Endoscopic Distal Biceps Repair: Endoscopic Anatomy and Dual-Anchor Repair Using a Proximal Anterolateral “Parabiceps Portal” Deepak N. Bhatia, M.S.(Orth), D.N.B.(Orth)
Abstract: Distal biceps rupture is associated with significant functional disability, and surgical treatment involves open or endoscopic-assisted repair of the ruptured tendon through an anterior incision. This report describes an endoscopic approach that is performed with 2 portals for visualization and instrumentation. Preoperative sonography is used to identify bony and soft-tissue landmarks. The viewing portal is a proximal anterolateral “parabiceps portal” developed by the author, and the landmarks and relevant anatomic relations have been derived from a preliminary anatomic study. The working portal is a distal anterior portal and permits access to the radial tuberosity through the internervous muscular plane. The parabiceps portal permits visualization of the anterior and medial region of the radial tuberosity. A detailed description of the endoscopic pathoanatomy of the distal biceps tendon region is presented. The distal anterior portal is used for retrieval of the ruptured tendon, and thereafter the tuberosity is debrided and anchors are placed under vision. The ruptured tendon is whipstitched and docked onto the tuberosity, and nonsliding knots are used to securely reattach the tendon to bone. Overall, the 2-portal technique provides a method for tendon repair under direct visualization and is safe and reproducible.
D
istal biceps tendon injuries and ruptures are infrequently encountered in professional athletes and are associated with pain and decreased elbow flexion and supination strength.1 Surgical repair is necessary, and open techniques using 1 or 2 incisions have been described.2 Recently, endoscopic-assisted techniques have been described, and suture anchors or EndoButtons (Smith & Nephew Endoscopy, Andover, MA) have been used to reattach the biceps tendon to the radial tuberosity.3-5 Most endoscopic-assisted techniques use a 3- to 5-cm anterior incision and open surgical dissection; an endoscope is then used directly through this incision to visualize the repair procedure. Two portals have been described for biceps endoscopy: Eames and Bain6 have described an
From the Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Mumbai, India. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received June 4, 2015; accepted July 31, 2015. Address correspondence to Deepak N. Bhatia, M.S.(Orth), D.N.B.(Orth), Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Parel, Mumbai 400012, India. E-mail:
[email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15506/$36.00 http://dx.doi.org/10.1016/j.eats.2015.07.031
anterior portal through a 2.5-cm incision distal to the elbow crease for visualizing the distal biceps tendon. Sharma and MacKay7 have described a technique for retrieving the ruptured distal biceps through a 1.5-cm longitudinal incision made in the midline of the anterior aspect of the arm at a point 5 cm proximal to the transverse anterior elbow crease; they used the tract of the retrieved biceps for endoscopic visualization of the radial tuberosity, and the repair procedure was performed under fluoroscopic guidance. This report describes an endoscopic technique that involves the use of a viewing portal, the proximal anterolateral “parabiceps portal,” developed by the author. The parabiceps portal can be used for diagnostic and therapeutic tendoscopy to assess biceps pathology and is the main viewing portal for the endoscopic repair technique for distal biceps ruptures described in this report. The portal is made directly through a 3-mm incision and is the viewing portal throughout the repair procedure. Endoscopic anatomy and the macroscopic anatomic relations of this portal are presented.
Technique Preoperative sonography is performed, and 2 levels are marked with a marking pen: (1) the level of the radial bicipital tuberosity and (2) the level of the distal end of the ruptured biceps tendon. The procedure is
Arthroscopy Techniques, Vol 4, No 6 (December), 2015: pp e785-e793
e785
e786
D. N. BHATIA
Fig 1. (A) Overview of elbow position (left elbow) and external anatomic landmarks. The transverse level of the radial tuberosity (Tu) and of the ruptured biceps tendon is predetermined sonographically and marked on the forearm (arrows). The parabiceps portal (P) is marked 5 to 7 cm proximal to the radial tuberosity, on the lateral aspect of the biceps muscle (BM) and adjacent to the distal biceps tendon (Tn). The distal anterior portal (D) is placed linearly along the one-third to two-thirds junction of the tuberosity level. (B) Sonographic evaluation of distal biceps region of left elbow. The ruptured distal biceps tendon is seen retracted 1.5 to 2 cm proximal to the tuberosity (double-headed arrow). The biceps sheath or pseudotendon (ST, white arrow) is seen attaching to the radial tuberosity (RT, black arrow). These sonographic landmarks are used to mark the skin levels of the tuberosity and tendon before surgery. (Cp, capitellum; RH, radial head.)
