Treatment of the Distal Biceps Brachii Tendon Rupture Using the Three Mini-Incisions Technique: Evaluation through MEPS and DASH
José Antonio Galbiatti1*, Luís Felipe Haber Figueiredo e Silva1, Gabriel Rodrigues dos Santos Milhomens1, Fernando Marega Imamura2, Carlos Henrique Bertoni Reis2 and Marilia Gabriela Palacio Galbiatti2
1Faculdade de Medicina de Marília, Marília, São Paulo, Brazil
2Universidade de Marília, Marília, São Paulo, Brazil
Submission: July 03, 2019; Published: July 16, 2019
*Corresponding author: José Antonio Galbiatti, Rua Oswaldo Florindo Coelho, 80 (Zip code: 17525-120), Marília, São Paulo, Brazil
How to cite this article: José A G, Luís Felipe H F S, Gabriel R S M, Fernando M I, et al. Treatment of the Distal Biceps Brachii Tendon Rupture Using
the Three Mini-Incisions Technique: Evaluation through MEPS and DASH. Ortho & Rheum Open Access J 2019; 14(3): 555888.
Background: The distal biceps brachii tendon rupture is a rather uncommon injury. The proper procedure to be followed is an early surgical treatment. This study aims to describe the surgical technique of three mini-incisions, as well as evaluating the treatment results.
Materials and Methods: Retrospective study of ten patients who underwent surgery using the three mini-incisions technique due to distal biceps brachii tendon rupture.
Results: The mean follow-up was 42.9 months. In Mayo Elbow Performance Score (MEPS), nine patients’ results were considered excellent (100 points). There was only one patient whose result in MEPS was considered good (85 points). Taking Disabilities of Arm, Shoulder and Hand (DASH) questionnaire into consideration, an average of 0.88 was found. There were two patients who reportedly felt mild pain in the Visual Analogue Scale (VAS). All patients expressed satisfaction with the treatment received. Movement amplitude and biceps brachii circumference did not demonstrate significant alterations when compared with the unaffected arm. There were neither complications nor clinically important late postoperative radiographic alterations among the ten patients who underwent evaluation.
Discussion: The three mini-incisions surgical technique associated with Bunnell suture and transosseus fixation has been proved adequate, safe and reproducible for the treatment of distal biceps brachii tendon rupture and has presented satisfactory results in MEPS and DASH questionnaires.
Distal biceps tendon ruptures are uncommon injuries, accounting for just 3% of cases of biceps ruptures. In 96% of patients, an impairment of the long head occurs, and in 1% of the short head [1-9], proximally on the shoulder. It typically affects the dominant limb of middle-aged men, between 30 and 60 years of age [4,5,10-16]. In 1843, Starks apud Quach et al.  pioneered the description of the injury and in 1897, Johnson  was responsible for the first surgical correction. The prevalence is of approximately 1.2 cases/100 000 inhabitants, but it has increased with the current growing practice of sports activities. Known risk factors include smoking and the use of anabolic steroids [7-10,18-20]. Although not yet fully understood, the pathogenesis is attributed to the degeneration, hypovascularization and friction of the tendon [1,3,14-16,21]. There is evidence that the degeneration arises from the inflammation of the deep radial bursa, and that the friction is explained by bone irregularities in the radial tuberosity [15,18].
The most common injury mechanism is an eccentric muscle contraction against resistance with the elbow flexed at 90º while the forearm is supinated [6,10,11,16,22]. Generally, the patient will report an audible crack in the elbow region. The
clinical picture includes pain, edema and ecchymosis in the
antecubital fossa, palpable defects in the distal tendon trajectory
with alteration of the relief of the arm, decreased strength of
supination of the forearm and elbow flexion. Positive results in
the hook test and biceps squeeze test reinforce the diagnosis. In
cases of complete rupture, a proximal muscle retraction occurs,
responsible for the Popeye deformity [1-10,18-23] (Figure 1).
The rupture is considered chronic after 4 weeks of the injury
The imaging tests used to confirm the diagnosis include
ultrasound and magnetic resonance imaging, the latter being
considered the gold standard for definitive diagnosis and
surgical planning (Figure 2). In addition, the exams assist in the
investigation of associated lesions, the degree of retraction of
the tendinous stump and the identification of the type of injury
- partial or complete [2,10,15,18,20]. The main differential
diagnoses are partial rupture of the distal biceps, cubital bursitis,
biceps tendinitis, lesion of the lateral cutaneous nerve of the
forearm and posterior interosseous nerve syndrome [12,14].
