import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Emerges between brachialis and brachioradialis 5-7cm proximal to elbow crease, crosses antecubital fossa obliquely lateral to medial with variable branching pattern. **Protection**: Early identification during initial dissection, gentle mobilization without traction, protect throughout case with vessel loops or retraction, preserve all branches. **Location**: Branches from radial nerve 3-4cm proximal to radiocapitellar joint, enters supinator muscle 3-5cm distal to radial tuberosity, wraps around radial neck within supinator from anterior to posterior. **Protection**: FULL supination mandatory (rotates PIN posteriorly away from field), stay on bone during tuberosity preparation, avoid lateral/posterior dissection, never operate in pronation. **Location**: Lies 1-2cm medial to brachioradialis muscle belly in antecubital fossa, courses between BR (lateral) and pronator teres (medial), usually with venae comitantes. **Protection**: Retract laterally as a unit with BR muscle, palpate pulse before and during retraction, gentle handling to avoid spasm/thrombosis, identify and protect recurrent radial branches. **Location**: Lies 2-3cm medial to the BR-PT working interval, passes deep to pronator teres, gives off anterior interosseous nerve branch distally. **Protection**: Stay within BR-PT interval (true internervous plane), avoid medial dissection beyond PT muscle, no aggressive medial retraction, identify if anatomy unclear. **Location**: Variable branches crossing antecubital fossa from lateral to medial, arise from superficial radial nerve, multiple small fascicles at risk during skin/subcutaneous dissection. **Protection**: Sharp dissection under direct vision during exposure, preserve all visible nerve branches, avoid blind cautery in subcutaneous plane, retract gently without tension. ### Critical Anatomical Relationships **Radial Tuberosity Anatomy**: - Bicipital tuberosity located on anteromedial proximal radius 2-3cm distal to radial head - Footprint oval-shaped, 15-20mm length, 8-12mm width in most patients - Tuberosity rotates: SUPINATION brings anterior/medial (accessible), PRONATION rotates posterior/lateral (inaccessible) - Separated from ulna by interosseous membrane, thick at this level - Bicipital bursa normally present between tendon and tuberosity (reduces friction) **Nerve Anatomy - Critical for Safe Surgery**: - **LABCN**: Terminal sensory branch of musculocutaneous nerve, emerges lateral edge of biceps tendon 5-7cm proximal to crease, pierces brachialis fascia, crosses field obliquely, innervates lateral forearm skin, variable branching (1-5 branches), injured in 15-30% of cases - **PIN**: Motor branch from radial nerve bifurcation, enters supinator 3-5cm distal to tuberosity, innervates ECRL, ECRB, supinator before becoming purely motor PIN, supplies finger/thumb extensors, wrist extensors, abductor pollicis longus - **Radial nerve proper**: Bifurcates into PIN (deep motor) and superficial radial nerve (sensory) at level of radiocapitellar joint, lies anterior to lateral epicondyle - **Median nerve**: Medial structure, 2-3cm from working interval, safe if stay in BR-PT plane **Vascular Anatomy**: - Radial artery: Main vessel at risk, courses between BR and PT, 1-2cm medial to BR muscle belly, gives recurrent radial branch to brachioradialis - Posterior interosseous artery: Accompanies PIN through supinator, at risk during posterior dissection - Brachial artery bifurcation: Usually proximal to field but variable **Muscular Intervals**: - **BR-PT interval**: TRUE internervous plane (radial vs median innervation), this is the working space for single anterior approach - **EDC-ECU interval**: Posterior approach internervous plane (radial vs PIN innervation) for two-incision technique ### Patient Setup and Positioning **Position**: Supine on operating table. Affected arm on radiolucent arm board extended 90° from body OR brought across chest on bolster (allows easier elbow flexion). Ensure adequate shoulder external rotation to access antecubital fossa comfortably. **Tourniquet**: Non-sterile tourniquet on proximal arm, inflate to 250-280mmHg. Exsanguinate with elevation (avoid Esmarch wrap as may displace tendon further proximally). Tourniquet time