performed with the patient in the supine position, and a tourniquet cuff is used with a pressure of 200 mm Hg. The arm is placed in a slightly flexed position (10 to 20 ) with the forearm in full supination (Fig 1). After preparation, the radial tuberosity and the distal biceps tendon are marked using the predetermined sonography levels. A 2.9-mm arthroscope and sheath (2.9 mm 152 mm; ConMed, Linvatec, Largo) are used, and a 50-mL syringe is used for initial air arthroscopy. Subsequently, gravity inflow is used to minimize fluid extravasation into the arm and forearm. The key steps and surgical pearls of the technique are summarized in Table 1 and Table 2, respectively, and the steps are demonstrated in Video 1.
bicipital tuberosity and is just lateral to the palpable distal biceps tendon at this level. A 3- to 4-mm skin incision is made, and a 3-mm sheath is passed in a proximal-to-distal direction toward the sonographically marked radial tuberosity. The sheath is angled approximately 20 to 30 inferiorly and medially and is parallel to the distal biceps tendon. At the entry point, the sheath is above and lateral to the distal biceps; thereafter the sheath is radial and inferior to the tendon. The sheath passes below the radial artery and its recurrent branches and is in close approximation to the biceps tendon. The radial tuberosity can be palpated with the sheath, and this marks the end point of insertion (Fig 2).
Step 1: Parabiceps Portal (Viewing) Placement The proximal anterolateral parabiceps portal is placed approximately 5 to 7 cm proximal to the radial
Step 2: Diagnostic Endoscopy A 2.9-mm 30 arthroscope is used to perform a diagnostic endoscopy through the parabiceps portal.
Table 1. Key Steps of Procedure Correct elbow positioning is important; the elbow is placed in slight flexion and full supination for safe portal placement. Preoperative sonography is used to mark the radial tuberosity. The proximal anterolateral parabiceps portal is the viewing portal for the entire procedure. The portal is placed anterolateral to the distal biceps tendon. Inferomedial angulation is necessary to place the arthroscope safely under the radial vessels. The distal anterior portal is the working portal for the entire procedure. The portal is placed adjacent to the sonographic marking of the tuberosity, and its placement is confirmed by digital palpation under endoscopic viewing through the parabiceps portal. A short cannula is placed into this portal to protect the surrounding soft tissues. Exteriorization of the ruptured distal biceps tendon is performed through the distal portal with a small-joint grasper under endoscopic vision. Tuberosity preparation is performed with a 3-mm shaver and burr to excise remnant soft tissues and to decorticate the tuberosity. Anchor placement is performed in the distal and proximal region of the tuberosity and on its ulnar aspect. The distal biceps tendon is whipstitched using 1 suture of each anchor. The other sutures of each anchor are pulled, and the sliding mechanism docks the tendon onto the tuberosity. Nonsliding knots are used to securely attach the tendon to bone. Dynamic assessment (pronation-supination, flexion-extension) is used to confirm tendon repair integrity. A final panoramic view is obtained through the distal anterior portal.
