Rupture distale du Biceps brachial

- La technique endoscopique - Didier FONTÈS

Espace Médical Vauban - Paris VIIe

Hôpital Européen Georges Pompidou

SOFEC Paris 2010

Clinical Recall w  Less frequent than proximal lesions (3%) w  = Avulsion of the radial attachment

(almost no partial lesion of distal tendon)

w  Univocal clinical context

92% Males 4th decade 86% dominant elbow Excessive eccentric tension from flexion of the elbow 1,2 ruptures / 100 000 patients / year 43% smokers (over-risk x 7,5) Anabolic steroids consumers Professional sportsmen

Clinical Recall

w  Positive diagnosis with comparative clinical exam n  Local swelling n  Ascension of the muscle n  Resisted Flexion-supination

painfull and weak n  Superficial dysesthesia (forearm

cutaneous lateral nerve, Bassett & Nunley type syndrom)

Clinical Recall

w  Positive diagnosis with comparative clinical exam n  Local swelling n  Ascension of the muscle n  Resisted Flexion-supination

painfull and weak n  Superficial dysesthesia (forearm

cutaneous lateral nerve, Bassett & Nunley type syndrom)

Clinical Recall

w  Positive diagnosis with comparative clinical exam n  Local swelling n  Ascension of the muscle n  Resisted Flexion-supination

painfull and weak n  Superficial dysesthesia (forearm

cutaneous lateral nerve, Bassett & Nunley type syndrom)

Radiographic Diagnosis

FABS

Tendon Distal Normal

FABS View

“T1 weighted”

Flexed elbow Abducted shoulder Supinated forearm w  US non reliable for distal

avulsions w  MRI with « australian »

FABS incidence n  Jeff Hughes (Sydney)

n  Diagnosis n  Retraction n  « Partial » Lesions

Radiographic Diagnosis

w  US non reliable for distal avulsions

w  MRI with « australian » FABS incidence n  Jeff Hughes (Sydney)

n  Diagnosis n  Retraction n  « Partial » Lesions

Radiographic Diagnosis

w  US non reliable for distal avulsions

w  MRI with « australian » FABS incidence n  Jeff Hughes (Sydney)

n  Diagnosis n  Retraction n  « Partial » Lesions

Therapeutic Attitude w  Bad functional tolerance

of non operative treatment (weakness in flexion and supination)

w  Painfull retracted tendon w  Cutaneous adherences w  Dysesthesia (Bassett &

Nunley) w  Cosmetic disorder

=> Surgery

Different types of procedures

w  Support an early treatment n  First description en 1898 (Acquavica)

w  Tenodesis to Brachialis n  Guibal (1933) : adossement n  Dobbie (1941) : 2 strips

w  Osseous reattachment n  1 incision : pull-out, trans-osseous

sutures then suture anchors and endobuttons

n  2 incisions : Boyd & Anderson (1961)

Different types of procedures

w  Support an early treatment n  First description en 1898 (Acquavica)

w  Tenodesis to Brachialis n  Guibal (1933) : adossement n  Dobbie (1941) : 2 strips

w  Osseous reattachment n  1 incision : pull-out, trans-osseous

sutures then suture anchors and endobuttons

n  2 incisions : Boyd & Anderson (1961)

Different types of procedures

w  Support an early treatment n  First description en 1898 (Acquavica)

w  Tenodesis to Brachialis n  Guibal (1933) : adossement n  Dobbie (1941) : 2 strips

w  Osseous reattachment n  1 incision : pull-out, trans-osseous

sutures then suture anchors and endobuttons

n  2 incisions : Boyd & Anderson (1961)

Results of classical treatments

w  Non operative management : n  Weakness in flexion and supination

(from 30 to 50%) n  Decrease of endurance (Cybex) ++

(>60%)

w  Brachialis tenodesis : n  Flexion weakness (-30% Catonné -

1995) and supination (-50% Klonz-2003) n  Rare nervous complications n  No heterotopic ossifications n  Dissatisfaction of sportsmen

