Two-Incision Distal Biceps Repair

Instruments/Equipment

• Sterile tourniquet

• Mini C-arm fluoroscopy

• Round or pineapple-shaped 4-mm burr

• Side-cutting 1-mm drill bit

• No. 2 looped nonabsorbable high-strength suture

• Kelly clamp

• Hewson suture passer

• Bipolar electrocautery

Positioning

• The patient is positioned supine with the arm placed across a hand table, and general or regional anesthesia is administered.

• A sterile tourniquet is placed on the upper arm and inflated before the incision is made.

Surgical Exposure

• The biceps tendon is palpated before the incision is made to confirm the location of the retracted tendon.

• An anterior approach is first used to locate the biceps tendon.

• A single 2- to 3-cm transverse incision is made at the distal extent of the antecubital crease (Fig. 28-1).

▪ The length of incision should allow enough space for finger palpation of the biceps tendon stump.

▪ The incision should lie along the ulnar border of the brachioradialis muscle.

• Dissection is performed down to the antebrachial fascia.

▪ The traversing lateral antebrachial cutaneous nerve is identified.

• Blunt finger dissection is used to facilitate biceps stump identification.

▪ The biceps tendon will often be more superficial than expected.

▪ Hematoma/seroma will likely be encountered before identifying the tendon.

• An Allis clamp is used to grasp the tendon.

▪ The distal tendon is carefully freed of adhesions and care is taken to ensure that the stump is not folded onto itself.

Figure 28-1 | A transverse 3-cm planned incision is drawn in the antecubital fossa in this patient who suffered an acute distal biceps rupture. (Courtesy of Columbia University Center for Shoulder, Elbow and Sports Medicine.)

• The distal end of the tendinotic biceps tendon is debrided (Fig. 28-2).

▪ It may be difficult to insert the distal end of the tendon within the biceps footprint if the tendon edge is insufficiently trimmed.

• Two sutures (no. 2 looped nonabsorbable high-strength sutures) are passed 2.5 cm proximal to the distal edge of the tendon (Fig. 28-3).

▪ A whipstitch technique is used to tubularize the distal portion of the tendon.

▪ Surgical Pearl: Using blunt dissection along the entire length of the biceps will maximize tendon excursion. This should be done after the whipstitch is placed.

• The tendon can be sized at this point (typically 7 mm) to assist with estimating the size of the biceps docking site.

Figure 28-2 | The ruptured distal biceps is retrieved and brought outside the wound. Note the degenerative and widened distal extent of the tendon. (Courtesy of Columbia University Center for Shoulder, Elbow and Sports Medicine.)

Figure 28-3 | The degenerative and widened distal 5 mm is excised and a running, locking nonabsorbable suture is placed to maximize control of the tendon and minimize suture pullout in line of the collagen fibers. (Courtesy of Columbia University Center for Shoulder, Elbow and Sports Medicine.)

Only gold members can continue reading. Log In or Register to continue