Orthopedics

Tips & Techniques 

A Single-Incision Technique for Distal Biceps Repair Using a Flexible Reamer

Todd P. Pierce, MD; Casey M. Pierce, MD; Kimona Issa, MD; Vincent K. McInerney, MD; Anthony Festa, MD; Anthony J. Scillia, MD

Abstract

Distal biceps tendon ruptures are rare injuries that usually occur in middle-aged men. Most of these injuries are repaired acutely to restore preinjury function and strength. There is concern regarding the higher prevalence of certain complications with the double-incision technique. As such, the single-incision technique has also been studied to determine if it may produce superior safety and efficacy. In addition, the point of fixation may be created with either a rigid or a flexible reamer. The authors describe a technique that uses a single-incision cortical fixation achieved with a flexible reamer. [Orthopedics. 2017; 40(4):e744–e748.]

Abstract

Distal biceps tendon ruptures are rare injuries that usually occur in middle-aged men. Most of these injuries are repaired acutely to restore preinjury function and strength. There is concern regarding the higher prevalence of certain complications with the double-incision technique. As such, the single-incision technique has also been studied to determine if it may produce superior safety and efficacy. In addition, the point of fixation may be created with either a rigid or a flexible reamer. The authors describe a technique that uses a single-incision cortical fixation achieved with a flexible reamer. [Orthopedics. 2017; 40(4):e744–e748.]

Distal biceps rupture is a rare injury, having an incidence of 1.2 per 100,000 patients with most being men 40 to 59 years old, that accounts for approximately 10% of all injuries to the biceps brachii muscle.1,2 The mechanism of this injury is commonly an eccentric load being placed on a flexed elbow, after which a pop is commonly heard accompanied by pain and swelling surrounding the antecubital fossa.3 Patients will often present with their elbow in flexion and supination and with a “Popeye” deformity.3 Most of these injuries are repaired acutely to restore preinjury function and strength. However, there is some discussion regarding which surgical technique will optimize outcomes while minimizing complications.

One area of discussion involves the use of a single- or a double-incision technique (Table 1). There is concern regarding the higher prevalence of certain complications, such as heterotopic ossification and stiffness, with the double-incision technique.4 As such, the single-incision technique has also been studied to determine if it may produce superior safety and efficacy. In addition, the point of fixation may be made with either a rigid or a flexible reamer. The authors describe a novel technique that uses a single-incision Endobutton (Smith & Nephew, London, United Kingdom) fixation achieved with a flexible reamer.

Advantages and Disadvantages of Single-and Double-Incision Distal Biceps Repairs

Table 1:

Advantages and Disadvantages of Single-and Double-Incision Distal Biceps Repairs

Surgical Technique

Step 1: Patient Positioning and Incision

The patient is placed in the supine position. The arm is placed on an arm board, and the tourniquet is placed and inflated to 250 mm Hg. A 3-cm incision is made using a 12-blade scalpel, taking advantage of the interval between the brachioradialis and the pronator teres (Figure 1).

A surgical marker is used to identify the interval between the brachioradialis and the pronator teres of a left arm. A 3-cm incision is made with a 12-blade scalpel using this interval.

Figure 1:

A surgical marker is used to identify the interval between the brachioradialis and the pronator teres of a left arm. A 3-cm incision is made with a 12-blade scalpel using this interval.

Step 2: Deep Fascial Dissection

Using Metzenbaum scissors, dissection is continued down to the antecubital fossa; care is taken to identify and protect both the lateral antebrachial cutaneous nerve and the cephalic vein (Figure 2A). The lateral antebrachial cutaneous nerve is protected using an Army-Navy retractor (Figure 2B).

Dissection is carried down to the antecubital fossa (A). Care is taken to identify and protect the lateral antebrachial cutaneous nerve and the cephalic vein (B).

Figure 2:

Dissection is carried down to the antecubital fossa (A). Care is taken to identify and protect the lateral antebrachial cutaneous nerve and the cephalic vein (B).

Step 3: Biceps Tendon Identification

Blunt dissection is performed until the biceps tendon is identified (Figure 3A). The tendon may be retracted proximally and potentially may require extension of the incision obliquely across the flexion crease. A clamp is placed under the tendon to allow for complete release from its insertion (Figure 3B). Proximally, the lacertus fibrosus can be identified and released if additional excursion is needed on the tendon (Figure 3C).

Blunt dissection is continued until the biceps tendon (arrow) is identified (A). A clamp is placed under the biceps tendon to allow for complete release (B). If necessary, the lacertus fibrosus (arrow) can be identified and released (C).

Figure 3:

Blunt dissection is continued until the biceps tendon (arrow) is identified (A). A clamp is placed under the biceps tendon to allow for complete release (B). If necessary, the lacertus fibrosus (arrow) can be identified and released (C).

