Distal Biceps Tendon Repair: 1-Incision Versus 2-Incision Techniques

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1 Techniques in Shoulder and Elbow Surgery 7(1):61 71, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia m R E V I E W m Distal Biceps Tendon Repair: 1-Incision Versus 2-Incision Techniques Gregory K. Deirmengian, MD, Pedro K. Beredjiklian, MD, Charles Getz, MD, Matthew Ramsey, MD, and David J. Bozentka, MD From the Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA m ABSTRACT Treatment options for distal biceps tendon ruptures include nonoperative and operative approaches. Candidates for conservative nonoperative management include elderly low-demand patients, those in whom surgery is contraindicated because of medical comorbidities, and those who are unable to adhere to the strict postoperative rehabilitation regimen. Data have clearly shown the superiority of operative over nonoperative management of these injuries. Currently, the most commonly used approaches are the 2-incision modified Boyd-Anderson approach and the limited 1-incision anterior approach. Transosseus suture fixation is typically combined with the 2-incision technique, whereas alternative fixation methods, such as the suture anchor or Endobutton techniques, are combined with the 1-incision technique. The clinical evidence reported in the literature to date does not support a clear single approach that should be used as the standard of care for distal biceps tendon ruptures. In fact, the data that are available show good to excellent results with both procedures and only relatively minor differences in outcomes. Thus, at this point in time, the decision of the technique to use for repair of these injuries should be based on surgeon preference, surgeon training, and comfort level with the approaches. Keywords: distal, biceps, tendon, repair, 1-incision technique, 2-incision technique, radioulnar synostosis m INTRODUCTION Rupture of the biceps tendon at the radial tuberosity is an uncommon injury with a reported incidence of 1.2 per 100,000 individuals per year, accounting for only 3% of all biceps tendon injuries. 1Y3 The traumatic injury is typically sustained after application of an eccentric load on a flexed elbow of the dominant extremity, as in heavy lifting. 4,5 Unlike most other tendon ruptures, Address correspondence and reprint requests to Pedro K. Beredjiklian, MD, Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, 39th and Market Streets, 1 Cupp Pavilion, Presbyterian Medical Center, Philadelphia, PA pedro. beredjiklian@uphs.upenn.edu. which occur at the musculotendinous junction or within the tendon itself, distal biceps tendon ruptures typically occur as a complete avulsion from its insertion. Patient factors associated with these injuries include male sex, ages between 30 and 60 years, smoking, and activities such as weight lifting, heavy labor, and athletics. 1,6,8 Although the exact pathogenesis of distal biceps tendon ruptures remains unknown, it is generally accepted that only weakened tendons tend to rupture. Factors that have been hypothesized to play a role in weakening tendons include hypovascularity, impingement, and degeneration. Branches of the brachial artery supply the proximal aspect of the distal biceps tendon, whereas the posterior interosseous recurrent artery supplies the distal aspect of the tendon at its insertion. This organization leaves a watershed zone just proximal to the insertion site that is supplied only by a plexus of vessels located within a thin layer of paratenon. It is thought that this hypovascularity predisposes the tendon to rupture. 7 The additional strains of increased vascular insufficiency and decreased oxygenation to this already hypovascular area may explain the observed association of smoking with distal biceps tendon ruptures. 1 Impingement may also play a role in distal biceps tendon ruptures, especially during pronation when the space occupied by the tendon is diminished. It has been suggested that bony prominences near the radial tuberosity can cause repetitive friction and impingement with forearm rotation, leading to tendon weakening and eventual rupture with eccentric loading. 9,10 Lastly, degenerative processes within the tendon have been implicated as a factor leading to their weakening and rupture. It is hypothesized that 30- to 60-year-old patients are at highest risk for rupture because it is within this specific age range that significant loads are applied to relatively degenerated tendons. 1,5 The diagnosis of distal biceps ruptures relies mostly on a thorough history and physical examination, supplemented by radiographic evaluation. The typical history associated with an acute biceps tendon rupture involves a popping sound and severe pain in the antebrachial fossa after lifting a heavy object. Several physical examination findings secure the diagnosis. The Volume 7, Issue 1 61