typically 45-90 minutes for repair. **Forearm Position**: **SUPINATION MANDATORY** - this is the critical protective position maintained throughout surgery. Assistant holds forearm supinated or use arm board with forearm pronated holder that surgeon rotates to supination. **Imaging**: Ensure C-arm available if using fluoroscopy to confirm tuberosity position, button deployment, or anchor placement (optional, most surgeons rely on palpation). **Landmarks**: Mark with surgical marker: 1. Antecubital fossa crease (incision location) 2. Palpable biceps muscle belly and expected tendon course 3. Radial pulse (marks radial artery course) 4. Lateral epicondyle (reference point) ### Step 1: Skin Incision and LABCN Identification **Incision**: 3-4cm transverse incision in antecubital fossa skin crease (Langer's lines for optimal cosmesis). Center incision over palpable biceps tendon course or slightly lateral. Deepen through subcutaneous tissue with sharp dissection under direct vision. **LABCN Identification**: This is the FIRST and MOST IMPORTANT step. LABCN emerges between lateral edge of biceps/brachialis and medial edge of brachioradialis. Appears as 1-5 small nerve fascicles (variable anatomy) crossing field obliquely from lateral-proximal to medial-distal. Often accompanied by small vessels. **Critical Exam Point**: "LABCN is THE most commonly injured structure in distal biceps repair with 15-30% temporary numbness rate and 5% permanent injury. I identify it FIRST before any deeper dissection. The nerve has highly variable branching - I protect ALL branches throughout the case with vessel loops or gentle retraction." **LABCN Protection Strategy**: - Identify all visible branches early - Gently mobilize with nerve dissector (no traction) - Tag with vessel loop for visibility - Protect with Senn retractor or Army-Navy retractor (avoid sharp rake) - Avoid cautery near nerve - Check nerve at case end - should be visible and intact - Use sharp dissection under vision (not blind spreading) - Expect variable anatomy - may have 1-5 branches - Nerve crosses from lateral to medial - retract gently - Permanent injury (5%) causes painful neuroma requiring excision - If transected, consider immediate repair with microsurgical technique ### Step 2: Deep Interval Development - BR-PT Plane **Identify Brachioradialis (BR)**: Lateral muscle, palpable as firm muscle belly, easily identified by its surface anatomy and mobile nature. Originates lateral supracondylar ridge humerus, inserts radial styloid. Innervated by radial nerve (before bifurcation). **Identify Pronator Teres (PT)**: Medial muscle, two heads (humeral head from medial epicondyle, ulnar head from coronoid), inserts lateral mid-shaft radius. Innervated by median nerve. Forms medial border of working interval. **Develop Interval**: The space BETWEEN BR (lateral) and PT (medial) is the working interval. This is a TRUE internervous plane (radial nerve territory vs median nerve territory). Spread bluntly with hemostat or finger dissection. Interval bloodless if proper plane. **Radial Artery Management**: Radial artery lies 1-2cm medial to BR, typically adherent to deep surface of BR muscle. Retract BR and radial artery TOGETHER as a unit laterally. Palpate pulse. Gentle handling to avoid spasm or thrombosis. **Critical Exam Point**: "The BR-PT interval is my safe working space - true internervous plane between radial and median territories. I identify BR laterally (mobile, palpable muscle) and PT medially (deeper, two heads). I retract BR and radial artery as a UNIT laterally - this protects the vessel. The interval should develop bloodlessly if in correct plane." ### Step 3: Tendon Identification and Retrieval **Tendon Location**: In acute rupture (<4 weeks), tendon typically retracted to level of antecubital crease. In delayed cases (4-12 weeks), may retract to mid-arm. Chronic cases (>12 weeks) may retract to axilla or be scarred in place. **Tendon Retrieval**: - Identify biceps muscle belly proximally (thick, fusiform) - Follow muscle to musculotendinous junction - Tendon appears as white, glistening structure with longitudinal fiber pattern - May be surrounded by hematoma (acute) or scar (chronic) - Deliver into wound with Kocher clamp or Allis clamp on tendon substance (not edges) - May require proximal extension of incision or separate 1cm stab incision **Tendon Preparation**: - Debride MINIMALLY - remove only frayed tissue (1-2mm maximum) - Every millimeter of length is precious - Remove only non-viable tissue (gray, mushy, no longitudinal fibers) - Goal: healthy tendon end with intact fiber architecture - Typical prepared tendon length 2-3cm from musculotendinous junction **Suture Placement**: - Pass locking whipstitch through tendon with #2 FiberWire, FiberTape, or equivalent high-strength suture - Locking configuration: Start 1cm from end, pass through tendon substance centrally, exit 2cm from end, pass back through creating lock, repeat 3-4 throws creating 2cm of locked suture within tendon - Ensures suture won't pull through tendon during tensioning - Leave long suture tails for passage through bone - Chronic cases (>12 weeks): Tendon may be irretrievable or severely retracted - may need graft reconstruction - Excessive debridement: Insufficient length to reach tuberosity - major error - Rough handling: Can tear tendon substance - use atraumatic clamps - Partial ruptures: Rare distally, ensure complete rupture diagnosed (MRI helpful) ### Step 4: Radial Tuberosity Exposure **Supination - The Critical Maneuver**: Ensure forearm in FULL supination. Palpate radial tuberosity - should feel like firm prominence on anteromedial proximal radius 2-3cm distal to radial head. Tuberosity moves ANTERIORLY and MEDIALLY with supination (accessible through anterior approach). In pronation, tuberosity rotates POSTEROLATERALLY (inaccessible, and brings PIN into field). **Tuberosity Preparation**: - Clear soft tissue from tuberosity surface with elevator or freer - Remove bicipital bursa (normally present, may be thickened) - Remove any adhesions or scar tissue - STAY ON BONE - do not dissect laterally or posteriorly off tuberosity - Expose tuberosity footprint: oval area 15-20mm x 8-12mm - Gentle decortication with rongeur or curette to create bleeding bone surface (enhances healing) **PIN Protection During Exposure**: - PIN is 3-5cm distal to tuberosity, within supinator muscle - Supination rotates PIN posteriorly around radial neck - SAFE - Pronation brings PIN anterolaterally - DANGER - STAY ON BONE - PIN is muscular, will not be encountered if stay on bony tuberosity - No lateral or posterior dissection off bone **Critical Exam Point**: "FULL supination is THE protective maneuver for PIN safety and THE key to tuberosity access. Supination rotates the tuberosity anteriorly (I can access it easily through my anterior interval) and rotates PIN posteriorly around radial neck (3-5cm away, protected). I stay on bone clearing tuberosity - PIN is in supinator muscle laterally. Operating in pronation would bring PIN directly into my field - unacceptable risk." ### Step 5: Fixation - Cortical Button Technique (Preferred) **Rationale**: Cortical button (EndoButton, TightRope, or equivalent) provides biomechanically strongest fixation. Published biomechanical studies show superior load to failure (300-400N) versus suture anchors (200-300N) or interference screws (150-250N). Button engages posterior cortex distributing load over larger area. **Drilling Technique**: 1. **Drill Guide Placement**: Position drill guide on center of tuberosity footprint (anteromedial oval). Angle drill perpendicular to bone surface (usually 30-40° from vertical, aiming slightly distal). 2. **Unicortical Pilot**: Drill 3.2mm pilot hole through near cortex only. STOP when feel decreased resistance (entering medullary canal). 3. **Posterior Cortex Palpation**: Place finger on posterior radial cortex (posterolateral aspect of proximal radius). Feel for pilot hole exiting posteriorly - should not be palpable yet (still unicortical). 4. **Bicortical Completion**: Change to larger drill bit (4.5mm for most systems). Drill slowly through medullary canal to posterior cortex. FEEL for "give" when enter posterior cortex. STOP immediately after penetrating posterior cortex. 5. **Depth Measurement**: Use depth gauge through drill hole to measure posterior cortical thickness. Typical 2-3mm. This determines button suture length needed. **Button Deployment**: 1. **Thread Button**: Pass button-attached sutures through prepared tendon (through whipstitch loop or separate holes). 