Okay, so we're going to get started for our live surgery demo. I'm Pat Smith from Columbia, Missouri. I'm going to moderate with Dr. Mark Myle, who's going to do the repair. Are we ready to get into surgery with Dr. Myle? Can you hear me, Pat? Yeah, Mark. How are we doing? We're good. We're all set to get going, so I would just say a real quick introduction. Across from me is Dr. Brewley, who's one of my fellows this year. Then at the end is one of our OR managers, Anthony, who was formerly my nurse and my OR tech at one point. We've known each other for about 15 years, and then Christian's handing us the instrument. So we basically have here, and if you wanted to talk about the patient a little bit, Pat, that's okay. Sure. But I got everything set up. I just wanted to show you guys this. This is a knee roll, and what I do is I put a Raytech or a lap in the hand, so then I can pull that down and supinate the hand and clamp it. Right now I've got a lot of help, but if you don't have a lot of help, that's sometimes helpful when you're trying to get the arm positioned. I use a tourniquet. We've basically made a vertical incision. I just put this in because we were waiting for you guys. This guy's a 47-year-old meteorologist and a Cub Scout leader, so he's here today to get his bicep fixed. All right, let's go ahead, and Earl, if you want to get the tendon, if you can find the tendon for me. Mark, do you ever use a transverse incision, or do you always go longitudinal? I started out doing transverse, which is a little more, it's cosmetic, but if you ever have to extend, it really is tougher to do. So I've kind of switched back to this, and also doing the vertical incision allows me to kind of get a better look at the lateral intervectinous nerve or the superficial centribranch, the radial nerve. And as we've talked about, Pat, sometimes those can be, so Dr. Brewley got the tendon out here, so sometimes those actually can be a problem. In this case, we're going to use the Arthrex system. This is really nice. I mean, I think probably everybody in the audience is familiar with the fiber loop, so Christian's going to hand me the fiber loop so we can get weaving on this. But you know, this is, I don't know who came up with this, but they're really smart, smarter than me. I'm going to pull this in here, and basically this is the thicker part, and I'm going to put that up as high as I can, so in this guy's tendon. And then we're going to come through, and I'm going to try not to stab poor Dr. Brewley. He's a good-natured guy, so I'll try not to do that to him. All right, and then we're just doing this weave, and this is one of those things that I know you guys all do. There's no magic to this, but I will say that if you look at the way I go in the tendon, I'm going to alternate so I'm not going in the same spot every time. So using this technique, basically I have now done, give me a coker actually, just don't pull too hard. I've done about 300, I looked it up this morning, 357 tricep distal bicep repairs at this point, and I reported on this in 2014. Using this technique with the screw, we had a 1.2% failure rate, so it's a nice surgery, it's predictable. I'm going to try to tighten that up in the tendon a little bit, and I think it's a nice operation for the patient. Those are great numbers, Mark. Question for you, do you do much debridement on the end of the tendon before you suture it? Yeah, that was kind of magically done by the elves here, but yeah, we did that. If you look at this, I don't know if you can get a little closer, but there's always some of this, this guy had probably pre-existing degenerative changes, Earl's bringing in the arthroscope, but if you look at the tip of the tendon, it's always a little bit bulbous, and so we kind of sculpt that and weave it to get it a little nicer when we're doing this case. Because what'll happen if you don't, and I've been there, it doesn't go down in the tunnel, and then you have to redo everything. So we really want to have that bulletized so it goes nice, freshen it up so it really goes into the tunnel. So I typically will use a 7.5 millimeter tunnel unless the guy is really, really big, and the actual screw is 7 millimeters. So it's a really nice instrumentation system, I mean, tried and true, I mean, I've been using this for probably 10 years now, I think that's about right. And so once I get to the tip, I'm going to come back behind the stitch one time, but I really want to kind of try to bulletize it, I'm trying to pull it a little tighter, sometimes that'll knock your thing off. So here, it started to knock off a little bit, but I'm going to come behind it, and then I'll trim that last little bit up. So with this one, I'll come back behind one of the other stitches and try to come out just to kind of create a nice bullet on this. So once, I'm going to have Anthony hold this, and then I'm going to take the little knife and Earl's going to hold this up. Now, here's the other thing, hopefully