Thanks for the opportunity that Ann has provided me to talk about distal biceps repair. Made easy. That basically means level five evidence for the most part, and we'll share that. So these are my disclosures. You'll find them in the book. We all know the biceps is a form supinator, and there are two heads that merge distally. There are two distal attachments, though. It's important to remember the Lacerda fibrosis is also an attachment site distally. Distal biceps tears occur almost exclusively in middle-aged males, and they can be partial or complete, as we all know. The mechanism of injury is almost always a sudden eccentric force with the elbow in full extension. Patients who complain of pain and weakness and on examination have edema, ecchymosis, and there's a lot of variability in how retracted those tears might be. As far as mechanism of injury, this is what's the left biceps. That's his expression. I love this. And then the guy says, you didn't finish the lift. So the hook test is a classic and very effective technique to identify these complete ruptures, and we all should be familiar with that. And as far as repair goes, surgical indications, complete tears are repaired generally in active individuals. Partial tears, unresponsive to nonoperative treatment, often undergo surgery as well. And in fact, these partial tears are very common, nonoperative treatment initially, but pain and decreased function often persist in these individuals, and surgical repair can be carried out using standard techniques in that situation. So we can repair these tears, as we know, either with a one-incision or a two-incision technique. Both techniques in the literature are highly successful. The two-incision technique is probably more anatomic, but it doesn't and hasn't translated in a lot of the literature to demonstrate improved outcomes. I want to do just a very brief survey, if we could, of those that do distal biceps repair. Raise your hand if you do a one-incision technique. Okay, two-incision technique. So I'd suggest that probably 70, 75% of the attendees are doing a one-incision technique currently. So the two-incision technique, originally described by Boyd and Anderson and modified by Morey, is well-described and proven. It's an antecubital incision. We're all familiar with how that works with the Kelly pass-down. Recess and drill holes are made in the tuberosity, and sutures are passed and tied. The one-incision technique is, of course, a one-incision anteriorly, and there are multiple fixation options anteriorly, suture anchors, endo buttons, interference screws, or some combination. Two suture anchors were described years ago, good reported outcomes and low complications, but more recent literature suggests potentially increased failure rates with the suture anchor technique. Buddy and I published our results probably 10, 12 years ago on suture anchor techniques and had no failures, two cases of HO and one case of temporary radial neuropalsy. The button technique, the tendons recessed into the radius, cortal fixations occurs opposite on the dorsal cortex. And generally, a perpendicular drill hole is drilled and the button advanced. The interference screw technique, originally described by Mazzocchi et al., was at least in part developed to try to hopefully improve and accelerate rehabilitation outcomes. There are a number of biomechanical studies. This one is just one example comparing these fixation options, and they found in this study the button was strongest and a single suture anchor was weakest. Combined fixation is commonly carried out as well. Typically, that's a combination of the button plus the interference screw. Dr. Heisman, one of our fellows, published on our results using this technique, and we had an advanced post-operative protocol that we employed for the purposes of this study with full activities allowed at six weeks after this combined fixation, and in that study we had no failures in 32 elbows and had a return to work average of just 6.5 weeks. So the charge for me today is to distal biceps repair made easy. So I wanted to share at least some of my personal experience with this. I think it's important to use a simple, relatively simple, and a very reproducible technique. I think it's important to operate as early as is practical. This is one of those pathologic conditions is when they come to the office, I really do all I can to accommodate their repair because I think there's a difference in my mind between a tear that's one week old and a tear that's even three weeks old. The scarring and retraction and anatomy is more distorted in that setting, and of course we want to avoid complications, and complications are either neurologic for the most part or they're related to heterotopic ossification. And so with respect to techniques and pearls, I wanted to acknowledge that I'm a one-incision combined technique guy, an inner button plus interference screw. I've used that for quite a number of years. I look back just to see over the last nine years how many of these I've done using that technique in preparation for this talk, and I've done 311. So I see this a lot, and we do it a lot. Of that group, we've had no PIN injuries in that group. We've had three patients who had some development of HO that caused motion restriction, although none of those patients had very significant or even severe HO, and none required revision surgery. And we did have one recurrent radial artery injury. If you look to the right labeled D, there's a lot of vast, there's a vascular leash around this biceps, and we had an injury there that required a debridement of a hematoma. So any technique tips that I can share, remember the radial tuberosity is about 23 millimeters distal to the radial head. That may have implications into where you make your incision. I used to make my incision in the antecubital fossa. Now I move it down distally about three centimeters. It seems to be right over the radial tuberosity. It makes the operation easier, at least for me. I only use blunt dissection, almost exclusively digital dissection to help protect the structures. I use maximum supination, and I never use Holman retractors. I only use right angle retractors again because I'm concerned about the PIN in that setting. I use a central guide wire perpendicular in AP. I try not to get too fancy with the location of this drill hole because it's a big unicortical drill hole if you use this technique, and as Shakespeare said, striving to better oft we mar what's well. I use extensive irrigation in the hopes that I can reduce HO, and I use the fluoroscope to confirm my button position intraoperatively. Now with respect to complications, the lateral antebrachial cutaneous nerve injury is surprisingly common in this one incision technique. It's approximately 10% general in most studies. It's almost always transient, thankfully, however, and it's, I think, important to consider identifying and protecting this nerve, especially with chronic tears or very retracted tears. PIN is a significant risk, mainly in two incision technique. It's really uncommon in a one incision technique in the literature. A two incision technique is surprisingly common, 1 to 10% in studies. It's important, I think, with that two incision technique if you use it to maintain pronation to try to avoid using Holman or other retractors over the top of the radius, and to even consider visualizing the PIN if you need to dissect the supinator for some reason. So in summary, both one and two incision techniques are highly and probably equally successful in outcomes. Tips for making the repair easy, try to operate early, make allowances to get that patient in the operating room if you can, avoid Holman retractors when possible, and the one incision technique, maximize supination, try to use a central guide wire to protect the bone, irrigate liberally and use the fluoroscope, and in two incision technique, beware the PIN injury. Personally, I'd rather have 50 transient lateral antebrachial cutaneous nerve injuries to deal with than one permanent PIN injury. There's synostosis risk, it's low, but it's real for two incision techniques, so minimize soft tissue dissection and avoid the ulna. Thank you very much. Thank you, guys.

distal biceps repair

middle-aged males

eccentric force

one-incision technique

two-incision technique