2 Deirmengian et al patient presents with edema, ecchymosis, and tenderness in the antebrachial fossa; a palpable defect in the region compared with the uninjured arm; pain and weakness with active flexion and supination; and, occasionally, a visibly retracted biceps muscle belly subcutaneously. Weakness in active supination is the hallmark finding in this setting. Recently, a biceps squeeze test has been described and shown to be a simple and reliable sign of the injury. 11 Similar to the Thompson test for Achilles tendon rupture, failure of the forearm to show a supination response with manual squeeze of the biceps brachii muscle indicates a complete rupture of the tendon. Plain radiographs usually do not show osseous changes associated with the injury, although partial avulsion of the radial tuberosity in association with the injury has been reported. 9 Magnetic resonance imaging is useful when the diagnosis is unclear by history and physical examination alone, in differentiating complete and partial tears, and in clarifying the degree of retraction and integrity of the tendon. Treatment options for distal biceps tendon ruptures include nonoperative and operative approaches. Candidates for conservative nonoperative management include elderly low-demand patients, those in whom surgery is contraindicated because of medical comorbidities, and those who are unable to adhere to the strict postoperative rehabilitation regimen. Data have clearly shown the superiority of operative over nonoperative management of these injuries. Compared with those treated surgically, patients managed conservatively have significantly decreased strength and endurance, increased pain with motion, increased difficulty with sports and activities of daily living, and decreased cosmesis and are much less likely to have good to excellent results. 4,12,14 Data have also shown that results in repair of ruptures of the dominant extremity are better than that of the nondominant extremity. 13 Results of anatomic repair of the ruptured tendon to the radial tuberosity have shown to be functionally superior to nonanatomic approaches, such as tenodesis to the brachioradialis. 4 The latter approach might be used for cases of chronic rupture if anatomic reconstruction is difficult, the goal of surgery is pain relief, or decreased strength and endurance in flexion and supination are tolerable. 5 In 1898, Acquaviva 15 first described surgical repair of a distal biceps tendon rupture to the radial tuberosity. Since that time, multiple surgical techniques have evolved. Although many variations exist in the method of surgical dissection and method of attachment of the distal biceps tendon to the radial tuberosity, 2 exposures have predominatedva 1-incision and a 2-incision technique. Although both exposures each have advantages and disadvantages, neither has been shown to be the clear exposure of choice. m SURGICAL TECHNIQUE Initial efforts to repair distal biceps tendon ruptures used a single relatively large anterior incision superficial to the radial tuberosity. 16 The approach mandated detection and retrieval of the injured tendon, relocation of the tendon to its normal site of insertion, and sufficient exposure and preparation of the radial tuberosity for fixation of the tendon. Achievement of these goals through a single incision required a great deal of dissection, placing surrounding neurovascular structures at risk. The result was several associated complications, including reports of median and radial nerve palsies. 17 In an effort to reduce such complications and to improve exposure of the radial tuberosity, Boyd and Anderson 18 described a 2-incision technique in 1961, involving limited incisions anteriorly and posterolaterally. This soon became the standard approach for the repair of distal biceps tendon ruptures. With time, several complications of the conventional Boyd and Anderson were reported, prompting attempts to improve the technique. The primary complication associated with this approach was proximal radioulnar synostosis secondary to heterotopic ossification, potentially limiting postoperative range of motion. Several explanations for this phenomenon have been proposed. It has been suggested that the aggressive subperiosteal exposure of the ulna and subsequent damage of the interosseous membrane predispose to hematoma formation and activate the ulnar periosteum, which contributes to radioulnar synostosis. Another factor that may contribute to radioulnar synostosis formation is the tissue deposition of bone dust created with high-speed burring of the radial tuberosity. 