Chronic Distal Biceps Repair With an Achilles Allograft David Y. Ding, M.D., William E. Ryan, B.S., Eric J. Strauss, M.D., Laith M. Jazrawi, M.D.  Arthroscopy Techniques  Volume 5, Issue 3, Pages e525-e529 (June 2016) DOI: 10.1016/j.eats.2016.02.016 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 In cases of biceps tendon rupture greater than 4 weeks, a modified Henry approach is used to gain exposure for potential allograft reconstruction. A vertical incision is made 3 fingerbreadths in length distal to the antecubital crease on the lateral aspect of the forearm. The incision is extended through the antecubital crease and proximally on the medial aspect of the arm as necessary. This extensive incision allows for wide exposure in cases where the biceps tendon may be retracted from its normal anatomic insertion at the radial tuberosity. Arthroscopy Techniques 2016 5, e525-e529DOI: (10.1016/j.eats.2016.02.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Diligent exposure is critical in cases of chronic distal biceps tears as surrounding structures may be obscured because of fibrosis. The neurovascular bundle of the median nerve can be seen here, encased in scar tissue medial to the distal biceps tendon insertion. Adequate dissection and identification of the distal biceps tendon stump allows for approximation of the length discrepancy between the retracted tendon and the distance to the radial tuberosity. Arthroscopy Techniques 2016 5, e525-e529DOI: (10.1016/j.eats.2016.02.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Adequate visualization of the radial tuberosity is achieved using a 3-position retraction technique. Army-navy retractors are used instead of Hohmann retractors to avoid excessive traction ulnarly due to the risk of posterior interosseous nerve injury. Arthroscopy Techniques 2016 5, e525-e529DOI: (10.1016/j.eats.2016.02.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 Distal fixation of the Achilles allograft into the bicipital tuberosity tunnel should be performed first because this makes achieving appropriate tensioning easier later in the procedure. Fixation occurs with the arm flexed to 45° and alternatively tensioning each suture limb until the allograft is fully seated into the drill tunnel. Fluoroscopy is used to ensure proper positioning of the tension slide button deep to the bicipital tunnel. Arthroscopy Techniques 2016 5, e525-e529DOI: (10.1016/j.eats.2016.02.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 After distal fixation of the allograft, proximal fixation is achieved. An incision is made in the midline of the Achilles and the graft is draped over the native biceps. Allis clamps are used to facilitate adequate positioning and the graft is fixed to the native biceps using a No. 2 FiberWire sutured in a Krakow fashion. The arm is flexed to 60° to achieve proper tension. Arthroscopy Techniques 2016 5, e525-e529DOI: (10.1016/j.eats.2016.02.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 The final repair construct with the Achilles allograft can be seen fixed distally into the biciptial tunnel using an EndoButton, and proximally sutured into the native biceps tendon using a No. 2 FiberWire in a Krakow fashion. Allograft reconstruction allows successful restoration of tendon length and avoids flexion contractures in cases of chronic distal biceps rupture. Arthroscopy Techniques 2016 5, e525-e529DOI: (10.1016/j.eats.2016.02.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions