Thank you. I'm talking about distal biceps tears and repairs, the dual approach. So with distal biceps tendon, you get two types of pathology. The obvious is a Popeye sign, but the obscure is terminal supination weakness. If you look on the right side of this gentleman, he ruptured his right biceps tendon, but he's weak with terminal supination compared to his other side. He can't resist a supination force. So look at his left side. He's strong, but his right side is weak. So this is a guy fixed. I did bilateral biceps tendons on, and on the right side, he's strong with resist supination, but on the left side is weak. So the purpose of this talk is to explore why terminal supination is weak and the factors that we can control to improve terminal supination during a biceps tendon repair. So a surgeon can control the tendon reattachment site, whether it's an onlay versus an inlay repair, the tendon rotation, whether you externally rotated or internally rotated in the time zero repair strength. So the tendon is attached posteriorly on the radial tuberosity. The short head is distal, the long head's proximal. The tendon is attached posterior to the radial protuberance. So on the MRI on your right, what you see is a tendon that's coming in and attaching, and the arrowhead shows the radial protuberance, and the radial protuberance acts as a cam structure and increases terminal supination torque. So we did an experiment and we looked at where if you repair the biceps tendon, what happens at different positions of repair? And what we show is that if you repair the biceps tendon anteriorly, you lose a supination torque or supination moment arm in six degrees and in neutral. So when the form's in a supinated position, you lose about 98% of supination torque. When it's in about neutral, you lose about 20 or 27, 30% of supination's torque. But if it's in a pronated position, there's no effect. So in summary, an atopic insertion site, you regain native supination strength. So if you repair it where God put it, you regain native supination strength. And this is also shown by other authors. And in this biomechanics study, if they put the biceps tendon back to its insertion site, they regain supination strength or torque in neutral pronation supination form positions. If they put it anteriorly, you lose supination torque in neutral and in supinated position. So it's important to put the biceps tendon back to regain native supination torque. And the reason why is twofold. One, it's simply when you pronate, the biceps tendon is wound around the bone and it acts on the same position. So on the left side, the blue is an anterior repair, and the red is a anatomic repair. And when the forearm is pronated, it acts on the bone at the same time. But as you get to neutral, you have less mechanical advantage with an anterior repair, as you see in the middle schematic. And it starts to unwind prematurely. And when you're supinated, there's no torque that it can give. But in an anatomic repair, you can still get torque. And another way of looking at it, if you put it anteriorly, like on the protuberance, as you rotate, the tendon can't be wrapped around the protuberance anymore. So it can't give that cam effect. So in summary, an anatomic repair gives you full rotation torque back. An anterior repair, you'll lose rotation torque for two reasons. Again, it prematurely rewinds and you lose the cam effect. So let's talk about inlay and onlay. So in these diagrams, the cadaver's dissections are on your left. In an inlay, you put the tendon in bone. Onlay, you put the tendon on top of the bone. And if you look at A4 and B4, the pictures onto your right lower corner, what you see is that an onlay, you get a bigger moment arm than an inlay. And so you preserve that protuberance with an onlay and you don't with an inlay. And does that mechanically have an effect? And the answer is yes. If you drill a hole into the radius, you'll lose about 27, 25% of the tuberosity distance or the moment arm. And what happens is you lose 27% of supination power in a supinated position. So if you put the tendon within bone, you decrease your supination strength as well as you put the tendon on top of the bone. So what about, and this is the schematic shows us. So if you put the tendon in the bone, it's a star. That's where the tendon is attached. If you put the tendon and it's the red star, but if you put the tendon on top of the bone, it's the blue star. And what you see again is that a tendon that's in the bone, it can act normally on the protuberance and then you enterize the repair. So when you put a tendon within the bone, the bone acts on the anterior part of the bone and you enterize the repair. So you don't get an anatomic repair. So by putting a tendon in an inlay, it loses a mechanical advantage of supination torque. So what about if you do external rotation versus internal rotation? So on A, it's externally rotated and the short head is distal and the long head is proximal. If you look at B, the long head is distal and the short head is proximal and the tendon looks funny. Instead of the tendon being a ribbon, the tendon looks kind of like an odd-shaped biceps tendon. So does this affect mechanics? It actually does not affect rotation mechanics, either pronation, neutral supination. So whether you externally rotate or internally rotate, it does not affect supination torque or flexion torque. However, when you look at it closer, what you see with an anti-cut repair, the biceps tendon cups the protuberance or the radial tuberosity. But when you put the long head distally, it bunches the repair up. So see where the arrow is on your left, that's