- Email: [email protected]
Distal Biceps Tendon Repair: Anterior Approach
Accepted Manuscript
Distal Biceps Tendon Repair: Anterior Approach Aaron M Roberts MD , Ilya Voloshin MD PII: DOI: Reference:
S1048-6666(18)30058-2 https://doi.org/10.1053/j.oto.2018.08.011 YOTOR 697
To appear in:
The End-to-end Journal
Please cite this article as: Aaron M Roberts MD , Ilya Voloshin MD , Distal Biceps Tendon Repair: Anterior Approach, The End-to-end Journal (2018), doi: https://doi.org/10.1053/j.oto.2018.08.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Distal Biceps Tendon Repair: Anterior Approach
Aaron M Roberts, MD Ilya Voloshin, MD
CR IP T
From Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
M
AN US
Corresponding Author: Aaron Roberts Box 665 601 Elmwood Ave Rochester, NY 14642 Email: [email protected], [email protected] Phone: (513) 919-1676
ED
Key Words: Distal biceps tendon repair, anterior approach, single incision, tension slide
AC
CE
PT
technique, interference screw
ACCEPTED MANUSCRIPT
Abstract Historically, both anterior and posterior approaches have been described for distal biceps tendon repair. In an effort to minimize heterotopic ossification and avoid a second incision with splitting of the supinator muscle, the anterior approach has gained
CR IP T
popularity. The anterior approach takes advantage of the internervous plane between the brachioradialis and the pronator teres, avoiding damage to the musculature. While multiple fixation methods have been described, we advocate the use of a cortical button using the tension-slide technique and an interference screw, which has been shown to be
AN US
biomechanically superior. The interference screw directs the tendon posteriorly for a more anatomic repair. Differences in clinical outcomes and major complications have not been shown between surgical approaches or fixation types. A higher rate of lateral
M
antebrachial cutaneous nerve palsy has been reported with the anterior approach, which we believe is technique related and can be decreased by using rounded-edge direct-pull
ED
retractors. Overall, good to excellent clinical results can be expected following biceps
CE
Rationale
PT
tendon repair.
Historically, both anterior and posterior approaches have been described for distal
AC
biceps tendon repair. The early anterior approach described by Dobbie was complicated by radial nerve palsy, while the early posterior approach described by Boyd and Anderson was complicated by radioulnar synostosis. (1, 2) This led to the development of the muscle-splitting posterior approach by Morrey. (3) Most recently, to minimize heterotopic ossification and with the advent of modern fixation techniques (suture
ACCEPTED MANUSCRIPT
anchors, cortical buttons and interference screws), the anterior approach has gained popularity. In several large series, the anterior approach is the most commonly performed (4,5). The anterior approach takes advantage of the internervous plane between the
CR IP T
brachioradialis and the pronator teres. By using this interval, muscle splitting, which occurs to the extensor carpi ulnaris and supinator during a posterior approach, is avoided. The posterior approach has been associated with fatty infiltration of the supinator, a contributor to residual supinator weakness (6).
AN US
For our repair, we use the “tension-slide technique,” which has been shown to be biomechanically superior to bone tunnels, typically used in the posterior approach, and suture anchors (7,8). The tension-slide technique maintains the strength of a standard
M
cortical button repair, but significantly reduces gap formation and motion at the repair site (7). A proposed drawback of the anterior approach is that it is difficult to supinate the
ED
arm sufficiently to recreate the anatomic insertion of the biceps tendon to the biceps tuberosity (9,10). This results in a repair that is anterior to the native insertion, which has
PT
been associated with supination weakness when tested at 60° supination (6). Thus, while
CE
an interference screw has been shown not to add biomechanical strength to the repair (7), we place an interference screw to direct the tendon posteriorly for a more anatomic
AC
repair.
Indications and Contraindications Operative repair is typically chosen for healthy, active individuals. Non-operative management can be pursued, but a 40% to 50% reduction in supination strength, 30%
ACCEPTED MANUSCRIPT
reduction in flexion strength and 15% reduction in grip strength is expected. (3, 6, 11) Strengthening the brachioradialis may compensate for supination strength loss from pronation to neutral, but there is a limited ability of the forearm muscles to make up for strength loss from neutral to end-supination. (11) In this range, patients use their trunk
CR IP T
and shoulder muscle to compensate, which can make activities requiring terminal supination strength with the limb away from the body particularly affected. The loss in terminal supination would make it difficult for a patient to lock or unlock a stiff deadbolt, turn a car key, tighten or loosen a screw, and swing a baseball bat or golf club (11).