4 In an attempt to eliminate the risk of radioulnar synostosis associated with the conventional Boyd and Anderson technique, several adjustments have been made. One recommendation is to either thoroughly irrigate the wound of bone dust debris before closure or to use alternative means to high-speed burring of preparing the radial tuberosity for reattachment of the injured tendon, such as the formation of a trough with an osteotome. 20 To eliminate subperiosteal ulnar exposure, Morrey et al 4 described the 2-incision modified Boyd-Anderson technique, which involves a limited muscle-splitting approach through the extensor muscle mass. It is important to note that the use of the 2- incision technique does not eliminate the risk of nerve injuries and palsies associated with the early 1-incision technique and that the use of the modified Boyd- Anderson technique does not eliminate the risk of 62 Techniques in Shoulder and Elbow Surgery

3 Distal Biceps Tendon Repair extended in the proximal or distal direction if needed (Fig. 1). A superficial dissection is executed, carefully identifying and retracting important structures such as the lateral antebrachial cutaneous nerve and basilic vein. After exposure of structures underlying the deep fascia, the ruptured biceps tendon is identified, retrieved, and debrided (Fig. 2). At this point, the distal end of the tendon is secured with 2 nonabsorbable sutures using the modified Burnell technique (Fig. 3). Extensive dissection of the anterior structures is avoided by identifying the sheath previously occupied by the torn biceps tendon, using careful blunt dissection. With the FIGURE 1. The two-incision technique employs a Henry type incision in the antecubital space and a 4-cm incision over the posterolateral aspect of the proximal forearm. Adapted from Morrey BF. Distal biceps tendon rupture. In: Morrey BF, ed. Master Techniques in Orthopaedic SurgeryVThe Elbow. 1st ed. New York: Lippincott-Raven, 1994:115 [figures 1a,b, p116]. radioulnar synostosis associated with the conventional Boyd and Anderson technique. 21,22 To address the complications associated with initial attempts at single anterior incision exposure for the anatomic repair of the distal biceps ruptures and those associated with 2-incision techniques, surgeons have recently reexamined the anterior single-incision approach. Using recent advances in surgical fixation technique, such as suture anchor, Endobutton, and Biotenodesis screw fixation, has allowed for a more limited incision and exposure. 23Y25 Recently, this approach to repair of distal biceps tendon ruptures has been popularized. Although the details of the techniques used in the modified Boyd-Anderson technique and the limited 1- incision technique are surgeon-dependent, the following sections describe 2 such examples. m MODIFIED BOYD-ANDERSON 2-INCISION APPROACH The supinated and extended forearm of the supine patient is prepped and draped in the usual manner, using a tourniquet to achieve hemostasis. A transverse incision is made in the flexion crease and can be FIGURE 2. The dissection is carried through the forearm fasica to the biceps muscle. Depending upon the acuteness of the injury a hemorrhagic reaction may surround the structure. Usually the tendon is reacted. Adpated from Morrey BF. Distal biceps tendon rupture. In: Morrey BF, ed. Master Techniques in Orthopaedic SurgeryVThe Elbow. Lippincott-Raven, 1st ed, p 115, New York, Lippincott-Raven, 1994, Figure 2a,b, page 117. Volume 7, Issue 1 63

4 Deirmengian et al forearm supinated, a curved hemostat is passed through the sheath to the level of the space between the radius and ulna. Posterolaterally, the tip of the hemostat is FIGURE 4. The curved hemostat is passed between the radial tuberosity and the ulna to emerge through the common extensor muscle ass and tent the skin on the proximal posterolateral aspect of the forearm. Adapted from Morrey BF. Distal biceps tendon rupture. In: Morrey BF, ed. Master Techniques in Orthopaedic SurgeryVThe Elbow. 1st ed. New York: Lippincott-Raven, 1994:115 [figures 6a,b, p119]. FIGURE 3. The first of two #5 nonabsorable crisscross Bunnell type sutures, which are placed in the tendon. Adapted from Morrey BF. Distal biceps tendon rupture. In: Morrey BF, ed. Master Techniques in Orthopaedic SurgeryVThe Elbow. 1st ed. New York: Lippincott-Raven, 1994:115 [figures 4a,b, p118]. palpated superficially, and a small incision is made through the skin (Fig. 4). The forearm is pronated, and the posterolateral muscle-splitting dissection is executed, exposing the radial tuberosity. A cavity large enough to accommodate the prepared tendon is created within the radial tuberosity with a high-speed bur or a small osteotome. Three small drill holes are then made through the cavity, traversing the far cortex of the radius. A curved hemostat is inserted in the anterior incision and used to carry the prepared tendon out the second incision, passing through the sheath (Fig. 5). The sutures are then passed through the drill holes and secured (Fig. 6). The wounds are copiously irrigated and 64 Techniques in Shoulder and Elbow Surgery

