Repair of Distal Biceps Tendon Rupture with Endobutton

Operative Technique

Aims

  • To repair biceps tendon to anatomical origin on radial tuberosity

Indications

  • Full thickness rupture of biceps tendon
  • Failed nonoperative treatment of partial tendon rupture

Contraindications

  • ? Elderly

Consent / Preop Planning

  • No imaging necessary
  • MRI or Ultrasound for diagnosis with clinical unclear

Principles

  • Single incision anterior approach

Options

  • 2 incision
  • Single incision
    • Extensile Anterior
    • Fixation
      • Anchors
      • Endobutton

Position

  • General anaestheitc
  • Tournique

Landmarks

  • Elbow skin crease
  • Biceps Musculature

Incision

Start

  • 5 cm Transverse Incision
  • 2 cm distal to elbow skin crease

Internervous Plane

Superficial Dissection

  • Identify lateral antebrachial cutaneous nerve
  • Often – inflammatory bursa filled with haemoserous fluid is encountered

Deep Dissection

  • Locate Tendon End
  • Locate Tendon tunnel down to Radial tuberosity

Dangers

Nerves

  • Lateral Antebrachial Cutaneous Nerve
  • Superficial branch of radial nerve
  • Posterior interosseous nerve
  • Median Nerve

Vessels

  • Radial Artery
  • Ulnar Artery

Procedure

  • Expose Radial Tuberosity
    • Elbow in full extension and supination
  • Cortical window (near cortex)
    • made with high speed burr
    • large enough for tendon
    • as medial as possible in fully supinated forearm (more anatomical)
  • Far cortex
    • made with drill and tissue protector
  • Prepare Biceps Tendon
    • deliver tendon external to wound
    • debride necrotic tissue
    • No 5 Ethibond
      • used to secure tendon to central 2 holes of Endobutton
      • Bunnell sutures on either side of tendon with knots placed proximally
      • allow space of 2mm between Endobutton and Tendon end
Bunnel Suture
  • Pulling Sutures
    • Leading Hole
      • 1 Ethibond
    • Trailing hole (flipping)
      • 1/0 Prolene
  • Thread both sutures into a long straight eyed needle
  • Needle is pushed through hole in Radius and out throught the posterior skin
    • angle needle in ulna direction
      • away for PIN
  • flex elbow
  • Pull on Leading Suture
  • Flip using Trailing suture (Prolene)
  • II to check
  • Check ROM of elbow

Postop / Rehab

  • Backslab in 90° flexion and full supination for 1 week
  • Aftre 1 week, plaster off and then sling
    • elbow moblizied as tolerated
  • No heavy lifting or grasping for 3 months

Results

  • Some studies show strongest fixation strength

Complications / Dangers

Perioperative

General
Local
  • Damage of nerves and vessels

Postoperative

Early
  • Infection
Late
  • Radioulnar synostosis
    • much less than 2 incision approach

External Links