mr. Shadegg is discussing today distal
00:04
biceps allograft reconstruction this
00:07
patient presented with a more than four
00:10
month history of disrupted distal biceps
00:12
here you can see the Popeye deformity he
00:17
also had a palpable void and a negative
00:19
hook sign we make a curvilinear incision
00:22
crossing the antecubital fossa from
00:26
medial to lateral once the skin and
00:32
subcutaneous tissue is divided we then
00:34
dissect deeper until we identify the
00:37
antecubital veins there's typically a
00:41
large antecubital vein in the area which
00:44
occasionally has to be tied off and here
00:46
we've identified the latter antebrachial
00:48
cutaneous nerve once that nerve is
00:52
identified it is protected throughout
00:55
here we are now tying off our
00:58
antecubital vein next our goal is to
01:04
identify the sheath of the tendon itself
01:09
ascending distantly approximately we're
01:12
not able to identify the tendon itself
01:19
you can see here significant adhesion
01:22
and scarring an easy way to identify the
01:28
tendon in these chronic situations is to
01:30
follow the lateral and brachial
01:31
cutaneous nerve approximately
01:39
here we are further detecting the tendon
01:42
and here you can see significant amount
01:45
of fitness and scar formation an attempt
01:49
is made to mobilize the muscle belly
01:53
with an attempt to possibly try and
01:56
reattach the tendon primarily here you
02:01
can see the limited amount of excursion
02:07
we're attempting to release the muscle
02:10
belly approximately and then the distal
02:19
sheath is now identified by placing your
02:22
finger in the hole and pronating and
02:24
supinate in the forearm the radial
02:27
tuberosity is identified a tonsil is in
02:35
place through the previous tendon sheath
02:40
and passed through the form through the
02:42
interosseous membrane is palpating on
02:44
the dorsum of the forearm the skin is
02:47
then divided and here the tonsil is
02:49
identified that section is made around
02:52
the area of the tonsil and dissection is
02:54
carried down to the border of the radius
02:59
in full pronation the radial tuberosity
03:03
is now visualized retractors are placed
03:06
around the radial tuberosity to ensure
03:09
appropriate visualization but also to
03:12
ensure protection from the P I am the
03:17
site is in marked and using a bur the
03:22
insertion side of the bone block is in
03:26
formed an Achilles tendon allograft with
03:30
bone block in place is now shaped to the
03:34
size appropriate for placement in the
03:36
radius
03:43
this area is cut here care is taken to
03:48
cut a piece that may be potentially
03:50
larger and then we can shave it down you
03:54
can see here illustration of our drill
03:56
holes will put drill holes on either
03:59
side and then run the suture through our
04:03
graft and tie over the top after drill
04:08
hole placement sutures in passed through
04:11
the most owner hole that sutures in
04:15
passed through the tendon and portion
04:17
and portion of the bone lock it now
04:23
passes through the other side of the the
04:27
drill site and this is done twice and
04:29
then sutured down now that we have
04:39
placed the bone block in position we
04:42
again pass the tonsil through into the
04:45
wound post early we spread the area and
04:49
spread the interosseous membrane to
04:51
allow for adequate passage of our tendon
04:53
graft we then use a whip stitch to allow
04:57
for passage of the tendon appropriately
04:59
and the tendon is in passed into the
05:02
antecubital fossa the form is in
05:09
supinated and now the tendon graph is
05:14
fanned and the previous tenant will now
05:17
be pulled through a hole in the graph to
05:20
sell
05:28
now we'll attempt to tension and using a
05:34
zero ethibond suture we then tie our
05:38
suture against an hour attendant against
05:41
the allograft we then check the tension
05:43
again once the tension is confirmed we
05:49
were then shorten the allograft tendon
05:54
this tendon isn't wrapped around the
05:59
previous remnant and sutured on itself
06:09
it was sutured up and down with
06:12
inclusion of the tendon and now at the
06:14
conclusion of this we can see adequate
06:19
visualization of the tendon the lateral
06:22
and braking cutaneous nerve and the
06:25
tendon is mobile and with pronation and
06:29
supination the tenant moves
06:31
appropriately the posterior wound is
06:35
irrigated with again care taken to
06:38
ensure that there are no excessive bone
06:44
in the interosseous membrane the fashion
06:46
is closed the skin is closed with a
06:49
nylon suture the incision was made off
06:53
the edge of the ulna purposely to ensure
06:56
again to limit the potential for
06:59
synostosis the skin on the volar side is
07:02
closing in 3o at the zero Vicryl suture
07:05
and then a 3o nylon in an alternating
07:08
interrupted mattress type fashion
07:11
patient is placed in a posterior splint
07:13
at 90 degrees and the splint is
07:17
maintained to a follow-up appointment