Mini 2 Incison for
Acute Distal Biceps
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| Kelly 2002 | Drosdowech 2002 |
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Partial or complete tear of distal biceps less than 3 weeks old.
See text on acute distal biceps rupture
Mini incision is contraindicated in chronic tears (> 3 weeks), the tendon becomes adherent to the surrounding tissue proximally and the tunnel to the bicipital tuberosity closes.
Patients who have delayed repair require more anterior dissection and may require a tendon graft to restore length.
A two-incision technique risks radioulnar synostosis or posterior interosseous nerve injury.
Radioulnar synostosis is unlikely if careful technique is used, avoid the spillage of bone dust, avoid the ulna and thoroughly washout the wound each time the bone is drilled or burred.
Deirmengian et al reviewed the literature 2006, the data showed good to excellent results with both, 2-incision modified Boyd-Anderson approach with transosseus suture fixation and 1-incision anterior approach with alternative fixation methods.
To see single incision technique with suture anchor or endobutton, or interference screw fixation.
Supine, arm board.
The key to using a mini-incision anteriorly is, milk the biceps distally and apply a tourniquet as high as possible on the arm to force the distal end of the biceps further distally.
2 - 3cm transverse incision centred in the antecubital crease.
Avoid subcutaneous veins and the lateral antebrachial cutaneous nerve.
The lateral antebrachial cutaneous nerve should lie lateral to incision.
Milk biceps to deliver tendon stump into the wound.
If it does not emerge, it can be extracted with a finger.
Place a stay-suture in the tendon stump to control the tendon and avoid crushing it with a forceps.
Trim the ragged, degenerative, end of the tendon to fresh, healthy tendon.
Weave a Krackow suture up and down the tendon to produce four strands, using two strong nonabsorbable sutures (No. 2 or No. 5).
Identify the radial tuberosity through the anterior incision.
If the repair is performed less than 10 days after injury, the tract or tunnel to the tuberosity is easily identifiable and can be followed with the small finger.
While the tuberosity is palpated through the anterior incision, a large, blunt, curved haemostat is carefully inserted over the finger into the space previously occupied by the biceps tendon.
Slip the instrument past the tuberosity till you feel its tip on the dorsal aspect of the proximal forearm.
Make a 4-cm incision centred over tip of the instrument.
Alternatively to passing the haemostat, the tuberosity can be palpated posteriorly, just antero-lateral to the ulna, with the forearm in full pronation.
A 4-cm incision is then made centred over the radial tuberosity and 1 cm anterolateral to the subcutaneous border of the ulna.
Identify the fascia of extensor digitorum communis and split longitudinally in line with the skin incision, avoiding the subcutaneous border of the ulna.
With the forearm fully pronated to protect the posterior interosseous nerve, the supinator fascia is identified and split longitudinally over the radial tuberosity.
The ulna is never exposed.
Once the radial tuberosity is exposed, debride any residual soft tissue.
Using a burr create a bone trough in the radial tuberosity.
Excavate the cavity exposing the medullary canal of the proximal radius, creating a secure place for the tendon.
Drill three holes, 7 - 8 mm apart and 7 - 10 mm from the edge of the trough with the arm in slight pronation.
Irrigate copiously to remove bone dust.
Smooth the sharp leading edge of the radial bone trough to prevent irritation of the tendon with supination and pronation.
After the tuberosity preparation pull the tendon sutures out through the posterior incision.
Do this by placing a large curved haemostat through the anterior incision, moving the arm from supination to full pronation, passing it down to the tuberosity and out the posterior incision between the radius and ulna.
Grab a loop of suture with the curved clamp and pull back through the posterior incision and out through the anterior incision.
Place the sutures previously placed in the tendon stump through this loop and pull them back out the posterior incision.
Thread the strands of suture through the bone trough and out the drill holes, one at each of the proximal and distal holes and two out the middle hole.
Maintain the correct orientation of the tendon as it passes through the tunnel and into the bone trough.
Pull the tendon into the bone trough by supinating the forearm and pulling on the sutures.
Tie the sutures over the bone bridges.
Washout bone dust thoroughly and
close in layers.
Backslab in neutral
rotation and 90° of elbow flexion for comfort for 24 hours.
Kelly - in the presence of a secure repair early functional rehabilitation with immobilization limited to the first 36 hours.
Gravity assisted extension.
Passive and active assisted flexion and prono-supination exercises.
Sling for comfort 3 to 6 weeks to prevent a constant gravitational pull on the tendon.
Remove the sling frequently to permit full active and passive motion of the elbow and forearm.
Lift nothing heavier than cup of tea or telephone for 12 weeks.