AN US
Contraindications to operative management include low-demand patients and those medically unfit for surgery. Additionally, while chronic tears are not a contraindication to surgery, one must consider the need for a repair in high-flexion or for
M
tendon augmentation. Operative Technique
The patient is placed supine on the operating table with the operative limb
ED
abducted away from the body on a hand table. A padded tourniquet is placed proximally on the arm. Alternatively, a sterile
PT
CE
tourniquet may be used. Distal to the antecubital fossa flexion crease, a 4 cm longitudinal incision starting
AC
is made over the ulnar border of the brachioradialis with the forearm in full supination (Figure 1).
Dissection is taken down through the subcutaneous tissues, taking care to identify and protect the lateral antebrachial cutaneous nerve (LACN) (Figure 2). Deeper, care is taken to ligate the recurrent radial vessels traversing perpendicular to the
ACCEPTED MANUSCRIPT
arm’s long axis and lying ventral to the radial tuberosity (Figures 3) (12).
Blunt dissection is carried down to the biceps tuberosity. In acute tears, one’s finger can usually follow the tendon sheath vacated by the torn biceps tendon. The
CR IP T
tuberosity is prepared, debriding any remaining tendinous tissue down to abraded, bleeding cortical bone. The biceps protuberance anterior to the tendon footprint is left intact to preserve its cam function (13).
The detached biceps tendon is identified and delivered from the wound (Figures
AN US
4). Flexing the elbow and squeezing the arm in a proximal-to-distal direction can help deliver the tendon. If the tendon is retracted too far proximally to be retrieved, the incision can be extended proximally, curving medially at the
M
antecubital fossa to avoid a longitudinal incision across the flexion crease. Alternatively, a second incision can be made in the proximal arm over the
ED
retracted tendon. The biceps tendon can be identified and tunneled under the subcutaneous tissue to the distal incision for the repair. The distal tendon is prepared by resecting any degenerative tissue.
#2 FiberWire (Arthrex, Naples, FL) is placed in locking stitch fashion, leaving
CE
PT
two free ends (Figure 5). A 3.2 mm guidewire is placed into the biceps tuberosity bicortically, aiming 30
AC
degrees ulnar (if possible based on local anatomy of the biceps tuberosity and the range of available supination in the forearm) to maximize the distance between the guidewire and the posterior interosseous nerve (PIN) (Figure 6).(14) The
ACCEPTED MANUSCRIPT
acorn reamer is then used to create a unicortical tunnel over the guidewire (Figure 7).
The wound is thoroughly irrigated to remove all bony debris.
The #2 FiberWire tails are loaded into a BicepsButton (Arthrex, Naples, FL)
CR IP T
(Figures 8). The button is deployed through both cortices, seated against the radius and the tendon is reduced into the tunnel by applying tension to the suture limbs in the tension-slide technique (8).
A tenodesis screw (Arthrex) is then used to augment the fixation of the distal
AN US
biceps tendon and to create a more anatomic repair. The screw is seated flush with the anterior cortex to push the tendon more posterior (Figures 9). The sutures limbs are tied over the tenodesis screw (Figures 10).
Postoperatively, the extremity is placed in a posterior splint with the elbow at 90°
M
and forearm in neutral. The splint is removed and active range of motion is begun
ED
at 5 to 7 days postoperatively. After 6 weeks, patients are advanced to a 10-lb lifting restriction. At 12 weeks, they begin progressive resistance exercises as
CE
PT
tolerated. All patients attend formal physical therapy.