this doesn't happen, it's happened to me once, where you do all this wonderful weaving and then you cut your suture, that always looks bad if you're doing it live, but I'm just going to kind of trim this up a little bit like you were talking about, Pat. So you can see that tissue is not too healthy, and then I'll have him come off here, and I'm going to trim this up just a little bit, okay. So now, we've got a nice bulletized tip that we can pull in, and one of the things that's nice to do right now is to kind of free up any adhesions on the muscle, so I can kind of make sure that the muscle, it's got nice excursion, you know, when we're doing this. You can see the tendon will come down quite nicely. So I'm going to cut this needle off right now, and we'll load the button. Just cut that with the knife. So we've got the endo-button now that we're going to load, and I use that, that needle is nice to keep because you can actually take the needle and use that needle to actually feed the suture through the endo-button. So I'll just put that through, and I don't want it to fall off, but you've got to go opposite ways, so you kind of go up and down, and keep it close, because if you don't, the suture falls out. So you go up and down with the one, and then you go the opposite way with the other. Earl's going to load that up for me real quick. But this is really, this button really, it's like a grappling hook, so it really will engage on that contralateral cortex, and gives you great fixation. Hold that that way. So Earl's pulling that out of the way so I don't stab my suture, all right, and then we'll pull it the other way, and we've got our button loaded, okay? So once I get the button loaded, I kind of get things so I can kind of get a sense of where those sutures are, so I'll pull them out, kind of adjust them a little bit, and I'll get the inserter. So do you have the inserter? Pull this out, Earl, see how it's like, the blue inserter. Right through here. Right here. No, this. Right here. There it is. Don't do that. Pull it back through. So what I'm going to do is I'm going to put this on here just to make sure I like it and adjust my sutures. So where are my two sutures? Here's one. Hand me the other one. And this is always the hardest part, just getting all the sutures, but I can get the sutures onto the blue thing, and this is what actually delivers it into the wound. So we like that. I'm going to take it off this, and I'm going to put this up here until we need it. So I'm going to move this up here, and I'm going to use the hemostat to put it out of the way. So I've got this out of the way with the hemostat, and now we have to look at actually the tuberosity. So this is the inserter. We'll use that in just a little bit. And so usually I'll use a Wheatlander, and I put that in, and if I put this Wheatlander in, I'm going to show you guys something. Do you have a pick-up, a DeBakey pick-up, and a dissecting scissor to me? So I'll use this. So right here, as he's getting my scissor, this is the nerve. I don't know how well you guys can see that right here. And so we talked about this a little bit. I'm not going to try to anger it too much, but you want to be really careful. So when you do a transverse incision, you're really going to push on this more. So hopefully, if I don't crank on this nerve, we won't get that numbness. But about 40% of people get numbness in the hand. So I usually will actually, I'll never use a levered retractor on the lateral side, because I think that'll lead to a PIN palsy, but you can do that on the medial side. So you don't want to have anything that's pushing on that PIN, because you do not want a palsy. But if I put this in here, and then I'm going to actually give this to Anthony. And Anthony, I always do this, it drives the techs crazy, but I bent the Hohmann. And so that way, he can kind of tow in. And I'm going to have him pull back, relax for a sec, hold that right there. And then I'll take the last Army-Navy, and I'll put it right here. So then Earl's going to drop that scope in, and you can see the radial, do you have the DeBakey for me? This is the actual radial tuberosity right here. We're trying to get you a view down here. But you want to see this. And so we're going to bring the light source up a little bit for you guys. But you want to have the radial tuberosity exposed. And he's bringing the light up a little bit more light. And so I want to make sure that I can put my guide pin right in the center of that. Anyhow, what was the question you were asking me, Pat? You know, we always have that radial recurrent leash of vessels. Do you suture ligate those typically, I mean, to get this exposure? Yeah, every time. So that's what we did before you guys got here, is I use silk ties. And I do a silk tie plus a 2-0 vicryl suture through the leash of Henry, because otherwise you can't get this exposure, or you'll avulse those vessels and it will bleed at the end. So a little bit of time in the beginning