Step 4: Radial Tuberosity Preparation

At this time, the radial tuberosity is identified. A small rongeur is used to remove the remaining portions of the tendon (Figure 4).

A small rongeur is used to prepare the radial tuberosity.

Figure 4:

A small rongeur is used to prepare the radial tuberosity.

Step 5: Tendon Whipstitching

The free edge of the biceps tendon is whipstitched with two No. 2 nonabsorbable Ethicon sutures (Johnson & Johnson, New Brunswick, New Jersey). These are tied together over the Endobutton, leaving 6 mm of space between the Endobutton and the tendon to allow it to flip. The stitches interlock to prevent the graft from stretching out following repair (Figure 5). Free sutures are then placed through the more lateral holes of the Endobutton to pass and flip it. The end is tubularized to allow for easy passage through the bone tunnel. A Hohmann-type retractor is used to aid in visualization of the tendon.

The tendon is whipstitched using No. 2 nonabsorbable Ethicon sutures (Johnson & Johnson, New Brunswick, New Jersey). The stitches interlock to prevent stretching following repair.

Figure 5:

The tendon is whipstitched using No. 2 nonabsorbable Ethicon sutures (Johnson & Johnson, New Brunswick, New Jersey). The stitches interlock to prevent stretching following repair.

Step 6: Flexible Guidewire Placement

A flexible guidewire is passed into the radial tuberosity in line with the anatomic insertion of the biceps tendon using the VersiTomic curved drill guide (Stryker Orthopaedics, Mahwah, New Jersey) (Figure 6). The guidewire is drilled to the far cortex but does not penetrate it to avoid damage to the posterior interosseous nerve. Appropriate placement is confirmed using fluoroscopy.

A flexible guidewire is passed into the radial tuberosity in line with the anatomic insertion of the biceps tendon using the curved drill guide. Care is taken not to penetrate the far cortex to avoid damaging the posterior interosseous nerve. The near cortex is then reamed using a flexible guidewire. The reamer is sized appropriately to the biceps tendon.

Figure 6:

A flexible guidewire is passed into the radial tuberosity in line with the anatomic insertion of the biceps tendon using the curved drill guide. Care is taken not to penetrate the far cortex to avoid damaging the posterior interosseous nerve. The near cortex is then reamed using a flexible guidewire. The reamer is sized appropriately to the biceps tendon.

Step 7: Reaming of Near Cortex of Radius

A flexible reamer sized to the tendon graft is passed over the VersiTomic guidewire. The near cortex is reamed. Care is taken not to penetrate the far cortex of the radius.

Step 8: Reaming of Far Cortex of Radius

A second, rigid reamer (4.5 mm in diameter) is then used to ream the far cortex to allow for Endobutton passage (Figure 7). The reamer is angled distal and ulnar to avoid damage to the posterior interosseous nerve.

The far cortex is reamed using a 4.5-mm diameter rigid reamer that is angulated distal and ulnar to avoid damaging the posterior interosseous nerve.

Figure 7:

The far cortex is reamed using a 4.5-mm diameter rigid reamer that is angulated distal and ulnar to avoid damaging the posterior interosseous nerve.

Step 9: Guidewire Passage

The passing sutures are loaded in the guidewire, which is then passed through the tunnel in the radial tuberosity and out of the skin of the dorsal forearm (Figure 8). The forearm is held in supination to protect the posterior interosseous nerve.

The guidewire is passed through the tunnel in the radial tuberosity and out of the skin of the dorsal forearm with the passing sutures loaded onto the guidewire.

Figure 8:

The guidewire is passed through the tunnel in the radial tuberosity and out of the skin of the dorsal forearm with the passing sutures loaded onto the guidewire.

Step 10: Cortical Fixation and Graft Placement

The Endobutton is then flipped on the far cortex of the radius using the free passing sutures (Figure 9).

The Endobutton (Smith & Nephew, London, United Kingdom) (arrow) is flipped on the far cortex of the radius using free passing sutures.

Figure 9:

The Endobutton (Smith & Nephew, London, United Kingdom) (arrow) is flipped on the far cortex of the radius using free passing sutures.

Step 11: Confirmation of Placement

The resting tension on the biceps is recorded to coincide with the postoperative physical therapy protocol. The Endobutton is checked by ensuring toggling of the button with alternating tension on the free sutures (Figure 10). Fluoroscopy may also be used to confirm appropriate placement.

The strands are toggled to confirm appropriate placement of the tendon.

Figure 10:

The strands are toggled to confirm appropriate placement of the tendon.

Step 12: Wound Closure

The incision is closed with one 3-0 Monocryl suture (Johnson & Johnson) and one 4-0 Monocryl suture (Figure 11). The patient is placed into a well-padded posterior splint in flexion and supination to protect the repair (Video; Table 2).