ENDOSCOPIC DISTAL BICEPS REPAIR
e787
Table 2. Technical Pearls for Key Steps of Procedure Step
Pearls
Portals and visualization
The parabiceps portal is placed with a 3-mm sheath, and a gentle insertion technique is necessary to prevent damage to the radial vessels. Inferior angulation is crucial, and any resistance to insertion should caution the surgeon against deeper penetration. Initial viewing through the parabiceps portal should be performed with air insufflation. This provides excellent views of the pathoanatomy and prevents soft-tissue swelling. The distal anterior portal should be placed directly above the tuberosity. Sonographic marking and digital palpation while viewing from the parabiceps portal are necessary for precise placement. A 2.9-mm 30 arthroscope is preferred for ease of placement and provides good visualization. A 70 arthroscope provides excellent views and is beneficial in partial tears for visualization of the posteromedial aspect of the radial tuberosity. Cannula placement The cannula is placed in the working distal anterior portal by gently retracting tissue with a retractor to protect the soft tissues. Usually, a short cannula is useful (Twist-In cannula, 6 mm 7 mm, or CapsLock cannula [ArthroCare, Sunnyvale, CA], 8.2 mm 35 mm). A good alternative to the regular cannula is the disposable sheath of a Bio-Interference screw (6 mm 23 mm; Arthrex). The distal hood of the sheath is useful for protection of surrounding soft tissues. The sheath may be sectioned externally to a shorter length for use of small-joint instruments (shown in Fig 4). Radial tuberosity preparation Tuberosity preparation is performed with a 3.5-mm shaver and burr (Sabre; Arthrex) through the cannula (Twist-In cannula, 6 mm 7 mm). A small-joint 3-mm shaver and burr (Arthrex) are useful, and their application is less aggressive; however, these cannot be passed through a cannula of regular length. Hence, a short cannula should be used (Caps-Lock cannula, 8.2 mm 35 mm). The shaver and burr are placed with the hood facing the soft tissues to prevent any neurovascular injury. Radiofrequency may be used for debridement; however, this is best avoided to protect the neurovascular structures in a limited potential space. Anchor placement and tendon stitching A titanium screw-inetype anchor (2.8-mm FasTak) provides good purchase into the tuberosity. The anchor eyelet must be subcortical, and this is ensured under endoscopic vision. Two anchors provide an optimal repair strength. The whipstitch is placed at 2 levels to ensure a 10- to 15-mm contact area between the tendon and bone. The anchors are placed in the ulnar aspect of the radial tuberosity to re-create the original footprint. An image intensifier is used to confirm anchor position and depth. Tendon docking and final assessment The sliding mechanism of the suture anchors is used for tendon docking. The free suture of each anchor is pulled, and the whipstitched sutures and the tendon are drawn onto the tuberosity. Endoscopic viewing through the parabiceps portal is necessary to confirm the adequacy of tendon approximation to the tuberosity. Both portals are used for viewing to confirm correct tensioning of the tendon. The parabiceps portal gives an end-on view of the tendon-bone construct, whereas the direct anterior portal provides a panoramic view of the tendon (Fig 9).
Initially, air is injected through a 50-mL syringe to prevent fluid extravasation. The distal biceps tendon is visualized along the ulnar aspect of the field, and the soft-tissue sleeve of the biceps is seen forming the roof of the tract. The radial tuberosity forms the floor of the region, and the avulsed footprint of the biceps is clearly visualized. The forearm is supinated and pronated to ascertain the radial and ulnar boundaries of the radial tuberosity. Next, the arthroscope is passed ulnar to the radial tuberosity; this view shows any remaining attached fibers of the biceps sheath or the “pseudotendon” of the distal biceps (Fig 3). Step 3: Distal Anterior Portal Placement The distal anterior portal is placed at the level of the sonographic marking of the radial tuberosity and is at
the radial one-third of the forearm width at this level. The level is further confirmed with digital palpation while the surgeon is viewing from the parabiceps portal. The length of the skin incision is approximately 8 mm and is sufficient to accommodate a 6- to 8-mm cannula (Twist-In cannula, 6 mm 7 mm; Arthrex, Naples, FL). Direct viewing through this portal is not necessary, and hence the size of the skin incision can be kept to the minimum necessary for cannula placement. Blunt dissection is performed with small retractors to retract the brachioradialis radially, and the flexor carpi radialis is retracted ulnarly. The superficial branch of the radial nerve is safe under the brachioradialis, and the radial artery is retracted to the ulnar side. A short 6or 8-mm cannula is passed through this portal and is used as a working portal (Fig 4).
