher risk of LABC nerve injury, while dual-incision techniques are associated with a higher risk of synostosis and heterotopic ossification. LABC nerve injuries are the most common complication overall and usually resolve in three to six months with observation.

Grewal et al. conducted a randomized controlled trial comparing single-incision and dual-incision techniques for distal biceps tendon rupture repair in 91 patients. There was a significantly higher rate of early, transient LABC neuropraxia after single-incision repairs (19/47) compared to dual-incision repairs (3/44). There was an average of 10% advantage in final isometric flexion strength after dual-incision repair, but overall outcomes were otherwise similar between the two approaches. The authors concluded that the outcomes were overall similar regardless of the utilized surgical approach, though minor complications were more common after single-incision repairs.

Prud’homme-Foster et al. performed a cadaveric study to assess the impact of anatomic versus non-anatomic distal biceps tendon repair on resultant supination torque. There were no differences between anatomic repairs and intact tendon measurements. Comparing anatomic and non-anatomic repairs, there was 40% less torque generated in the non-anatomic repair group with the forearm tested in 45° of supination and 15% less with the forearm in neutral rotation. The authors concluded that anatomic repair of the distal biceps tendon on the ulnar side of the radial tuberosity is an important consideration, noting that too radial of a repair may result in a loss of full supination torque with the forearm in neutral rotation or in supination.

Figure A is a sagittal STIR MRI sliced image demonstrating complete rupture of the distal biceps tendon.

Incorrect Answers:
Answer 1: Dual-incision approaches are associated with a higher rate of synostosis and heterotopic ossification. LABC neuropraxia is less common when compared to single-incision techniques.
Answers 2 and 4: Intraosseous screw fixation and suture anchor fixation are both strategies that can be utilized through a single-incision approach. The type of fixation strategy utilized is not responsible for the higher rate of LABC nerve injury seen with single-incision techniques compared to dual-incision.
Answer 5: A delay in surgical intervention can make direct, primary repair more challenging and warrant a more extensile approach but is not directly associated with a higher rate of LABC neuropraxia compared to the utilization of single-incision approaches.