2. **Pass Through Bone**: Fold button flat, pass through drill hole from anterior to posterior. Button passes through 4.5mm hole easily when folded. 3. **Deploy Button**: Once button emerges from posterior cortex (feel "pop"), pull sutures anteriorly. Button flips 90° and engages posterior cortex. Confirm deployment by feeling button seated flush on posterior cortex. 4. **Dock Tendon**: Pull tendon down to tuberosity footprint via button sutures. Tendon end should sit flush on prepared bleeding bone surface. 5. **Tension Repair**: Position elbow at 30-40° flexion, forearm supinated. Tension button sutures pulling tendon firmly to bone. This tension optimizes healing while allowing full extension post-op. 6. **Secure Sutures**: Tie button sutures over bone bridge on anterior cortex OR through separate small drill holes. Multiple square knots. Alternative: some systems have self-tensioning mechanisms. **Critical Exam Point**: "I use cortical button because it's the biomechanically strongest fixation - published studies show 300-400N load to failure, significantly superior to anchors or screws. I drill unicortical pilot first, then complete to posterior cortex carefully. Button flips on far cortex distributing load. I tension with elbow at 30-40° flexion - this allows full extension without gapping post-operatively." - Button too deep posteriorly: Can impinge on PIN (rare but catastrophic) - ensure button seats flush on posterior cortex, no excessive drilling - Radial shaft fracture: Risk if drill hole >5mm in small radius or osteoporotic bone - use appropriate sized drill, gentle technique - Screw divergence: If button deploys incorrectly, sutures can cut through bone - confirm proper deployment before tensioning - Over-tensioning: Creates flexion contracture - elbow should achieve full extension easily after repair - Under-tensioning: Persistent weakness, gap formation with extension - ensure firm fixation ### Suture Anchor Technique **Indications**: Good alternative when surgeon prefers single-cortex fixation (avoids posterior cortex violation), osteoporotic bone where button may be risky, revision cases where previous button hole present. **Technique**: 1. **Anchor Placement**: Place 2-3 suture anchors (typically 5.0mm or 5.5mm diameter) in radial tuberosity footprint 2. **Drill Pilot Holes**: Use anchor-specific drill guide, create pilot holes perpendicular to bone surface 3. **Insert Anchors**: Screw or impact anchors fully seated below bone surface (countersink slightly) 4. **Suture Configuration**: Pass anchor sutures through tendon in locking mattress or modified Mason-Allen configuration 5. **Tension Repair**: Position elbow 30-40° flexion, forearm supinated, tie sutures securing tendon to tuberosity 6. **Test Fixation**: Should be robust - each 5.5mm anchor typically rated 150-200N load to failure **Advantages**: - Single cortex violation (no posterior cortex drilling) - Theoretically safer for PIN (no posterior hardware) - Easier technique for less experienced surgeons - Can use multiple anchors for customized repair **Disadvantages**: - Biomechanically weaker than button (200-300N vs 300-400N) - Anchor pullout risk in poor bone quality - Requires adequate bone stock in tuberosity - Tuberosity fracture risk if anchors too close together - More expensive (2-3 anchors vs 1 button) **Technical Comparison**: "Suture anchors provide single-cortex fixation - the benefit is no posterior cortex violation which theoretically protects PIN. I use 2-3 anchors in tuberosity footprint. Biomechanically slightly weaker than button (200-300N vs 300-400N) but clinical outcomes are equivalent in published studies. I prefer this for osteoporotic bone or revision cases." ### Interference Screw Technique **Technique**: 1. **Socket Creation**: Create unicortical socket in radial tuberosity using cannulated reamer over guidewire 2. **Socket Dimensions**: Diameter 7-9mm (matches tendon diameter), depth 20-25mm 3. **Tendon Docking**: Insert prepared tendon into socket with tendon end at socket base 4. **Screw Insertion**: Advance bioabsorbable interference screw (usually 7mm x 23mm) alongside tendon, compressing it against socket walls 5. **Tension**: Position elbow 30-40° flexion during screw