The recommended treatment is early surgical intervention,
because it provides better clinical and functional outcomes when
compared to conservative treatments. An attempt to re-insert
the tendon after three weeks should be thoroughly analyzed,
since it will typically be retracted and not possess the adequate
length to reach the radial tuberosity [11,19,22,23]. Surgery is
particularly recommended for young patients, people who work
with their arms and athletes, especially when the affected side
is the dominant one. In general, the conservative treatment
will lead to a deficit in muscular strength, changes in mobility
and aesthetic deformities, which result in restrictions in daily
activities. However, it is preferable in patients without clinical
conditions for surgery or elderly patients with low functional
demands [1-10,12-15]. Several surgical approaches are currently
used for the reinsertion of the distal biceps. One can choose for
single or dual access, with different methods of fixation, such as
bone tunnel, interference screw, endobutton and suture anchor.
It is worth stating that there is no consensus in the literature
about the best approach or method of fixation [7-9,12,13,16,22].
Complications include lesions of the radial, median, ulnar and
lateral cutaneous nerve of the forearm, posterior interosseous
nerve neuropraxia, heterotopic ossification, proximal radioulnar
synostosis, decreased range of motion, infection, complex
regional pain syndrome, proximal fracture of the radius and new
ruptures [6,10,14,18,23]. Our objective is to describe the surgical
technique with three mini-incisions for treatment of distal biceps
brachii tendon ruptures, evaluating the results of the treatment
of ten patients using MEPS and DASH questionnaires.
A retrospective assessment of ten patients operated on
between October 2010 and November 2018 was performed.
The inclusion criteria were: patients with a diagnosis of
acute complete rupture of the distal biceps brachii tendon,
surgically treated through the three mini-incisions technique.
The injuries were diagnosed based on the clinical history and
physical examination (Popeye deformity, palpation of the
path of the biceps tendon and Hook test), confirmed by MRI and/or ultrasound exam. A chronologically ordered number
was assigned to the patients based on the date of the surgical
treatment (Table 1).
All patients were male and of Caucasian ethnicity. The mean
age was 44.8 (ranging from 38 to 55). Two patients were using
anabolic steroids (patients number 2 and 5), one was a smoker
(patient number 1) and all practiced sports activities at the time
of the injury. In our study, both dominant and non-dominant
limbs were equally affected. The mean follow-up time was 42.9
months (ranging from 7 to 94). The patients were operated in
the supine position with the upper limb abducted at 90º and
supported on a narrow table under locoregional anesthesia.
We performed active exsanguination of the upper limb, using
sterile elastic bands with the garrote at the root of the arm.
The surgical technique in the treatment of distal biceps brachii
tendon ruptures using three mini incisions is initiated with an
incision of 3 to 4 centimeters (cm) at 5 to 6 cm proximally from
the elbow fold, in the region where the stump of the ruptured
tendon is located. The region is occasionally swollen and painful
on palpation, making it easier to plan for its location.
The subcutaneous tissue and thin brachial fascia are then
opened, allowing access to the stump of the tendon, which was
deinserted from the tuberosity of the radius by pulling out. We
detach the tendon and exteriorize it through the small incision.
Holding it with gauzes moistened in physiological serum at 0.9%,
an intense traction is performed on it in the distal direction in
order to minimize the retraction related to the contraction of the
biceps muscle. A resection of 0.3 to 0.5 cm of the distal portion
of the tendon should be performed, transforming the stump in a
vitalized sinewy area. Two twisted 5.0 R polyester threads and
a V-40, 4x75 cm needle (Figure 3A) were prepared, in which a
junction knot was made, transforming them into a single thread
with two needles. We reach the posterior portion of the brachial
biceps muscle in its muscle-tendon transition (region that will
remain in contact with the brachialis muscle) and then we
initiate a Bunnell suture, with the needles in opposite directions,
making each thread emerge in the distal portion of the tendon.
We emphasize that the complete externalization of the tendon
enables the execution of the Bunnell suture with ideal technical
quality, allowing three to four passes increasing the strength
of the tendon suture. The needles are then rectified using two
needle holders, thus keeping the tendon ready for sequence of
the surgical technique (Figure 3B).
By digit-palpation through the proximal incision, the tunnel
associated with the trajectory left by the distal tendon of the
biceps brachii is located, thus facilitating the planning of the second skin incision, located, on average, at 3 to 4 cm distally to
the elbow fold. Through this deeper incision, the region of the
radial tuberosity is projected, where the tendon was detached
from. The dissection of this area should be done carefully,
given the proximity of the superficial veins of the elbow, which
must be retracted. In the divulsion of the Lacertus fibrosus,
it is necessary to avoid injury to the cutaneous portion of the
muscular-cutaneous nerve, also called the lateral cutaneous
nerve of the forearm, since the neuropraxia of this nerve is
the main postoperative complication in the treatment of distal
biceps ruptures [13,14]. We use delicate and deep Langenbeck
retractors to remove deep noble structures from the region, such
as the median nerve and arteries and deep veins of the forearm.
With the forearm in supination, we access the tuberosity
of the radius, cleaning the periosteum with a spatula or rugine.
