SINGLE INCISION TECHNIQUE USING AN INTERFERENCE SCREW FOR THE REPAIR OF DISTAL BICEPS TENDON RUPTURES

A. D. MAZZOCCA, MD, F. G. ALBERTA, MD, N. S. ELATTRACHE, MD, and A. A. ROMEO, MD

Various techniques throughout the years have been published on surgical repair of the distal biceps tendon for acute ruptures or for recalcitrant biceps tendinosis. The first report of a single incision technique to repair this tendon was in 1897 by S. Johnson in the New York Medical Journal. Since that time many different approaches and techniques have been developed. Interference screw fixation has been a reliable and well-tested method of tendon/ligament to bone attachment. There is a large body of literature concerning the various aspects of interference fit in the anterior cruciate ligament and proximal biceps tendon literature. Anatomic measurements, osteological analysis, and radiographic examination have provided information for the design of an interference screw that can be safely used in the proximal radius. We describe a technique using an interference screw through a single incision. We present two techniques for open tenodesis of the long head of the biceps. KEY WORDS: distal biceps, interference screw, elbow, tendon rupture. Copyright 2003, Elsevier Science (USA). All rights reserved.

Ruptures of the distal biceps tendon have received in- creased attention recently. A MEDLINE search identified 53 articles with "distal biceps tendon" in the title pub- lished since 1995 and only 58 in the previous 25 years. One theory to explain this interest is an apparent increase in the incidence of injury. This trend is probably the result of increased demands placed on the upper extremities as well as increased activity in the middle-aged population. Treatment options have also expanded simultaneously with this renewed interest.

Historically, a single extensile anterior exposure was used to reinsert the avulsed tendon. Boyd and Anderson subsequently described a two-incision technique designed to minimize anterior exposure and limit the risk to neuro- vascular structures in proximity to the tuberosity. ~ Their two-incision technique introduced heterotopic ossification and proximal radioulnar synostosis as new complications. In 1985, Morrey and coworkers modified Boyd's original approach by splitting the supinator and avoiding subpe- riosteal dissection. 2 These modifications led to a decrease in the rate of heterotopic bone formation and synostosis.

Modifications in the method of fixation have also been proposed. Single incision techniques have been revived

From the Department of Orthopaedic Surgery, University of Connecti- cut, Farmington, CT; Section of Shoulder and Elbow Surgery, Midwest Orthopaedics, Chicago, IL; Kerlan-Jobe Orthopaedic Clinic, Los Angeles, CA.

Address reprint requests to Augustus D. Mazzocca, MD, University of Connecticut Health Center, Department of Orthopaedics, 10 Talcott Notch Road, Suite 100, Farmington, CT 06034-4037.

Arthrex Inc, (Naples, FL) has provided research support for the biome- chanical and clinical evaluation of this technique.

Copyright 2003, Elsevier Science (USA). All rights reserved. 1060-1872/03/1101-0001 $35.00/0 doi:l 0.1053/otsm.2003.35886

with the advent of suture anchors. These procedures use a Henry exposure and secure the tendon to the cortical surface of the tuberosity and not into a tunnel or trough. Benefits of the single incision technique include decreased morbidity as well as technical ease in use of the suture anchors. Biomechanical studies have shown that the su- ture anchor techniques are not as stiff or strong compared to fixation over a bone bridge. 3 However, in cyclic loading, the suture anchors have performed adequately to allow early passive range of motion. 4

To combine both a single incision and the use of a tunnel into which to place the tendon, Bain has described a tech- nique using the Endobutton (Acuflex; Smith & Nephew Endoscopy, Mansfield, MA). s Studies evaluating its stiff- ness and strength are ongoing but the Endobutton has performed well in other applications. However, potential complications in passing a Beath pin through the radius, approximating the length of the suture loop, and "flip- ping" of the device on the posterior cortex can make it a challenging technical procedure. Furthermore, cyclic load- ing early on might lead to pistoning of the tendon in the tunnel and impaired healing.

