1. Surgical Approach

2. Incision

a. Identification and Preservation of Lateral Antebrachial Nerve

3. Superficial Dissection to Antebrachial Fascia

4. Identification and Mobilization of Distal Biceps Tendon Stump

a. Whip Stitches Through Tendon

b. Debride Distal End of Tendon Stump

c. Confirm Tendon Sizing

d. Mark Distal Centimeter of Tendon Stump

e. Place Shuttle Stitch

f. Place Limbs of Whip Stitch Through Distal Biceps Tendon Button

g. Place Button on Insertion Device

5. Preparation of Tendon Stump

a. Deep Dissection to Proximal Radius

b. Sharp Excision of Tendon Remnant from Footprint

c. Decortication of Radial Tuberosity Footprint

6. Preparation of Proximal Radius Insertion Site

a. Unicortical Placement of Guidewire in Radial Tuberosity

b. Confirm Guidewire Placement via Fluoroscopy

c. Advance Guidewire Through Second Cortex

d. Place 7.5-mm Acorn Reamer over Guidewire and Across First Cortex

e. Irrigation to Remove Bone Shavings

f. Place Biceps Button Through Both Cortices

g. Deliver Tendon Through Bone Tunnel

h. Deliver Second Limb of FiberWire Through Tendon via Previously Prepared Shuttle Stitch

i. Tie Two Ends Together to Lock Distal Biceps Tendon in Bone Tunnel

j. Examine First Point of Fixation

k. 7-mm Tenodesis Screw Placement for Second Point of Fixation

l. Tie Two Limbs of FiberWire Together for Third Point of Fixation

7. Tenodesis Tendon Repair

8. Remarks on Closure and Splint

The annual incidence of distal biceps tendon ruptures is 1.5 per 10,000 per year. In 93% of cases, men aged 30–59 are involved, mainly in the dominant extremity. Distal biceps tendon ruptures can result in loss of supination and elbow flexion strength, for which surgical repair is often indicated to restore preinjury level of functionality. The distal biceps tendon can be repaired via single- or double-incision techniques using several associated implants, including endobuttons, suture anchors, or interference screws. Here, we present the case of a middle-aged male presenting with an acute distal biceps tendon rupture. The tendon was repaired via a single-incision technique using an endobutton and an interference screw. 

<h4>CHAPTER 1</h4>

<p>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.</p>

<h4>CHAPTER 2</h4>

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

<h4>CHAPTER 3</h4>

<p>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.</p>

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

<h4>CHAPTER 4</h4>

<p>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.</p>

<h4>CHAPTER 5</h4>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>

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

<h4>CHAPTER 6</h4>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<h4>CHAPTER 7</h4>

<p>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.</p>

<p>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.</p>

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

<p>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.</p>

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

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<h4>CHAPTER 8</h4>

<p>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.</p>


Watch this surgical video of a biceps tenodesis to repair a distal biceps tendon rupture performed by Dr. Asif Ilyas at the Rothman Institute.

DOI
Publication Date	2023/06/30
Article ID	335
Production ID	0335
Volume	2023
Issue	335
https://doi.org/10.24296/jomi/335

Biceps Tenodesis for Distal Biceps Tendon Repair

Procedure Outline

Table of Contents