Results
AC
Low pain levels, normative DASH scores and good objective results on range of
motion and strength testing have been shown regardless of surgical approach or fixation type (5,10,15,16,17,18,19). Tendon repair does not fully restore terminal supination strength; the posterior approach resulted in 14% greater supination strength at 60° supination compared to an anterior approach, but the clinical significance of this
ACCEPTED MANUSCRIPT
difference is unknown (6). Significant complications such as deep infection, re-rupture, heterotopic ossification resulting in radioulnar synostosis and motor nerve palsy are rare. One surgical approach has not been shown to be superior in avoiding these complications; however, none of the studies were powered to detect differences in
CR IP T
complication rates (4,5,17,19,20). There is evidence of an increased rate of LACN palsy with the anterior approach, with rates in large series reported between 10% to 25% (4,20). This complication is mostly technique related and is most likely a modifiable risk factor that can be influenced by thoughtful retraction during the approach. Overall, good
AN US
to excellent clinical results can be expected following biceps tendon repair.
Pearls and Pitfalls
In general, direct-pull retractors with rounded corners (Thyroid or Richardson)
M
should be used for exposure to avoid injury to the LACN. Hohmann retractors
ED
should not be used radial to the biceps tuberosity to avoid injury to the PIN. When placing the 3.2mm guidewire, ensure there is enough surrounding bone that
PT
the subsequent 7 or 8mm acorn reamer does not breach the cortex, leading to
CE
fixation failure or iatrogenic fracture. Avoid aiming the guidewire in the radial direction to avoid injury to the PIN. If local anatomy does not allow placement of
AC
the guidewire in an ulnar direction for tunnel creation, consider placing the guidewire only through the near cortex, drilling the tunnel with the acorn reamer and then creating a far cortex hole in the ulnar direction at the bottom of the tunnel to avoid injury to the PIN.
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Place the guide wire posterior to the radial protuberance, because drilling out or into the protuberance leads to supination weakness and potentially an inferior outcome (6, 10)
Make sure that the interference screw is placed co-linear with the tunnel to avoid
CR IP T
blowout and fracture.
While not typically used by us, fluoroscopy can be used to confirm flipping and positioning of the cortical button. Marking the biceps tendon 1 cm from its end with a surgical marker can help ensure the tendon is adequately reduced during
AN US
docking.
Thoroughly irrigate the wound of all bony debris to minimize the risk of heterotopic ossification.
M
Summary
The single incision, anterior approach is a popular approach for distal biceps
ED
tendon repair that takes advantage of an internervous plane without muscle splitting. We advocate the use of a cortical button using the tension-slide technique and an interference
PT
screw for a biomechanically strong, near-anatomic repair. Using the surgical technique
CE
presented, we believe the proposed drawbacks of the anterior approach, including a less anatomic repair and LACN palsy, can be mitigated. Ultimately, the approach for distal
AC
biceps tendon repair should be decided by surgeon preference and comfort, as good to excellent clinical results can be expected regardless.
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References 1. Dobbie RP. Avulsion of lower biceps brachii tendon: analysis of fifty-one previously unreported cases. Am J Surg 1941;51:21. 2. Boyd, H.B. and L.D. Anderson, A Method for Reinsertion of the Distal Biceps Brachii
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Tendon. Journal of Bone and Joint Surgery. 43(7): p. 1041-1043. 1961.
3. Morrey, B.F., L.J. Askew, K.N. An, et al., Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg Am. 67(3): p. 418-21. 1985
4. Dunphy TR, Hudson J, Batech M, et al: Surgical treatment of distal biceps tendon
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ruptures: An analysis of complications in 784 surgical repairs. Am J Sports Med 45(13):3020-3029, Nov 2017.
5. Waterman BR, Navarro-Figueroa L, Owens BD: Primary repair of traumatic distal
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biceps ruptures in a military population: Clinical outcomes of single- versus 2-incision technique. Arthroscopy 33:1672-1678, 2017.
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6. Schmidt CC, Brown BT, Qvick LM, et al: Factors that determine supination strength following distal biceps repair. J Bone Joint Surg Am 98:1153-60, 2016.
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7. Sethi P, Obopilwe E, Rincon L, et al: Biomechanical evaluation of distal biceps
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reconstruction with cortical button and interference screw fixation. J Shoulder Elbow Surg 19:53-7, 2010.