an anatomic repair and it's nice, thin repair and it looks normal. But when you switch it, you get this bunching effect of the repair. The pair becomes thicker. It doesn't affect mechanics, but if you have a thicker repair, you can cause impingement and you can cause early failure. So this is a recording of me doing it afterwards. I did an endoscopic repair. And you can see there's not much room with an anti-repair between the radius and ulna. And if you have a bunching of the repair, in theory, you can get impingement. And in theory, this can cause a re-tear. So the last factor that a surgeon can control is a time zero repair strength. And it's been shown that if you use a two-button repair on the near cortex, it's as strong as a native tendon. So in summary, what I discussed, if you put an anti-attack repair, a footprint repair, you restore the native supination torque and the native flexion torque. If you do an onlay repair and it's at the right spot, you restore the native supination torque. But if you put an inlay, you lessen the torque, you anteriorize the repair. Almost similar like you put an anterior repair instead of an anti-attack repair. And if you do external rotation, it looks good and it may improve impingement, but it has no effect. It may decrease the chance of impingement and decrease the chance of a tendon rupture, but it has no mechanical effects on supination torque or flexion torque. And a two-button near cortical repair is the strongest repair that we can do. And it's a similar strength, pull-out strength to the native biceps tendon. So now how do you get there? How do you do these repairs? And there's really two approaches. You can go, and the first is an anterior approach, which is described by Doby and popularized by Dean Sturianis. And basically you go, you hyper supinate to get to the tuberosity and you go between the brachioradialis and pronator. Or you can do a posterior approach where you pronate and you go pretty much through the extensor carpi ulnaris, and it's a muscle splitting approach. And then you go through a supinator and that's popularized by Dr. Mori. There's been a number of categoric studies, and these are two. And the bottom line is, if you go through an anterior approach with straight instruments, about 10% of the time you can hit the footprint. Otherwise, 90% of the time the repair is anterior on the protuberance. But if you go to a posterior approach, majority of the time you can hit the footprint. So the posterior approach gets you to the footprint easier than an anterior approach by categoric studies. Now, the reason why this happens is because 40% of the population, the tuberosities on people are hyper pronated. So if you hyper supinate, you still can't get the footprint to the anterior elbow. So it's hard to do an anterior approach and hit the footprint because it just doesn't work. Even if you hyper supinate, you can't get the footprint to the working area through an anterior approach just because of an anatomy. So when you look at the literature that compares, clinical literature compares anterior and posterior approaches, what you see is a mixed bag. It's like apples and oranges. Like this is a great randomized study, but their anterior approach was an onlay and their posterior approach was an inlay. So even the repair techniques are different. And they compared them only in neutral and didn't compare them in supination, pronation, neutral. And also they didn't verify the repair position. So mechanically, the number one determination of supination torque is where the tendon is located on the radial tuberosity, where it's repaired or reattached back to. And so in this study, it's a great study, but it didn't repair, they didn't verify or look at the repair location. Now, there's only been two studies that I know of that looked at the repair location. One of these is out of Canada. And they looked at it and they verified the repair location with CT scans with metal anchors. And what they noticed, if it was an anterior repair, you know, on the tuberosity or anterior to a footprint, they had weakness in supinated positions. They had decreased work performed. And about 50% of people had difficulty with Tuesday living because they lacked terminal supination. And the other study is the one that I was involved in. And we took a group of people that we repaired anteriorly and took a group of patients that we repaired posteriorly. And we compared the two core cohorts. And the first thing we did was after we did the surgery, and after healing, we MRI their arm. And we looked at the location of the biceps tendon. And what we found was when you did an anterior repair, you were about seven millimeters anterior to the native tendon location. So when you did an anterior approach, you repaired the tendon anteriorly. Now, if you did a posterior approach, you're right on the footprint. So a posterior approach hit the native footprint where the native tendon was located. So in summary, we're only talking about seven millimeters, but seven millimeters seems to mean a lot. So again, if you do an anterior approach, you're anterior to the footprint on average. But if you do a posterior approach, on average, you're right at the footprint. And then we tested these people. We found they were statistically weaker with an anterior approach, and they were stronger with a posterior approach. And then we did regression analysis. The number one predictor of return of full supination strength was an anatoch reattachment. So an anatoch reattachment gives you that terminal supination strength back. So when you look at this, this is my patient again, I did a posterior approach