e788
D. N. BHATIA
Fig 2. (A) The parabiceps portal (P) is created by passing the arthroscopic sheath in a distal direction toward the tuberosity (Tu) and is angled approximately 20 inferomedially. The sheath is parallel to the distal biceps tendon (Tn), and the passage should be smooth without any resistance. A 50-mL syringe (Sy) is used to insufflate the space with air, and a diagnostic endoscopy is performed. (B) Anatomic relations of the parabiceps portal (P) are shown in a left cadaveric elbow as viewed from the radial aspect. At the entry point (P), the arthroscopic sheath is above and lateral to the distal biceps (BM) and tendon (Tn). The lateral cutaneous nerve (LN) is seen exiting under the biceps muscle (BM) and is 5 to 10 mm away from the portal site (white arrow). One should note the inferior angulation of the arthroscope as it courses parallel to the distal biceps tendon (Tn); this angulation places the sheath below the radial and recurrent radial arteries (Ra, black arrow). The arteriovenous arcade (black arrow, asterisk) is in close approximation to the arthroscope sheath. The distal anterior portal (D) is placed in the internervous plane between the flexor carpi radialis muscle (FCR) and brachioradialis muscle (BRD). (C) Anatomic relations of the parabiceps portal (P) are shown in a left cadaveric elbow as viewed from the ulnar aspect. At the entry point (P), the arthroscopic sheath is above and lateral to the distal biceps muscle (BM) and tendon. One should note the inferior angulation of the arthroscope as it courses below the radial and recurrent radial arteries (Ra, asterisk). The arteriovenous arcade (white arrow, asterisk) is visualized from this aspect and is in close approximation to the arthroscope sheath. (D) Anatomic relations of the parabiceps portal (P) are shown in a left cadaveric elbow as viewed in the coronal plane. At the entry point (P), the arthroscopic sheath is above and lateral to the distal biceps muscle (BM) and tendon. One should note the medial angulation of the arthroscope as it courses below the radial and recurrent radial arteries (Ra, asterisk). The arteriovenous arcade (white arrow, asterisk) is visualized from this aspect and is in close approximation to the arthroscope sheath. The distal biceps tendon is seen attaching (white arrow) to the radial tuberosity through the distal anterior portal (D). (Ar, arthroscope; Br, brachial vessels; BRD, brachioradialis muscle; BM, biceps muscle; CV, cephalic vein; DP, distal portal; DS, distal; FCR, flexor carpi radialis muscle; L, lacertus fibrosus; LN, lateral cutaneous nerve; M, medial epicondyle; PX, proximal; R, radial; U, ulnar.)