Subsequently, two holes are made under direct vision in the
radial tuberosity, about 0.5 cm apart - using a 2.0 milimeters
(mm) Kirschner wire -, trying to keep the forearm in supination
at this moment (Figure 3C). We use Kelly tweezers introduced
through the distal incision until the proximal incision to bring
the already prepared tendon over the wire. At this time, we
use a needle holder to insert the bottom (non-piercing) part of
the needles into each of the previously prepared holes in the
tuberosity of the radius. After palpating the forearm, the needles’
exit area is located, where the third incision will be made (Figure
3D). At this time, it is important to perform a divulsion of the
musculature between the emergent area of the two needles /
wires, since branches of the posterior interosseous nerve cross
in this region and, under direct vision, one should avoid that it
interposes itself to the wires. Subsequently, the wires are pulled
with the elbow in supination and at a 90º flexion. Knots are then
made, and a digit-palpation evaluation of the tendon contact
in the tuberosity of the radius is performed (Figure 4). Finally,
a stability test of the tendon reinsertion, hemostasis, a skin
suture and the development of an axilopalmar plaster splint is
In the postoperative period, simple weekly dressings are
applied and passive movements of flexoextension and partial
pronosupination of the elbow are performed, with the arm
supported on a stretcher. Between 18 and 25 days, the plaster
is removed and replaced by a Velpeau-type fabric bracing, which
should also be used when sleeping. At this point, the patient is
allowed to perform active elbow flexion and pronosupination
movements three to four times a day with the upper limb resting
on a table in order to minimize the effect of gravity. In four to six
weeks, on average, the patient is released from immobilization.
The patients were evaluated based on a protocol previously
developed by the authors. In the anamnesis, the presence of
pain was investigated through the Visual Analogue Scale (VAS)
and the function of the previously affected limb through the
Mayo Elbow Performance Score (MEPS) and Disabilities of the
Arm, Shoulder and Hand (DASH) questionnaires. The patients
were questioned regarding the improvement of symptoms after
surgery and the degree of satisfaction in relation to the applied
treatment, defining it as satisfactory or unsatisfactory. In the
physical examination, the region of greatest circumference of
the arm at rest and under contraction was measured, in addition
to checking the amplitude of movement in flexoextension and
pronosupination with the use of a goniometer. The examinations
were performed bilaterally, which allowed a comparative analysis
between the limbs. Photographs of all patients were taken
during the evaluation. An x-ray of the elbow was requested in
the late postoperative period in two incidences (anteroposterior
and profile). All patients signed an Informed Consent Form (ICF)
before the evaluation and were informed about the nature of
the research. The study was submitted to the evaluation and
approval of the Ethics in Research Committee of our institution
under the number CAAE 90111918.9.0000.5413.
All ten patients declared themselves satisfied with the
established treatment with regard to the degree of satisfaction
after surgery. All patients reported functional recovery of the
affected upper limb after the surgical treatment concerning the
improvement of the symptoms. Eight scores of 0 and two scores
of 3 were obtained with the application of the VAS. As for the
MEPS, 100 points were obtained for nine patients. One patient
scored 85 points. A mean of 0.88 (ranging from 0 to 6.66) was
obtained for the DASH score. Table 2 shows the information
regarding the VAS, MEPS and DASH results, as well as a bilateral
comparison of the greatest circumference of the arm (at rest and
under contraction) and the range of motion in flexoextension and
pronosupination. Patients returned to their daily living activities
without restriction six months after surgery. All had good
functional results and did not present significant changes in the
range of motion regarding flexoextension and pronosupination
(Figures 5 & 6). There were no postoperative complications. In
the late radiographic evaluation, patient number 2 presented
calcifications of the soft tissue anterior to the radial tuberosity
and avulsion of the olecranon enthesophyte, which do not cause
functional impairment (Figures 7 & 8).
Distal biceps tendon ruptures are uncommon injuries,
accounting for just 3% of cases of biceps ruptures. It mainly affects
the dominant limb of middle-aged men [1-7]. The prevalence has
increased in recent years due to the growing practice of sports
activities [8-10,18-20]. The most common mechanism of injury
is an eccentric muscular contraction against resistance with the
elbow flexed at 90º and the forearm supinated [6,10,11,16,22].
In our study, the mean age was consistent with the range
predicted in the literature, corresponding to 44.8 years (with
extremes of 38 and 55), as was the sex of the patients - all males.
All the patients had an injury mechanism related to the practice
of sports activities. Both dominant and non-dominant limbs
were equally affected, each one in five cases [4,5,10,11,16].