Results of classical treatments

w  Trans osseous reattachment n  More anatomical (suture anchors) n  Best results in strength and

endurance n  Neurological Complications

sometimes serious and definitive (5-10%)

n  Heterotopic Ossifications and n  Synostosis (5-14%) / 2 incisions

Results of classical treatments

w  Trans osseous reattachment n  More anatomical (suture anchors) n  Best results in strength and

endurance n  Neurological Complications

sometimes serious and definitive (5-10%)

n  Heterotopic Ossifications and n  Synostosis (5-14%) / 2 incisions

Results of classical treatments

w  Trans osseous reattachment n  More anatomical (suture anchors) n  Best results in strength and

endurance n  Neurological Complications

sometimes serious and definitive (5-10%)

n  Heterotopic Ossifications and n  Synostosis (5-14%) / 2 incisions

Results of classical treatments

w  Trans osseous reattachment n  More anatomical (suture anchors) n  Best results in strength and

endurance n  Neurological Complications

sometimes serious and definitive (5-10%)

n  Heterotopic Ossifications and n  Synostosis (5-14%) / 2 incisions

Anatomy of Biceps tendon and radio-bicipal sheath

w  2 individual muscles bellies n  Long Head (LH) and Short Head

(SH)

w  Distal Interdigitations w  Lacertus fibrosus w  Radial footprint w  Best supination action moment

of LH / axis enhanced by forarm muscle contraction

w  Circular radio-bicipal bursal sheath surrounding SH & LH easily distended / saline solution

Anatomy of Biceps tendon and radio-bicipal sheath

w  2 individual muscles bellies n  Long Head (LH) and Short Head

(SH)

w  Distal Interdigitations w  Lacertus fibrosus w  Radial footprint w  Best supination action moment

of LH / axis enhanced by forarm muscle contraction

w  Circular radio-bicipal bursal sheath surrounding SH & LH easily distended / saline solution

Anatomy of Biceps tendon and radio-bicipal sheath

w  2 individual muscles bellies n  Long Head (LH) and Short Head

(SH)

w  Distal Interdigitations w  Lacertus fibrosus w  Radial footprint w  Best supination action moment

of LH / axis enhanced by forarm muscle contraction

w  Circular radio-bicipal bursal sheath surrounding SH & LH easily distended / saline solution

Anatomy of Biceps tendon and radio-bicipal sheath

w  2 individual muscles bellies n  Long Head (LH) and Short Head

(SH)

w  Distal Interdigitations w  Lacertus fibrosus w  Radial footprint w  Best supination action moment

of LH / axis enhanced by forarm muscle contraction

w  Circular radio-bicipal bursal sheath surrounding SH & LH easily distended / saline solution

Anatomy of Biceps tendon and radio-bicipal sheath

w  2 individual muscles bellies n  Long Head (LH) and Short Head

(SH)

w  Distal Interdigitations w  Lacertus fibrosus w  Radial footprint w  Best supination action moment

of LH / axis enhanced by forarm muscle contraction

w  Circular radio-bicipal bursal sheath surrounding SH & LH easily distended / saline solution

Anatomy of Biceps tendon and radio-bicipal sheath

w  2 individual muscles bellies n  Long Head (LH) and Short Head

(SH)

w  Distal Interdigitations w  Lacertus fibrosus w  Radial footprint w  Best supination action moment

of LH / axis enhanced by forarm muscle contraction

w  Circular radio-bicipal bursal sheath surrounding SH & LH easily distended / saline solution

w  Forearm cutaneous lateral nerve w  Radial Nerve outwards of the

sheath (18 mm)

w  Ulnar artery (6 mm) w  Median nerve (12 mm) ⇒ «Noble » structures all in the

anterior plan

Anatomical neighborhood of bicipital tendon

w  Safe anterior zone

w  Well identified sheath as a working space (hematoma)

w  Endoscopic magnification optimize operative safeness

Feasibility of an endoscopic approach

Goals of the classical one incision technique

Useless

w  Location of the retracted biceps tendon w  Vasculo-nervous pedicles control w  Opening of the sheath and exposition of

radial tuberosity (retractors ++) w  Trans osseous reattachment w  Large sinuous anterior incision

Goals of the classical one incision technique

Dangerous

Useless

w  Location of the retracted biceps tendon w  Vasculo-nervous pedicles control w  Opening of the sheath and exposition of

radial tuberosity (retractors ++) w  Trans osseous reattachment w  Large sinuous anterior incision

Goals of the classical one incision technique

Dangerous

Useless

w  Location of the retracted biceps tendon w  Vasculo-nervous pedicles control w  Opening of the sheath and exposition of

radial tuberosity (retractors ++) w  Trans osseous reattachment w  Large sinuous anterior incision

Goals of the classical one incision technique

Dangerous

Useless

w  Location of the retracted biceps tendon w  Vasculo-nervous pedicles control w  Opening of the sheath and exposition of

radial tuberosity (retractors ++) w  Trans osseous reattachment w  Large sinuous anterior incision