5 Distal Biceps Tendon Repair FIGURE 5. The tendon is then pulled through the forearm wound. Adapted from Morrey BF. Distal biceps tendon rupture. In: Morrey BF, ed. Master Techniques in Orthopaedic SurgeryVThe Elbow. 1st ed. New York: Lippincott-Raven, 1994:115 [figures 12a,b, p122]. closed in layers. The upper extremity is then immobilized with the elbow in 90 degrees of flexion and the forearm in supination. m LIMITED 1-INCISION APPROACH The patient is positioned, and the extremity is prepared as described above. A small transverse incision is made centered at the flexion crease and is extended distally as a radial limb. A proximal ulnar limb can also be extended, creating an S-shaped incision, to improve exposure (Fig. 7). Superficial structures are identified and carefully retracted as in the anterior exposure of the 2-incision technique, and the biceps tendon is identified, debrided, tagged, and retracted (Fig. 8). Next, exposure is gained to the radial tuberosity by retracting the brachioradialis laterally and the pronator teres medially, after which the radial and posterior interosseous nerves are identified and retracted. The radial tuberosity is then exposed with the forearm in supination and roughened FIGURE 6. The sutures are tied while the forearm is allowed to supinate slightly to facilitate this process. Adapted from Morrey BF. Distal biceps tendon rupture. In: Morrey BF, ed. Master Techniques in Orthopaedic SurgeryVThe Elbow. 1st ed. New York: Lippincott- Raven, 1994:115 [figures 14a,b, p123]. FIGURE 7. Ectopic bone bridging the proximal ulna and radius. The exposure of the radial tuberosity was across the periosteal surface of the ulna. Adapted from Strauch RJ, Rosenwasser MP. Single incision repair of distal biceps tendon rupture. Tech Hand Up Extrem Surg. 1998;2:253Y261 [figures 3a,b, p256]. Volume 7, Issue 1 65

6 Deirmengian et al FIGURE 8. A: Right elbow of patient shown in Fig. 2, with incision for repair marked out. B: Position of the incision with respect to underlying structures. Adapted from Strauch RJ, Rosenwasser MP. Single incision repair of distal biceps tendon rupture. Tech Hand Up Extrem Surg. 1998;2:253Y261 [figures 5a,b, p257]. using an instrument such as a power osteotome. At this point, 2 suture anchors are applied to the prepared tuberosity 1 cm apart (Fig. 9). With the elbow between 60 and 90 degrees, the sutures are then applied through the stump to the torn tendon (Fig. 10). The tendon is then approximated to the tuberosity with the use of a clamp and then secured to the bone (Fig. 11). The position of the metallic anchors can be checked intraoperatively with the use of fluoroscopy (Fig. 12). Additional sutures can be used to reinforce the repair. Alternatively, the torn biceps tendon can be fixated to the radial tuberosity using other techniques, such as the Endobutton technique or a Biotenodesis screw. The wound is copiously irrigated and closed in layers. The upper extremity is then immobilized with the elbow in flexion and the forearm in supination. FIGURE 9. A: Round structure in vessiloops on the left side is the lateral antebrachial cutaneous nerve. The vessiloops on the right side encircle the radial recurrent vessels. B: Schematic diagram shows ligation of radial recurrent vessels. Adapted from Strauch RJ, Rosenwasser MP. Single incision repair of distal biceps tendon rupture. Tech Hand Up Extrem Surg. 1998;2:253Y261 [figure 7, p257]. 66 Techniques in Shoulder and Elbow Surgery

7 Distal Biceps Tendon Repair FIGURE 10. Birds eye view of suture anchor being placed into radial tuberosity. Adapted from Strauch RJ, Rosenwasser MP. Single incision repair of distal biceps tendon rupture. Tech Hand Up Extrem Surg. 1998;2:253Y261 [figures 8a,b, p258]. m COMPARATIVE ANALYSIS OF 1-INCISION VERSUS 2-INCISION RE- PAIR Currently, the most common surgical approaches to the repair of distal biceps tendon ruptures are the 2-incision modified Boyd-Anderson technique and limited single anterior incisions with suture anchor fixation. The 2- incision technique has been in use for several decades, and much has been written regarding experiences with the approach. The single-incision exposure with suture anchor fixation has been in wide use for less than a decade, and as such, relatively little has been reported on results of the technique. To make an appropriate decision regarding the technique a surgeon should use to repair these injuries, one must factor the advantages and disadvantages of each procedure and compare outcomes associated with them. The 2-incision Boyd-Anderson technique was originally devised in an attempt to minimize paresthesias and other nerve injuries associated with the conventional 1-incision technique by minimizing the anterior exposure. 