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Two-incision technique superior to one-incision technique in anatomic repair of biceps tendon
Hasan SA. J Shoulder Elbow Surg. 2011. doi:10.1016/j.jse.2011.04.027
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Anatomic repair of the biceps tendon to the original insertion site can be improved more effectively through a 2-incision technique than a 1-incision technique, according to researchers in Maryland.
To compare the 2-incision technique with the 1-incision technique, the researchers randomly assigned 20 cadaveric arms to one of two groups: a 1-incision group or a 2-incision group. The 1-incision group had their bicipital tuberosity exposed through a single anterior incision, while the 2-incision group underwent a posterolateral approach. The axis for creating a virtual bone tunnel was marked through a guide pin placed into the tuberosity, and radius was harvested with an intact biceps insertion.
A 3D computerized digitizer measured the length, width and area of the insertion footprint for each tendon, and a virtual bone tunnel 7.5 mm in diameter was centered over a guidewire-created drill hole. Researchers then determined the percentage of the virtual tunnel within the original footprint.
According to the study results, the team found 73.4% of the virtual tunnel was within the original tendon footprint when the posterolateral approach was used, as opposed to 9.7% for the anterior approach. The authors noted a statistically significant difference between medial values of covered footprint in a comparison of the two types of repair.
“Prospective clinical studies directly comparing the two techniques with regard to the strength of supination after repair may be helpful,” the authors wrote.
As debate continues regarding whether a single-incision or two-incision technique is superior for distal biceps repair, this study adds to the literature by taking a novel approach to studying the anatomy of the repair. Hasan et al prove their hypothesis that the two-incision technique they used yielded a more anatomic repair utilizing cadaveric specimens and a 3-dimensional computerized digitizer. By performing the typical surgical approaches, placing a guide pin and simulating a tunnel they found that the percentage of the virtual tunnel inside the footprint was 9.6% when using a single anterior incision and 73.4% when using the two incision approach, which was statistically significant.
While the authors did not mention whether the same surgeon performed all of the procedures, this would be important to note as different techniques could lead to variable results. Perhaps single-incision techniques in which fluoroscopic guidance is used could help create a more anatomic repair. Furthermore, these results do not necessarily imply worse clinical outcomes, because some studies have certainly shown better results with single-incision approaches.
The authors nevertheless should be commended for recognizing and acknowledging the limitation of using only one method of fixation, conducting a virtual repair and performing a pilot study to test the ability to conduct the procedure leaving the biceps tendon intact. Within the limitations of a cadaveric study they took great care to achieve clinical relevance; however, well designed clinical studies are still needed to assess the outcomes in terms of strength of a more anatomic repair. Clearly, a decision of which technique to be used in practice will have to carefully factor in the risks of each approach. This original anatomic study provides new data on the insertion footprint of the distal biceps and questions the ability to perform an anatomic repair through a single anterior incision.
— Peter J. Millett, MD, MSc and Robert Boykin, MD
The Steadman Clinic
Vail, CO