is very nice. Can you see that okay? Yes, we can see it. Okay. So what I'm going to do right now is I'm going to have, I'm going to take the guide pin. So we're going to take the guide pin for this. What position do you have the arm in right now, the forearm mark? The forearm is 30 degrees flexed and maximally supinated. Can you hold this here, Christian? Just kind of don't, yeah. Okay. So I'm going to look down the hole. I'll probably block you guys for a second. And I just want to make sure I'm dead center. And so this has to be bicortical, and I just want to make sure I get a nice footprint. So this is a bicortical pin. I'll take that from you, Christian. And then Christian's going to load the 7.5 millimeter reamer. So Earl's kind of showing you where the pin is. What I always do is it's just like I'll make a footprint to make sure I'm not going to blow out a cortex. So I'm going to take the 7.5 reamer, just make a little bit of a footprint. If I like it, we'll come down and we'll actually, can you hold this, hang on one second, Christian. Relax. Do you try to be toward the ulnar side at all, Mark, or just right in the middle? I try to be right in the middle. I'll tell you, relax, Anthony. Okay. Got that. Christian, got that? That's a good look. So what I think is that when you actually put the screw in, you can push the tendon a little bit ulnar, which will be a little bit more anatomic. So I'm just going to ream here. I'm going to look at it. I really like it. So then if I like it, I'll go through. And you can see it. And now I'm going to take this pin out. I'm going to wash this out with some wash water just to get all that bone debris out. Quite frankly, I haven't had too many cases of HO after this, but you know, I think it's important to get all that bone dust out. You can put the camera down for a second, Earl. Earl's going to put that scope down while we get the bone dust out. So we'll go for the more up, a little bit more. HO has been shown to be more common in the two-incision technique as well. I have seen that more of a problem with the two incision technique. So here's one thing I like to do. I learned this from, you know, the guys who do ACLs. There's a guy at Portsmouth Naval Hospital who was with me named Kevin Bonner, who's like an awesome surgeon. But I'll take a ronger and I'll make a little notch because sometimes your screw, these screws have soft threads. They won't cut the tendon, but they don't get going. So you're sitting there trying to screw it. So I'll take the little nibbler, as they call it in Ireland, and I'll make a little notch, okay? Can I have the neck size up? I'm trying to create, so the screw has something to bite into when it gets going. Yep, it's a good idea. All right, so we did that. And yeah, I got that from our Irish colleagues. I like it, the big and the little nibbler. So that'll be kind of the ronger. And then the next step is then to get our button in there. So I'm gonna have Christian hold this. All right, make sure the screw, where's the screw? Okay, we got the, oh. We almost threw the screw on the floor. Okay, that would have been lovely. Okay, so we'll put the screw just in the. Okay, so let me do that. Relax, Christian. And then let me just have, where's that suction roll back one more time? That's a good look. We can almost see the hole if you suction that. He's gonna suction, there it goes. So you can see down into the little hole. And then I'm gonna actually take the inserter for this. And I'll tell you, this Arthrex instrumentation system for this is just, I think it's really easy. You know, it makes it just so this operation, which used to take me, with the two incision technique, at least 90 minutes, I can do it in less than 40. So what I try to do is, if you can see this, I make sure the button, I can kind of bend the button so I'm controlling it. And then I'll find the hole and I'll put it down through there. And there's this nice little thing that I'll pull back on. And it deploys it. So hopefully you'll hear. And the other thing that's nice to have right here is a freer. And as you're doing this, you can oftentimes bring the arm up. So see how the tendon doesn't wanna go quite into that hole right here, right? So Christian, can you get me the freer? So right now, Pat, the arm is probably almost fully extended. So what I'm gonna have Earl do, just so I can get the tendon into the hole, he's gonna put the camera down. Put the camera down for a second. He's gonna hold this, he's gonna grab a freer. And he's gonna lift up the tendon so it just slides right into the hole. And then what I'm doing is I'm gonna kind of bring the arm up to here. Anthony's, here Anthony. I'm not pulling yet Earl. Bend it up. About 30 degrees or so, mark. Now it's in. So now I'm flexed up more like 45, but I got it in. Now, I've got a hold of these sutures and I'll let the arm come back down. Okay? So, hold this Christian. And Earl's gonna put that camera back in. What I'm trying to do with Anthony, hang