The wound is closed using a 3-0 Monocryl suture (Johnson & Johnson, New Brunswick, New Jersey) and a 4-0 Monocryl suture.

Figure 11:

The wound is closed using a 3-0 Monocryl suture (Johnson & Johnson, New Brunswick, New Jersey) and a 4-0 Monocryl suture.

Pearls and Pitfalls of the Single-Incision Technique

Table 2:

Pearls and Pitfalls of the Single-Incision Technique

Discussion

The use of a single incision to repair a rupture of the distal biceps tendon has been studied with the goal of optimizing outcomes while maintaining repair survivorships of at least 90% (Table 3).5–10 However, there has been little literature regarding the use of a single incision with a flexible reamer. The authors have clearly described a technique that takes advantage of a single incision while using a flexible reamer to produce an adequate point of fixation.

Recent Studies on Single-Incision Distal Biceps Repair

Table 3:

Recent Studies on Single-Incision Distal Biceps Repair

Single incisions have been similar in efficacy and safety to other techniques. Grewal et al6 evaluated the outcomes of patients who underwent single-incision (47 repairs) or double-incision (44 repairs) distal biceps tendon repair in a randomized clinical trial. After a 2-year follow-up, they found comparable outcomes in terms of final Disabilities of the Arm, Shoulder and Hand scores (8 vs 6 points; P=.3) and repair survivorship (94% vs 98%; P=.3). However, they noted that the single-incision cohort had a higher incidence of transient neuropraxia (<6 months) of the lateral antebrachial cutaneous nerve (40% vs 7%; P<.001). Furthermore, several small noncomparative studies have reported Disabilities of the Arm, Shoulder and Hand scores of less than 11 and survivorships of greater than 90% (Table 1).5,7–10

Additionally, this technique uses a flexible reamer, which may provide for a more anatomic repair. Although the clinical outcomes of single-incision distal biceps repairs using a flexible reamer have not been extensively investigated, there is one well-known cadaveric study regarding the use of this reamer. Alsheikh et al11 compared the anatomic positions of fixation with flexible vs rigid reamers in 14 cadaveric elbows. Using computed tomography, the tunnel position for each reamer was compared with what was the center of the native tendon. Elbows for which the flexible reamer had been used had their repair in a more central position within the radial shaft when compared with elbows for which the rigid reamer had been used (mean offset ratio, 0.17 vs 0.35; P=.043). Therefore, given the results of this cadaveric study, unlike techniques that use a rigid reamer for graft preparation, this technique using a flex ible reamer allows for a more anatomic repair while protecting underlying neurovascular structures and minimizing the risk of heterotopic ossification.

Conclusion

The authors have described a single-incision distal biceps repair technique that makes use of a flexible reamer to create the point of fixation. They believe that others will be able to easily replicate this technique. Future studies should focus on the short- and long-term outcomes of patients who undergo this technique.

References

  1. Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002; 404:275–283. doi:10.1097/00003086-200211000-00042 [CrossRef]
  2. Kelly MP, Perkinson SG, Ablove RH, Tueting JL. Distal biceps tendon ruptures: an epidemiological analysis using a large population database. Am J Sports Med. 2015; 43(8):2012–2017. doi:10.1177/0363546515587738 [CrossRef]
  3. Garon MT, Greenberg JA. Complications of distal biceps repair. Orthop Clin North Am. 2016; 47(2):435–444. doi:10.1016/j.ocl.2015.10.003 [CrossRef]
  4. Watson JN, Moretti VM, Schwindel L, Hutchinson MR. Repair techniques for acute distal biceps tendon ruptures: a systematic review. J Bone Joint Surg Am. 2014; 96(24):2086–2090. doi:10.2106/JBJS.M.00481 [CrossRef]
  5. Cusick MC, Cottrell BJ, Cain RA, Mighell MA. Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw. J Shoulder Elbow Surg. 2014; 23(10):1532–1536. doi:10.1016/j.jse.2014.04.013 [CrossRef]
  6. Grewal R, Athwal GS, Mac-Dermid JC, et al. Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am. 2012; 94(13):1166–1174. doi:10.2106/JBJS.K.00436 [CrossRef]
  7. Hrubina M, Behounek J, Skotak M, Krumpl O, Mika P, Olgun D. The results of primary repair after distal biceps tendon rupture. Acta Orthop Traumatol Turc. 2013; 47(5):301–306. doi:10.3944/AOTT.2013.2820 [CrossRef]
  8. Pangallo L, Valore A, Padovani L, et al. Mini-open incision for distal biceps repair by suture anchors: follow-up of eighteen patients. Musculoskelet Surg. 2016; 100(1):19–23. doi:10.1007/s12306-015-0372-1 [CrossRef]
  9. Hansen G, Smith A, Pollock JW, et al. Anatomic repair of the distal biceps tendon cannot be consistently performed through a classic single-incision suture anchor technique. J Shoulder Elbow Surg. 2014; 23(12):1898–1904. doi:10.1016/j.jse.2014.06.051 [CrossRef]
  10. Gasparella A, Katusic D, Perissinotto A, Miti A. Repair of distal biceps tendon acute ruptures with two suture anchors and anterior mini-open single incision technique: clinical follow-up and isokinetic evaluation. Musculoskelet Surg. 2015; 99(1):19–25. doi:10.1007/s12306-014-0314-3 [CrossRef]
  11. Alsheikh K, Behrends D, Cota A, Martineau PA. A cadaveric analysis of tunnel position created using flexible versus rigid instrumentation in a single-incision distal biceps tendon repair. Arthroscopy. 2014; 30(5):561–567. doi:10.1016/j.arthro.2014.01.013 [CrossRef]