Bioabsorbable interference screw fixation has become popular, especially around the knee. Multiple studies test- ing the biomechanical properties of bioabsorbable inter- ference screws have been performed. They have routinely shown that the constructs fail by graft slippage past the screws but at a level equal to or greater than other fixation methods. 6-s In cyclical loading models, the screws have performed favorably as well. On a histological level, direct tendon healing to bone has been observed with interfer- ence screw fixation. 6,7 A mature fibrocartilage intratunnel, direct ligamentous insertion can be found at 9 to 12 weeks. 9 When indirect methods of tendon fixation are

36 Operative Techniques in Sports Medicine, Vol 11, No 1 (January), 2003: pp 36-41

Fig 1. The anterior approach of Henry is used in this technique. A longitudi- nal incision on the radial aspect of the proximal forearm of 3 to 4 cm is used. If needed, this incision can be extended proximally.

used, healing progresses via a zone of vascular, highly cellular fibrous tissue that matures through orientation of collagen fibers over a period of 12 to 26 weeks. 1°,11

With the development of new equipment, a bioabsorb- able screw can be delivered into a prepared socket without the need for passage of a needle or suture through the socket. The combination of intratunnel fixation, a bioab- sorbable device, and a single anterior approach provide an attractive alternative to other techniques. These technical advances provide the surgeon with yet another useful option for fixation of the avulsed distal biceps tendon.

OPERATIVE TECHNIQUE

APPROACH

We will describe and illustrate a single incision approach to fixation of the distal biceps tendon with an interference screw. However, one of the senior authors (N.S.E) uses the same fixation technique through the modified Boyd- Anderson two-incision approach. Tuberosity preparation and fixation with the interference screw can proceed as described below through the posterior incision. The Boyd- Anderson surgical approach has been described multiple times 1,2 and is illustrated elsewhere in this issue.

The patient is positioned supine on the operating room table with all anatomical protuberances padded. The arm is placed on a padded arm board with a tourniquet placed as close to the axilla as possible to allow room for an extensile approach if needed. If this is impossible second- ary to patient habitus, then a sterile tourniquet is used.

The approach is a modification of an anterior longitu- dinal Henry approach with extension along the antecubi- tal fossa if needed (Fig 1). The subcuticular tissue is dis- sected with Metzenbaum scissors to avoid injury to the lateral antebrachial cutaneous. The plane of the dissection should be in the direction of the incision that also parallels the superficial sensory nerve.

The muscular interval between the pronator teres and brachioradialis (Fig 2) is bluntly developed to the level of

the lacertus fibrosis and surrounding hematoma or scar. Directly in the plane of the dissection lies a series of veins (Leash of Henry) and the recurrent branch of the radial artery that must be addressed by suture ligature, coagu- lation, or retraction. The frayed edge of the tendon should be found at this level or proximally.

PREPARATION OF THE DISTAL BICEPS TENDON

Anatomical evaluation has revealed that the distal biceps tendon attaches on the ulnar side of the tuberosity in a 2 × 14 mm ribbon-like configuration after rotating 90 ° from the musculotendinous junction. Depending on the chro- nicity of the tear, the biceps tendon is usually retracted from the tuberosity with a bulbous end. The tendon is then measured and trimmed to an 8-mm thickness. If the ten- don end is frayed with degenerated collagen, up to 1 cm can be resected from the end with no adverse effects. A no. 2 Fiberwire (Arthrex, Inc., Naples, FL) is then placed in a Krackow or whipstitch fashion (Fig 3) for a distance of 12 to 13 mm proximally. The Fiberwire has a Kevlar core allowing it to have the strength of a nou 5 nonabsorbable braided suture but the size of a no. 2. Strength and dura- bility are critical when using the Arthrex Tenodesis driver as the metal end can damage and prematurely cut stan- dard braided suture.

BICIPITAL TUBEROSITY PREPARATION

The arm is placed in maximal supination and extension to adequately visualize the tuberosity. Care should be taken with deep tissues not to retract too vigorously on the radial side of the proximal radius as the posterior in- terosseous nerve can be damaged. The tuberosity is gen- erally covered with a fibrous layer of immature scar, which should be removed for visualization. An Arthrex guide pin is placed into the center of the tuberosity and a 8 mm acorn reamer (Arthrex, Inc., Naples, FL) is then used to ream an 8-mm hole through the proximal cortex only (12 to 15 ram; Fig 4),

SINGLE INCISION TECHNIQUE 37

Fig 2. A cadaver dissection il lustrating the median nerve proximally diving under the lacertus fibrosis. The pronator teres and brachioradialis muscular interval is demonstrated along with the proximity of the radial recurrent artery to the distal bi- ceps tendon. The arm is placed in maxi- mum extension and supination for com- plete evaluation of the bicipital tuberosity.

