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Spring AOAO Postgraduate Seminar
Nashville, TN
Kristopher Avant, D.O.
Anatomy
Treatment Options
Operative Techniques
Post-op Rehabilitation
Complications
Recertification / OITE Questions
Origin:
Long Head: Supraglenoid tubercle
Short Head: Coracoid
Insertion: Bicipital tuberosity
Lacertus fibrosus (bicipital aponeurosis)
Originates from distal tendon and blends ulnarly with forearm fascia
Innervation: Musculocutaneous nerve
Function: Elbow flexion & forearm supination
Musculotendinous Junction (Watershed)
Proximal portion of tendon - Supplied by the brachial artery
Insertion - Supplied by the posterior interosseous recurrent artery
Relative hypovascular zone
Functional Defecits
40% loss supination
15 - 30% loss flexion
Mild loss of grip strength
Decreased endurance
Treatment
Temporary immobilization
Pain management
Early PT
Partial Tears
Cosmesis
47 patients – 50 ruptures
40 repaired
10 non-op
Flexion (93% vs. 70%)
Supination (88% vs 59%)
Grip Strength – Not statistic. Sig.
Complications
1 I&D Suture Abscess
8 LABCN Transient
2 PIN Palsy - Resolved
14 H.O. - Did not limit function
J Shoulder Elbow Surg (2016) 25, 341–348
Single Incision
Dual Incision
Endoscopic
Suture vs. Various Anchor Configurations – Cost Analysis?
Timing – How it affects complication rate? Acute
Subacute
Chronic
2-incision technique
Endobutton vs. trans-osseous
F/U – 2.1 years
46 males
19 Endobutton - Sling
27 transosseous – Immobilized 6 weeks
Mean age 50 y.o.
No difference in post-op strength
30% LABCN
1 H.O. required Sx
6 incidental H.O.
1 wound infection
J Shoulder Elbow Surg (2015) 24, 928-933
J Shoulder Elbow Surg (2013) 22, 305-311
Location of the tears uniformly is on the radial side
Can be difficult to diagnose
MRI - FABS view vs. O’Driscoll Hook test?
How to treat?
Conservative Initially
Detachment and repair
17 patients – mean age 48 y.o.
Unilateral partial tears
Single incision – 13
Dual incision – 1
Posterior incision - 3
Min. 12 month F/U
2 - LABCN
1 - asymptomatic H.O.
1 partial re-rupture
JHS Vol35A, July 2010
Biceps tendon heals to cortical bone w/o intramedullary socket
Laboratory-derived evidence shows advantages of an anatomic repair through a 2-incision approach
Does this translate to differences that are meaningful to the patient?
More biomechanical studies needed
Autograft morbidity vs. Allograft cost
Choice of graft type
Risk of disease transmission
Slow time for incorporation
Tensioning of graft – Will it stretch out?
6 males
Mean delay 79 days (35-116)
Mean age 47.5 y.o.
20 month F/U
94% Flexion – 95% Supination
Extension – (-1.6º)
Supination Endurance down 9 reps/min
All received second incision to retrieve
Repair done at 80-110º
Sling post-op
2 wound complications
1 LABCN
J Shoulder Elbow Surg (2012) 21, 1342-1347
21 males
Achilles tendon allograft
Pulvertaft weave proximally
Endobutton distally
Mean age 44 y.o.
Mean time to surgery 25 months
F/U 15 months
2 LABCN
2 patients -5º extension
Does not restore normal contour
J Shoulder Elbow Surg (2016) 25, 1013–1019
Immobilize?
Sling?
Flexion / Extension Brace?
When to resume strenuous activity?
Nerve Dysfunction
LABCN
PIN
Drill Trajectory
Radial/Ulnar – Proximal/Distal
Arterial Injury
Infection
Superficial vs. Deep
Radial Neck Fracture (Badia et al)
Heterotopic Bone Formation
Recurrent Rupture
198 patients - 36% complication rate
188 Single-incision / 10 Dual
LABCN 26%
PIN 4%
Symptomatic H.O. 3%
Superficial Infection 2%
Re-rupture 2%
Lo et. al. - Arthroscopy 2011
Endobutton technique
Perpendicular orientation of guidewire - 11.2 mm from the PIN
Distal guidewire - 2 mm from the PIN
Direct contact in 30% of specimens
PIN anatomy varies
25% had PIN within 5 mm of tuberosity
4 Fellowship-trained surgeons
Single-anterior incision
Endobutton & Suture-anchor
280 patients
9 (3.2%) PIN palsy
Complete resolution – 86 days (41-145)
Rec. direct-pull retraction vs. Hohman radially
J Shoulder Elbow Surg (2013) 22, 70-73
Tourniquet +/-
Incision
Transverse
Longitudinal
Dissection
Pin Trajectory
Managing Complications
How many people routinely treating conservatively?
Single-incision vs. Double-incision?
Single-Incision surgeons: Button + Screw?
How many people immobilize?
How many people use allograft in subacute setting?
What is the initial management of a suspected distal biceps rupture with a tendon that can be palpated but is painful during the hook test examination?
1. Operative exploration of distal biceps tendon 2. Immobilization for three weeks followed by repeat physical examination 3. Early physical therapy with emphasis on ROM and strengthening 4. CT scan 5. MRI scan
A patient sustains a distal biceps brachii tendon rupture. If treated non-operatively, the greatest loss of strength would be seen with which activity?
1. Forearm supination 2. Forearm pronation 3. Elbow flexion 4. Shoulder forward flexion 5. Shoulder internal rotation
What nerve is injured most commonly when repairing a distal biceps rupture through a single incision anterior approach?
1. medial antebrachial cutaneous 2. lateral antebrachial cutaneous 3. radial 4. ulnar 5. posterior interosseous
During an anterior approach to the biceps tubercle and neck of the radius, which of the following structures must be directly identified and protected?
1) musculocutaneous nerve
2) cephalic vein
3) radial recurrent artery
4) posterior interosseous nerve
5) lateral antebrachial cutaneous nerve
A 35-year-old carpenter has pain in the antecubital fossa that is worse with turning a screwdriver. He has undergone non-operative treatment for 6 months without relief. An MRI shows a partial biceps tendon tear. The next most appropriate treatment is?
1. Exploration of the radial tunnel 2. Superficial radial neurectomy 3. Detachment and repair of the biceps tendon 4. Transfer of the biceps to the brachialis 5. Biceps tenotomy
• A 40-year-old male was moving his furniture several days ago when he developed anterior forearm pain. On physical exam he is tender just distal to the antecubital fossa. He has decreased strength on supination and elbow flexion when compared to the contralateral side. His MRI is shown in Figures A and B (Partial Tear) . His injury typically occurs in what portion of the tendon’s distal insertion?
1. Proximal 2. Distal 3. Central 4. Radial 5. Ulnar
• A 28-year-old male sustains a distal biceps rupture while lifting a heavy table and elects to undergo surgical repair using a two-incision technique. What is the most likely neurologic deficit to occur as a complication of this surgical approach?
1. Intrinsic hand weakness 2. Numbness of the volar radial three and a half digits 3. Wrist extension weakness 4. Numbness to lateral aspect of volar forearm 5. Inability to flex thumb and index interphalangeal joints
Operative Treatment for majority of my patients
Allograft role for me has significantly diminshed
Rarely immobilize
Implant cost evaluation
Preoperative discussion critical
Management of complications
THANK YOU!!!