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Distal Biceps Tendon Rupture: part three

- One Incision - Modified Henry Approach:
     - see: Henry Approach to the Forearm;
     - some surgeons feel that this is the prefered technique noting that modern suture anchors anchors have permitted safe repair of
            biceps tendon through one anterior incision;
     - advantages: direct approach, avoids PIN injury, and minimal ectopic bone formation;
     - disadvantages: may injury radial nerve if surgeon attempts to pass tendon thru drill holes made in the radius;
            - this is less of a problem now that stronger bone anchors are available;
     - incision:
            - begins either medial or lateral to biceps, extends transversely over antecubital fossa, and then extends distally over the BR;
     - identify and protect the lateral antibrachial cutaneous nerve;
            - anatomic variations have been described in the musculocutaneous nerve pierces the distal biceps tendon;
     - muscle interval:
            - exposure between the brachioradialis (w/ radial / lateral retraction) and pronator teres (medial retraction);
            - limiting forceful lateral retraction of BR helps avoid injury to the PIN;
     - tendon end is identified, elevated out of wound, and debrided;
     - thru the empty space (occupied by the biceps), insert a tonsil and identify the radial tuberosity (forearm fully supinated);
     - saline lavage of the tendon tract to prevent heterotrophic ossification;
     - in the traditional approach, deep interval lateral to the biceps tendon is developed and the leash of radial recurrent vessels is
            ligated to increase the exposure;
     - avoid injury to the PIN and anterior interosseous nerve;
            - keep forearm supinated inorder to keep the PIN as far away as possible;
            - retractors placed around the radial tuberosity are the main cause of nerve compression;
            - limiting forceful lateral retraction of BR
     - bone anchors:
            - inserted into the ulnar aspect of the tuberosity, and reattach the tendon;
            - main mistake is to position the anchor proximal to the tuberosity (needs to be in the ulnar aspect of the tuberosity);
            - note the length of the bone anchor (avoid excessively long bone anchors which might penetrate the far cortex);
            - references:
                   - The effect of drilling angle on posterior interosseous nerve safety during open and endoscopic anterior single-incision repair of the distal biceps tendon.
                   - The Effect of Drill Trajectory on Proximity to Posterior Interosseous Nerve During Cortical Button Distal Biceps Repair
                   - The pullout force for Mitek mini and micro suture anchor systems in human mandibular condyles.  
                   - How to Avoid Posterior Interosseous Nerve Injury During Single-Incision Distal Biceps Repair Drilling

     - postoperative care:
            - immobilize the elbow in 90 deg flexion for 2 weeks followed by progressive increases in elbow ROM using hinged brace;
            - passive pronation and supination with the elbow flexed at or greater than 90° of flexion is allowed after 2 weeks;
            - active flexion is started at 8 weeks

Rupture of the distal insertion of the biceps brachii tendon.

Rupture of the distal tendon of the biceps brachii. A biomechanical study.

Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment.

Distal biceps brachii tendon avulsion: a simplified method of operative repair

Partial rupture of the distal biceps tendon.

Repair of the distal biceps tendon using suture anchors and an anterior approach

Single-incision repair of acute distal biceps ruptures by use of suture anchors. 

Distal biceps brachii repair. Results in dominant and nondominant extremities.

A method for reinsertion of the distal biceps brachii tendon

Repair of avulsion of insertion of biceps brachii tendon

Clinical, Functional, and Radiographic Assessments of the Conventional and Modified Boyd-Anderson Surgical Procedures for Repair of Distal Biceps Tendon Ruptures.

Complications of Repair of the Distal Biceps Tendon with the Modified Two-Incision Technique

Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach.

The Effect of Drilling Angle on Posterior Interosseus Nerve Safety During Open and Endoscopic Anterior Single-Incision Repair of the Distal Biceps Tendon

Complications of distal biceps tendon repairs.

Proximity of the Posterior Interosseous Nerve During Cortical Button Guidewire Placement for Distal Biceps Tendon Reattachment

High complication rate following distal biceps refixation with cortical button