Advantages and Disadvantages of Single-and Double-Incision Distal Biceps Repairs

TechniqueAdvantagesDisadvantages
Single incisionStronger repair Similar functional outcomes with only 1 incision Shorter operative time Less blood lossIncreased risk of transient neuropraxia of the lateral antebrachial cutaneous nerve
Double incisionSome reports of potential greater flexionIncreased risk of heterotopic ossification and stiffness

Pearls and Pitfalls of the Single-Incision Technique

Technique StepPearlsPitfalls
1. Patient positioning and incisionBlunt dissection may be used for better mobilizationBridging veins may be encountered and must be cauterized
2. Deep fascial dissectionThe lateral antebrachial cutaneous nerve runs in between the biceps brachii and the brachioradialis and runs distally on top of the brachioradialisProtect the lateral antebrachial cutaneous nerve
3. Biceps tendon identificationTendon is often retracted proximally and requires extension of the incision by a centimeterDown by the tendon, there is often an arcade of veins that should be avoided
4. Radial tuberosity preparationA small rongeur allows for appropriate removal of the remaining tendonIf the tendon is not completely removed, it can affect graft and Endobuttona fixation
5. Tendon whipstitchingThis can prevent the graft from stretching following repairIf tubularizing is not complete, there can be difficulties passing the tendon through the insertion point
6. Flexible guidewire placementIt should be passed anatomicallyIf the far cortex is penetrated, the posterior interosseous nerve could be damaged
7. Reaming of near cortex of radiusThe reamer for the near cortex is often wider in diameter than the reamer for the far cortexInadequate reaming will cause inability to pass the tendon for fixation
8. Reaming of far cortex of radiusAngle the reamer distal and ulnarInappropriate angulation or penetrating the far cortex could damage the posterior interosseous nerve
9. Guidewire passageSupinate during guidewire passageWithout supination, the posterior interosseous nerve could be damaged
10. Cortical fixation and graft placementFlipping the Endobutton should lead to it fitting into the socket of the radial tuberosityCare is taken to avoid the posterior interosseous nerve during final fixation
11. Confirmation of placementFluoroscopy may be used to confirm appropriate placementOvertensioning the tendon may increase the risk of rerupture and subsequent revision
12. Wound closureUse 3-0 Monocrylb suturePlace in a posterior splint in flexion and supination to protect the repair

Recent Studies on Single-Incision Distal Biceps Repair

Study (Year)No. of PatientsMean Follow-up (Range), moMean DASH Score (Range), PointsRepair Survivorship
Pangallo et al8 (2016)20NR (1 to NR)4.8 (NR)100%
Gasparella et al10 (2015)142.2 (NR)4.7 (0 to 20)100%
Cusick et al5 (2014)170NR (0.3 to NR)NR99%
Hansen et al9 (2014)212.3 (NR)10.7 (NR)100%
Hrubina et al7 (2013)2110 (4 to 23)7.8 (0 to 22)90%
Grewal et al6 (2012)a47NR (24 to NR)7.8 (NR)94%
Authors

The authors are from the Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey.

Drs C M Pierce, Issa, McInerney, and Festa have no relevant financial relationships to disclose. Dr T P Pierce is a paid consultant for Isto Biologics, has received research support from Isto Biologics, and is a paid distributor for Shaklee, Inc. Dr Scillia is a paid consultant for Mitek.

Correspondence should be addressed to: Anthony J. Scillia, MD, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, 400 S Orange Ave, South Orange, NJ 07079 ( anthonyjscillia@gmail.com).

Received: February 15, 2017
Accepted: June 07, 2017
Posted Online: June 21, 2017

10.3928/01477447-20170615-03

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