on the right and he's strong, he's got terminal supination strength. I did an anterior approach on the left and he's weaker. He doesn't have supination strength. In fact, he's weaker from supination to neutral because his tendon, I repaired anterior to the footprint instead of at the footprint. So does that terminal supination strength matter? Well, if you're trying to hit a home run, it may. It may be the difference between a home run or a deep out, so terminal supination could matter depending who the patient is. So the solution is then, if you look at it, it's an onlay repair, preserving the protuberance with a posterior approach and an anatomic repair attachment. And that's what I'm gonna discuss here. I'm gonna discuss a two hole, two button. And the button is the strongest repair technique as we discussed previously. So two hole, two button anatomic repair. And we devised a set that's from Arthrex and I helped design this. So I do have a conflict here. And you have a biceps passer, you have a dilator and you have two buttons and a drill pin. And you need a double loaded fiber wire suture not in the kit, they're single loaded but you have to get double wire fiber wire suture. But basically I'll show you a video of this. So here's a biceps tendon that's ruptured and I'm sitting on the lateral side. So that is the long head. And I put a crack out stitch laterally. And then immediately they get a running stitch. So there's two stitches, one through the long head and one through the short head. And then you're gonna externally rotate the tendon and you're gonna pass it externally rotated. And then I made a counter dorsal incision right over the ECU, which is about two centimeters from the ulnar border. And you're pretty safe from real nerve. And so you have the acanias, EDC and ECU. EDC is striped, I'll go over that later. You wanna go through the ECU, it's not striped. And here I'm dividing the ECU and I'm gonna feel through the supinator. I'm only gonna cut the supinator right over the tuberosity. So I'm cutting the supinator and I'm gonna explore the radial tuberosity, the footprint. And so making a small incision directly over the right and there's the footprint. And I'm gonna drill two holes and I'm gonna suck out all the heterotopic bone. Now I'm gonna pass the biceps passer between the radius and the ulna. And I put my finger on the other side and I'm gonna feel it and bring it through. And it's really key that you pass this medial to the lateral and brachial cutaneous nerve. And then you're gonna pass the dilator and you're gonna dilate the bicipital tunnel. And so we're gonna dilate the bicipital tunnel. And then I use a loop, I tie, and I dilate it. So you saw me dilate it. Now, when I pass the suture, I'm gonna externally rotate and I'm gonna pass the long head near the rubber and the short head away from the rubber. And what that's gonna do is gonna externally rotate the tendon. So the short head I'm gonna pull down or the long head I'm gonna pull down and the short head I'm gonna pull up. And then what I'm gonna do is pass the button into the thing, I put sutures to the button and I'm gonna pull the pull stitch over and I put the docking stitch into the button and I'm gonna tie it down. So I cycle it to make sure the button's flat and it's really important to cycle it. And then you get this anatomic repair and that's what it looks like after the repair. And you can see the two buttons are on the knee near cortex and it's anatomic repair. And so that's a two button anatomic repair and it preserves the radial protuberance so you get that terminal supination torque. Now, what are the complications that can occur from this? And one is a nerve injury. And if you do an injury approach, it's been shown by multiple authors that you get lateral and brachial cutaneous nerve palsies, not permanent injuries of palsies, more than a posterior muscle splitting approach. Now, if you look at posterior osseous nerve, there's one study that shows there's no difference in a posterior osseous nerve between anterior or posterior muscle splitting approach or two incision approach. But there's another study that shows there's a 2% difference with a posterior muscle splitting approach than an anterior approach. So they're pretty much even with a posterior osseous nerve palsies. And what you don't wanna, and you wanna look at permanent posterior osseous nerve palsy. Now, this guy came to me and he had an anterior approach with a button on the forecortex and a button caught the nerve. But if you look in the literature, it's pretty rare for a posterior approach to get a permanent posterior osseous nerve palsy. And it can happen, but it's pretty rare. Now, the things that keep you out of trouble, if you do a posterior muscle splitting approach, is you go through the ECU. Now, it's just shown in my video, if you look at it, you find the achineas and you find the EDC. The EDC is striped and you just go through the ECU. So it's important to find the achineas and it's usually noted by blood vessels and the diagonal path. And then the EDC is always striped. So just take time and look at this picture again. EDC is striped, ECU not striped, achineas is diagonal and has these vessels. If you go through the ECU, it gives you the farthest distance from the posterior osseous nerve. And we did a study to show this. If you go through the EDC, you get the farthest distance. In pronation, it's four centimeters approximately from the posterior osseous nerve branch. If you go through the EDC, if pronation is 25 millimeters. But if you supinate the forearm, it's only 14, it's in harm's way. So the best approach is to pronate