DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right distal biceps tendon rupture.
POSTOPERATIVE DIAGNOSIS: Right distal biceps tendon rupture.
PROCEDURE PERFORMED: Open repair of right distal biceps tendon rupture using an EndoButton.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 25 mL.
DRAINS: None.
SPECIMENS: None.
COMPLICATIONS: None.
CONDITION: Stable to recovery.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male who recently had trauma to his right upper extremity and felt a pop and was diagnosed with a right biceps tendon rupture. The rupture was distally at the insertion of the biceps into the radial tuberosity. The patient was seen and evaluated and told of his options regarding treatment. The patient has elected to undergo operative treatment of this injury and understands the risks and benefits of this procedure. The patient has been consented appropriately.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating room table. General anesthesia was initiated. A right hand table was affixed to the operating room table. Clippers were used to shave the volar aspect of the proximal forearm and elbow as well as the dorsal aspect of the forearm in the region directly behind the proximal radius. Before prepping and draping, a nonsterile tourniquet was placed around the right upper extremity. The right upper extremity was prepped and draped in a sterile fashion, and the extremity was then exsanguinated with an Esmarch and the tourniquet was raised to 275 mmHg.
At this point, a single volar longitudinal incision was made on the medial aspect of the brachioradialis, starting at the level of the elbow flexion crease and continuing distally approximately 12 cm. The superficial veins were coagulated, and the fascia was incised. The interval between the brachioradialis and the pronator teres was identified. The distal aspect of the brachialis was also visible.
At this point, a finger was placed into the more proximal aspect of the arm and the stump of the biceps tendon rupture was palpated. At this point, palpation was carried distally and the radial tuberosity could be palpated with the arm in full supination. With the arm in full extension and supination, dissection was carefully carried down to the level of the radial tuberosity with care to protect the multiple neurovascular structures in the region. Baby Hohmanns were carefully placed along the side of the radius with care not to place retractors along the radial neck.
An Army-Navy was used to mobilize neurovascular structures distally, thereby exposing the radial tuberosity. A rongeur was used to clean the tuberosity of previous tendon fibers and to clean any scar and debris. A guidewire was then passed directly through the radial tuberosity and a 4.5 mm drill, which was cannulated, was then placed over the guidewire and used to drill a hole in the radial tuberosity, starting volar and proceeding out the distal cortex.
At this point, a bur was used to enlarge the more volar cortical drill hole while leaving the dorsal cortical drill hole intact. The volar surface was enlarged to accommodate the future passage of the tendon into the bone. After the hole had been enlarged with the bur, attention was turned proximally and the tendon stump was obtained and the end was debrided.
At this point, an interlocking Bunnell suture was placed using a #5 TiCron, starting proximally and proceeding distally. When the first limb was brought out distally, the #5 TiCron was placed through one of the central holes in a 15 mm EndoButton. The suture was then brought back through the other central hole of the EndoButton and again run in an interlocking fashion across the medial side of the tendon. The suture was then tied to itself proximally. The EndoButton was placed at a distance only approximately 1 mm from the end of the tendon stump.
At this point, a 2-0 Ethibond and a 0 Prolene were placed in each of the far medial and lateral holes of the EndoButton to use for guidance and control. The Ethibond was used as the leading side. A Beath needle was placed through the burred hole in the radius, and through the dorsal drill hole in the radius and brought out through the dorsal aspect of the arm.
The Ethibond and the Prolene were placed through the eyelet of the Beath needle and brought out dorsally, and the tendon was then advanced into the prepared burred hole. The elbow was flexed slightly to accommodate this passage of the tendon. Once the EndoButton was through the dorsal aspect of the radius, it was flipped using the two control sutures and this was checked under fluoroscopic imaging. The two sutures were then removed, and the wound was irrigated out well with normal saline.
The tourniquet was released and hemostasis was obtained. 3-0 Vicryls were then used in an inverted interrupted fashion to close the subcutaneous tissues followed by a 4-0 Monocryl in a running subcuticular fashion to close the skin. Steri-Strips with benzoin were placed, and a standard sterile dressing and splint were placed on the patient with his arm in 90 degrees of flexion and neutral rotation. The patient was then awoken from general anesthesia and transported to the recovery room in stable condition.
