Biceps Tenodesis for Distal Biceps Tendon Repair

CHAPTER 1

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

CHAPTER 2

After exsanguination of the limband elevation of the sterile tourniquetto 250 mmHg,the incision is placed.

CHAPTER 3

Blunt dissection is then performeddown to the antebrachial fascia.The first structure to be identifiedis the lateral antebrachial cutaneous nerve.The dotted line next to the incisionis the anticipated location of this nerve.

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

CHAPTER 4

Once mobilized and retracted,dissection can then be performedto identify the distal biceps tendon stump.Often, with blunt use of your finger alone,the tendon end can be identifiedloose within the soft tissue proximallyand then can be retracted out into the woundand 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 brachialiscan be performed with one's finger.Moreover, the lacertus fibrosus can also be releasedif necessary.Care must be taken, however,to avoid injury to any neurovascular structuresduring such a release.Broadly speaking, there are a number of waysto classify distal biceps tendon repair techniques.The first distinction is whether a one-incisionor a two-incision technique is being utilized.In this case,a single-incision Arthrex BicepsButton fixation systemwill be utilized,which involves placement of a troughwithin the proximal radiusto dunk the biceps tendon,followed by tensioning of the biceps tendonwithin the proximal radius using a BicepsButton,followed by interference fixation of the biceps tendonusing an interference screw.This system provides three points of fixationto maximize repair strength of the distal biceps tendon,as will be shown.The repair is initiated by placing a whip stitcharound the distal biceps tendon, as being illustrated here,using a number 2 FiberWire suture.At least three to four whip stitches are placedthrough the distal biceps tendonprior to freshening up the distal biceps tendon for repair.

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

Since the manufacturer's techniqueutilizes a 7-mm tenodesis screw,the tendon is then debrided downto ideally a 7-mm or 8-mm widthso that a 7.5-mm bone tunnel can be created.Here, the tendon is shownto comfortably fit within a 7-mm sizer.

To aid in confirmingthat adequate amount of distal biceps tendonhas 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 fixationof the distal biceps tendononce docked in the tunnel and tensioned,a shuttle stitch is placed one centimeter proximalto the distal biceps tendon stump as shown hereto deliver the second limb of the FiberWire sutureand then repair of the tendon to the proximal radius.The shuttle stitch consists of an 0 Vicryl suturewith the needle cut off,both limbs are placed through a free needleand 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 herefor later shuttling of one limb of the FiberWireonce the biceps tendon is inserted.

Attention is now turned backto the distal biceps tendon stump and its whip stitchwith the number 2 FiberWire.The loop is cut,and the freed Keith needle is then usedto pass each limb of the whip stitchthrough the distal biceps tendon button as shown here.With the aid of the Keith needle,each limb of the FiberWire is placedthrough the Biceps Buttonbut in an opposite direction.The entrance of one side represents the exitof the other side.This will provide the necessary relationshipfor the Biceps Button to slide once tensionedon the other side of the proximal radius.

Lastly, the Biceps Button is placed on its insertion devicefor later insertion into the second cortexof the proximal radius, as shown here.

CHAPTER 6

Next, once the distal biceps tendon stumphas been prepared for insertion and repairinto the proximal radius,deep dissection can now be performed downto the proximal radius.Often, a pseudotendon, or a stump,of the distal biceps tendonmay be identified in the wound.This is very helpful,as it can be followed downto the level of the proximal radiusto identify the footprint for repairof the distal biceps tendonback down to the radial tuberosityof the proximal radius.To aid in visualization, the camera angle has been changed.The hand is now pointed towards the top of your screenand the shoulder towards the bottom of your screen.During deep dissectionas well as preparation of the proximal radial tunnelthrough the radial tuberosity,the forearm must be kept in maximal supination at all timesto deliver the radial tuberosity footprint,as well as to keep the posterior interosseous nerveaway from the surgical site.With the radius kept supinated,the distal biceps tendon cyclops lesion, or pseudotendon,is being carefully dissected downto the footprint of the proximal radiusat the level of the radial tuberosity.

Once careful blunt dissectiondown to the radial tuberosity of the proximal radiushas been confirmedand the footprint palpable, sharp dissectionof the remnants of the distal biceps tendon,or the pseudotendon, can be sharply elevated offwith a blade as shown here.It is typical to encounter veinscrossing the surgical field,which represent the recurrent leash of Henry.These vessels can either be retracted, cauterized, tied off,or hemoclipped as neededto 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 tissueto aid an exposure of the footprint.

CHAPTER 7

Next, with the radial tuberosity exposedand the radius held in maximal supination,the step guidewire for the tenodesis set is positioned.The guidewire should be placed directlyover the radial tuberositybut angled slightly ulnarto avoid injury to the posterior interosseous nerve.First, only a unicortical placement of the guidewireis placed to confirm positionbefore accessing the second posterior cortexof the proximal radius.

Intraoperative fluoroscopy can then be usedto confirm appropriate position of the guidewirewithin the radial tuberosity of the proximal radiusbefore proceeding with bicortical placementof the guidewire.

One satisfied, the guidewire can then be advancedacross the second cortex,again, making sure to angle just slightly ulnarwhile placing this guidewire.

Next, the 7.5-mm acorn reamerfrom the tenodesis setis placed over the guidewire and advancedacross only the proximal cortex, not bicortically.

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

With the bone tunnel established within the proximal radius,the distal biceps tendon is now dunked through the tunnelusing the BicepsButton insertion guide as shown here.The BicepsButton should be placed bicorticallyand disengaged from the insertion deviceuntil satisfied that it has crossedthe far second cortex of the radius.It can help to place a hand on the other side of the forearmto feel the biceps tendon penetratethe second cortex of the radius.

Next, with the BicepsButton deployedon the far side of the radius,the elbow is slightly flexedand sequentially tensioning the two limbs of the FiberWire,the distal biceps tendon is then deliveredwithin the bone tunnel.

Once satisfied that the distal biceps tendonhas been adequately dunkedwithin the proximal radius bone tunnel,and with one limb of the FiberWire under tension,the second limb is then deliveredthrough the distal biceps tendonthrough the shuttle stitch previously prepared,as shown here.

Now with one limb servingas a post through the second cortex of the proximal radius,and the second limb now runningthrough the distal biceps tendon,the two ends are then sewn togetherto lock the distal biceps tendonwithin the proximal radius bone tunnel as shown here.

At this point, the distal biceps tendon has been repairedwithin the proximal radius,and this represents the first point of fixation.You will know that the distal biceps tendonwill be under tensionwhen manipulated.

Next, the second point of fixation is achievedwith the 7-mm tenodesis screw.a Nitinol loop is then usedto deliver one limb of the FiberWire stitchacross the insertion device for the Tenodesis Screwas shown here.With only a short length of the FiberWireemanating from the Nitinol loopto maintain enough lengthto come across the insertion device,the Nitinol loop is pulled,and the FiberWire limb is then broughtthrough the insertion deviceand tensioned on the backside.Next, the insertion deviceis seated within the radial tunnelalong 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 tunneluntil adequately countersunk.The interference screw fixationrepresents the second point of fixationof the distal biceps tendon.

The final and third point of fixationis 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 undertakenafter 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.