advancement **Advantages**: - Similar concept to ACL interference fixation (familiar to sports surgeons) - Single cortex - No knots - Good compression of tendon-bone interface **Disadvantages**: - Screw divergence out of socket (10-15% in some series) - major complication - Larger bone defect than other methods - Cannot adjust tension after screw inserted - Fracture risk with oversized socket - Less commonly used for distal biceps (more data for ACL) ### Two-Incision Technique - Detailed Description **Historical Context**: Original Boyd-Anderson technique (1961). Fell out of favor due to heterotopic ossification, then modified and reintroduced. Still used by some surgeons, particularly for revision cases or chronic ruptures. **Anterior Incision and Tendon Retrieval**: Same as single-incision technique (Steps 1-3 above). 3-4cm transverse antecubital crease incision, identify LABCN, develop BR-PT interval, retrieve tendon, prepare with whipstitch. **Posterior Incision and Approach**: 1. **Incision**: 3-4cm longitudinal incision over posterolateral forearm, 2cm distal to lateral epicondyle, centered over palpable radial neck 2. **Interval**: Split between extensor digitorum communis (EDC) and extensor carpi ulnaris (ECU) - true internervous plane (radial nerve vs PIN) 3. **Supinator Identification**: Supinator muscle wraps around radial neck. PIN lies WITHIN supinator muscle substance, entering anteriorly and exiting posteriorly 4. **Sub-Supinator Plane**: Develop plane BETWEEN supinator (lateral/superior) and interosseous membrane (medial/inferior). This protects PIN which stays in supinator. 5. **Tuberosity Palpation**: Palpate anteriorly through this plane to identify radial tuberosity on anteromedial radius 6. **Drilling**: Drill from posterior to anterior through tuberosity. Can palpate drill bit emerging anteriorly. 7. **Tendon Passage**: Pass tendon from anterior wound through bone tunnel posteriorly (either through drill hole or separate bone tunnel) 8. **Posterior Fixation**: Secure tendon posteriorly over bone bridge, through button on posterior cortex, or with suture tied over periosteum **Advantages of Two-Incision**: - DIRECT visualization of radial tuberosity from posterior (easier for some surgeons) - Maximal PIN protection (PIN never near anterior field) - Easier in obese patients where anterior exposure difficult - Better for chronic cases or revisions where anterior scarring extensive - Can address pathology at tuberosity directly (bursitis, osteophytes) **Disadvantages of Two-Incision**: - **HETEROTOPIC OSSIFICATION**: 5-10% rate versus 1-2% single incision (5-fold higher) - Two separate bone violations (radius anteriorly and posteriorly) - Radioulnar synostosis risk (rare, <3%, but catastrophic - complete forearm rotation loss) - Two scars (cosmetic) - Longer operative time - More soft tissue dissection - Higher complication rate overall **HO Mechanism**: Posterior approach requires periosteal stripping of radius posteriorly. Combined with anterior tuberosity violation creates dual ossification stimulus. Hematoma formation between radius and ulna osteogenic. Inflammatory cascade triggers heterotopic bone formation, often bridging radius to ulna (synostosis pattern). **Two-Incision Comparison**: "Two-incision provides DIRECT posterior access to tuberosity and maximal PIN protection since PIN never near the working field. However, heterotopic ossification rate is 5-10% versus 1-2% for single incision - that's a 5-fold increase. This is due to dual bone violation and periosteal stripping. I reserve two-incision for revision cases, chronic ruptures where anterior retrieval difficult, or if I cannot safely access tuberosity anteriorly." - Heterotopic ossification (5-10%): Bone forms between radius and ulna, causes forearm rotation stiffness, may require excision - Radioulnar synostosis (2-3%): Complete fusion of radius to ulna, total loss of rotation, requires osteotomy - PIN injury during posterior approach: Despite being "safer," PIN can be injured if dissect through supinator rather than beneath it - Posterior interosseous artery injury: Accompanies PIN, can cause hematoma and HO - Longer recovery due to more soft tissue trauma ### Additional Complications **Median Nerve Injury (<1%)**: - Cause: Excessive