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Dean G. Sotereanos, MD Clinical Professor of Orthopaedic Surgery

Learn the preferred grafting technique for chronic distal biceps ruptures, ensuring successful recovery for athletes. Understand the criteria for primary repair and reconstruction with allograft, with a step-by-step surgical approach outlined by Dr. Sotereanos. Discover the importance of tendon length, tissue quality, and flexion angle for optimal outcomes. This technique is proven to enhance supination and flexion strength, providing a comprehensive solution for long-standing biceps injuries.

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Dean G. Sotereanos, MD Clinical Professor of Orthopaedic Surgery

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  1. Distal Biceps Tendon Rupture You Need to Graft Every Time to Get Him Back to Competition, Let Me Show You the Way Dean G. Sotereanos, MD Clinical Professor of Orthopaedic Surgery University of Pittsburgh School of Medicine Orthopaedic Specialists - UPMC Pittsburgh, PA

  2. Chronic Distal Biceps Ruptures chronicity NO consensus on timeframe in literature: 3 weeks to 4 months • up to 8 weeks: anatomic repair • > 8 weeks: much more difficult repair

  3. Chronic Biceps Ruptures Repair • Retraction • Scarring • Poor tissue quality • Effective pain relief BUT •  Results compared to early repair

  4. Chronic Biceps Ruptures Repair Often a cocoon of connective tissue gives the impression of tendon continuity to the bicipital tuberosity cocoon

  5. Biceps mobilization Gradual traction Relaxing incisions to the epimysium Debride to healthy tendon Anatomic repair Chronic Biceps Ruptures Repair

  6. Chronic Ruptures Repair • When the stump cannot be approximated to the bicipital tuberosity: • Primary repair in extreme flexion • Biceps to brachialis transfer • Reconstruction w/ allograft

  7. Primary repair in extreme flexion > 70o flexion • criteria • Tendon adequate length ( >4 cm) & substance • Decreased chronicity • Lacertus intact

  8. Primary repair in extreme flexion > 70o flexion • Potential complications • Flexion contracture • Rerupture • Vascular compromise (> 90o flexion)

  9. Reconstruction with allograft • criteria • If someone requests supination strength: • electricians • weekend warriors

  10. Reconstruction with allograft • criteria • Decreased Tendon length ( <4 cm) / poor tissue • Increased chronicity • Lacertus not intact (greater retraction)

  11. Our Preferred Technique • Anterior Approach - One incision method Reconstruction with Achilles Tendon Allograft Darlis & Sotereanos J Shoulder Elbow Surg 2006

  12. Anterior Approach – modified anterior Henry S-shaped incision antecubital fossa Inability to approximate tendon stump to bicipital tuberosity with the elbow in less than 70o of flexion or poor tendon quality forearm fully Supinated at all times!

  13. Surgical technique Exposure of the radial tuberosity with the forearm in full supination Placement of 2 suture anchors with #2 non-absorbable suture

  14. Fresh-frozen Achilles tendon allograft The bone block is discarded The allograft is separated to 2 strips

  15. Allograft attached to radius first The sutures are passed through the distal part of the allograft in a modified Kessler sliding stitch

  16. The allograft is woven through the distal biceps stump in a Pulvertaft fashion

  17. One Incision MethodBone anchors & Achilles tendon allograft 13 ptschronic distal biceps tendon rupture • chronicity • mean 31 w (11- 47 w) • Synostosis •  PIN injuries • complications from allograft mean f-up 37 m (24-112m) • mean supination strength 88% • mean flexion strength 100% vs contralateral arm Sotereanos et al. ASES 2012 Darlis N, Sotereanos D. JSES 2006

  18. Would you be comfortable to suture that to the tuberosity in > 70o flexion? 1.7 cm of tendon

  19. Thank you

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