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!!!