Step 4: Tendon Preparation The distal biceps tendon is identified as a thick, white, bulbous structure seen along the ulnar aspect of the space. In acute ruptures, a hematoma may be seen within the tendon sheath. A part of the tendon sheath is in continuity with the tuberosity, and dynamic movement of the forearm facilitates identification. A 3mm grasper (Arthrex) is introduced through the short cannula or may be directly inserted through the distal anterior portal. The distal biceps tendon is grasped and retrieved out through the distal anterior portal directly, and a looped suture is used to prevent retraction. The
frayed end is excised, and the tendon is held retracted externally for the next 2 steps (Fig 5). Step 5: Tuberosity Preparation The radial tuberosity is prepared before tendon reattachment. A small-joint shaver (3 mm; Arthrex) is used to debride the soft-tissue remnants on the tuberosity until bare bone is visualized. Tuberosity rotation is used to identify and debride the entire tuberosity to provide an optimal surface for tendon healing after reattachment. Thereafter an arthroscopic burr (3 mm; Arthrex) is used to lightly decorticate the
ENDOSCOPIC DISTAL BICEPS REPAIR
e789
Fig 3. Diagnostic tendoscopy of left distal biceps tendon region. (A) The arthroscope is placed in the parabiceps portal and is positioned halfway along the portal tract. The distal biceps tendon (Tn) is seen along the ulnar (U) aspect, and the brachioradialis muscle (BRD) is seen on the radial (R) aspect. The radial tuberosity (RT) is seen in the depth of the field and is under the softtissue sleeve of the biceps tendon (BS). (B) The arthroscope is placed in the parabiceps portal and is positioned adjacent to the radial tuberosity. The avulsed footprint (arrows) of the distal biceps on the tuberosity is visualized. The biceps sleeve forms the arched roof of the space. The ulnar-most aspect of the tuberosity and the distal-most tip of the biceps are not visualized from this position. (C) The arthroscope is placed in the parabiceps portal and is positioned ulnar to the radial tuberosity. The bulbous distal end of the biceps is visualized, and the narrow remnant fibers (arrows) are seen extending to the posteromedial aspect of the tuberosity. (D) The arthroscope is placed in the parabiceps portal and is positioned ulnar to the radial tuberosity to visualize the posteromedial aspect of the radial tuberosity. The attachment of any remnant or pseudotendon (ST, arrows) of the distal biceps is visualized and confirmed with pronation-supination.
tuberosity in a radial-to-ulnar direction. Throughout this step, the blades are used with their hooded part facing the superior aspect; this is necessary to prevent any neurovascular damage (Fig 6). Step 6: Anchor Placement Anchor placement is performed after adequate tuberosity debridement. The distal anchor is placed first and should be inserted as ulnarly on the radial tuberosity as possible. Forearm rotation is used to identify this region, and an anchor sleeve (3 mm; Arthrex) is placed through the cannula onto this zone. A 2.8-mm anchor (FasTak;
Arthrex) is inserted until the marking on the inserter is flush with the cortical surface. The inserter is removed, and the subcortical placement of the eyelet is confirmed. The proximal anchor is placed next, and a distance of 10 to 15 mm is necessary to provide an adequate fixation area. The sutures of both anchors are held segregated outside the distal portal (Fig 7). Step 7: Tendon Locking Stitch One suture from each anchor is used to whipstitch the distal biceps tendon across the breadth. The distal anchor suture is passed first and stitches the tendon for
e790
D. N. BHATIA
Fig 4. Overview of the 2 portals used for distal biceps repair. The distal anterior portal (DP) is created using a 6- to 8-mm skin incision adjacent to the sonographically marked tuberosity (Tu). Blunt dissection is performed down to the radial tuberosity, and a short 6- to 8-mm cannula (Cn) is placed through this portal. The parabiceps portal (P) is the viewing portal and the distal anterior portal is the working portal for the entire procedure. (Ar, arthroscope; BM, biceps muscle; Tn, distal biceps tendon.)
pulling on the free suture of each anchor. The 2 locking stitches permit a 10- to 15-mm contact area between the tendon and the tuberosity. Thereafter nonsliding knots are used to secure the tendon to the tuberosity. The distal knot is tied first, followed by the proximal knot. A final assessment of the repair integrity is performed by moving the forearm into full pronation and supination and moving the elbow into flexion and extension; a panoramic view of the repaired tendon is possible by now switching the arthroscope into the distal anterior portal for the dynamic assessment (Fig 9). Biplanar imaging, using an image intensifier, is necessary to confirm the position of the anchors within the radial tuberosity (Fig 10). The portals are closed, and the tourniquet is deflated. A bulky dressing is used for the first 2 postoperative days and is changed to a lighter portal-site dressing thereafter. A sling is used for 3 to 4 weeks and then discarded. The rehabilitation protocol involves early passive and active range-of-motion exercises (weeks 4 to 6), and strengthening commences after the sixth week. Return to heavy work and sports is permitted only after 3 months of rehabilitation.
