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Distal Biceps Repair - Single Incision

Planning

B

Preoperative Plan

1

Template repair

  • template placement of the anchor device

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • description of potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • anchor device

2

Room setup and equipment

  • mini c-arm on same side as operative extremity

3

Patient positioning

  • supine
  • radiolucent armboard
  • pad all bony prominences
  • place sterile tourniquet

Technique

D

Superficial Dissection

1

Mark and start the incision

  • mark and make a 2cm incision distal to elbow crease over biceps attachment

2

Develop interval

  • develop interval between FCR and brachioradialis and palpate radial tuberosity

3

Locate and tag the biceps tendon

  • tag tendon with heavy suture
  • tendon may be retracted requiring accessory proximal incision

4

Identify neurovascular structures

  • identify and protect location of lateral antebrachial nerve
E

Deep Dissection

1

Expose the tuberosity

  • dissect down to the radial tuberosity
  • place retractors

2

Remove any remaining soft tissues

  • clear tuberosity of residual soft tissue
F

Tendon Preparation

1

Locate and tag the biceps tendon

  • tag tendon with heavy suture
  • tendon may be retracted requiring accessory proximal incision

2

Identify neurovascular structures

  • identify and protect location of lateral antebrachial nerve

3

Place anchor device

  • deliver anchor device into tuberosity

4

Secure tendon using anchor device to tuberosity

G

Bone Preparation

1

Drill guide pin

2

Use fluoroscopy for placement confirmation

  • confirm proper placement in tuberosity with fluoroscopy

3

Measure diameter of tendon

4

Overdrill guide pin

  • overdrill guide pin with appropriate sized bit through near cortex
H

Tendon Fixation

1

Place anchor device

  • deliver anchor device into tuberosity

2

Secure tendon using anchor device to tuberosity

I

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound
  • perform meticulous hemostasis

2

Deep closure

  • close subcuticular tissue
  • avoid button-holing
  • atraumatically handle tissue

3

Superficial closure

  • close skin
  • +/- local anesthetic

4

Dressings and immobilization

  • apply sterile dressing
  • apply splint and sling

Patient Care

K

Preoperative H & P

1

Perform focused orthopedic physical exam

  • age
  • gender
  • mechanism of injury
  • check neurovascular status

2

Order basic imaging studies

  • obtain radiographs of the elbow
  • AP and lateral

3

Perform operative consent

  • describe complications of surgery including
  • neurovascular injury
  • infection
  • heterotopic ossification
L

Perioperative Inpatient Management

1

Discharge patient appropriately

  • pain meds
  • wound care
  • schedule follow up in 2 weeks
  • physical therapy
M

Outpatient Evaluation and Management

1

Focused history and physical

  • perform hook test
  • document neurovascular status
  • concomitant and associated orthopaedic injuries

2

Knowledge of imaging studies/lab studies

  • radiographs of the elbow
  • AP
  • lateral
  • advanced imaging
  • MRI
  • ultrasound

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides postoperative management and rehabilitation

  • postop: 10 day postoperative visit
  • wound check
  • remove sutures
  • continue active assisted flexion
  • continue active extension with gravity
  • start full active range of motion at 4 weeks
  • postop: 4-6 week postoperative visit
  • start strength training at 10 weeks

5

Diagnose and early management of complications

  • recognizes healing incision vs. infection
N

Advanced Evaluation and Managment

1

Order appropriate imaging studies

  • radiographs
  • CT scan/3D reconstruction

2

Provides post-op management and rehabilitation.

  • increase ROM as healing progresses
  • adequate/proper postop xrays
O

Complex Patient Care

1

Comprehensive pre-op planning/alternatives

2

Modify and adjust post-op plan as needed

  • revise therapy

3

Understands how to avoid/prevent potential complications

4

Treat simple complications both intraoperatively and postoperatively.

  • recognize improper hardware position
 

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