the forearm and go through the ECU. It gives you a protection from the posterior osseous nerve and there's safety there. So also when you pass this dilator, pass the biceps and the biceps cannula and to find the radial, to find the biceps tunnel, it's important to go between the radius and ulna and supinate the forearm and feel your finger, the tip and make sure, and you always angle it laterally, don't angle it medially. If there's any trouble, you have to find and expose the tuberosity to make sure you have safe passage. So chronic repairs, you may have to find the tuberosity and you always want to put the passer medial to the lateral and brachial cutaneous nerve. So the passer is lateral to the brachial artery, lateral to the medial nerve, but medial to the lateral and brachial cutaneous nerve. And the best is to put your finger again on the tuberosity and pass the tuberosity in between the radius and ulna and feel the biceps passer as you pass this. Because you don't want this to happen, there's a reported case from Mayo where they passed it dorsal and not between the ulna and the radius and they caught the posterior osseous nerve and the patient had a posterior osseous nerve palsy. It eventually recovered, but they had to reroute the biceps tendon. And you can see the MRI, the biceps tendon is the star, it's dorsal, it's not between the radius and the ulna and that's where the biceps tendon needs to be. So what about heterotopic ossification? So if you look at it, it's in a couple of studies, it's anterior approach is 2%, a muscle splitting approach, it's about 4%, another study it's 3% and about 8%. And the issue is how it is. And this is with passage, a lot of this is just with a COCA, the original Bernie Mowry technique. And, but if you go posteriorly and split it and split the supination and don't go and rub the ulna, we think it's a lot less than this. But we did a study and we did an MRI post-op with a single incision repair, an anterior repair, 42% of our patients did have heterotopic bone within the biceps tendon on an MRI, but it was asymptomatic. So what happens no matter what approach you use, whether you use an anterior approach or a posterior approach now the location may matter, it may be easier if you get heterotopic bone with a posterior approach to get stenostosis. But if you look on the left, that's an anterior approach with a mountain of bone and that caused a loss of supination and pronation motion. He had a stenostosis and if you look on the left, he's got, he ossified his entire biceps tendon. So heterotopic ossification, there's a good article out of the group in Philadelphia. And basically if you do endomethysin with your bicep tendon repairs, it's about 1%. Without endomethysin, it's 38%. This is a level three study. And so they looked at single incision repairs and it was a 14% had a heterotopic bone. And if you did an ECU splitting approach, only 3%. And if you had ECU splitting approach endomethysin, it was 0%. So take home, this is a level three study, but the take home, if you use an ECU splitting approach like I described, and you use endomethysin, slow relief, 75 milligrams Q day, you have a less of a chance of having significant heterotopic bone. Now there's another study that looked at an ANTER approach recently, and they compared meloxicam to endomethysin. The dosing is a little bit different, but there was no difference. And again, a level three retrospective study between meloxicam and endomethysin. So meloxicam may be a little bit easier on the stomach. So the other thing then is Graham Crean's group, you know, out of Canada, did a level one study with endomethysin for elbow trauma. And they found no difference whether you give endomethysin or not. It's so you can maybe look at that with a biceps tendon, but with a biceps tendon, Philadelphia study said it does. So I think the jury is really out whether endomethysin prevents heterotopic bone. Anecdotally, I give endomethysin and I feel it does prevent heterotopic bone. And, you know, I really haven't had a significant heterotopic bone since I've been getting endomethysin knock on wood, but I do think it does matter. So the take-home message, it's really key to restore the footprint. And you restore the footprint by drilling a hole in the short head and the long head and doing a posterior approach. And you need to preserve the radial protuberance where the arrowhead is, because it acts as a cam. And you preserve the radial protuberance by doing an onlay repair. Again, you want to externally rotate so you don't bulk up your onlay repair and get impingement with rotation after repair. And in fact, if you get impingement with rotation or form clicks after repair, it's because you probably internally rotated the tendon and repaired the long head distal and the short head proximal instead of the other way around. And it may be worthwhile to redo it and externally rotate the tendon and put it anatomic. And you need to protect the nerves. And you protect the nerves through a posterior approach by pronation and going through the ECU, not the EDC. And you protect the nerves by using your biceps passer between the radius and the radial tuberosity and not going on the other side of the radius because you don't want to catch the nerve. And you want to protect your patients. At least I feel it's important by giving endomethacin. But I have to admit the jury's still out on this. But I want to thank you. I hope you have a great course. And I hope to see you in Chicago. Thank you again.

distal biceps tear

terminal supination strength

tendon reattachment

anatomic repair

surgical approaches

heterotopic bone formation