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8. Sethi PM, Tibone JE: Distal biceps repair using cortical button fixation. Sports Med Arthrosc 16:130-5, 2008. 9. Schmidt CC, Diaz VA, Weir DM, et al: Repaired distal biceps magnetic resonance imaging anatomy compared with outcome. J Shoulder Elbow Surg 21:1623-31, 2012.
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10. Schmidt CC, Savoie FH, Steinmann SP, et al: Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting2015. J Shoulder Elbow Surg 25:1717-30, 2016. 11. Schmidt CC, Brown BT, Sawardeker PJ, et al: Factors affecting supination strength
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after a distal biceps rupture. J Shoulder Elbow Surg 23:68-75, 2014.
12. Zeltser DW, Strauch RJ: Vascular anatomy relevant to distal biceps tendon repair. J Shoulder Elbow Surg 25:283-8, 2016.
13. Schmidt CC, Brown BT, Williams BG, et al: The importance of preserving the radial
AN US
tuberosity during distal biceps repair. J Bone Joint Surg Am 97:2014-23, 2015.
14. Thumm N, Hutchinson D, Zhang C, et al: Proximity of the posterior interosseous nerve during cortical button guidewire placement for distal biceps tendon reattachment. J
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Hand Surg Am 40:534-6, 2015.
15. Grewal R, Athwal GS, MacDermid JC, et al: Single versus double-incision technique
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for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am 94:1166-74, 2012.
PT
16. Olsen JR, Shields E, Williams RB, et al: A comparison of cortical button with
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interference screw versus suture anchor techniques for distal biceps brachii tendon repairs. J Shoulder Elbow Surg 23:1607-11, 2014.
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17. Savin DD, Watson J, Youderian AR, et al: Surgical management of acute distal biceps tendon ruptures. J Bone Joint Surg Am 99:785-796, 2017. 18. Shields E, Olsen JR, Williams RB, et al: Distal biceps brachii tendon repairs: a single-incision technique using a cortical button with interference screw versus a double-
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incision technique using suture fixation through bone tunnels. Am J Sports Med 43:10726, 2015. 19. Watson JN, Moretti VM, Schwindel L, et al: Repair techniques for acute distal biceps tendon ruptures: a systematic review. J Bone Joint Surg Am 96:2086-90, 2014.
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20. Amin NH, Volpi A, Lynch TS, et al: Complications of distal biceps tendon repair: A meta-analysis of single-incision versus double-incision surgical technique. Orthop J
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Sports Med 4:2325967116668137, 2016.
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Figure Captions
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Figure 1A
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Figure 1B
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Figure 1C
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Figure 1D
Figure 1: Incision Planning. The elbow is flexed to identify the flexion crease and marked with a parallel line. With the forearm in full supination, the incision is marked over the
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CE
Figure 2A
PT
ED
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AN US
CR IP T
ulnar border of the brachioradialis starting 1 centimeter distal to the flexion crease.
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Figure 2B
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Figure 2C
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Figure 2D
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Figure 2E
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Figure 2F
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Figure 2: Dissection is carried down through subcutaneous tissue and the scissors LACN is identified and protected. The interval between the brachioradialis and pronator teres is
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identified.
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Figure 3A
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Figure 3B
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Figure 3C
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Figure 3D
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Figure 3: The leash of recurrent radial vessels is encountered during deep dissection.
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PT
Crossing vessels are ligated exposing the bicipitial tuberosity.
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Figure 4A
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Figure 4B
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Figure 4: The biceps tendon is retrieved and delivered from the wound.
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Figure 5A
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Figure 5B
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Figure 5C
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Figure 5D
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Figure 5: A Krackow stitch is placed into the torn tendon.
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Figure 6A
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Figure 6B
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Figure 6C
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Figure 6E
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Figure 6F
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Figure 6G
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Figure 6H
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Figure 6: Biceps Tuberosity Preparation. A. The 3.2 millimeter guidewire is placed into
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nerve.
PT
the biceps tuberosity aiming ulnar and proximal to avoid injury to the poster interosseous
AN US
CR IP T
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Figure 7
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Figure 7: An acorn reamer is used to create a large hole to fit the tendon and interference
ED
screw.
Figure 8: The #2 FiberWire (Arthrex, Naples, FL) tails are loaded into the cortical button.