T E N O D E S I S

The Tenodesis driver consists of a cannulated handle and post. Sutures from the end of the prepared tendon can be

passed through the driver after the chosen screw has been placed onto the driver. The post is used to insert the tendon to the bottom of the socket and hold the tendon in place while the interference screw is advanced over it via a threaded mechanism. To perform the tenodesis, one limb

Fig 3. The distal aspect of the biceps tendon is tr immed to an 8-mm circumference. Note posit ion of retractor on ulnar side of radius. Extreme care should be used when placing retractors radially due to the proximity of the posterior os- seous nerve. A nonabsorbable braided suture (no. 2 Fiber- wire, Arthrex, Inc., Naples, FL) is then placed approximately 12 to 14 mm into the tendon using a Krackow or whipst i tch suture technique.

Fig 4. A guide wire and an 8-mm acorn cannulated reamer are used to ream the central part of the tuberosity to 15 mm as shown.

3 8 MAZZOCCA ET AL

of the Fiberwire suture is then placed through the tenode- sis driver with the 8 x 12 m m screw attached (Fig 5). The driver is then inserted into the 8-ram hole, ensuring that the tendon is on the ulnar side of the tuberosity (Fig 6A). While the tendon is stabilized with an Addson forceps, the screw is advanced via the tenodesis driver as described above (Fig 6B). After the screw is inserted and the teno- desis driver is removed, the suture passing through the cannulated screw is then tied to the outside of the interfer- ence screw. This allows both an interference fit of the tendon to bone as well as a suture anchor effect (Fig 7).

POSTOPERATIVE REHABILITATION

In the immediate postoperative period, the arm is held in a sling or posterior mold splint for w o u n d healing and pain control. After the w o u n d has been determined to be stable, active assisted range of motion in a neutral position is allowed. Active range of motion with the weight of a coffee cup or less is allowed in the first 6 weeks. Range of

A ,: t

Fig 6. (A) Tendon is inserted on the ulnar aspect of the tuberosity with one suture through the tenodesis driver and one suture on the outside. (B) Tenodesis driver set.

motion and strengthening exercises are then advanced as tolerated. Any pain producing activity is discouraged. The patient is generally discharged to work and full activities between 3 to 6 months.

Fig 5. (A) Illustration of one suture placed into the tenodesis driver with the other suture placed on the outside. (B) Ar- threx 8 × 12 mm bioabsorbable proximal radius interference screw designed specifically for the proximal radius. The thread pitch is that of a cortical screw and there is no head for improved purchase in the cortex of the proximal radius.

BIOMECHANICAL AND ANATOMIC RESULTS

In an anatomical dissection and measurement of 26 ca- daver specimens (mean age 78.5 + 15) the mean length of the tendon at tachment to the tuberosity was 14.3 m m with a mean width of 1.8 mm. The osteologic dimensions of the bicipital tuberosity measured 22 x17 mm. In reviewing 178 specimens from the Hemann-Todd Osteological Col- lection, a consistent ridge on the ulnar side was identified as well as five different tuberosity types (Fig 8). The most common type was small (42%), followed by med ium (35%), large (11%), no ridge or tuberosity (6%), and a bifid ridge (6%). Finally, computed tomography (CT) scans of a

SINGLE INCISION TECHNIQUE 39

A f I

B

Fig 7. The completed tenodesis with the distal biceps tendon on the ulnar aspect of the tuberosity possessing both interference and suture anchor fixation.

subgroup of 48 samples evaluated the actual dep th of the tuberosity. A measurement f rom the per ios teum of the outer cortex to the endos teum of the inner cortex had a mean length of 12.5 + 1.4 mm. The screw was then de- signed f rom this data.

BIOMECHANICAL ANALYSIS

Eighteen fresh frozen cadaver elbows (mean age 77.6 _+ 10.4) were then s t r ipped of soft tissue, pot ted, and ran- domly assigned to three groups (Bone Tunnel , 7 × 12 m m screw wi th a 7-mm tunnel, and 8 × 12 m m screw wi th an 8-mm tunnel). The specimens were tested on an Instron material testing device (Instron Inc., Canton, MA) wi th the

axial load orientated at 45 ° to better approximate the angle of pull of the biceps tendon. There was no statistical dif- ference (P < 0.05) be tween the bone tunnel group (111.6 _ 63.2), 7 × 7 m m interference screw (168.3 + 34.3) and the 8 × 8 m m interference screw (200.8 + 87.5). Furthermore, the insertion of the distal biceps is long and thin and located on the ulnar aspect of the tuberosity. This method allows the tendon to be placed on the ulnar aspect of the tuberosity which mimics the anatomy closer than the other techniques.