Discussion approximately 10 mm. The proximal anchor suture is passed next, for another 10 mm proximal to the previous whipstitch. The second remaining suture of each anchor can now be used to pull the tendon onto the prepared tuberosity (radial tuberosity) through the distal portal (Fig 8). Step 8: Tendon Docking and Nonsliding Knots The sliding mechanism of the anchors is used to dock the tendon onto the tuberosity. This is achieved by
Distal biceps tendon repair is currently performed through an open single incision or by a 2-incision technique. Anterior open repair alone may potentially injure the posterior interosseous nerve, and the 2-incision technique is associated with heterotopic bone formation.8-13 The described endoscopic technique was developed to improve visualization and optimize the repair process to reduce potential complications associated with open and endoscopicassisted procedures. Endoscopic distal biceps repair is technically challenging because of the complex
Fig 5. (A) Retrieval of left distal biceps tendon region. The arthroscope is placed in the parabiceps portal and is positioned ulnar to the distal biceps (Tn). The biceps tendon is identified as a bulbous structure on the ulnar aspect of the view. A grasper (Gr) is introduced through the distal portal, and the tendon is grasped. (B) The tendon (Tn) is retrieved through the distal anterior portal (DP) and is held with a looped suture to prevent retraction. One should note that the tendon end is frayed and thin and should be excised before repair. (Ar, arthroscope; BM, biceps muscle; P, parabiceps portal; R, radial; U, ulnar.)
ENDOSCOPIC DISTAL BICEPS REPAIR
e791
Fig 6. (A) Tuberosity (RT) preparation (left elbow, viewed through parabiceps portal) is initiated with an arthroscopic shaver (Sh) placed through the distal anterior portal. A large amount of the tuberosity surface is debrided, and the radial (R) and ulnar (U) limits are identified (arrows) by forearm rotation. (B) Tuberosity (RT) preparation (left elbow, viewed through parabiceps portal) is continued, and decortication of the radial tuberosity is performed with an arthroscopic burr (Br). The hood of the instrument is used to protect the ulnar and superior soft tissues.
anatomy of the cubital fossa, as well as the presence of vital neurovascular structures.14 The bicipital tuberosity is seated deep under the bulk of the forearm musculature, and the brachial and radial arteries are in close approximation. The endoscopic-assisted techniques described in the literature are mostly endoscopic viewing techniques of open approaches; these have used a 3- to 5-cm anterior incision, and the endoscope is used directly through the incision to
obtain a better magnified view of the anatomy and repair. A “true” endoscopic technique would involve visualization of the entire pathoanatomy without using a mini-open approach, and each step of the repair process would be under endoscopic vision for optimal safety and precision. Currently, the described portals for endoscopy in this region cannot visualize the entire repair process unless the procedure is viewed through the open anterior incision approach; hence a viewing
Fig 7. (A) Anchor placement (left elbow, viewed through parabiceps portal). The distal anchor (An1) is placed first in the distal region of the radial tuberosity (RT) by use of an anchor sleeve (SL). The placement should be in the ulnar region and approximately beyond the central zone across the breadth of the tuberosity. (B) The distal anchor is seen placed flush with the cortex (arrow) and in the central-ulnar zone of the radial tuberosity. Sutures are retrieved externally through the distal anterior working portal. (C) Anchor placement (left elbow, viewed through parabiceps portal). The proximal anchor (An2) is placed after the distal anchor (An1) in the proximal region of the radial tuberosity (RT) by use of an anchor sleeve (SL). The placement should be in the central-ulnar region. The anchors should be placed at a distance of 10 to 15 mm from each other (arrow). (R, radial; U, ulnar.)
e792
D. N. BHATIA
Fig 8. The distal biceps tendon (Tn) is stitched using a locking configuration at 2 levels. One suture from the distal anchor (upper suture of An1) is used to whipstitch the tendon for approximately 10 mm. Similarly, one suture from the proximal anchor (upper suture of An2) is used to whipstitch the tendon for another 5 to 10 mm proximal to the previous whipstitch. The remaining suture from each anchor (lower suture of An1 and lower suture of An2) is used to dock the tendon onto the radial tuberosity. (An1, distal anchor; An2, proximal anchor; BM, biceps muscle; DP, distal anterior portal; P, proximal parabiceps viewing portal.)
