Name: Distal Biceps Repair Current Concepts and Surgical Strategies
Uploaded: 2019-10-11T00:00:00Z
Channel: Arthrex
Description: John J. Fernandez, MD (Chicago, IL), discusses single- versus dual-incision distal biceps repair. He also demonstrates his single-incision repair using a large pec button and the Tension-Slide Technique to repair the distal biceps tendon.

<p>John J. Fernandez, MD (Chicago, IL), discusses single- versus dual-incision distal biceps repair. He also demonstrates his single-incision repair using a large pec button and the Tension-Slide Technique to repair the distal biceps tendon.</p>

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VID1-000461-en-US | A | Distal Biceps Repair Current Concepts and Surgical Strategies

John J. Fernandez

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Distal Biceps Repair Current Concepts and Surgical Strategies

Biceps rupture. We're not going to get into too much of the incidence or the anatomy. I really want to kind of get into the pearls, the pitfalls, what I've learned over the last 25 years of doing the biceps tendons. We'll get into a little bit of the controversies that have to do with it. Randy covered a little bit of the anatomy. Something that's kind of up and coming is the whole concept of the of the distal tendon having two heads, which it does in some people. And that's a, that's something that you have to take into account if you're doing something that's a little semi chronic, because you can go in there and you can see something that looks like pseudo tendon and respect it. And in actuality it could be the long head or the short head component. So you have to be a little bit careful with that. There's a lot that's been done with anatomy pathophysiology describing the watershed area. That's why they tend to rupture. Their 85% of the tendon takes up the space between the radius and the ulna. And this is part of the challenge of single incision versus dual incision. And stuffing too much tendon with suture into that space which can block pronation, which we're starting to see in some studies so far, not achieving a lot of significance. There is a significant decrease in the space from pronation supination, which you can see on CT scan studies. Hutchinson did an awesome job describing the footprint of the tendon, which is ribbon shaped. I mean, you've seen this tendon. It's extremely small or very thin, I should say. And when we're done tubular izing it and implanting it into the bone, it doesn't look like this anymore. And so there's questions as to whether or not that's pertinent. Pertinent rotation of center of insertion when we're inserting these anterior is something that Chris Schmidt makes a big point of. And debriding the radial tuberosity, which Hutchinson made a big point of as being some, some of the anatomy that we have to correct when we're doing the repair. Chris Schmidt, who was one of my Co fellows at the hand center, actually, later when he went into when he went on to UPMC, did a really nice job, a lot of elegant work looking at distal biceps tendons and the single incision and kind of became my nemesis in a way And showed Biomechanically in the lab. Why? Why? Doing it through a single incision or through the anterior approach only can be difficult or impossible to get anatomic. The question is whether or not it's truly clinically relevant or significant. Schmidt showed or compared the anterior versus the true anatomic versus the posterior, and showed that particularly at the end of supination, it can make a difference. History came full circle. The first described technique of a distal biceps repair was a single incision, and it was a direct repair. The problem was that there was a significant price to pay a high complication rate. At that time. There wasn't the technology that we have now. And so one of the first meta analyzes that was done in the 1940s by Derby basically said, probably shouldn't be doing this unless you have a high level of expertise. And part of the reason was the highest level technology that they had was like a goat tendon that you could wrap around the, the radius. And so you would have to expose the radius in a significant fashion, which obviously exposed to significant risk. So the new repair technique came out. Boyd Anderson in the 60s. Then kind of there was a resurgence then given to repairing distal biceps tendons because until then we weren't really repairing all of them or we'd repair them to the brachialis. But it didn't last long. We started seeing complications with heterotopic ossification. And so Failla then came up with a modification, splitting the muscle to try to decrease that risk. Unfortunately, the risk has not gone away. It's significantly diminished, but it has not gone away. And so in the two incision series that you'll see, you will still see a modest incidence because it's one of my most feared complications, 1 or 2% of of a radioulnar synostosis, not just heterotopic ossification. So the single anterior approach again initially started up with the two anchors and then quickly moved on to using cortical buttons once it was described in the late 90s. And then all these publications started coming out in the early 2000, which really then brought on this surge of devices Anterior devices. Posterior devices. Taking the tuberosity down, leaving the tuberosity in place. Modifying it with an interference screw, and obviously the cortical button. This is now my drug of choice. I use a cortical button. This is actually the pec button. I like the PEC button better in terms of how it deploys. There's the BicepsButton which is a little bit smaller and it has a different deployment kit. And the meta analyzes that have come out that have really looked carefully at single incision versus dual incision, have not really shown a significant difference in in what I would call significant complications. When you really look at the results, they're relatively equivalent. You can quibble about pull out strengths and things like that, but it doesn't necessarily translate into clinical differences, complications. This is where I learn all my lessons, and the two that I fear the most is posterior interosseous nerve, of which I've never had one. I've done over 700 distal biceps tendon repairs. I've never had one. I've had plenty of lateral cutaneous neuritis, neuromas, neurapraxia and Synostosis. I've also never had a motion limiting synostosis. I've had a little bit of heterotopic heterotopic ossification. In our study, we