• Tourniquet

• Seine, Army/Navy, and baby Bennett retractors

• Wire driver/drill

• 3.2-mm guidewire

• Acorn reaming drill bit

• Implants

• Cortical button with insertion device

• No. 2 nonabsorbable suture

• Bioabsorbable tenodesis screw

• The patient is positioned supine and can remain on the stretcher or be transferred to an operating room table.

• A hand table should be used as the primary working surface for the operative extremity.

• A tourniquet can be applied high on the upper arm before preparation and draping, but a sterile tourniquet may be necessary for shorter arms.

• The incision is drawn over the midline volar forearm starting 2 cm distal to the elbow crease, extending distally about 3 cm (Fig. 27-1).

• The midline incision is made using a no. 15 blade scalpel, incising skin and dermis to the subcutaneous fat.

• The subcutaneous tissues are dissected, and the fascial plane between the flexor carpi radialis and the brachioradialis is identified.

• This plane is then carried down, carefully preserving the lateral antebrachial cutaneous nerve.

• A leash of vessels is identified within the fascial plane. Depending on the location of the vessels relative to the radial tuberosity, they may be preserved or ligated to adequately develop the plane.

• Blunt baby Bennett retractors are placed around the proximal radius, identifying the radial tuberosity. Tip: Pronosupinating the forearm while palpating the tuberosity will give the best idea of its orientation and position.

• At this point, it is important to maintain the forearm in supination to effectively expose and identify the radial tuberosity and to shift the posterior interosseous nerve away from danger.

• The radial tuberosity is identified and any remaining tissue is elevated with a key elevator and a rongeur.

• The distal biceps tendon is identified and mobilized with an Allis clamp (Fig. 27-2). It may be partially attached to the radial tuberosity, sitting relatively close to the native insertion or retracted proximal to the elbow. Tip: If retracted proximally, it may be necessary to make a second incision directly over the biceps muscle belly, tracing it distally to find the tendon.

• Once the tendon is mobilized, the distal end is prepared and trimmed such that it fits within an 8-mm sizing guide to ensure that it will be able to slide into the 8-mm tunnel. A smaller tendon will require a smaller tunnel, but the tunnel should be no larger than 8 mm in diameter.

• Using a no. 2 nonabsorbable suture, 5 or 6 whipstitches are passed up and back through the distal end of the tendon (Fig. 27-3).

• Attention is taken to ensure any remaining soft tissue is debrided from the radial tuberosity.

• The 3.2-mm guidewire is placed centrally in the radial tuberosity, angled slightly radial to create the bone tunnel. Tip: Central placement on the tuberosity is critical because enough space is needed around all sides of the guidewire to avoid breaching one of the cortices with the acorn bit reamer and risk fixation failure of the bioabsorbable tenodesis screw (Fig. 27-4).

• Once adequate bony architecture has been verified on all sides of the pin, with enough room to allow for the acorn bit drill tip, the 3.2-mm guide pin is drilled bicortically and left in place.

• The acorn reaming drill bit is placed over the 3.2-mm guidewire, and only the near cortex of the radial tuberosity is drilled to create the bone tunnel for passage and seating of the distal end of the biceps tendon (Fig. 27-5).