PT
The button is deployed through both cortices, seated against the radius and the tendon is
CE
reduced into the tunnel by applying alternating tension to the suture limbs in the tensionslide technique.
AC
Figure 9: A tenodesis screw is used to augment the fixation and it is seated flush with the anterior cortex to push the tendon more posterior. Figure 10. Illustration of the final fixation construct. This image provided courtesy of Arthrex, Inc., Naples, FL.
Distal Biceps Tendon Repair: Anterior Approach Aaron M Roberts MD , Ilya Voloshin MD PII: DOI: Reference:
S1048-6666(18)30058-2 https://doi.org/10.1053/j.oto.2018.08.011 YOTOR 697
To appear in:
The End-to-end Journal
Please cite this article as: Aaron M Roberts MD , Ilya Voloshin MD , Distal Biceps Tendon Repair: Anterior Approach, The End-to-end Journal (2018), doi: https://doi.org/10.1053/j.oto.2018.08.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Distal Biceps Tendon Repair: Anterior Approach
Aaron M Roberts, MD Ilya Voloshin, MD
CR IP T
From Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
M
AN US
Corresponding Author: Aaron Roberts Box 665 601 Elmwood Ave Rochester, NY 14642 Email: [email protected], [email protected] Phone: (513) 919-1676
ED
Key Words: Distal biceps tendon repair, anterior approach, single incision, tension slide
AC
CE
PT
technique, interference screw
ACCEPTED MANUSCRIPT
Abstract Historically, both anterior and posterior approaches have been described for distal biceps tendon repair. In an effort to minimize heterotopic ossification and avoid a second incision with splitting of the supinator muscle, the anterior approach has gained
CR IP T
popularity. The anterior approach takes advantage of the internervous plane between the brachioradialis and the pronator teres, avoiding damage to the musculature. While multiple fixation methods have been described, we advocate the use of a cortical button using the tension-slide technique and an interference screw, which has been shown to be
AN US
biomechanically superior. The interference screw directs the tendon posteriorly for a more anatomic repair. Differences in clinical outcomes and major complications have not been shown between surgical approaches or fixation types. A higher rate of lateral
M
antebrachial cutaneous nerve palsy has been reported with the anterior approach, which we believe is technique related and can be decreased by using rounded-edge direct-pull
ED
retractors. Overall, good to excellent clinical results can be expected following biceps
CE
Rationale
PT
tendon repair.
Historically, both anterior and posterior approaches have been described for distal
AC
biceps tendon repair. The early anterior approach described by Dobbie was complicated by radial nerve palsy, while the early posterior approach described by Boyd and Anderson was complicated by radioulnar synostosis. (1, 2) This led to the development of the muscle-splitting posterior approach by Morrey. (3) Most recently, to minimize heterotopic ossification and with the advent of modern fixation techniques (suture
ACCEPTED MANUSCRIPT
anchors, cortical buttons and interference screws), the anterior approach has gained popularity. In several large series, the anterior approach is the most commonly performed (4,5). The anterior approach takes advantage of the internervous plane between the
CR IP T
brachioradialis and the pronator teres. By using this interval, muscle splitting, which occurs to the extensor carpi ulnaris and supinator during a posterior approach, is avoided. The posterior approach has been associated with fatty infiltration of the supinator, a contributor to residual supinator weakness (6).
AN US
For our repair, we use the “tension-slide technique,” which has been shown to be biomechanically superior to bone tunnels, typically used in the posterior approach, and suture anchors (7,8). The tension-slide technique maintains the strength of a standard
M
cortical button repair, but significantly reduces gap formation and motion at the repair site (7). A proposed drawback of the anterior approach is that it is difficult to supinate the
ED
arm sufficiently to recreate the anatomic insertion of the biceps tendon to the biceps tuberosity (9,10). This results in a repair that is anterior to the native insertion, which has
PT
been associated with supination weakness when tested at 60° supination (6). Thus, while
CE
an interference screw has been shown not to add biomechanical strength to the repair (7), we place an interference screw to direct the tendon posteriorly for a more anatomic
AC
repair.