18 Although the approach decreases the risk of nerve injury, it does not eliminate it. There have been several reports of both temporary and permanent palsies of nerves at risk during the exposure, including the lateral antebrachial cutaneous nerve, posterior interosseous nerve, and superficial radial nerve. 26,27 Kelly et al 26 reported on the complications associated with the 2-incision Boyd-Anderson technique in 74 patients. Their data showed an 8% rate of nerve injury associated with the technique and also suggested that the main risk factors for nerve injuries are extensive anterior exposure and delay in repair, which makes dissection to the radial tuberosity more difficult, because of scar tissue. The second risk associated with the 2-incision Boyd-Anderson technique is heterotopic ossification in the area of the radial tuberosity that may result in radioulnar synostosis (Fig. 13). Although this complication is rare, it causes severe patient dysfunction and morbidity. 4,12,14,19 The modified musclesplitting Boyd-Anderson technique was devised to minimize radioulnar synostosis, but it has not eliminated the risk. 28 Because of the complications associated with the 2- incision technique, a limited anterior single incision has become popularized over the last decade. Frequently, this less invasive approach is used in combination with alternative fixation techniques such as suture anchors. Compared with the 2-incision technique, the potential advantages of the procedure include decreased number and length of incisions, less dissection and soft tissue trauma, and theoretically less risk of radioulnar synostosis. Because of the relatively recent advent of the technique, data regarding outcomes and complications associated with it are scant. Of the case series that have been reported, complications have included transient paresthesias involving the lateral antebrachial cutaneous and posterior interosseous nerves as well as heterotopic ossification. 29Y31 The reports of heterotopic ossification associated with the limited anterior single-incision raise the question of whether radioulnar synostosis is a complication that has yet to be reported because of the relatively recent advent of the procedure. Critics argue that one of the disadvantages of using a single-incision technique with suture anchors is decreased strength of fixation. There have been several biomechanical studies that have compared the fixation of suture anchors with that of bone tunnel tendon repairs. Using a cadaveric model, initial studies sug- Volume 7, Issue 1 67

8 Deirmengian et al FIGURE 11. Sutures are placed into end of the biceps tendon. B: Schematic drawing shows method of initial suture placement. Adapted from Strauch RJ, Rosenwasser MP. Single incision repair of distal biceps tendon rupture. Tech Hand Up Extrem Surg. 1998;2:253Y261 [figures 9a,b, p259]. gested that bone tunnel tendon fixation gives a stronger and stiffer result than that of single suture anchors. 32,33 A more recent randomized controlled study compared bone tunnel fixation with 2 suture anchor fixation in vitro, using suture types, sizes, and patterns currently used in patients with success. Using a similar experimental design of the previous studies, this study showed equal, if not superior, yield strength associated with suture anchor fixation, compared with bone tunnel fixation. 34 Although there has been no study that directly compares failure of the repairs of the 2 techniques, rerupture has been reported with both. 26,31 It is clear that anatomic reinsertion of the biceps tendon yields a superior result than nonoperative treatment in terms of outcomes such as strength and endurance of elbow flexion and supination, return to preinjury levels of activity, and patient satisfaction. 4,12,13,20 Many individual studies of outcomes of the limited 1-incision FIGURE 12. A: After placement of all sutures, the biceps tendon is seen flush with the tuberosity (vessiloops on lateral antebrachial cutaneous nerve). B: Schematic drawing shows how a clamp is used to push the tendon down to the tubersity before typing the initial sutures. Adapted from Strauch RJ, Rosenwasser MP. Single incision repair of distal biceps tendon rupture. Tech Hand Up Extrem Surg. 1998;2:253Y261 [figure 13, p260]. 68 Techniques in Shoulder and Elbow Surgery

