Distal Biceps Rupture - Biceps tendon surgery - Vail, colorado

distal biceps tendon rupture surgical management with single incision approach and cortical button fixation the incidence if distal biceps rupture is approximately 1.2 per 100,000 with the mean age being fifty years old smoking has been shown to increase the risk of rupture by 7.5 times injury usually is a result of a rapid unexpected eccentric load to the flexed elbow patients predominately experience loss of supination strength whereas flexion strength loss is minimal the hook test as described by O'Driscoll is a reliable physical exam finding MRI imaging has been shown to have a sensitivity of 92 percent and is useful to differentiate musculotendinous junction injuries from the more common distal biceps tendon avulsion operative options include a single verses two incision technique complications associated with the two incision technique included higher incidence of heterotopic ossification and radioulnar synostosis multiple fixation options exist when performing a single incision technique cortical button fixation has been shown to have the highest load to failure in the following video we illustrate our preferred single incision technique for repair of distal biceps tendon rupture with cortical button fixation the patient is positioned supine with an arm board and a sterile tourniquet a positive hook test is demonstrated here the incision is localized using fluoroscopy to identify the biceptical tuberosity the extremity is accentuated and tourniquet inflated a single transverse incision is made care is taken to identify and protect the lateral antebrachial cutaneous nerve if encountered the leash of henry should be ligated blunt palpation is used to develop the plane between the pronator teres and brachioradialis muscles in cases of acute injury the biceps is easily delivered from its sheath and grasped with an alice clamp the bulbous end of the tendon is sharply debrided a tacks suture is then placed next attention is turned to preparation of the tuberosity the forearm is placed in extreme supination for optimal exposure care should be taken so as to not retract vigorously on the radial soft tissues to prevent injury to the posterior interosseous nerve a guide pin is then placed perpendicularly through the radial tuberosity and care should be taken to aim the guide pin away from the posterior interosseous nerve ideally the pin is placed on the ulnar aspect of the tuberosity to maximize the moment arm supination guide pin placement is confirmed with fluoroscopy a bone socket is prepared by drilling the anterior cortex with a six or seven millimeter drill the cortical fixation button is prepared by placing two sutures through the button the button is subsequently placed on an inserter the button is then passed through the anterior and distal cortices and flipped the tendon is secured with a type stitch utilizing one limb from each suture the remaining two sutures are the intentions allowing the botton to act as a pulley introducing the tendon to the socket each set of sutures are then securely tied with the elbow in maximal extension and supination fluoroscopy is once again used to confirm adequate placement of the button our routine post operative protocol includes immediate active and active assisted flexion no resisted flexion or supination for six weeks there are multiple advantages to this technique first of all it is minimally invasive it provides strong fixation and maximum bone contact for healing this allows for early rehabilitation this procedure is also associated with a decreased risk of complications such as herotopic ossification and radioulnar synostosis