PREOPERATIVE DIAGNOSIS: Left distal biceps tendon rupture, acute.
POSTOPERATIVE DIAGNOSIS: Left distal biceps tendon rupture, acute.
SURGICAL PROCEDURE: Repair of left distal biceps tendon rupture.
INDICATIONS: The patient is a 64-year-old left hand-dominant male truck driver, who popped his anterior elbow cinching down a load. He had immediate pain and swelling. The patient was worked up with an MR, revealing findings consistent with a biceps tendon rupture. After a thorough PAR&Q conference regarding the pros and cons of surgical repair, his consent was obtained for this purpose.
TECHNIQUE: The patient was brought to the operating room and placed on the operating room table. After administration of a general anesthesia, a proximal tourniquet was applied to the left upper arm. He was prepped and draped in the usual sterile fashion.
An oblique incision roughly transverse across the antecubital region was made, beginning medially and extending laterally as the incision was brought distal. This was carried out down through skin and subcutaneous, and care was taken to protect neurovascular structures, including the large veins in the antecubital region. The superficial fascia was incised sharply, exposing the underlying stump of the underlying biceps tendon. The tunnel for the biceps tendon was identified in the upper forearm, and blunt dissection was carried out down through this digitally. The tract allowed for adequate exposure to the bicipital tuberosity, which revealed some small amounts of soft tissue tendon residual still attached. However, the bulk of the tendon peeled right off of the bone at the tuberosity location. Hand-held deep retractors were placed, and curettage of the bicipital tuberosity was performed to decorticate and remove soft tissue. A high-speed bur was then used to create an oval window measuring approximately 1.5 cm in diameter. Anchors were then placed on either side of this defect. The 0 Ethibond was the suture attached to these anchors. A Mayo needle was then used to place a whipstitch, with one limb of each suture from separate anchors. These limbs came out the proximal portion of the tendon, and were tied together. The other limbs of each suture were then used to draw the tendon down to the oval opening, so that direct contact of the tendon to the bone was achieved. The other limb of the suture was then brought back through the tendon in a modified Kessler technique, and then tied again to each other securely. This allowed for direct contact of the tendon to bone, without significant shortening of the tendon itself.
Pronation and supination motion was free, without significant binding, crepitus, or impingement. The patient came to within approximately 20 degrees of full extension, without undue tension placed on the repair. He was placed in approximately 80 degrees of elbow flexion for his initial postoperative recovery. The superficial fascia was reapproximated after copious irrigation deeply was performed with absorbable suture. Subcutaneous closure was performed with 30 Polysorb. The 4-0 Monocryl was then used to perform a subcuticular closure, and the skin was reinforced with benzoin and Steri-Strips. The wounds were cleaned. A splint was applied, after a sterile dressing was placed, in the previous position noted.
Tourniquet time was just over 1 hour.
There were no complications and minimal blood loss, and overall, the patient tolerated the procedure well.