Indications and Contraindications Operative repair is typically chosen for healthy, active individuals. Non-operative management can be pursued, but a 40% to 50% reduction in supination strength, 30%
ACCEPTED MANUSCRIPT
reduction in flexion strength and 15% reduction in grip strength is expected. (3, 6, 11) Strengthening the brachioradialis may compensate for supination strength loss from pronation to neutral, but there is a limited ability of the forearm muscles to make up for strength loss from neutral to end-supination. (11) In this range, patients use their trunk
CR IP T
and shoulder muscle to compensate, which can make activities requiring terminal supination strength with the limb away from the body particularly affected. The loss in terminal supination would make it difficult for a patient to lock or unlock a stiff deadbolt, turn a car key, tighten or loosen a screw, and swing a baseball bat or golf club (11).
AN US
Contraindications to operative management include low-demand patients and those medically unfit for surgery. Additionally, while chronic tears are not a contraindication to surgery, one must consider the need for a repair in high-flexion or for
M
tendon augmentation. Operative Technique
The patient is placed supine on the operating table with the operative limb
ED
abducted away from the body on a hand table. A padded tourniquet is placed proximally on the arm. Alternatively, a sterile
PT
CE
tourniquet may be used. Distal to the antecubital fossa flexion crease, a 4 cm longitudinal incision starting
AC
is made over the ulnar border of the brachioradialis with the forearm in full supination (Figure 1).
Dissection is taken down through the subcutaneous tissues, taking care to identify and protect the lateral antebrachial cutaneous nerve (LACN) (Figure 2). Deeper, care is taken to ligate the recurrent radial vessels traversing perpendicular to the
ACCEPTED MANUSCRIPT
arm’s long axis and lying ventral to the radial tuberosity (Figures 3) (12).
Blunt dissection is carried down to the biceps tuberosity. In acute tears, one’s finger can usually follow the tendon sheath vacated by the torn biceps tendon. The
CR IP T
tuberosity is prepared, debriding any remaining tendinous tissue down to abraded, bleeding cortical bone. The biceps protuberance anterior to the tendon footprint is left intact to preserve its cam function (13).
The detached biceps tendon is identified and delivered from the wound (Figures
AN US
4). Flexing the elbow and squeezing the arm in a proximal-to-distal direction can help deliver the tendon. If the tendon is retracted too far proximally to be retrieved, the incision can be extended proximally, curving medially at the
M
antecubital fossa to avoid a longitudinal incision across the flexion crease. Alternatively, a second incision can be made in the proximal arm over the
ED
retracted tendon. The biceps tendon can be identified and tunneled under the subcutaneous tissue to the distal incision for the repair. The distal tendon is prepared by resecting any degenerative tissue.
#2 FiberWire (Arthrex, Naples, FL) is placed in locking stitch fashion, leaving
CE
PT
two free ends (Figure 5). A 3.2 mm guidewire is placed into the biceps tuberosity bicortically, aiming 30
AC
degrees ulnar (if possible based on local anatomy of the biceps tuberosity and the range of available supination in the forearm) to maximize the distance between the guidewire and the posterior interosseous nerve (PIN) (Figure 6).(14) The
ACCEPTED MANUSCRIPT
acorn reamer is then used to create a unicortical tunnel over the guidewire (Figure 7).
The wound is thoroughly irrigated to remove all bony debris.
The #2 FiberWire tails are loaded into a BicepsButton (Arthrex, Naples, FL)
CR IP T
(Figures 8). The button is deployed through both cortices, seated against the radius and the tendon is reduced into the tunnel by applying tension to the suture limbs in the tension-slide technique (8).
A tenodesis screw (Arthrex) is then used to augment the fixation of the distal
AN US
biceps tendon and to create a more anatomic repair. The screw is seated flush with the anterior cortex to push the tendon more posterior (Figures 9). The sutures limbs are tied over the tenodesis screw (Figures 10).
Postoperatively, the extremity is placed in a posterior splint with the elbow at 90°
M
and forearm in neutral. The splint is removed and active range of motion is begun
ED
at 5 to 7 days postoperatively. After 6 weeks, patients are advanced to a 10-lb lifting restriction. At 12 weeks, they begin progressive resistance exercises as
CE
PT
tolerated. All patients attend formal physical therapy.
