How to perform a distal biceps tendon repair

Patient Positioning, Anesthesia and Preparation

• The patient is positioned supine with the affected arm abducted on an arm table with the palm facing up.

• The surgical field is prepared to the proximal third of the arm, allowing for a proximal incision if significant tendon retraction requires it.

• The forearm must be freely mobile to allow full hypersupination during the procedure.

• A C-arm is positioned on the operative side if fluoroscopy is desired to verify drilling placement.

• A brachial plexus block is the typical form of anesthesia.

Landmarks and Incision Site

The aim is to center the incision over the bicipital tuberosity, where the biceps tendon anatomically inserts. The retracted tendon end is typically accessible through the same incision unless proximal retraction is extensive.

1. By flexing the elbow, the anterior elbow crease is identified as the reference landmark.

2. The bicipital tuberosity level is located approximately three fingerbreadths distal to the crease.

3. The medial-lateral placement of the incision is guided by the edge of the brachioradialis muscle.

4. A longitudinal incision approximately 1–2 cm in length is centered over this site, providing adequate exposure to the bicipital tuberosity and tendon retrieval.

This placement establishes a plane between the brachioradialis laterally and the pronator teres medially. The superficial branch of the radial nerve and the posterior interosseous nerve lie laterally, while the median nerve and brachial artery lie medially to the biceps tendon.

Skin Incision and Advancing to Antebrachial Fascia

1. The skin is incised with a scalpel according to the planned line, advancing through the skin layer.

2. The lateral antebrachial cutaneous nerve (LABCN) may be encountered in the subcutaneous tissue beneath the skin in this area. Due to anatomical variation, it is not always visible, but its presence should always be checked. If encountered, it is protected by retracting laterally.

3. Two retractors are placed to maintain exposure. Hemostasis is achieved with diathermy as needed.

4. In this case, the subcutaneous layer is very thin and the antebrachial fascia is immediately visible under the skin. If the subcutaneous tissue is thicker, advancement is made carefully with blunt dissection and retractors to protect the LABCN.

5. Once the antebrachial fascia is clearly visualized throughout the incision’s length, dissection can proceed to the muscular layers.

Opening the Fascia and Exposing the Bicipital Tuberosity

The aim is to expose the bicipital tuberosity by developing an interval between the brachioradialis and the pronator teres, and incising and retracting the supinator muscle, while protecting adjacent neurovascular structures.

1. The fascia is incised with a scalpel along the medial border of the brachioradialis, matching the length of the skin incision.

2. The interval between the muscles is developed by positioning retractors deeper, retracting the pronator teres medially and the brachioradialis laterally.

3. The supinator muscle is identified as the next muscular layer.

4. The supinator is incised with a scalpel through its superficial fibers and retracted laterally to expose the underlying tuberosity.

5. The lateral retractor is kept superficial and pointed retractors are avoided, as the deep branch of the radial nerve wraps around the radial neck in this area and is at risk of compression or direct injury. Maintaining full supination provides additional protection by keeping the radial nerve away from the field.

6. After clearing the field, the biceps tendon becomes visible. Here the tendon is still intact. In cases with actual rupture, the tendon may still be found close to the attachment site, or it may be retracted proximally, requiring palpation or further exploration proximally to locate.

7. The tuberosity is exposed by clearing soft tissue distally. Branches of the radial recurrent artery may cross the field at this area and require coagulation or ligation.

8. Retractors are repositioned distally, exposing the tendon end, or the bicipital tuberosity underneath it in a clinical scenario.

Tendon Retrieval

The tendon end is located and mobilized so it can reach the tuberosity for reattachment.

1. Following rupture, the tendon may retract to varying degrees. In this simulated case, the ruptured tendon is identified proximally in the wound. In acute cases, hematoma may be present around the tendon stump.

2. Pronating and supinating the forearm confirms the tendon is fully detached. This movement also shows the native footprint on the bicipital tuberosity. Pronation rotates it posteriorly, while supination brings it anteriorly into view.

3. If the tendon is not immediately found, flexing the elbow or milking the biceps muscle from proximal to distal can help deliver it into the wound.
   With increasing time from injury, the tendon may become retracted, shortened, and scarred. If the tendon remains inaccessible through the primary incision, a separate proximal incision, placed approximately three fingerbreadths proximal to the cubital crease, may be required. This avoids extensive dissection through the antecubital fossa, where the brachial artery and median nerve are at risk.