medial dissection beyond PT muscle, aggressive medial retraction - Recognition: Post-op numbness thumb/index/middle fingers (radial 3.5 digits), thenar weakness (APB, opponens), Tinel's over nerve - Prevention: Stay within BR-PT interval, no medial dissection, identify nerve if anatomy unclear - Management: Most neurapraxia - observe 3-6 months. If neurotmesis, surgical exploration and repair **Radial Shaft Fracture (rare, <1%)**: - Cause: Drill hole too large (>5mm), osteoporotic bone, thin cortex, multiple drill attempts - Recognition: Intraop: Crack heard/felt during drilling. Post-op: Pain, radiographs show fracture line through tuberosity region - Prevention: Appropriate sized drill (4.5mm for button, not >5mm), gentle technique, assess bone quality, fluoroscopy if unsure - Management: Most stable and heal with conservative treatment (protected ROM). If displaced: ORIF with plate/screws, protect repair during fracture healing **Wound Complications (2-3%)**: - Superficial infection: Antibiotics, local wound care - Deep infection: Rare, requires washout, hardware removal if chronic, IV antibiotics - Dehiscence: Re-closure if early, local wound care if late - Hematoma: Evacuate if tense/expanding, otherwise observe **Chronic Pain (5-8%)**: - Multifactorial: Nerve injury (LABCN neuroma most common), stiffness, HO, hardware prominence, regional pain syndrome - Workup: Examine for specific cause (neuroma Tinel's, HO on imaging, hardware palpable) - Management: Treat underlying cause, consider neuroma excision if LABCN, HO excision if limiting function, hardware removal if prominent and bothersome after healing ### Rehabilitation Timeline - Evidence-Based Protocol **Phase 1: Protection (Weeks 0-2)** - **Immobilization**: Posterior splint, elbow 90° flexion, forearm NEUTRAL rotation (between supination/pronation for comfort) - **Rationale**: Neutral rotation protects repair in both supination and pronation directions, allows tendon-bone healing - **Allowed**: Active wrist flexion/extension, finger ROM (prevent stiffness, maintain grip) - **Prohibited**: Elbow motion, forearm rotation, lifting, resistance - **Wound care**: Suture removal 10-14 days, keep dry until then **Phase 2: Early Motion (Weeks 2-6)** - **Bracing**: Hinged elbow brace (0-120° or 30-120° depending on surgeon preference and repair strength) - **Motion**: ACTIVE elbow flexion encouraged (biceps contracts but minimal load on repair). PASSIVE elbow extension (gravity, therapist assists - avoid active triceps firing). Light forearm rotation (active supination/pronation) in neutral elbow position - **Rationale**: Motion prevents stiffness (major problem if immobilized >6 weeks). Active flexion safe because minimal tensile load. Passive extension safe because low load. Active extension prohibited (loads repair) - **Restrictions**: NO resisted supination (main load on repair - supinator and biceps both fire). NO lifting >500g. NO active extension (triceps load). NO eccentric biceps loading - **Goals**: Achieve 0-130° elbow motion, full forearm rotation, prevent adhesions **Phase 3: Active ROM (Weeks 6-12)** - **Bracing**: Discontinue brace at 6 weeks if repair strong, motion good, patient compliant - **Motion**: Progress to active elbow extension (wean brace, activate triceps), full AROM all planes (flexion, extension, supination, pronation) - **Strengthening**: Begin LIGHT resistance at 8 weeks. Isometric biceps contractions. Light resistance bands. Progress gradually - **Restrictions**: NO heavy lifting (>2kg). NO eccentric loading. NO sudden forceful activities - **Goals**: Full or near-full ROM (0-140° flexion, full rotation), independent ADLs, pain-free motion **Phase 4: Strengthening (Weeks 12-24)** - **Progressive Loading**: Increase resistance gradually. Concentric strengthening first (biceps curl, supination against resistance). Introduce eccentric loading at 16+ weeks (controlled lowering) - **Return to Activity**: Light sports 3 months (golf, swimming). Heavy sports 4-6 months (rock climbing, heavy weightlifting) - **Full Recovery**: 4-6 months for complete healing, return to all activities including heavy manual labor - **Restrictions**: Avoid lifelong repetitive eccentric biceps loading (mechanism of initial rupture) - patient education on activity