Results
AC
Low pain levels, normative DASH scores and good objective results on range of
motion and strength testing have been shown regardless of surgical approach or fixation type (5,10,15,16,17,18,19). Tendon repair does not fully restore terminal supination strength; the posterior approach resulted in 14% greater supination strength at 60° supination compared to an anterior approach, but the clinical significance of this
ACCEPTED MANUSCRIPT
difference is unknown (6). Significant complications such as deep infection, re-rupture, heterotopic ossification resulting in radioulnar synostosis and motor nerve palsy are rare. One surgical approach has not been shown to be superior in avoiding these complications; however, none of the studies were powered to detect differences in
CR IP T
complication rates (4,5,17,19,20). There is evidence of an increased rate of LACN palsy with the anterior approach, with rates in large series reported between 10% to 25% (4,20). This complication is mostly technique related and is most likely a modifiable risk factor that can be influenced by thoughtful retraction during the approach. Overall, good
AN US
to excellent clinical results can be expected following biceps tendon repair.
Pearls and Pitfalls
In general, direct-pull retractors with rounded corners (Thyroid or Richardson)
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should be used for exposure to avoid injury to the LACN. Hohmann retractors
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should not be used radial to the biceps tuberosity to avoid injury to the PIN. When placing the 3.2mm guidewire, ensure there is enough surrounding bone that
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the subsequent 7 or 8mm acorn reamer does not breach the cortex, leading to
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fixation failure or iatrogenic fracture. Avoid aiming the guidewire in the radial direction to avoid injury to the PIN. If local anatomy does not allow placement of
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the guidewire in an ulnar direction for tunnel creation, consider placing the guidewire only through the near cortex, drilling the tunnel with the acorn reamer and then creating a far cortex hole in the ulnar direction at the bottom of the tunnel to avoid injury to the PIN.
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Place the guide wire posterior to the radial protuberance, because drilling out or into the protuberance leads to supination weakness and potentially an inferior outcome (6, 10)
Make sure that the interference screw is placed co-linear with the tunnel to avoid
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blowout and fracture.
While not typically used by us, fluoroscopy can be used to confirm flipping and positioning of the cortical button. Marking the biceps tendon 1 cm from its end with a surgical marker can help ensure the tendon is adequately reduced during
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docking.
Thoroughly irrigate the wound of all bony debris to minimize the risk of heterotopic ossification.
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Summary
The single incision, anterior approach is a popular approach for distal biceps
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tendon repair that takes advantage of an internervous plane without muscle splitting. We advocate the use of a cortical button using the tension-slide technique and an interference
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screw for a biomechanically strong, near-anatomic repair. Using the surgical technique
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presented, we believe the proposed drawbacks of the anterior approach, including a less anatomic repair and LACN palsy, can be mitigated. Ultimately, the approach for distal
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biceps tendon repair should be decided by surgeon preference and comfort, as good to excellent clinical results can be expected regardless.
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References 1. Dobbie RP. Avulsion of lower biceps brachii tendon: analysis of fifty-one previously unreported cases. Am J Surg 1941;51:21. 2. Boyd, H.B. and L.D. Anderson, A Method for Reinsertion of the Distal Biceps Brachii
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Tendon. Journal of Bone and Joint Surgery. 43(7): p. 1041-1043. 1961.
3. Morrey, B.F., L.J. Askew, K.N. An, et al., Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg Am. 67(3): p. 418-21. 1985
4. Dunphy TR, Hudson J, Batech M, et al: Surgical treatment of distal biceps tendon
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ruptures: An analysis of complications in 784 surgical repairs. Am J Sports Med 45(13):3020-3029, Nov 2017.
5. Waterman BR, Navarro-Figueroa L, Owens BD: Primary repair of traumatic distal
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biceps ruptures in a military population: Clinical outcomes of single- versus 2-incision technique. Arthroscopy 33:1672-1678, 2017.
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6. Schmidt CC, Brown BT, Qvick LM, et al: Factors that determine supination strength following distal biceps repair. J Bone Joint Surg Am 98:1153-60, 2016.
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7. Sethi P, Obopilwe E, Rincon L, et al: Biomechanical evaluation of distal biceps
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reconstruction with cortical button and interference screw fixation. J Shoulder Elbow Surg 19:53-7, 2010.