portal was developed to facilitate and optimize biceps tendon endoscopy and repair. The proximal anterolateral parabiceps portal is a portal for endoscopic repair and visualization around the distal biceps tendon. This portal is placed parallel to the orientation of the distal biceps tendon and is at a safe distance from the lateral cutaneous nerve at the
Fig 10. Biplanar imaging shows the correct positioning of the anchors within the radial tuberosity. The anchors are placed on the ulnar aspect of the tuberosity at a distance of 10 mm from each other. The anchor eyelets are subcortical. (An1, distal anchor; An2, proximal anchor; H, humerus; R, radius; UL, ulna.)
entry point. The radial vessels are close to the portal tract, and correct angulation is necessary to avoid damage to these vessels. The presence of the biceps tendon maintains a barrier between the sheath and medial neurovascular structures. In a preliminary anatomic study, the author has evaluated the safety of this portal, and the radial vessels were not damaged when sufficient inferior angulation and approximation to the biceps tendon were maintained (unpublished data, Bhatia et al., 2015). The author has used this portal safely in several cases of distal biceps endoscopy and repair, and no complications have been
Fig 9. (A) The distal biceps tendon (Tn) is seen securely docked onto the prepared radial tuberosity (asterisk). The distal anchor sutures (An1) are tied first using a knot pusher (KP), and a nonsliding distal knot (K1) is placed through the distal anterior portal (left biceps, viewed through parabiceps portal). (B) The distal biceps tendon is seen securely docked onto the radial tuberosity. The proximal anchor sutures are tied after the distal knot (K1) is placed using a knot pusher and a second nonsliding knot (K2) is placed through the distal anterior portal. The arrows show the distance between the 2 anchors, and this length of tendon is now in approximation with the radial tuberosity (left biceps, viewed through parabiceps portal). (C) Final view of repaired distal biceps tendon. The repaired tendon is dynamically assessed by viewing through the distal portal. This portal provides a panoramic view of the tendon-tuberosity construct. The distal (K1) and proximal (K2) nonsliding knots are shown before the remaining sutures are cut (left biceps, viewed through distal anterior portal). (D, distal; P, proximal; R, radial; U, ulnar.)
e793
ENDOSCOPIC DISTAL BICEPS REPAIR Table 3. Advantages and Pitfalls of Technique Advantages The endoscopic distal biceps repair described in this article is a true endoscopic technique. The entire procedure is performed while viewing through a 3-mm parabiceps portal and working through a distal anterior 8-mm portal. This minimizes the risks associated with larger incision repair techniques. Optimal tuberosity preparation and tendon-bone approximation will result in improved healing of the ruptured tendon. Small-joint instruments and motorized blades are easy to maneuver within the restricted space and permit adequate tendon and bone preparation. Suture anchors are used for fixation, and this avoids the need for bicortical drilling and retrieval associated with EndoButton fixation techniques. The step-by-step approach simplifies the procedure and shortens the learning curve for the technique. Pitfalls Precise parabiceps portal placement is crucial. The radial recurrent vessels and the lateral cutaneous nerve are in close proximity to the portal tract. Inadequate angulation of the sheath can result in damage to the radial vessels. The lateral cutaneous nerve may be damaged at its exit between the biceps and brachialis muscles if the portal is too proximal and lateral. It is recommended that surgeons explore this technique in cadavers before performing surgery. The distal anterior portal may potentially damage the radial artery and the superficial branch of the radial nerve. The portal should be created in the safe internervous plane as described, and a cannula should be placed. All instruments should be introduced through the cannula. Additional retractors should be used if soft tissues are in the field of vision. Motorized arthroscopic shavers and burrs can damage surrounding soft tissues. This may be avoided by (1) using a short cannula through the distal anterior portal, (2) using small-joint shavers and burrs (2 or 3 mm; Arthrex), (3) using the hood of the blades to protect the tissues, and (4) remembering that the blades must be used under direct endoscopic viewing at all times. Fluid extravasation into the forearm and a potential increase in compartment pressures are possible. These risks are minimized by using air as an insufflation medium for the initial diagnostic endoscopy. Fluid inflow must be minimized by using gravity inflow instead of a fluid pump. Compartment pressures may be monitored if the forearm is tense and swollen excessively. Rerupture of the repaired biceps tendon can rarely occur. The risk is minimized by paying careful attention to each step described in the technique. Incorrect knot tying results in poor tendon-bone contact. Poor postoperative compliance with the rehabilitation protocol, smoking, and early return to sports are risk factors for tendon rerupture.