9 Distal Biceps Tendon Repair similar outcomes between the groups in terms of range of motion, strength, pain, and rate of complications. They did find that the patients treated with a 1-incision approach showed less operative time and shorter time to return to regular activity and work. FIGURE 13. X-rays after placement of the two suture anchors and tendon repair. Adapted from Morrey BF. Distal biceps tendon rupture. In: Morrey BF, ed. Master Techniques in Orthopaedic SurgeryVThe Elbow. 1st ed. New York: Lippincott-Raven, 1994:115 [figure 16, p125]. and Boyd-Anderson 2-incision techniques have shown excellent results of each procedure. Karunakar et al 28 reported the results of the repair of 21 distal biceps tendon ruptures using the Boyd-Anderson technique. Although showing some diminished strength and endurance, all patients showed a good or excellent result and were satisfied with their treatment. D Arco et al 35 reported excellent outcomes in 13 such injuries treated in the same manner with no evidence of decreased strength or motion. More recent studies by Balaboud et al 36 and McKee et al 37 show similar excellent outcomes with minimal to no decrease in strength and endurance for distal biceps tendon ruptures treated with a limited single-incision technique. Recently, a few studies have more directly compared the outcomes of distal biceps tendon ruptures treated with the 2 techniques. El-Harawy et al 38 prospectively compared 3-, 6-, and 12-month postoperative outcomes of 9 patients treated with a 1-incision technique and 10 patients treated with a 2-incision technique by 3 surgeons over a 4-year period. Their results showed largely similar results, and the few differences that did exist were minor. They found that 1 year after repair, patients treated with a 1-incision technique regained a small-degree more elbow flexion than those treated with the 2-incision technique, but those treated with the latter technique had a more rapid recovery of flexion strength and had fewer minor complications. Ozyurekoglu and Tsai 39 compared the outcomes of 29 patients treated with a 1-incision technique (fixation via suture anchor or Endobutton) and 17 patients treated with a 2-incision technique with a mean follow-up of 14 months. They also found largely m CONCLUSIONS Since the first description of the surgical repair of a distal biceps tendon rupture in 1898, many varieties of the procedure have evolved with a goal of limiting incision length and number while minimizing complications. Currently, the most commonly used approaches are the modified Boyd-Anderson approach and limited single anterior approach. Although the approach does not dictate the type of fixation used, transosseus suture fixation is typically combined with the 2-incision technique, whereas alternative fixation methods such as the suture anchor or Endobutton techniques are combined with the 1-incision technique. Both clinical and biomechanical studies have shown that the type of fixation used in the repair has little influence on clinical outcomes or rate of complications. 34,40 However, the 2 most commonly used approaches have individual advantages, disadvantages, and complication profiles. The clinical evidence reported in the literature to date does not support a clear single approach that should be used as the standard of care for distal biceps tendon ruptures. In fact, the data that are available show good to excellent results with both procedures and only relatively minor differences in outcomes. Thus, at this point in time, the decision of the technique to use for repair of these injuries should be based on surgeon preference, surgeon training, and comfort level with the approaches, and the desire to limit incision number and length and avoid specific complications such as nerve injuries and radioulnar synostosis. m REFERENCES 1. Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002;404:275Y Gilcreest EL, Albi P. Unusual lesions of the shoulder girdle and upper arm. Surg Gynecol Obstet. 1939;68:903Y Dobbie RP. Avulsion of the lower biceps brachii tendon: analysis of fifty-one previously unreported cases. Am J Surg. 1941;51:662Y Morrey BF, Askew LJ, An KN, et al. Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg Am. 1985;67:418Y Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg. 1999;7:199Y207. Volume 7, Issue 1 69

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11 Distal Biceps Tendon Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach. J Hand Surg Br. 2004;29: 178Y McKee MD, Hirji R, Schemitsch EH, et al. Patientoriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique. J Shoulder Elbow Surg. 2005;14:302Y El-Hawary R, MacDermid JC, Faber KJ, et al. Distal biceps tendon repair: comparison of surgical techniques. J Hand Surg Am. 2003;28:496Y Ozyurekoglu T, Tsai TM. Ruptures of the distal biceps brachii tendon: results of three surgical techniques. Hand Surg. 2003;8:65Y Bell RH, Wiley WB, Noble JS, et al. Repair of distal biceps brachii tendon ruptures. J Shoulder Elbow Surg. 2000;9:223Y226. Volume 7, Issue 1 71