4. Regardless of whether the tendon required proximal retrieval, after identifying it, the next step is to carefully free it from surrounding adhesions to deliver it.

5. The tendon is mobilized sufficiently when it reaches the tuberosity level without excessive tension.

Tendon Preparation

The tendon end is prepared to achieve durable fixation to the tuberosity.

1. The tendon tissue is inspected and any degenerative or fibrotic distal portion is trimmed until healthy tendon tissue is visible.

2. Once trimmed, a suture is placed in the tendon that will be used for fixation. The technique must provide a durable grip that resists pullout under load during healing. In this case, a whipstitch is used, placed over approximately 3 cm with a size 0 high-strength braided suture.

3. The looped suture is positioned at the proximal starting point.

4. The needle is passed through the tendon and the suture is pulled through, tightening it.

5. The suture strands are then spread apart and passed around the tendon.

6. The needle is passed through the tendon again distally, creating a secure grip.

7. This is repeated distally until the tendon end is reached.

8. The final pass of the whipstitch is made through the tendon end.

9. The suture is pulled to tighten and then cut distally, leaving sufficient length for tensioning.

Fixation Site

The correct fixation site allows for optimal supination and flexion movements. A reinsertion that is too proximal or too lateral compromises functional recovery. A tendon reinsertion that is too proximal or too lateral compromises functional recovery of the biceps.

1. A third retractor is placed distally to optimize exposure of the tuberosity.

2. The forearm is positioned and firmly maintained in extension and hypersupination by the assistant. Hypersupination rotates the bicipital tuberosity anteriorly, providing maximum exposure and moving the posterior interosseous nerve away from the operative site.

3. Once the tuberosity area is visualized, it can be divided into quadrants. The fixation site is identified on the medial-distal quadrant, optimizing both supination and flexion function.

Inserting the Intramedullary Button

The aim is to insert the fixation button into the intramedullary canal, through which the whipstitch sutures will pass, connecting the tendon to bone.

1. The drill guide is positioned on the identified site, on the medial-distal quadrant, and held firmly in place. If there is uncertainty, fluoroscopy can confirm the guide and drill is correctly positioned.

2. The drill trajectory is perpendicular to the cortex.

3. A 2.6-millimeter drill hole is created through the near cortex only. The far cortex is not drilled.

4. The drill bit is withdrawn, leaving the guide in place. The button inserter is then passed through the guide.

5. The button inserter is tapped to advance the button into the intramedullary canal.

6. The shuttle sutures are released and the inserter and guide are removed.

7. The shuttle sutures are pulled to confirm the button is deployed.

8. Supination/pronation is tested to ensure the fixation site will allow full rotation arc.

Connecting the Tendon to the Button

The whipstitch sutures are passed through the button, connecting the tendon to the button.

1. Four suture strands emerge from the button: two from each shuttle suture. The strands are separated into pairs.

2. One whipstitch limb is passed into the same side shuttle loop, ensuring the tendon is not twisted.

3. Traction on the shuttle pulls the limb through the button. Slight tugs help advance the suture once it meets the button sheath.

4. The second whipstitch limb is passed through the button with similar technique using the remaining shuttle suture.

5. Both whipstitch limbs now pass through the button and the tendon can be tensioned onto the bone.

Tensioning

The aim is to secure the tendon to the tuberosity with appropriate tension.

1. The elbow is flexed to reduce tension on the tendon before final tightening. Approximately 45 degrees of flexion is used, depending on tendon retraction. Supination of the forearm is maintained.

2. Both suture limbs are pulled, drawing the tendon toward the bone.

3. The tendon is drawn down until resistance is felt and bone contact is confirmed visually.

4. The tension is reassessed in full supination. The repair should remain taut.

5. With tension maintained, the sutures are tied to secure the repair.

6. Multiple knots are used for secure fixation and the suture ends cut short.

Assessment of Fixation

The repair is tested to confirm it is secure and does not restrict motion.

1. The elbow is brought into full extension. This confirms the repair does not restrict motion.

2. The forearm is then moved through full supination and pronation. Full pronation confirms the tendon does not impinge in the radio-ulnar space.

3. Full range of motion through both arcs confirms the repair allows normal movement. Functional recovery will follow with healing and progressive return to activity.

Closure

1. The wound is thoroughly irrigated with saline to remove bone debris.

2. The wound is closed in two layers: subcutis and skin.