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Distal Biceps Repair - Dual Incision

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Focused history and physical

  • document neurovascular status
  • concomitant and associated orthopaedic injuries

2

Knowledge of imaging studies/lab studies

  • radiographs of the elbow
  • AP
  • lateral

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

  • recognize infection
B

Advanced Evaluation and Management

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
C

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

Operative Techniques

E

Preoperative Plan

1

Template repair

  • template placement of cortical button

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
F

Room Preparation

1

Surgical instrumentation

  • 8x12 interference screw
  • cortical button

2

Room setup and equipment

  • c-arm perpendicular to OR table

3

Patient positioning

  • lateral decubitus position
  • place affected extremity over arm bolster
  • arm should be in 90 degrees of flexion
  • pad all bony prominences
  • place sterile tourniquet
G

Boyd Anderson Two Incision Approach

1

Mark and start the incision

  • draw a 2cm long transverse incision over the anterior elbow distal to the elbow crease

2

Incise the deep fascia

3

Locate and tag the biceps tendon

  • tag the tendon with heavy suture
  • tendon can be retracted up to 7 cm

4

Identify the lateral antebrachial cutaneous nerve

  • nerve is identified in the antebrachial fossa where it exits between the biceps and the brachioradialis
H

Deep Dissection

1

Expose the tuberosity

  • dissect down to the radial tuberosity

2

Place the kelly clamp

  • fully supinate the forearm
  • advance a kelly clamp along the medial border of the radial tuberosity to the dorsolateral aspect of the proximal forearm
I

Posterolateral Incision

1

Make the second incision

  • flex the elbow

2

Make a posterolateral incision over the palpated clamp

  • incise the fascia over the muscle mass

3

Develop interval

  • develop the interval between the anconeous and the ECU
  • avoid going to posterior and disrupting the periosteum
  • maximally pronate the forearm
  • this is to protect the posterior interosseus nerve
J

Tendon Preparation

1

Identify the biceps tendon

2

Prepare the tendon

  • resect and clean up any frayed edges of the tendon

3

Place sutures

  • place heavy non absorbable suture using the standard Krackow suturing technique
  • place sutures approximately 2 cm proximal to the stump
  • this should continue distally and the suture should be placed through the inner two holes of the cortical button

4

Place a second suture

  • this suture should begin distally, then placed through the cortical button and travel proximally to the level of the start of the first suture and then again distally to its starting point

5

Pass sutures through cortical button

  • place 2 nonabsorbable sutures in the outer hole of the cortical button to be passed
K

Bone Preparation

1

Identify the tuberosity

2

Ream the proximal cortex

3

Place guidepin

  • place a guidepin in the central area of the tuberosity
  • make sure that there is at least 2 mm of good bone on either side of the pin

4

Ream the tuberosity

  • ream perpendicular to the tuberosity
  • hypersupinate the forearm
  • ream near the cortex
  • ream in an ulnar direction
  • use a 7 or 8 mm cannulated reamer to ensure that there is no blowout of the cortex

5

Prepare the posterior cortex

  • once the anterior cortex is drilled, prepare the posterior cortex
  • use a 3 mm spade tip drill if using the Arthrex biceps button or 4.5 mm tunnel if using the endobutton
  • copiously irrigate the site to prevent heterotopic ossification
  • tap the bone tunnel
L

Tendon Fixation

1

Pass the cortical button

  • load the 2 sutures from the outside holes of the cortical button through a Beath pin
  • pass Beath pin through the tunnel
  • flex the arm
  • pass button through the dorsal aspect of the skin
  • pull the button through the dorsal cortex and secure by toggling

2

Confirm button placement

  • use fluoroscopy to confirm placement

3

Pass tendon into tunnel

  • pull the sutures to deliver the tendon into the tunnel
  • use an arthroscopic knot pusher to tie the sutures deep in the tunnel

4

Place interference screw

  • pass suture ends through the interference screw
  • use a tenodesis driver to hold the tendon on the ulnar side of the bone
  • advance the interference screw over it

5

Tie sutures

  • tie the suture that is passed through the interference screw to the suture outside of the screw
N

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Deep closure

  • close the deep tissue of the flexor and extensor compartments with undyed absorbable suture

3

Superficial closure

  • close the skin with subcuticular absorbable suture

4

Dressing and immediate immobilization

  • place adhesive strips and soft dressings
  • start active assisted flexion and active extension with gravity

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Discharge patient appropriately

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

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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