encountered so far. However, it is recommended that surgeons should familiarize themselves with the anatomy and technique in cadavers before performing this procedure in the operating room. The distal anterior portal provides direct access to the tuberosity through the internervous plane between the flexor carpi radialis (median nerve) and the brachioradialis (radial nerve) muscles. An 8-mm incision is sufficient to dissect this plane, and a 6- to 8-mm cannula is passed for instrumentation. Additional retractors may
be used to protect the neurovascular structures during the procedure. The indications for the 2-portal technique in elbow surgery are as follows: (1) diagnostic biceps exploration, (2) debridement of low-grade partial tears of the distal biceps tendon, (3) detachment and repair of high-grade partial tears of the distal biceps tendon, and (4) repair of acute complete distal biceps tendon ruptures. The overall advantages and pitfalls of the procedure are summarized in Table 3.
References 1. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am 1985;67:414-417. 2. Watson JN, Moretti VM, Schwindel L, Hutchinson MR. Repair techniques for acute distal biceps tendon ruptures: A systematic review. J Bone Joint Surg Am 2014;96:20862090. 3. Phadnis J, Bain G. Endoscopic-assisted distal biceps footprint repair. Tech Hand Up Extrem Surg 2015;19:55-59. 4. Greenberg JA, Fernandez JJ, Wang T, et al. EndoButtonassisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg 2003;12:484-490. 5. Grégory T, Roure P, Fontès D. Repair of distal biceps tendon rupture using a suture anchor: Description of a new endoscopic procedure. Am J Sports Med 2009;37:506511. 6. Eames MJ, Bain GI. Distal biceps tendon endoscopy and anterior elbow arthroscopy portal. Tech Shoulder Elbow Surg 2006;7:139-142. 7. Sharma S, MacKay G. Endoscopic repair of distal biceps tendon using an EndoButton. Arthroscopy 2005;21:897.e1897.e4. 8. Cohen MS. Complications of distal biceps tendon repairs. Sports Med Arthrosc 2008;16:148-153. 9. Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal biceps rupture using the modified two-incision technique. J Shoulder Elbow Surg 2008;17:67S-71S (suppl). 10. Ruch DS, Watters TS, Wartinbee DA, Richard MJ, Leversedge FJ, Mithani SK. Anatomic findings and complications after surgical treatment of chronic, partial distal biceps tendon tears: A case cohort comparison study. J Hand Surg Am 2014;39:1572-1577. 11. Hinchey JW, Aronowitz JG, Sanchez-Sotelo J, Morrey BF. Re-rupture rate of primarily repaired distal biceps tendon injuries. J Shoulder Elbow Surg 2014;23:850-854. 12. Vidal AF, Koonce RC, Wolcott M, Gonzales JB. Extensive heterotopic ossification after suspensory cortical fixation of acute distal biceps tendon ruptures. Arthroscopy 2012;28:1036-1040. 13. Lo EY, Li CS, Van den Bogaerde JM. The effect of drill trajectory on proximity to the posterior interosseous nerve during cortical button distal biceps repair. Arthroscopy 2011;27:1048-1054. 14. Eames MHA, Bain GI, Fogg QA, et al. Distal biceps tendon anatomy: A cadaveric study. J Bone Joint Surg Am 2007;89: 1044-1049.