had an incidence of about 35 to 40%, but not a not motion limiting the complication rate. When you compare single incision to dual incision in the studies is really relatively equivalent. Again, it's the major complications that I'm worried about. And that's where you do see a different single incision to dual incision. So how do we do the repair? I spend a lot of time at the beginning. So the first thing I do is I'll get my fluoroscopy in, even though I can do the entire procedure without a scan, because I want to get a sense of where that tuberosity is for my approach. As I get older, my incision gets longer and bigger, and that's going to prevent you from number one struggling with the vessels, but more importantly, screwing up the lateral cutaneous nerve and also the posterior interosseous nerve. The you need a longer incision to relax the nerve. No matter how well you release it, if the skin incision doesn't allow you allow you to retract it, you're going to get a Neurapraxia vessels are number two most important on the list. You have to have a way to take these down methodically and carefully. I use a clip, a plier or a clip clip and I basically take those down relatively slowly. This is where I spend three fourths of my case. Is the initial incision the nerve and the vessels. It's easy after that. So this is where everybody struggles and they try to go through that quickly. And then you've got bleeding. You can't see what you're doing, you don't have adequate exposure and then you're dreading the complications later. And so here you can see the tuberosity has been exposed. There's a close up. There's the radial recurrent vessels that I've taken down with the clips. Or you can tie them off. You can see the lateral cutaneous nerve to the left. And here I am now detaching the tendon. And again be very careful that what you're looking at is pseudo tendon. As you know, the pseudo tendon can look almost exactly like the tendon. And in some cases the distal biceps can have very two distinct heads which you would want to salvage to really get a good repair. Here. So here we are debriefing through the actual pseudo tenant. And you can see the split between the long and the short head of the biceps. Now I repair it as a unit. Chris Schmidt advocates for doing a two anchor repair will repair the short and the long head separately. That's a little bit too much trouble for me. So most of us are repairing this as a single unit, which you could argue biomechanically may make a difference, but clinically I haven't seen that be a difference. Here we are resecting it. If you don't know how long it should be. There's two really well done clinical studies that have shown that six centimeters is the magic number. And you'll see this. I also took the liberty of putting in a chronic case very quickly. I use a loop technique. I use a suture loop or I'm sorry, a SutureTape loop. You can use a FiberLoop. That's what I started out with. And or you can use a running locking suture. So it's whatever drug of choice you like. Some of us are even using SutureTape and reinforcing the SutureTape with a fiber wire as well an actual suture locking into it. So once you've got control of it. Of the tendon. I then read the radial tuberosity again. Hutchinson showed that we got to get rid of those osteophytes and those those bone spurs. We then get the guide pin posterior interosseous nerve should be safely at least a centimeter away. You put it, you put the arm in full supination. You don't want to go beyond the perpendicular of the forearm in that position, because that's when you'll get into trouble with the posterior interosseous nerve, especially if you're going to penetrate the posterior cortex. Not such a big issue if you're going to do an intramedullary technique. So here's the guide pin getting drilled across the tuberosity. You can. Then I would highly recommend and suggest that you take a fluoroscopic image. I can't tell you how many times I was sure I was in the right spot. And I take a fluoro image and I'm a good half centimeter or centimeter off. I then use a reamer. I ream it up to about 8 to 9mm. By the way, I use TransFix acid before the tourniquet goes up, and then I'll use a soaked sponge at the end to kind of kind of sop up some of the venous bleeding that will occur in some of the bone bleeding. This is a semitendinosus allograft. This is actually a case that I recently did. And basically weaving that into the end. And again, two really well done studies that showed that the extra tendinous length should be about six centimeters. So you don't necessarily have to guess like you're doing a tendon transfer. And in what position do you put them in. You just cut it at six centimeters. Or if you're going to dock it at seven centimeters and bury it and forget it, there's the distal length. I'm measuring it to six centimeters. And then I'm going a centimeter beyond to basically tuck it into the bone. I do make a hole in the radial tuberosity. There's the cortical button. Basically that's the deployment mechanism. Really simple. There's no tension. I'm using a tension slide suture technique. So basically you don't have to tie any knots. You don't have to guess how long the button is from the end of the tendon. I just popped through the posterior side. You can confirm it Fluoroscopic there you can see the suture sliding. So now you can take all the time in time in the world to get it right. Get the arm in slight flexion again using fluoroscopic imaging, confirming button placement and then basically tying it to itself up into the tendon rehab. Not a big difference. Again, as I get older, my incisions get longer and I get more conservative with my rehab. Not a big difference between early range of motion versus delaying the motion, or holding them back for the majority of the ruptures that you'll see will either be within the first week to three weeks. It's very rare to get a rupture beyond 3 to 4 weeks. You can use a hinge brace. I tend to keep it simple with an ortho splint, basically blocking terminal extension for the first four weeks, allowing active assisted flexion. And the results speak for themselves. But you can get these results using any number of techniques. But again, what differentiates the complications from the good results is the approach. The simplicity of the approach. It's not getting focused on the fixation. Thank you.

Distal Biceps Repair Current Concepts and Surgical Strategies

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