The usual clinical presentation includes pain, edema,
ecchymosis, a palpable defect in the distal trajectory of the tendon,
as well as decreased strength and range of motion. Classical
findings include positive Hook test and biceps squeeze test, in addition to the Popeye deformity. Magnetic resonance imaging
is considered the gold standard for diagnostic confirmation and
surgical planning [1-10,18-22]. The recommended treatment
is early surgical intervention, which is considered superior
to conservative treatments. Ward et al.  advocate the use
of conservative treatments only for the elderly and patients
with low functional demand. Morrey et al.  showed that,
compared to the surgical treatment, the conservative treatment
results in a loss of 40% of the supination strength and 30% of
the flexion force. The use of an adequate surgical technique
and the time elapsed between the injury and the surgical
procedure are the most important factors for the prevention of
complications . Kelly et al.  reinforce the importance of
an early surgical intervention in order to obtain better results.
In their studies, they found an increase from 22% to 41% in the
rate of complications when surgery was performed 10 days after
the injury. In this regard, our study had an average time between
injury and surgery of 11.8 days, ranging from 1 to 34, which also
influenced the good results obtained.
This study uses a relatively small number of cases, as in
other publications about the rupture of the distal biceps brachii,
which is explained by its low incidence. No patient has been
lost since the surgery so far. The results obtained using the
three mini-incisions technique were satisfactory according to
both subjective assessments - the residual pain scale (VAS),
the degree of satisfaction with the established treatment and
the preservation of the limb‘s functional capabilities, which
is reflected in the results of the MEPS and DASH scales, which
have been validated in the literature - and objective criteria,
manifested through the absence of postoperative complications
and a timely return to daily life activities. These data can be
easily observed by evaluating the postoperative photographic
documentation of the described patients.
Historically, surgical treatment began with the use of a single
anterior access route, proposed by Henry apud Ward et al. .
Conversely, given its extensive exposure, several cases of radial,
medial, ulnar and cutaneous-lateral forearm lesions as well
as neuropraxia of the posterior interosseous nerve have been
reported due to excessive cutaneous retraction [1-3,5,19,23].
To date, a high rate of complications is still documented in the
literature, close to 25% [15,20]. In 1961, Boyd & Anderson 
developed the two-incisions technique in an attempt to reduce
dissection and the risk of injury of the neurovascular structures.
Although this technique has favorable results, it may evolve
negatively with heterotopic ossification, proximal radioulnar
synostosis and a decreased range of motion [5,9,13-19,21]. In
1985, Morrey et al.  modified this technique in order to avoid
subperiosteal ulnar exposure [3,7,9,11,22]. Even today, several
approaches are used to reinsert the distal biceps. The continuous
appearance of new techniques is explained by the attempt to
recover the functional capacity of the affected limb while at the
same time reducing the rate of postoperative complications.
However, there is still no consensus regarding the superiority of
any technique or method of fixation.
The authors chose to use a surgical approach with three
mini-incisions. This technique requires materials that are
available at most hospitals worldwide (pneumatic perforator,
2.0 mm Kirschner wires and two polyester threads) and it seeks
to minimize surgical trauma and economic costs. In addition
to these factors, the technique has great reproducibility and it
ensures a satisfactory functional recovery of the affected limb in
the postoperative period and better aesthetic results regarding
Maciel et al.  conducted a study with 22 patients
operated by single access and fixation with a suture anchor.
The patients showed good functional results, as reflected by the
VAS, MEPS, degree of satisfaction and Andrews-Carson scores,
but the complication rate was 27.2%, with neuropraxia of the
lateral cutaneous nerve of the forearm as the main occurrence.
Chavan et al.  performed a systematic review comparing the
technique with single and two incisions, in which complication
rates of 18% and 16% were obtained, respectively. These data
reveal that both techniques still have considerable rates of
We emphasize that the good results observed have a
close association with the Bunnell suture technique, which
is considered a modality with a high tensioning capability,
enabling a satisfactory, direct coaptation between the distal
biceps tendon stump and its origin in the radial tuberosity .
It is worth stating that the tendon externalization performed
through the first incision, as described in the surgical technique,
allows the Bunnell suture to be performed with multiple passes,
which contributes to greater tension and stability. To date, our
approach seems quite adequate, since no patient presented
postoperative complications, functional deficits or new
ruptures. We consider this to be relevant since this is a study
with a relatively long follow-up, ranging from 7 to 94 months
(mean of 42.9). All patients were able to return to the original
sports practiced at the time of injury and reported satisfaction
with the treatment. We obtained positive results on the MEPS
and DASH scales, which have been scientifically validated as
sensitive and responsive instruments that evaluate the function
and symptomatology of the limb previously affected from the
patient‘s own perspective, thus reaffirming the quality of the
The surgical approach with three mini incisions, performed
by Bunnell suture and transosseous fixation, proved to be a lowcost
and adequate technique both aesthetically and functionally
for the treatment of distal biceps rupture, with satisfactory
results in the MEPS and DASH questionnaires.