Summary The Distal Biceps Repair System provides the user the abilityto repair a distal biceps rupture to its anatomical insertion point The system consists of a suture passing needle and a custom drill guide used to re-attach the biceps tendon on the dorsal aspect of the bicipital tuberosity through a single incision The implant consists of titanium buttons utilized with #2 UHMWPE suture to reattach the distal biceps tendon Indications Indications fixation of bone and soft tissue ligament or tendon reconstruction hand wrist forearm elbow shoulder Contraindications active local or systemic infection poor soft tissue envelope nonfunctional extremity Anatomy Biceps inserts into the ulnar (medial) side of the radial tuberosity this allows a lever arm for rotational torque Osteology repair targets the bicipital tuberosity technique describes re-attachment on the dorsal aspect of the bicipital tuberosity bone tunnels created using a bi-cortical bone tunnel technique if completing short and long head repair, bone tunnels are created approximately 12mm apart to prevent fracture or splitting of bone Muscles short head runs more medial in the arm and inserts distally on the bicipital tuberosity long head runs more lateral in the arm and inserts proximally on the bicipital tuberosity Nerves lateral antebrachial cutaneous nerve identified and released, then retracted laterally during superficial exposure instruction to identify and protect nerves during exposure Historical Approach Two Incision - Posterior Reinsertion biceps reinserted into the native footprint of biceps on posterior surface flexion - restored supination - restored Single Incision - Anterior Reinsertion biceps reinserted into anterior cortex of radius flexion - restored supination poorly restored can place whole more ulnar to help but limited by size of radius Suture Button Techniques Single Incision - Medial Reinsertion multiple techniques possible in cadavers difficult to do clinically ArthroTunneler - Wright (Tornier) use rotator cuff repair technology Technique Exposure Details position the patient with their arm on a hand table in full extension and supination make a 4-5cm incision, approx. 2cm distal to the elbow crease and expose the subcutaneous tissues Superficial Exposure identify and release the lateral antebrachial cutaneous nerve and retract laterally identify and retract the brachioradialis laterally identify and protect the nerves and vasculature Deep Exposure identify the ruptured distal biceps tendon use a blunt retractor to allow for exposure above the elbow crease once located, grasp the tendon and pull it distally, freeing it from surrounding adhesions Biceps Tendon Preparaton note: the system allows the repair of each head (short and long) individually to accomplish an anatomical repair if a single suture repair technique is preferred, skip to next step identify the short head (medial, inserts distally on the bicipital tuberosity) and long head (lateral, inserts proximally) use White-Blue #2 and White-Black #2 Sutures to whipstitch each tendon head for about 2cm Bicipital Tuberosity Preparation use the volar capsule elevator to elevate the distal tendon fibers, periosteum, and soft tissue opposite to the tuberosity Biceps Tendon Preparation (Single Suture Repair) use a #2 suture loop to prepare the tendon using a whipstitch technique spanning approximately 2cm in length Guide Placement rotate the forearm to 45 degrees of supination and slide the distal biceps drill guide between the radius and ulna at the bicipital tuberosity level pronate the forearm until the tuberosity contacts the guide insert the locking rod, aligning the laser etched arrows, and use it to lock the guide in a neutral position if needed, rotate the locking rod head clockwise 2-3 times for further compression Pilot Hole Preparation insert the 2.0mm drill into the drill guide from the anterior side of the radius and create a bi-cortical bone tunnel make sure the drill clears the far cortex leave the drill guide locked, in preparation for the suture passing needle Inserting The Suture Passing Needle insert the suture passer guide into the drill guide until it passes through both cortices and the guide hole position the elbow at 45 degrees flexion to identify and remove the 2-0 suture passing needle mark the straight portion of the needle, then insert it into the guide and pass it through until it pierces the opposite forearm skin Preparing Suture Retrieval pull the suture passing needle until 10-12cm of suture is through the dorsal surface cut the suture near the needle, then grasp both suture limbs with hemostats or a needle driver to prevent slippage. Removing The Suture Passer Guide And Drill Guide remove the proximal hemostat and guide, disengage the locking rod, and loosen if needed remove the rod, then rotate the guide 90 degrees and withdraw the suture loop from the wound Passing The Tendon Suture pass the suture limbs through the distal loop, pull the proximal loop through the tunnel, and ensure the tendon reaches the insertion site repeat for the double-head technique Threading The Button pass the suture limbs through the button holes using the threader, then squeeze the holder while pulling the handle back Cycling The Forearm To Prevent Suture Creep position the elbow in approximately 90 degrees of flexion while holding the suture limbs apply tension to the suture limbs while rotating the forearm in pronation and supination Confirming Button Position Prior To Final Tightening lock the suture with a half hitch knot, ensuring the button is down on the bone apply tension with the elbow at 90 degrees flexion, then use 6-7 half hitch knots to secure the suture confirm proper ROM Closure close the wound per surgeon’s preference Pearls & Pitfalls Pearls identify and protect the lateral antebrachial cutaneous nerve; retract laterally identify and retract the brachioradialis laterally if further compression is needed, rotate the head of the locking rod clockwise approximately 2-3 times align laser etched arrows on the drill guide and locking rod during guide placement if performing short and long head repair, create bone tunnels approximately 12mm apart to prevent fracture or splitting of bone use fluoroscopy to ensure the arm is pronated enough to allow the suture passing needle to exit the skin without contacting the ulna mark the straight portion of the suture on the suture passing needle prior to passing secure suture limbs on anterior and posterior sides with hemostats or a needle driver to prevent premature sliding cycle the forearm with tension to prevent suture creep confirm button position down on bone surface prior to final tightening and confirm ROM after fixation Pitfalls do not over-torque the locking rod beware of drill depth through the far cortex to avoid soft tissue damage avoid allowing the suture passing needle to hit the ulna upon exit avoid inadequate spacing between two bone tunnels during double-head technique (risk of fracture or splitting of bone) avoid premature suture back-sliding by failing to secure suture limbs with hemostats or a needle driver