From 3 to 6 months avoid violent force/ contact sports, begin strengthening against resistance. Unlimited activities after 6 months.
For the large Henry type of two-incision technique:
Overall incidence of complications 31%, including:
Sensory nerve paresthesias (7%) - lateral antebrachial cutaneous, and superficial radial nerve
Persistent anterior elbow pain (8%)
Heterotopic ossification (5%) that did not limit forearm rotation
Superficial infection (4%)
Re rupture (1%)
Loss forearm rotation (4%)
Reflex sympathetic dystrophy (1%)
Kelly reported no complications in 18 cases where small incision was used.
Posterior interosseous
nerve - At risk, pronating the forearm
will remove the nerve from the operative field. Take care positioning retractors/ Homan
along the superior edge of the radius, lift the supinator out of the way.
Radioulnar synostosis - avoid
subperiosteal exposure of the ulna and use copious irrigation to remove bone
dust.
Transverse in antecubital fossa
Deliver the distal biceps tendon and palpate the bicipital tuberosity.
Weave two No. 2 Ticron sutures in a Krackow fashion through the distal tendon stump (4strands).
Cut both arms of one suture shorter than the arms of the other pair to accurately identify each arm of the same suture for eventual tying over the bone bridge.
While palpating the bicipital tuberosity with the index fingertip, introduce a medium sized kelly forceps carrying the four sutures adjacent to the radial tuberosity with the curved end facing lateral.
Hold the forearm in maximal pronation to avoid injury to the posterior interosseous nerve.
Advance the forceps with the tendon sutures through the common extensor musculature while staying in contact with the radius and away from the ulna.
The key to preventing heterotopic bone formation is to avoid the subperiosteal ulnar interval, which is closer than one may expect.
Once the tip of the forceps is seen tenting the skin posterolaterally, make a 2 - 3 cm incision centred over the forceps.
Bluntly separate the extensor muscle group to expose the underlying bicipital tuberosity.
Use a burr to prepare a trough wide enough to allow the tendon to be docked into the radius.
Make three 2-mm drill holes 3 mm anterior to the trough, each separated by 5 mm, to avoid breaking the intervening bone bridge as the sutures are passed.
Pass the tendon sutures with a No. 5 Mayo needle through the trough and out the drill holes.
Place two sutures through the central hole, one proximally and one distally, so that each tendon suture is secured to a different bone bridge.
Advance the tendon into the trough with the elbow held at 90° flexion and full pronation, and tie the sutures over the bone bridge.
Maintain the forearm in maximal pronation throughout the procedure to best expose the docking site and to continue to protect the posterior interosseous nerve.
What is often not emphasized in descriptions of either
the one- or two-incision techniques is the difficulty
in attaining exposure of the operative site while at the
same time maintaining correct forearm and elbow position.
The surgeon may need one or two dedicated assistants
to carry out these procedures successfully.
Backslab 90° flexion and full supination for 1-2 days.
Physiotherapy - active assisted extension and supination and passive flexion and pronation.
As flexion increases beyond 90°, the reduced tension in the repair will permit unlimited pronation or supination.
Not to extend beyond the angle that the tendon was felt to be tight intraoperatively, typically 30°.
Increase elbow extension 10° degrees per week until full extension is achieved.
Unlimited active range of motion at 6 weeks.
No formal strengthening until 3
months.
The most commonly described nerve injury is paraesthesia of the lateral antebrachial cutaneous nerve, usually traction injury take care in the method and degree of retraction needed for ideal exposure.
Heterotopic ossification - avoid subperiosteal exposure of the ulna and damage to the interosseous membrane during tendon passage.
Drosdowech routinely uses Indomethacin 25 mg TDS for 3 weeks postoperatively to control pain, swelling, and limit the formation pf heterotopic ossification.
There is no evidence in the literature demonstrating the efficacy of Indomethacin in preventing heterotopic ossification in patients after distal biceps repair.
Personal observations
KELLY E W, O’DRISCOLL SW; Mini-Incision Technique for Acute Distal Biceps Tendon Repair; Techniques in Shoulder & Elbow Surgery 3(1):57–62, 2002
DROSDOWECH DS, FABER KJ, KING GJW; Distal Biceps Tendon Repair: One- and Two-Incision Techniques; Techniques in Shoulder & Elbow Surgery 3(2):90–95, 2002
Deirmengian G, Beredjiklian PK, Getz C, Ramsey M, Bozentka DJ; Distal Biceps Tendon Repair: 1-Incision Versus 2-Incision Techniques. Techniques in Shoulder & Elbow Surgery. 7(1):61-71, March 2006