on. I'm just putting the gown bump in, so. Yeah, there you go. Then I'm gonna have Christian, okay. And so, Anthony, just hold this Earl. Earl, forget the camera right now. I'm gonna have Earl stop the camera because I need him to help me hold this so I can pull, yeah, let me make this. But I'm gonna put the screw in. So I've got this, I've got this down. I'm gonna hand this to Earl. Earl's gonna hold hard. So this is what I was gonna say, is that, you know, you can see into the hole. I don't know how well you guys can see it, but I can look at the medial side and lateral side. I wanna push the tendon a little bit to the more medial side. So when I put the screw in, I'm gonna put the screw in on the lateral side a little bit, just a little bit. So I'm putting the screw in and I'm pushing the tendon a little bit medial. And this is a, I got a tremendous bite on this, great bone. And I bring it down so it's kind of flush with the bone. Perfect, maybe one more turn. That screw's seven by 10 millimeters, correct? Yeah, and I'm gonna show you what the, so here comes the camera. So if you guys can see that screw, that screw is just, but you know, I can't say I pushed it very much medial. I'm gonna say that, Pat. I tried, but I don't think I accomplished that. But you can see it's really nicely down in there. And then once I'm here, I have Earl just hold one of the sutures really tight. Can you hold this one, Anthony? And then I load the other one on a needle and I'll just bring it back through the tendon. Can you load that on, Christian? Looks good, though. Do you use a screw on every case? Can you comment on the unicortical fixation only, Mark? You know, I have used it on every case. I haven't seen, I've never had a personal case of a fracture. You know, you hear these things, that's never happened to me. Maybe it has and it's gone to one of you guys, but not that I'm aware of. I really think it, having this, you know, it's like belt and suspenders. You know, you wanna have, with whatever we do in orthopedics, having a backup is always a good thing, I think. You know, you don't wanna rely on just the screw and you don't wanna rely on just the button. What you won't see is, when we're done here, I gotta bring a C-arm in. Before I leave the OR, I'm gonna check that my button is down. Now, it's just, I felt great and I pulled it tight, but I always like to check before I leave the OR. And what, in arm position when you put the screw in, were you at that 30, 45 degree mark? Absolutely, about 30 degrees. So what I've done right here is I've just made a little locked loop at the end. I'm gonna hold this tight. I'll have Christian hold this again. Can you hold this, Christian? And then Earl's gonna give me back my suture. And this is where, just to tie it off at the end. But I keep my left hand pulling tight the whole time because I don't want that thing to slip back. So I'm just sliding these down and tying them. But I think this is a really tremendous repair. And then we'll look at the muscle here after I get this done. Looks great. Okay, I'll take a knife real quick. You wanna suck right there? Before you remove those retractors, I wanna ask you one other question when you get a second. Okay. Oh, I was gonna mention too, be careful. We have had some escapades in orthopedics with the veins and the knife when you cut your suture. So you wanna be careful when you do that. So can you show us a supinator? And we need to talk a little bit about the posterior osseous nerve and your exposure there. Sure. So I'm gonna let him relax here. And so if you hold this very gently. So you wanna put the... So you can see... Give me a pointer real quick. A pointer. The debakey's fine. Yeah. Light cords in a way. Here, watch this. Okay. Come on back. So here you can see in the thing, I've got the little notch for my screw. I just used it. This is a right angle retractor. I have this resting on the bone. So number one, if you... Can you give me another retractor? The PIN is actually a little bit distal. If I was saying where the track of the PIN, if you dissect it out, it's gonna be a little bit distal and lateral to where this is. So nerve injury is rate and time dependent. They've done that in rabbit model. So what you don't wanna have is a levered retractor here. So if I took a Hohmann retractor, this guy, and put that here on the lateral side, that's a big no-no. Because as soon as I pull that back, I'm pulling on the PIN. So I always make sure that this retractor is just resting on the bone lightly. You can start to see the fibers of the supinator. I don't wanna go crazy here, but right here. I don't know the light. Can you show this a little bit better, Earl? You can start to see the muscle fiber right in here. Okay, as you get down that way. So I don't wanna do too much retraction. Distal to where that screw is, and lateral. And anything that has a levered retractor on it. One tip that helps me a little bit, Mark, and you already made the exposure, but frequently