FiberLoop ist eine durchgängige FiberWire®-Schlaufe mit verschiedenen Nadeloptionen. Die Nadeln sind einfach in der Handhabung und am Faden frei beweglich, sodass sie sich nach dem Durchzug durch das Gewebe selbst zentrieren und die Fadenspannung erleichtern. Der Einsatz von FiberLoop zusammen mit der Arthrex SpeedWhip™-Technik verkürzt die Dauer der Transplantatpräparation erheblich und erlaubt eine einheitliche Kompression des Transplantats, eine bessere Fixierungsstärke und eine kurzfristige Anpassung der Transplantatlänge.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

Karim A. Meijer, MD (New Orleans, LA), presents an onlay two-incision distal biceps repair technique using two FiberLoop® sutures and two 7 mm cortical buttons.

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Two-Incision Distal Biceps Repair

Hi, I'm Kareem Mayer and I will present today my technique for distal bicep tendon repairs. It's using a double FiberLoop with bicortical buttons. I think this technique is amendable to any approach that you'd like to use. This will be through a two incision approach, but I think it works just as well for a one incision approach. Anytime we do any surgeries, the goal should be to recreate the anatomy and to really understand the anatomy of the distal bicep tendon is of utmost importance, so we understand how to repair it. It's more of a ribbon shaped structure, has two heads, a long head proximally and a short head distally that attaches to the radial tuberosity on its far ulnar aspect, typically maybe 7 to 8mm in width, maybe 2020 five millimeters in length. And it's a wide ribbon. And we see this in surgery when we take it out the antecubital fossa and see the fan shaped structure of that distal bicep tendon. Here's a gross anatomy photo demonstrating not only the distal bicep tendon, but the lacertus fibrosis proximally that we have to keep in mind with some of these partial ruptures or some of these ruptures that don't completely retract, because this can hold you up and up, and you need to know where the lacertus fibrosis is and how it attaches to not only release it, but to get excursion when you're repairing it. The evaluation of these are pretty common, and most of them most patients will tell you they feel a pop or a tearing sensation in the antecubital fossa. Their arm is typically extended and supinated. Physical exam findings are pretty typical. With these a positive hook test usually some bruising and swelling, obvious deformity, and then imaging your choice. Radiographs can be taken. An ultrasound can be done sometimes an MRI or if you're concerned for a partial, you can do a fabs view which will have you a little better profile of that distal bicep tendon to evaluate it a little bit better. So we're really talk today more about the management and the technique distal bicep tendon repair. So with surgeries the big camps here are just a one incision versus two incision approach. How do you want to get to fixing this. And there's plenty of data out there showing the risks and benefits of each approach. And I think whatever approach you choose, you just need to know that type of approach that you use, what you need to be concerned. And so with single versus double single incisions tend to have more have more neurapraxia issues where the double. The concern has always been the heterotopic ossification, or more concerning the radial ulnar synostosis. Rerupture rates tend to be lower in a two incision approach than a single incision approach. And then a pin palsy, which is concerning, is seen more in a single than a double. And then again, as I mentioned, what was the more concerning thing was a radial ulnar synostosis. And I think this is what really transitioned physicians away from a double to a single incision approach. When you really dive into that data, though, a proximal radial ulnar synostosis is typically really just seen with that two incision. However, it's not the the approach you take. It's the technique on how you fix it in the approach you use. And so most of the two incision approach were bone tunnels. There was drilled out quite a bit of the radial tuberosity. Placed additional bone tunnels to get the fixation, leaving that entire area open and leaving a lot more surgical dissection that needed to be done in that area, and allowing marrow elements to escape in that area of the proximal radial ulnar aspect. The Mayo Clinic showed a nice study. A 78 patients were consecutively followed through a muscle split approach, and they did not show any cases of proximal radio ulnar synostosis. So the approach is important. And this is typically how I get there with a large Kelly clamp that really hugs that radial tuberosity and will come out through a muscle split. When you look at healing for the distal bicep tendon, a lot of techniques just put it within the intraosseous space. What the group out of HSS showed in Jbj's that the healing really occurs on the surface. It's not healing inside the bone, it's really a surface healing. And so this is where I adapted more to an on lay technique, where really the healing of the tendon is better than within the bone. So to go through my technique, obviously with any surgery and anything you choose to do, the goal is pretty much the same to recreate the anatomy and minimize patient morbidity as you go about recreating that anatomy. So what I'll show here is what I've developed and have come to. It's a small antecubital fossa with a typical two incision approach. The distal bicep is easily and readily accessible. I debride a lot of the tissue and then once I'm ready, I bring two number two FiberLoop. I use two of them to both recreate a short head and long head as they can exit. So I'll have four exiting strands. Two of them will go to one button, two to another button, essentially making a short head and a long head. And I've looked at this technique using a two number two FiberLoop as we've done in the lab. We've tested it. We've tested it against using crackles. We've tested against using just a FiberLoop. And the strengths have been equal, if not better. And what this shows is just a simpler way of doing this. When you lock the last two sutures from from the ends, you get a very good construct, very strong and very simple and very efficient. During surgery, the two incision approach will take you to a small dorsolateral incision, typically about four centimeters. The first drill I do proximally, I typically do it under fluoro to make sure that I'm at the right spot. And then I place one more distal to this. It's a very easily and reproducible technique. I then load the buttons and they're flipped. Intramedullary one limb from each button is taken back through the tendon to create a locking construct, so I can get a compression onto the tendon. This will not only lock the construct, but again will compress the tendon onto the bone. The buttons are easily flipped using the small seven millimeter buttons, which will create two buttons, Intramedullary and Extramedullary, and no concern of going Bicortical. Once this is completed, you'll typically get your post-op incisions about again four centimeters dorsal lateral about two to 2.5cm in the antecubital fossa, and a radiograph that would look like this with the two buttons flipped intramedullary. This approach and this technique is also used again for partials or even chronic teres. I use the same approach and the same technique. The results whether you do a single or two incision. Most most of us get pretty decent results with these with good range of motion, good flexion extension and good supination and pronation, which is really the biggest thing that we worry about with these with the rehab protocol. Typically with these I place them in a splint for two weeks. I then move them to a hinge elbow brace and we progress that hinge elbow brace rather quickly. By six weeks they're out of it and they start a strengthening program, typically around 12 weeks, and I release them at four months. So in summary, this is my technique for a distal bicep tendon repair. I think the use of a double FiberLoop with bicortical buttons allows you to more recreate the anatomy. The two incision approach that I prefer to use. I think this technique can be easily done through a single incision approach. I think with the recreation of the inlay technique, using the bicortical buttons is very simple and reproducible. And as you can see, patient results do well. And I think whether it's through single or two incision, I think we can expect good results from our patients with this. And hopefully you've enjoyed this presentation.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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Two-Incision Distal Biceps Repair

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