Table 3.

Advantages and Pitfalls of Technique

Advantages

The endoscopic distal biceps repair described in this article is a true endoscopic technique. The entire procedure is performed while viewing through a 3-mm parabiceps portal and working through a distal anterior 8-mm portal. This minimizes the risks associated with larger incision repair techniques.

Optimal tuberosity preparation and tendon-bone approximation will result in improved healing of the ruptured tendon.

Small-joint instruments and motorized blades are easy to maneuver within the restricted space and permit adequate tendon and bone preparation.

Suture anchors are used for fixation, and this avoids the need for bicortical drilling and retrieval associated with EndoButton fixation techniques.

The step-by-step approach simplifies the procedure and shortens the learning curve for the technique.

Pitfalls

Precise parabiceps portal placement is crucial. The radial recurrent vessels and the lateral cutaneous nerve are in close proximity to the portal tract. Inadequate angulation of the sheath can result in damage to the radial vessels. The lateral cutaneous nerve may be damaged at its exit between the biceps and brachialis muscles if the portal is too proximal and lateral. It is recommended that surgeons explore this technique in cadavers before performing surgery.

The distal anterior portal may potentially damage the radial artery and the superficial branch of the radial nerve. The portal should be created in the safe internervous plane as described, and a cannula should be placed. All instruments should be introduced through the cannula. Additional retractors should be used if soft tissues are in the field of vision.

Motorized arthroscopic shavers and burrs can damage surrounding soft tissues. This may be avoided by (1) using a short cannula through the distal anterior portal, (2) using small-joint shavers and burrs (2 or 3 mm; Arthrex), (3) using the hood of the blades to protect the tissues, and (4) remembering that the blades must be used under direct endoscopic viewing at all times.

Fluid extravasation into the forearm and a potential increase in compartment pressures are possible. These risks are minimized by using air as an insufflation medium for the initial diagnostic endoscopy.

Fluid inflow must be minimized by using gravity inflow instead of a fluid pump. Compartment pressures may be monitored if the forearm is tense and swollen excessively.

Rerupture of the repaired biceps tendon can rarely occur. The risk is minimized by paying careful attention to each step described in the technique. Incorrect knot tying results in poor tendon-bone contact. Poor postoperative compliance with the rehabilitation protocol, smoking, and early return to sports are risk factors for tendon rerupture.