Case 02-biceps

Question 1

What is the most common complication of a single incision approach?

Answer 1

LABCN neuropraxia (10-26% of cases)

Question 2

What is the most common complication of a dual incision approach?

Answer 2

Heterotopic ossification and proximal radial ulnar synostosis (1-2% of cases versus <1% of cases in 1 incision)-inability to pronosupinate
This approach was developed to decrease the risk of LABCN/PIN injury

Question 3

What is the rate of PIN injury for a single incision approach?

Answer 3

3%

Question 4

What is the rate of SRN injury for a single incision approach?

Answer 4

6% in one study

Question 5

How can you minimize risk of PIN injury while drilling?

Answer 5

aiming in a slightly ulnar and slightly proximal direction can help avoid the PIN

Question 6

What does supinating the forearm do to the PIN

Answer 6

Protects the PIN. This moves the PIN lateral and anterior

Question 7

What is the overlap between the LABCN and SRN?

Answer 7

Distal lateral forearm around styloid is a common overlay where both nerves may supply adjacent or even overlapping cutaneous territories. Distal terminal branches of the volar and dorsal branches communicate with SRN

Question 8

Partial biceps tendon occur in what part of the tendon’s distal insertion?

Answer 8

Radial postion of the tendon

Question 9

What loss of strength do you see after a biceps rupture?

Answer 9

21-55% loss of supination, 40-60 in some studies
8-36% loss of flexion , 20-30 in some studies

Question 10

What is the mechanism of biceps tendon rupture?

Answer 10

eccentric force to a flexed elbow

Question 11

What is the rate of re-rupture after repair?

Answer 11

1-2 %

Question 12

Is there a difference in rerupture rates between one and 2 incision approaches?

Answer 12

Most studies show very low re-rupture rates for both, some studies have shown a slightly lower risk with 2 incision approach but fixation strategy is often more important than number of incisions and advent of cortical buttons which can be used in both approaches has brought rerupture rates to less than 2%

Question 13

What is an option for increased length without allograft?

Answer 13

Repair with lacertus fibrosis augmentation

Question 14

How do you know it was SRN not LABCN?

Answer 14

There can be overlap distally, so it’s possible this represented an LABCN neuropraxia, but since it was only present distally in the area of the SRN and he had no symptoms in the discrete LABCN territory, I reported it as a SRN neuropraxia. The reported rate of neuropraxia for SRN is 6% vs 10-26% for LABCN