1. Distal Biceps Injury: Surgery and Rehabilitation Caroline Chebli, MD Kennedy-White Orthopaedic Center

2. Distal Biceps Tears Caused by the elbow being forced straight against resistance (eccentric load) Caused by the elbow being forced straight against resistance (eccentric load) Most commonly seen in men 40-60 yrs old-86% in dominant arm Most commonly seen in men 40-60 yrs old-86% in dominant arm Incidence 1.2/100,000 people per year Incidence 1.2/100,000 people per year Rare in women Rare in women 7.5x incidence in smokers 7.5x incidence in smokers

3. Distal Biceps Tear Results in 30% loss of flexion strength 40% loss of supination strength Best if done within a few weeks of injury

4. Hook Test O’Driscoll et al O’Driscoll et al Elbow flexed 90 degrees Elbow flexed 90 degrees Forearm supinated Forearm supinated Examiner hooks biceps with finger from lateral side Examiner hooks biceps with finger from lateral side 100% sensitivity and specificity 100% sensitivity and specificity

5. Fixation Techniques Repair needs to withstand 50N of force=force on biceps with elbow flexed to 90 degrees Repair needs to withstand 50N of force=force on biceps with elbow flexed to 90 degrees 1kg weight, force at 90 degrees is 112N 1kg weight, force at 90 degrees is 112N Takes 204N to rupture a distal biceps Takes 204N to rupture a distal biceps

6. Fixation Techniques Two-Incision (Boyd-Anderson) Two-Incision (Boyd-Anderson) One Incision One Incision El-Hawary, et al. J Hand Surg Am. 2003;28:496-502. Mckee et al. J Shoulder Elbow Surg 2005;14:302-306. Kelly et al. JBJS Am. 2000;82:1575-1581

7. One-Incision Technique Originally an S-shaped Henry approach Originally an S-shaped Henry approach –Extensile –High rate of nerve injuries Now a smaller incision distal to the flexor crease is utilized Now a smaller incision distal to the flexor crease is utilized –Lower complication profile –Fixation techniques: suture anchor repair, cortical button, interference screw, hybrid technique

8. One Incision Technique Pros Pros –Direct approach, avoids PIN injury (?) –Lower risk of HO and radioulnar synostosis Cons Cons –May injure radial nerve –LABC nerve injury

9. 2-Incision Technique Originally described by Boyd and Anderson Originally described by Boyd and Anderson Modified by Kelley et al. Modified by Kelley et al. Small transverse incision antecubital fossa Small transverse incision antecubital fossa Retrieve tendon and palpate radial tuberosity Retrieve tendon and palpate radial tuberosity Curved clamp to identify dorsal surface Curved clamp to identify dorsal surface Split ECU Split ECU Repair via bone tunnels Repair via bone tunnels

10. Two Incision Technique Pros Pros –Limits anterior exposure/limits pain –Reduces injury to radial nerve –Reduces injury to LABC nerve Cons Cons –May have to detach supinator –Radioulnar synostosis risk

11. My Preferred Technique Tension Slide Technique Utilizing a Biceps Button Tension Slide Technique Utilizing a Biceps Button 1-incision 1-incision –4cm incision 4cm distal to flexor crease

12. Biceps Button Fiberloop suture distal 2 cm of biceps tendon Fiberloop suture distal 2 cm of biceps tendon

13. Biceps Button Exposure Exposure –Between brachioradialis (radial) and pronator teres (ulnar) –Limit traction on LABC nerve under BR

14. Biceps Button Maximally supinate forearm Maximally supinate forearm Expose radial tuberosity Expose radial tuberosity

15. Biceps Button Bicortical Pin Bicortical Pin –3.2 mm guide pin bicortical through center of radial tuberosity –Aim 30 degrees ulnar and proximal to avoid PIN –8mm unicortical hole –Irrigate

16. Biceps Button Thread the Biceps Button Thread the Biceps Button

17. Biceps Button Insert the Biceps Button Insert the Biceps Button –Hold all 4 strands and use button inserter –Flip button and slide tendon into 8mm unicortical hole

18. Biceps Button Insert 7x10 tenodesis screw Insert 7x10 tenodesis screw Push tendon ulnar Push tendon ulnar

19. Post Operative Care Splint arm at 90 degrees for 10 days to 2 weeks Splint arm at 90 degrees for 10 days to 2 weeks Place in removable elbow brace and lock at 90 degrees Place in removable elbow brace and lock at 90 degrees

20. 2-6 Weeks Hinged elbow brace at all times Hinged elbow brace at all times Remove for home exercises 3 times a day Remove for home exercises 3 times a day If not progressing well at 4 weeks with HEP will send to PT for ROM If not progressing well at 4 weeks with HEP will send to PT for ROM Passive ROM Passive ROM –Full flexion/extension/pronation/ supination supination

21. 2-6 weeks Shoulder ROM while in brace Shoulder ROM while in brace Hand and wrist ROM Hand and wrist ROM

22. 6 Weeks-3 Months Active and active assisted elbow ROM Active and active assisted elbow ROM Forearm strengthening Forearm strengthening Shoulder ROM Shoulder ROM Scapular stabilizer strengthening Scapular stabilizer strengthening 5 lb weight limit 5 lb weight limit

23. 3 Months Elbow, wrist, hand, and shoulder strengthening Elbow, wrist, hand, and shoulder strengthening 5 lb weight increase per week 5 lb weight increase per week

24. 5-6 Months Return to full activity Return to full activity

25. Thank You