Biceps Tenodesis for Distal Biceps Tendon Repair

CHAPTER 1

The incision is marked out just distal to the antecubital fossa and slightly radial in order to both access the retracted distal biceps tendon stump as well as the proximal radius site for repair. Alternatively, a transverse incision can also be placed. Occasionally in cases with a very retracted distal biceps tendon stump or contracted biceps muscle, proximal dissection is necessary, and the incision can be extended as shown here, proximally across the lateral border of the biceps musculature.

CHAPTER 2

After exsanguination of the limb and elevation of the sterile tourniquet to 250 mmHg, the incision is placed.

CHAPTER 3

Blunt dissection is then performed down to the antebrachial fascia. The first structure to be identified is the lateral antebrachial cutaneous nerve. The dotted line next to the incision is the anticipated location of this nerve.

Once the dissection is taken deeper, the lateral antebrachial nerve should be identified and carefully mobilized and subsequently retracted radially.

CHAPTER 4

Once mobilized and retracted, dissection can then be performed to identify the distal biceps tendon stump. Often, with blunt use of your finger alone, the tendon end can be identified loose within the soft tissue proximally and then can be retracted out into the wound and tagged with an Allis clamp.

CHAPTER 5

Once retrieved and mobilized, the distal biceps tendon is then tagged. Often, the tendon can be retracted, and to help mobilize the tendon, blunt dissection between the biceps and the brachialis can be performed with one's finger. Moreover, the lacertus fibrosus can also be released if necessary. Care must be taken, however, to avoid injury to any neurovascular structures during such a release. Broadly speaking, there are a number of ways to classify distal biceps tendon repair techniques. The first distinction is whether a one-incision or a two-incision technique is being utilized. In this case, a single-incision Arthrex BicepsButton fixation system will be utilized, which involves placement of a trough within the proximal radius to dunk the biceps tendon, followed by tensioning of the biceps tendon within the proximal radius using a BicepsButton, followed by interference fixation of the biceps tendon using an interference screw. This system provides three points of fixation to maximize repair strength of the distal biceps tendon, as will be shown. The repair is initiated by placing a whip stitch around the distal biceps tendon, as being illustrated here, using a number 2 FiberWire suture. At least three to four whip stitches are placed through the distal biceps tendon prior to freshening up the distal biceps tendon for repair.

The very distal end is sharply debrided in order to provide a clean stump for repair. In order to improve ease of placement and sliding of the distal biceps tendon within the tunnel in the proximal radius to be made, all loose ends and frayed ends are sharply debrided away as to not obstruct placement within the tunnel.

Since the manufacturer's technique utilizes a 7-mm tenodesis screw, the tendon is then debrided down to ideally a 7-mm or 8-mm width so that a 7.5-mm bone tunnel can be created. Here, the tendon is shown to comfortably fit within a 7-mm sizer.

To aid in confirming that adequate amount of distal biceps tendon has been dunked into the trough of the proximal radius, the distal centimeter of the tendon is marked.

Next, in order to aid in the first point of fixation of the distal biceps tendon once docked in the tunnel and tensioned, a shuttle stitch is placed one centimeter proximal to the distal biceps tendon stump as shown here to deliver the second limb of the FiberWire suture and then repair of the tendon to the proximal radius. The shuttle stitch consists of an 0 Vicryl suture with the needle cut off, both limbs are placed through a free needle and then run through the proximal biceps tendon stump. The looped end is run through, and the tails are left behind and then tagged as shown here for later shuttling of one limb of the FiberWire once the biceps tendon is inserted.

Attention is now turned back to the distal biceps tendon stump and its whip stitch with the number 2 FiberWire. The loop is cut, and the freed Keith needle is then used to pass each limb of the whip stitch through the distal biceps tendon button as shown here. With the aid of the Keith needle, each limb of the FiberWire is placed through the Biceps Button but in an opposite direction. The entrance of one side represents the exit of the other side. This will provide the necessary relationship for the Biceps Button to slide once tensioned on the other side of the proximal radius.

Lastly, the Biceps Button is placed on its insertion device for later insertion into the second cortex of the proximal radius, as shown here.

CHAPTER 6

Next, once the distal biceps tendon stump has been prepared for insertion and repair into the proximal radius, deep dissection can now be performed down to the proximal radius. Often, a pseudotendon, or a stump, of the distal biceps tendon may be identified in the wound. This is very helpful, as it can be followed down to the level of the proximal radius to identify the footprint for repair of the distal biceps tendon back down to the radial tuberosity of the proximal radius. To aid in visualization, the camera angle has been changed. The hand is now pointed towards the top of your screen and the shoulder towards the bottom of your screen. During deep dissection as well as preparation of the proximal radial tunnel through the radial tuberosity, the forearm must be kept in maximal supination at all times to deliver the radial tuberosity footprint, as well as to keep the posterior interosseous nerve away from the surgical site. With the radius kept supinated, the distal biceps tendon cyclops lesion, or pseudotendon, is being carefully dissected down to the footprint of the proximal radius at the level of the radial tuberosity.

Once careful blunt dissection down to the radial tuberosity of the proximal radius has been confirmed and the footprint palpable, sharp dissection of the remnants of the distal biceps tendon, or the pseudotendon, can be sharply elevated off with a blade as shown here. It is typical to encounter veins crossing the surgical field, which represent the recurrent leash of Henry. These vessels can either be retracted, cauterized, tied off, or hemoclipped as needed to aid in exposure of the radial tuberosity.

Next, again, with the radius maximally supinated, the radial tuberosity is prepared. First, it is decorticated of any residual soft tissue to aid an exposure of the footprint.

CHAPTER 7

Next, with the radial tuberosity exposed and the radius held in maximal supination, the step guidewire for the tenodesis set is positioned. The guidewire should be placed directly over the radial tuberosity but angled slightly ulnar to avoid injury to the posterior interosseous nerve. First, only a unicortical placement of the guidewire is placed to confirm position before accessing the second posterior cortex of the proximal radius.

Intraoperative fluoroscopy can then be used to confirm appropriate position of the guidewire within the radial tuberosity of the proximal radius before proceeding with bicortical placement of the guidewire.

One satisfied, the guidewire can then be advanced across the second cortex, again, making sure to angle just slightly ulnar while placing this guidewire.

Next, the 7.5-mm acorn reamer from the tenodesis set is placed over the guidewire and advanced across only the proximal cortex, not bicortically.

The bone shavings are aggressively washed away to remove all shavings, which could potentially be a nidus for heterotopic bone or a synostosis formation.

With the bone tunnel established within the proximal radius, the distal biceps tendon is now dunked through the tunnel using the BicepsButton insertion guide as shown here. The BicepsButton should be placed bicortically and disengaged from the insertion device until satisfied that it has crossed the far second cortex of the radius. It can help to place a hand on the other side of the forearm to feel the biceps tendon penetrate the second cortex of the radius.

Next, with the BicepsButton deployed on the far side of the radius, the elbow is slightly flexed and sequentially tensioning the two limbs of the FiberWire, the distal biceps tendon is then delivered within the bone tunnel.

Once satisfied that the distal biceps tendon has been adequately dunked within the proximal radius bone tunnel, and with one limb of the FiberWire under tension, the second limb is then delivered through the distal biceps tendon through the shuttle stitch previously prepared, as shown here.

Now with one limb serving as a post through the second cortex of the proximal radius, and the second limb now running through the distal biceps tendon, the two ends are then sewn together to lock the distal biceps tendon within the proximal radius bone tunnel as shown here.

At this point, the distal biceps tendon has been repaired within the proximal radius, and this represents the first point of fixation. You will know that the distal biceps tendon will be under tension when manipulated.

Next, the second point of fixation is achieved with the 7-mm tenodesis screw. a Nitinol loop is then used to deliver one limb of the FiberWire stitch across the insertion device for the Tenodesis Screw as shown here. With only a short length of the FiberWire emanating from the Nitinol loop to maintain enough length to come across the insertion device, the Nitinol loop is pulled, and the FiberWire limb is then brought through the insertion device and tensioned on the backside. Next, the insertion device is seated within the radial tunnel along the radial border of the distal biceps tendon. Once adequately seated, the paddle is held steady, downward pressure is applied, and the Tenodesis Screw is advanced within the radial tunnel until adequately countersunk. The interference screw fixation represents the second point of fixation of the distal biceps tendon.

The final and third point of fixation is then sewing the two limbs of the FiberWire together, one limb is outside the tenodesis screw, and the second limb is through the tenodesis screw.

CHAPTER 8

Once satisfied, closure is undertaken after copiously washing the wound again, the skin is closed in a layered fashion. No deep closure is required. With the wound closed, a posterior splint can be applied if desired. The elbow is held in 90 degrees, and the forearm supinated. This can be removed at the first postoperative visit. Thank you.