DISCUSSION The interference screw technique is new and its clinical effectiveness in the repair of distal biceps t endon ruptures

4 0 MAZZOCCA ET AL

Large

Medium

. . . . . . . . . . . (i ..... ! ! ; ; ; ~¢

............. ;,ii

Small

Bifid

Smooth (No Ridge)

Fig 8. Bicipital tuberosity ridge types.

h a s n o t b e e n d e m o n s t r a t e d to da te . A s u b s t a n t i a l a m o u n t

of a n a t o m i c a n d b i o m e c h a n i c a l r e s e a r c h has b e e n con-

d u c t e d in a n a l y z i n g l o a d to f a i lu re a n d t e n d o n a n a t o m y .

This is the o n l y t e c h n i q u e tha t e n s u r e s the a n a t o m i c p l ace -

m e n t of the d i s t a l b i c e p s t e n d o n w i t h the a d v a n t a g e of

c o m b i n e d in t e r f e r ence a n d s u t u r e a n c h o r f ixat ion. I t has

b e e n s h o w n to be as s t r o n g as the s t a n d a r d b o n e t u n n e l t e chn ique , w h i c h d o e s n o t e n s u r e a n a t o m i c p l a c e m e n t of

the t e n d o n . B i o m e c h a n i c a l cyc l ing a n d c l in ica l f o l l o w - u p

s t ud i e s a re o n g o i n g at th is t ime.

The i n t e r f e r ence s c r e w t e c h n o l o g y has b e e n a success fu l

m e t h o d of i n t e g r a t i n g a t e n d o n or l i g a m e n t in to a bone .

O u r t e c h n i q u e offers the s u r g e o n m a n y n e w o p t i o n s in

t r e a t m e n t of these in jur ies . I t can be p e r f o r m e d e i the r

t h r o u g h a s ing le a n t e r i o r i nc i s ion or a t w o - i n c i s i o n ap -

p r o a c h a n d e m p h a s i z e s b io log ic , a n a t o m i c , a n d b i o m e -

chan ica l p r i n c i p l e s of t e n d o n hea l ing . It is fel t tha t the

success d e m o n s t r a t e d in the knee a n d the s h o u l d e r wi l l be

c o n t i n u e d in the p r o x i m a l r ad iu s .

REFERENCES

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3. Pereira DS, Kvitne RS, Liang M, et al: Surgical repair of distal biceps tendon ruptures: A biomechanical comparison of two techniques. Am J Sports Med 30:432-436, 2002

4. Berlet GC, Johnson JA, Milne AD, et ah Distal biceps brachii tendon repair. An in vitro biomechanical study of tendon reattachment Am J Sports Med 26:428-432, 1998

5. Bain GI, Prem H, Hepinstall RJ, et al: Repair of distal biceps tendon rupture: A new technique using the Endobutton. J Shoulder Elbow Surg 9:120-126, 2000

6. Giurea M, Zorilla P, Amis AA, et al: Comparative pull-out and cyclic loading strength tests of anchorage of hamstring tendon grafts in anterior cruciate ligament reconstruction. Am J Sports Med 27:621- 625, 1999

7. Nagarkatti DG, McKeon BP, Donahue BS, et al: Mechanical evalua- tion of a soft tissue interference screw in free tendon anterior cruciate ligament graft fixation. Am J Sports Med 29:67-71, 2001

8. Weiler A, Peine R, Pashmineh-Azar A, et ah Tendon healing in a bone tunnel. Part I: Biomechanical results after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep. Arthroscopy 18: 113-123, 2002

9. Weiler A, Hoffmann RFG, Bail HJ, et ah Tendon healing in a bone tunnel. Part II: Histologic analysis after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep. Arthroscopy 18:124-135, 2002

10. Rodeo S, Arnoczky S, Torzilli P, et ah Tendon healing in a bone ttmnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am 75:1795-1803, 1993

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SINGLE INCISION TECHNIQUE 41