there's some bursal-type fibers at the tuberosity that points you to the right spot right when you go in on these cases. You almost have like a little bit of a rupture stump there at the more proximal aspect of the tuberosity. I think that helps us too, in terms of staying more proximal to the nerve. Give me another one of these. I'm gonna show you, because this, you know, if you look at where the bicep muscle is, I'm gonna kind of try to show you this. Can you guys see into the bicep with the camera? Or do you need him to do the scope? We'll try the scope. Earl's gonna come back with the scope, but I just wanted to show you this too. This is a little bit up off of it, but you can now see the tendon right here, and then the muscle belly from here to here. But it's, so this is more of towards the shoulder, down towards the elbow, but you can see that just nice peak of muscle. It's just really nice, robust. It's sitting right here, right at about the level of the joint. So the muscle belly is collinear with the joint right here. So that's our bicep repair. I'm gonna check it just to make sure. I'm basically doing, you know, and then I'm gonna do this too. I'm gonna take this out, and we're gonna let the arm come down. So you can see, he comes down all the way. So if I put my retractors back in right now, and I'm gonna go, and you can see, here, give me a pointer again. You're asking me, these are the vessels that you can see the little black ligatures right here. Earl, can you bring that down? So I've got some, I've got a little suture right here that I tied off those traversing vessels in the beginning, and this is kind of that leash of veins. I'll pull that out of the way gently, and then I'll show you down here. But you can see how that comes in very nicely. Earl's gonna show you down there. You can see the fibers of the brachialis right here. You can see the tendon coming down into its assertion. We get complete extension, okay? So what we're gonna do at this point is take a Raytec with some thrombin, and I'm gonna stick it in the wound, and then we're gonna let the tourniquet down. Yeah, that's fine. So great repair. Can we talk a little bit about your post-op management? Mark, what do you do post-op, splint, range of motion, strengthening, return to activity? Right, so I'm gonna pop this in here, and I'm gonna let Earl put a little pressure on that, and we're gonna let down our tourniquet. Give him a, and we'll wrap. So when I come to this point, I'll take a lap, and I'll wrap it. So the post-op, one of the things that I like to do is I like to make sure that the splint includes the hand. I mean, God forbid you have, because I do a block before surgery, right? So that's maybe controversial. Some people like to check the nerve afterwards, but the incidence of the PI and injury is so low that I've actually blocked the patient ahead of time. So, put good pressure with your heel, your hand on there. Just like that. So I put him in a posterior splint with the arm at about 60 degrees in a neutral position, supporting the hand, and I do that for the first 10 days till they come back to clinic. So I like a well-padded splint for that. Then I use, actually, a range of motion brace and limit their lifting to five pounds. So I let the range of motion brace go from 30 to 130 for about a month. And then it's increasing, strengthening, but no heavy lifting until four months. So, let me ask you one other important question about surgical timing and how far from injury are you able to get a primary repair successfully? Can you do it two to three months out? What's your experience on, you know, we don't always get to see these fresh, so kind of what's your algorithm there, timing-wise, preoperatively, in terms of when you can get this nice primary repair? Right, I think, Pat, the sooner the better with the bicep tendon. With the pec tendon, you know, you can wait a year, but if I rupture my bicep, Pat, I want you to fix it tomorrow, because I think the quicker you get to it, it's easy to find, there's a hematoma, you know, the surgical time is much less. So it starts to get difficult for me at four to six weeks, unless there's one thing that can occur that's really helpful, as if your lacertis is still intact and it keeps your tendon from retracting, then you have a little bit more latitude on when you fix it. But I think that if the lacertis goes and the tendon is retracted approximately, if you wanna get to that within the first two to three weeks, absolutely. And it's a much easier surgery, it's easier on you as a surgeon. Definitely don't put those off. I mean, if someone comes with a bicep tendon rupture, I put them on my surgical schedule for the next week. Yeah, that was a beautiful repair. Great, any questions from the audience? All right, Mark, thank you very much. Awesome job. All right, thank you guys, appreciate it. Great, see ya.

live surgery demo

repairing bicep tendon

Arthrex system

fiber loop

vertical incision

bulletized tip