References

w S. Sharma (endobutton) n  Arthroscopy 2005

w M. Eames, G. Bain (endobutton) n  Tech. in Shoulder & Elbow surgery 2006

w Didier Fontès (suture anchors) n  J. Traumato du Sport 2007 n  Chir. De la Main 2009 n  Am. J. Sports Medicine 2009

Our mini-invasive technique

w  Supine position, proximal tourniquet

w  Short approach in a distal crease (3 cm, rather medial) in the « safe area »

w  Superficial dissection just to open the sheath (removing the hematoma and washing to avoid post-op ossifications)

Our endoscopic technique

w  Grasping the retracted avulsed tendon inside and pulling down out of the wound

w  Refreshing of tendon end

w  Control of superficial nerves

w  Possibility of reinforcement with the lacertus fibrosus

Our endoscopic technique w  Location of the distal tendon

tract(following hematoma) w  Introduction of a mini single use

speculum or endoscopic sheath down to tuberosity +/- saline solution

w  Endoscopic control (scope 4,5 mm)

w  One or 2 suture anchors

Radial tuberosity Anchor fixation

Our endoscopic technique w  Removing of speculum and

scope w  Tacking the tendon with

sliding knots to pull it down onto the bone

w  Immobilization en Flexion 90° + supination (3 weeks)

Our series (from 2000 to 2009)

w  35 Males : (15 prof. Sport) n  5 international Rugby players n  10 carried out high level weigh

training n  1 mountain guide n  Age : 31-58 years old

w  Early procedure ≤ 3 weeks w  Loco regional anesthesia w  One day surgery w  Use of tourniquet

Our series

w  Quasi-normalization of range of

motion, strength and isocinetic tests w  Return to preinjury activities (3 months)

at same level (94%) w  Satisfying cosmetic aspect w  Complications :

n  Scar adherences n  1 Transitory radial nerve paralysis n  1 Median nerve paralysis 4 weeks after

procedure (past of anterior interosseous nerve syndrom) : re-intervention (scar ++ of residual lacertus fibrosus)

n  2 heterotopiques ossifications (no clinical consequences)

Our series

w  Quasi-normalization of range of

motion, strength and isocinetic tests w  Return to preinjury activities (3 months)

at same level (94%) w  Satisfying cosmetic aspect w  Complications :

n  Scar adherences n  1 Transitory radial nerve paralysis n  1 Median nerve paralysis 4 weeks after

procedure (past of anterior interosseous nerve syndrom) : re-intervention (scar ++ of residual lacertus fibrosus)

n  2 heterotopiques ossifications (no clinical consequences)

Our series

w  Quasi-normalization of range of

motion, strength and isocinetic tests w  Return to preinjury activities (3 months)

at same level (94%) w  Satisfying cosmetic aspect w  Complications :

n  Scar adherences n  1 Transitory radial nerve paralysis n  1 Median nerve paralysis 4 weeks after

procedure (past of anterior interosseous nerve syndrom) : re-intervention (scar ++ of residual lacertus fibrosus)

n  2 heterotopiques ossifications (no clinical consequences)

Our series

w  Quasi-normalization of range of

motion, strength and isocinetic tests w  Return to preinjury activities (3 months)

at same level (94%) w  Satisfying cosmetic aspect w  Complications :

n  Scar adherences n  1 Transitory radial nerve paralysis n  1 Median nerve paralysis 4 weeks after

procedure (past of anterior interosseous nerve syndrom) : re-intervention (scar ++ of residual lacertus fibrosus)

n  2 heterotopiques ossifications (no clinical consequences)

Our series

w  Quasi-normalization of range of

motion, strength and isocinetic tests w  Return to preinjury activities (3 months)

at same level (94%) w  Satisfying cosmetic aspect w  Complications :

n  Scar adherences n  1 Transitory radial nerve paralysis n  1 Median nerve paralysis 4 weeks after

procedure (past of anterior interosseous nerve syndrom) : re-intervention (scar ++ of residual lacertus fibrosus)

n  2 heterotopiques ossifications (no clinical consequences)

Conclusion w  Reliable for acute lesions w  Short learning curve w  No necessity of a second approach (≠

endobutton) w  Mini invasive procedure in a safe area

distant from neurovascular structures (decreasing risk of complications)

w  Raisonnable Alternative to simple Tenodesis when functional , sports or cosmetic demands need an

Anatomical Restitution