Distal Biceps Repair Using a Unicortical Intramedullary Button Technique: A Case Series  Nathan A. Monaco, MD, Alexander J. Duke, BS, Meghan W. Richardson, MD, David E. Komatsu, PhD, Edward D. Wang, MD  Journal of Hand Surgery Global Online  Volume 1, Issue 3, Pages 178-184 (July 2019) DOI: 10.1016/j.jhsg.2019.03.003 Copyright © 2019 The Authors Terms and Conditions

Figure 1 A Incision marking in the region of the radial tuberosity that is approximately 3 to 4 cm distal to the flexion crease of the antecubital fossa. B A number 2 looped nonabsorbable running locking suture is placed into the free end of the tendon. C Free ends of the suture are clamped and set aside. D Using deep skin retractors as needed, the footprint of the biceps tendon on the radial tuberosity is visualized and the LABCN is protected, usually with a freer elevator. E, F Under direct visualization, a pin is placed into the center of the radial tuberosity before a 4.5-mm cannulated drill bit is used to create a unicortical drill hole. G Sutures have been passed through the Endobutton but not the tendon. H Sutures have been passed through the Endobutton and are then passed back through the biceps tendon so that the knot can be on top. I The Endobutton is placed directly into the proximal radial intramedullary canal and the sutures are sequentially tensioned, which allows the tendon to be reduced down to the surface of the bone rather than pulled through into the intramedullary canal. J Sutures are ready to be tied with the assistance of an arthroscopic knot pusher. K Example of a completed repair. (Note: In A, B, G, H, and I, a block with color has been placed over the skin in the image to remove patient-identifying markings.) Journal of Hand Surgery Global Online 2019 1, 178-184DOI: (10.1016/j.jhsg.2019.03.003) Copyright © 2019 The Authors Terms and Conditions

Figure 2 Intraoperative A lateral and B anteroposterior imaging of a patient undergoing volar incision with placement of a unicortical intramedullary suture button technique for distal biceps tendon repair. The long axis of the Endobutton is currently being manipulated to align with the long axis of the radius. Journal of Hand Surgery Global Online 2019 1, 178-184DOI: (10.1016/j.jhsg.2019.03.003) Copyright © 2019 The Authors Terms and Conditions

Figure 3 Sample clinical construct illustrating placement of a unicortical intramedullary suture button technique for distal biceps tendon repair. A Prepared distal bicep tendon edge with intramedullary button placement. B Distal bicep repair to the radial tuberosity after passing the free suture limbs through the distal bicep tendon a final time and tensioning the construct with knot tying. This intramedullary position of the button differs from the extramedullary technique described by Bain et al.13 Journal of Hand Surgery Global Online 2019 1, 178-184DOI: (10.1016/j.jhsg.2019.03.003) Copyright © 2019 The Authors Terms and Conditions

Figure 4 Postoperative A anteroposterior and B lateral radiographs of a patient undergoing volar incision with placement of a unicortical intramedullary suture button technique for distal biceps tendon repair. Journal of Hand Surgery Global Online 2019 1, 178-184DOI: (10.1016/j.jhsg.2019.03.003) Copyright © 2019 The Authors Terms and Conditions