Dr. Garcia demonstrates his distal biceps repair technique.

This video features Dr. Grant H. Garcia demonstrating his surgical technique for a distal biceps tendon repair. The case involves an acute tendon rupture in a healthy middle-aged gentleman, with surgery performed roughly four to five weeks post-injury.

Here is a summary of the procedure shown in the video:

• Incision and Exposure: The surgeon makes a longitudinal incision about two to three finger-breadths away from the antecubital fossa. He identifies and carefully retracts the cephalic vein and the lateral antebrachial cutaneous nerve. Dissection is advanced through the interval between the pronator teres and the brachioradialis, staying slightly to the ulnar side to approach the radius.
• Preparing the Radial Tuberosity: The previous stump of the ruptured biceps tendon and surrounding damaged tissue are cleared away. Hohmann retractors are placed ulnarly and radially, keeping the arm in maximum supination. To protect the posterior interosseous nerve (PIN), a retractor is deliberately omitted in its vicinity. The radial tuberosity is debrided to expose a raw bone footprint, and an X-ray is taken with a single Hohmann retractor to confirm the proper structural location.
• Mobilizing and Preparing the Tendon: The ruptured biceps tendon had retracted about six centimeters and was heavily scarred medially. The surgeon mobilizes the tendon using an Allis clamp, dissecting away scar tissue up to the musculotendinous junction. The damaged insertional tip of the tendon is debrided to expose a fresh healing bed.
• Tubularizing the Tendon: A FiberWire loop is utilized to make seven to eight interlocking passes down to the tip of the tendon. This not only increases the overall biomechanical strength of the construct but also tubularizes the thick tendon so it can fit cleanly into a smaller bone socket. The tendon diameter is measured to determine the tunnel size, which typically ranges from seven to eight millimeters.
• Drilling and Reaming the Socket: Returning to the radial tuberosity, a guide pin is drilled unicortically into the centered footprint to prevent damage to the back of the radius. The tunnel is then created using an eight-millimeter reamer. After irrigating the site, a hole is drilled through the second (posterior) cortex, angling slightly ulnar at 90 degrees based on anatomical studies to avoid injuring the PIN.
• Securing and Flipping the Button: A cortical button is loaded with the suture limbs. A Keith needle and a 0.042 Kirschner wire (K-wire) are passed through the radius to push the button past the far posterior cortex. Once it exits, the K-wire helps flip the button flat against the back of the bone. The tendon is then tensioned and dunked deep into the bone socket. An intraoperative X-ray is obtained to verify that the button is perfectly flipped and seated.
• Final Construct and Testing: With the elbow positioned at roughly 70 to 80 degrees of flexion, the sutures are knotted down securely to lock the tendon rigidly into place. The surgeon concludes the procedure by testing the elbow in full supination and carefully checking extension to ensure the patient can immediately achieve at least 60 degrees of extension without putting excessive strain on the fresh repair.