The biceps muscle at the front of the upper arm is anchored to the forearm by the distal biceps tendon, just beyond the elbow. When that tendon tears away from the bone, the arm loses a good deal of its power to bend the elbow and to turn the palm upwards.
Distal biceps repair is an operation to reattach the torn tendon to the radius, one of the two forearm bones. The aim is to restore the strength and function of the biceps.
The procedure
The tendon is reattached to the radius using sutures, together with anchors or a button device that holds the tendon against the bone while it heals. The repair is usually carried out arthroscopically, through small keyhole incisions, although an open approach is sometimes needed. About two hours of operating theatre time is booked.
Risks and complications
All surgery carries risk. The risks that are relevant to you are discussed with you in consultation before any decision about surgery is made.
General surgical risks
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Bruising and haematoma. The amount of bruising varies from patient to patient and is a normal part of healing. It usually settles quickly. A haematoma, which is a collection of blood under the wound, occasionally needs to be drained in theatre.
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Infection. Infection is uncommon but possible, and is usually treated with antibiotics.
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Deep vein thrombosis (DVT) and pulmonary embolism (PE). Blood clots can form in the veins of the leg and can travel to the lungs. These are serious conditions, but the risk of lasting harm is significantly reduced when they are recognised and treated promptly.
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Anaesthetic risks. These are discussed with your anaesthetist before surgery. In Australia the risk of death from a general anaesthetic is around 1 in 100,000.
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Wound problems. Superficial wound problems can occur. Most are minor and settle with a small intervention.
Risks specific to this procedure
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Nerve irritation or damage. Several nerves run close to the front of the elbow. Irritation can cause tingling or numbness, which typically resolves quickly, but damage to a nerve is a recognised risk of the operation.
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Re-tear or rupture of the repair. The tendon can pull away from the bone again, particularly if the arm is used too early.
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Elbow stiffness. Loss of elbow movement, which the rehabilitation programme is designed to address.
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Fracture of the radius. The forearm bone is prepared to take the repair, and fracture of the bone is a recognised risk.
Before surgery
There are a number of things to work through while you are waiting for your surgery date. You will be given detailed written instructions covering all of this.
- Confirm with your health fund that the hospital fee is covered.
- Confirm your anaesthetist’s fees.
- Register your details with the hospital.
- Read, complete and return your paperwork to the rooms.
- Plan your transport to and from hospital. You cannot drive yourself home.
- Attend any pre-operative physiotherapy that has been recommended.
- Complete any pre-operative pathology, such as blood tests, if it has been requested.
- Wash the arm and shoulder with benzoyl peroxide 5% wash twice daily for two days, and then once more on the morning of surgery, five applications in total. This reduces the risk of infection with Cutibacterium acnes, a bacterium that lives in the skin.
- Pack your hospital bag: your regular medications in their original packaging, a loose button-up shirt, nightwear and toiletries. Bring your CPAP machine if you have sleep apnoea.
- If you take blood thinners, phone the rooms to confirm when to stop them.
- If you take tablets for diabetes, phone your anaesthetist to confirm whether to stop them.
- Confirm your admission details with the rooms one to two business days before surgery.
The day of surgery
- Your admission details are confirmed one to two business days beforehand. Make a note of your admission time, which may be as early as 6am, and the time from which you must fast.
- If you do not live in Brisbane, staying in the city the night before is usually recommended.
- After the admissions process you wait in the surgical waiting area. Your anaesthetist will see you for a brief consultation before you go through to theatre.
- Dr Cutbush will greet you in the anaesthetic bay and mark the operation site. You are then given the general anaesthetic.
- The usual stay is one night. Discharge is generally around 10am, after Dr Cutbush has reviewed you.
- You will be given a folder containing your post-operative pack: a letter describing what was found and what was done, together with your rehabilitation and aftercare information.
- Arrange for someone to take you home.
Recovery and healing
The elbow is immobilised in a sling, worn full time for six weeks. The biceps must not be used during this period, so there is no active bending of the elbow and no actively turning the palm upwards. While you are in the sling you will not be able to drive, work in most roles, or take part in physical activity.
Physiotherapy begins with assisted movements and progresses to active range of motion and then strengthening. Full recovery usually takes between three and six months.
Rehabilitation
Day one
Before you leave hospital the physiotherapist will fit your sling and show you how to put it on and take it off yourself, and how to manage eating, showering and dressing with one hand.
The goals on day one are to protect the repair, to keep elbow movement within the set limits, to maintain movement in the neighbouring joints (hand, wrist, shoulder and neck) and to keep good scapular posture.
The sling is worn for six weeks. It may be removed for showering, for eating and for sitting quietly. Use an alternate sling in the shower. The fit of the sling and how you manage daily activities in it are both checked.
Precautions: no active elbow flexion and no active forearm supination. That is, no bending the elbow or turning the palm upwards under your own muscle power on the operated side.
Day one exercises
- Passive elbow flexion, with active extension, in a gravity-minimised plane.
- Passive supination with active pronation. These can be done in the sling.
- Range of motion for the adjacent joints to keep them mobile.
- Measures to control swelling.
Follow-up
Arrange hand therapy or physiotherapy locally at around the two-week mark, or sooner if you have swelling, stiffness or pain that concerns you.
Results after surgery
The repair aims to restore elbow bending and forearm rotation strength. Most people regain functional movement of the elbow and return to their normal activities. Some are left with a degree of weakness compared with the uninjured arm, and a number of individual factors influence the outcome, including how long the tendon had been torn, the quality of the tendon tissue and how closely the rehabilitation programme is followed. Individual results vary.
Next steps
This page is general information about a surgical procedure and is not a recommendation that you have it. Whether surgery is appropriate for you can only be determined after assessment. All surgery carries risk; the risks relevant to you are discussed in consultation before any decision is made.