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8. Sethi PM, Tibone JE: Distal biceps repair using cortical button fixation. Sports Med Arthrosc 16:130-5, 2008. 9. Schmidt CC, Diaz VA, Weir DM, et al: Repaired distal biceps magnetic resonance imaging anatomy compared with outcome. J Shoulder Elbow Surg 21:1623-31, 2012.
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10. Schmidt CC, Savoie FH, Steinmann SP, et al: Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting2015. J Shoulder Elbow Surg 25:1717-30, 2016. 11. Schmidt CC, Brown BT, Sawardeker PJ, et al: Factors affecting supination strength
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after a distal biceps rupture. J Shoulder Elbow Surg 23:68-75, 2014.
12. Zeltser DW, Strauch RJ: Vascular anatomy relevant to distal biceps tendon repair. J Shoulder Elbow Surg 25:283-8, 2016.
13. Schmidt CC, Brown BT, Williams BG, et al: The importance of preserving the radial
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tuberosity during distal biceps repair. J Bone Joint Surg Am 97:2014-23, 2015.
14. Thumm N, Hutchinson D, Zhang C, et al: Proximity of the posterior interosseous nerve during cortical button guidewire placement for distal biceps tendon reattachment. J
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Hand Surg Am 40:534-6, 2015.
15. Grewal R, Athwal GS, MacDermid JC, et al: Single versus double-incision technique
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for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am 94:1166-74, 2012.
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16. Olsen JR, Shields E, Williams RB, et al: A comparison of cortical button with
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interference screw versus suture anchor techniques for distal biceps brachii tendon repairs. J Shoulder Elbow Surg 23:1607-11, 2014.
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17. Savin DD, Watson J, Youderian AR, et al: Surgical management of acute distal biceps tendon ruptures. J Bone Joint Surg Am 99:785-796, 2017. 18. Shields E, Olsen JR, Williams RB, et al: Distal biceps brachii tendon repairs: a single-incision technique using a cortical button with interference screw versus a double-
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incision technique using suture fixation through bone tunnels. Am J Sports Med 43:10726, 2015. 19. Watson JN, Moretti VM, Schwindel L, et al: Repair techniques for acute distal biceps tendon ruptures: a systematic review. J Bone Joint Surg Am 96:2086-90, 2014.
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20. Amin NH, Volpi A, Lynch TS, et al: Complications of distal biceps tendon repair: A meta-analysis of single-incision versus double-incision surgical technique. Orthop J
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Sports Med 4:2325967116668137, 2016.
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Figure Captions
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Figure 1A
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Figure 1: Incision Planning. The elbow is flexed to identify the flexion crease and marked with a parallel line. With the forearm in full supination, the incision is marked over the
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Figure 2A
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ulnar border of the brachioradialis starting 1 centimeter distal to the flexion crease.
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Figure 2: Dissection is carried down through subcutaneous tissue and the scissors LACN is identified and protected. The interval between the brachioradialis and pronator teres is
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Figure 3D
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Figure 3: The leash of recurrent radial vessels is encountered during deep dissection.
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Crossing vessels are ligated exposing the bicipitial tuberosity.
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Figure 4: The biceps tendon is retrieved and delivered from the wound.
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Figure 5: A Krackow stitch is placed into the torn tendon.
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Figure 6: Biceps Tuberosity Preparation. A. The 3.2 millimeter guidewire is placed into
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nerve.
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the biceps tuberosity aiming ulnar and proximal to avoid injury to the poster interosseous
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Figure 7: An acorn reamer is used to create a large hole to fit the tendon and interference
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screw.
Figure 8: The #2 FiberWire (Arthrex, Naples, FL) tails are loaded into the cortical button.
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The button is deployed through both cortices, seated against the radius and the tendon is
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reduced into the tunnel by applying alternating tension to the suture limbs in the tensionslide technique.
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Figure 9: A tenodesis screw is used to augment the fixation and it is seated flush with the anterior cortex to push the tendon more posterior. Figure 10. Illustration of the final fixation construct. This image provided courtesy of Arthrex, Inc., Naples, FL.