modification ### Expected Outcomes - Published Data **Strength Recovery**: - Flexion strength: 90-95% of contralateral side at 1 year (excellent recovery) - Supination strength: 85-90% of contralateral side (slightly more deficit than flexion) - Untreated rupture loses 40-50% supination strength, 20-30% flexion strength - repair clearly superior **ROM Recovery**: - 90% achieve full or near-full elbow flexion-extension (0-140°+) - 95% achieve full forearm rotation (supination-pronation) - 5-10% develop minor flexion contracture (10-20° extension loss) - usually well-tolerated **Return to Work/Sport**: - Sedentary work: 2-4 weeks - Light manual labor: 6-12 weeks - Heavy manual labor: 3-6 months - Competitive sports: 4-6 months **Patient Satisfaction**: - 85-95% satisfied or very satisfied with outcome - 90-95% would undergo surgery again - Main dissatisfaction: Residual weakness, nerve numbness (LABCN), stiffness **Functional Outcomes**: - DASH scores: Improvement from 40-50 pre-op to 5-15 post-op (lower = better) - QuickDASH: Similar improvement - Return to pre-injury activity level: 80-85% of patients **Complication Impact**: - LABCN injury: Most common complaint, affects satisfaction but not functional scores significantly - Re-rupture: Devastating, revision surgery outcomes worse (70-80% good vs 90-95% primary) - HO/synostosis: Significantly impacts outcome, rotation loss affects function - Stiffness: Minor extension loss (<20°) well-tolerated, >20° affects function ### Return to Activity Guidelines **Office Work**: 1-2 weeks in splint/brace **Driving**: 6 weeks (when out of brace, can grip wheel, emergency maneuvers safe) **Light Household**: 6-8 weeks (dishes, light cooking - no lifting >2kg) **Heavy Household**: 3-4 months (yard work, moving furniture) **Golf**: 3 months (controlled swing, no full power initially) **Tennis**: 4 months (volleys first, serves later) **Swimming**: 6-8 weeks (gentle strokes, no butterfly initially) **Weightlifting**: 4-6 months (light weights 3 months, heavy 6 months) **Rock Climbing**: 6 months (high eccentric load - last to return) **Manual Labor**: 3-6 months depending on demands ## References 1. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii: A biomechanical study. *J Bone Joint Surg Am*. 1985;67(3):418-421. doi:10.2106/00004623-198567030-00010 2. O'Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. *Am J Sports Med*. 2007;35(11):1865-1869. doi:10.1177/0363546507305016 3. Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal biceps rupture using the modified two-incision technique. *J Shoulder Elbow Surg*. 2008;17(1 Suppl):67S-71S. doi:10.1016/j.jse.2007.06.026 4. Greenberg JA, Fernandez JJ, Wang T, Turner C. EndoButton-assisted repair of distal biceps tendon ruptures. *J Shoulder Elbow Surg*. 2003;12(5):484-490. doi:10.1016/s1058-2746(03)00172-5 5. Kettler M, Tingart MJ, Lunger J, Kuhn V. Reattachment of the distal tendon of biceps: Factors affecting the failure strength of the repair. *J Bone Joint Surg Br*. 2008;90(1):103-106. doi:10.1302/0301-620X.90B1.19607 6. Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: A systematic review. *Am J Sports Med*. 2008;36(8):1618-1624. doi:10.1177/0363546508318117 7. Heinzelmann AD, Savoie FH, Ramsey JR, Field LD, Mazzocca AD. A combined technique for distal biceps repair using a soft tissue button and biotenodesis interference screw. *Am J Sports Med*. 2009;37(5):989-994. doi:10.1177/0363546508330132 8. Kodde IF, Baerveldt RC, Mulder PG, Eygendaal D, van den Bekerom MP. Refixation techniques and approaches for distal biceps tendon ruptures: A systematic review of clinical studies. *J Shoulder Elbow Surg*. 2016;25(2):e29-e37. doi:10.1016/j.jse.2015.09.001 9. Cil A, Merten S, Steinmann SP. Immediate active range of motion after modified 2-incision repair in acute distal biceps tendon rupture. *Am J Sports Med*. 2009;37(1):130-135. doi:10.1177/0363546508323747 10. Shields E, Thirukumaran C, Thorsness R, Noback P, Voloshin I. Patient factors predicting adverse outcomes in distal biceps repair. *J Shoulder Elbow Surg*. 2016;25(12):1942-1946. doi:10.1016/j.jse.2016.09.054

Distal Biceps Tendon Repair - Comprehensive (Single vs Two-Incision Techniques)

Distal Biceps Tendon Repair - Comprehensive (Single vs Two-Incision Techniques)